You are on page 1of 9

Child and Adolescent Mental Health 21, No. 2, 2016, pp.

8189

doi:10.1111/camh.12112

Dialectical behavior therapy for nonsuicidal selfinjury and depression among adolescents:
preliminary meta-analytic evidence
Nathan E. Cook1,2 & Maggie Gorraiz3
1

Massachusetts General Hospital Department of Psychiatry, Learning and Emotional Assessment Program, 151 Merrimac
Street 5th Floor, Boston, Massachusetts 02114, USA. E-mail: necook@mgh.harvard.edu
2
Department of Psychiatry, Harvard Medical School, Boston, MA, USA
3
Center for Cognitive and Dialectical Behavior Therapy, Lake Success, NY, USA

Background: Dialectical behavior therapy (DBT) has proven effective in reducing symptoms and behaviors
related to Borderline Personality Disorder. More recently, it has been modified and applied to adolescents
struggling with regulating their emotions and who may engage in impulsive, self-destructive behaviors,
including nonsuicidal self-injury (NSSI). However, there is limited research evidence regarding the effectiveness
of DBT for reducing NSSI behavior and depression among adolescents. Given the high suicide risk associated
with NSSI and its association with depression, this is clearly an important focus of clinical and research attention. Method: This meta-analysis sought to offer preliminary evidence regarding the effectiveness of DBT to
treat NSSI and depression in adolescents. Twelve published studies were included; all 12 reported pre- and
post-treatment measures of depression and six of these studies reported pre- and post-treatment measures of
NSSI. Results: The weighted mean effect size for NSSI was large (g = 0.81, 95% CI = 0.591.03); the weighted
mean effect size for depression was small (g = 0.36, 95% CI = 0.300.42). Conclusions: Intervention effects for
both outcomes were positive, suggesting decreased NSSI and improvement in depressive symptoms for adolescents following a course of DBT. However, given considerable limitations in the research base available for
meta-analysis, these findings are preliminary and tentative. Limitations in the current knowledge base and
suggestions for future research are discussed.

Key Practitioner Message

Research in adult populations suggests that DBT is effective in reducing emotional and behavioral difficulties, consistent with borderline personality disorder. However, limited research evidence exists regarding
the utility of DBT interventions in helping adolescents who have trouble modulating their emotions and
controlling their behaviors.
Meta-analytic results from 12 studies examining DBT interventions among adolescents suggest decreased
NSSI and improvement in depressive symptoms.
Practitioners can consider DBT interventions as a possible therapeutic option in the treatment of adolescents who engage in self-harm and suffer with depression; however, practitioners must also continue to
monitor the research evidence base as investigators seek to address and improve upon methodological
shortcomings in the extant literature.

Keywords: Dialectical behavior therapy; depression; nonsuicidal self-injury; adolescents; meta-analysis

Introduction
Dialectical behavior therapy (DBT; Linehan, 1993a,
2014) is a comprehensive, cognitive-behavioral treatment
(CBT), comprised of principles from behavioral science,
dialectical philosophy, and Zen practice (Lynch, Trost,
Salsman, & Linehan, 2007). It was originally developed
for chronically suicidal females who met the criteria for
Borderline Personality Disorder (BPD) (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991). Diagnostic features of BPD include a chronic, pattern of emotion
dysregulation, which may impact areas of interpersonal
functioning, self-identity and contribute to impulsive,
self-destructive behaviors (American Psychiatric Associa-

tion, 2013). Initially, Linehan, the treatment developer,


applied a standard CBT program to women with chronic
suicidality, but did not nd the treatment to be successful. As a result, the treatment was amended to incorporate acceptance strategies grounded in Zen mindfulness
to balance the change strategies emphasized in the CBT
treatment (Dimeff & Linehan, 2001). The balance, exibility, and synthesis of acceptance and change strategies in
the delivery of treatment are the foundation of DBT. Dialectical thinking uses the idea that there are no absolute
truths and two seemingly opposite truths may both be
valid. For example, an ineffective behavior, such as selfharm, may be both functional and dysfunctional in the
individuals life and working toward a synthesis will help

2015 Association for Child and Adolescent Mental Health.


Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA

82

Nathan E. Cook & Maggie Gorraiz

the individual make progress (Linehan, 1993a; Lynch


et al., 2007).
A standard DBT program includes individual therapy,
skills groups, phone coaching, and a DBT consultation
team for the treatment providers. Within the individual
treatment, the therapist adheres to a treatment hierarchy
addressing the following behaviors in order: life threatening,
treatment interfering, and quality of life interfering behaviors. The patient is permitted to contact the individual therapist, within the therapists personal limits to receive skills
coaching throughout the week. Within the skills group
training, two group cofacilitators teach and review four skills
modules: mindfulness, interpersonal effectiveness, emotion
regulation, and distress tolerance. To maintain delity of
treatment and reduce therapist burnout, the treatment providers participate in a DBT consultation team, where they
will provide support to one another (see Linehan, 1993a,b,
2014 for more detailed information on the skills, function,
modes, and stages of DBT).

Effectiveness of DBT for adults


Within the past two decades, there is strong research
support for the efcacy of DBT in the treatment of BPD,
and promising ndings supporting DBT for the treatment of other mental health concerns. Specically, DBT
has proven helpful in the reduction of suicidal, self-injurious behaviors and other BPD-related behaviors of
numerous randomized controlled trials (RCTs; e.g., van
den Bosch, Koeter, Stijnen, Verheul, & van den Brink,
2005; Koons et al., 2001; Linehan, Heard, & Armstrong,
1993; Linehan et al., 1991, 2006; Verheul et al., 2003).
There is also support for the treatment of BPD and comorbid substance abuse disorders (van den Bosch et al.,
2005; Linehan et al., 1999, 2002) and comorbid eating
disorders (Palmer et al., 2003) among adults. In addition, DBT has been modied and adapted to bulimia
(Safer, Telch, & Agras, 2001) and binge eating disorders
(Safer, Robinson, & Jo, 2010; Telch, Agras, & Linehan,
2001) among adults. Furthermore, there is preliminary
support that DBT skills group and phone coaching in
combination with antidepressant medication may help
decrease depression in elderly populations (Lynch,
Morse, Mendelson, & Robins, 2003).
There have been extensive and critical reviews of the
empirical research support for DBT (e.g. Lynch et al.,
2007; Robins & Chapman, 2004) and several metaanalyses examining DBTs effectiveness across multiple
treatment outcomes (Kliem, Kr
oger, & Kosfelder, 2010;

(2008)
Ost,
2008; Tarrier, Taylor, & Gooding, 2008). Ost
conducted a thorough meta-analysis on a large range of
third wave empirically supported behavioral therapies
examining the methodology, efcacy, and criteria for
empirically supported treatments. For DBT, 13 RCTs,
totaling 539 participants, were used. Nine RCTs examined the treatment of BPD, two examined disordered eating, and the other two examined the treatment of
depression in elderly adults. The overall meta-analysis
resulted in a moderate mean effect size of 0.58.
Similarly, Tarrier et al. (2008) conducted a systematic review and meta-analysis of 28 studies that used
a form of cognitive-behavioral therapy to reduce suicidal behavior in adolescent and adult populations.
The results indicated that cognitive therapy had an
overall positive effect on the outcome variables related
to suicidality (combined Hedges g = 0.59), while

Child Adolesc Ment Health 2016; 21(2): 819


studies that utilized primarily DBT interventions
(n = 7) or primarily CBT interventions (n = 18) revealed
a signicant effect size (Hedges g = 0.70; 95%
CI= 1.14 to 0.25), indicating DBTs efcacy in ameliorating suicidality outcomes.
In addition, Kliem et al. (2010) conducted a metaanalysis of 16 studies examining pre- and post-treatment outcomes of self-harm and suicidality following a
course of DBT. There was a moderate effect size for general pre- and post-treatment outcomes. Furthermore,
among the 11 studies reporting pre- and post-treatment
outcomes of self-injurious and suicidality (six of which
were RCTs) the effect size was 0.37 (Kliem et al., 2010).

Effectiveness of DBT for adolescents


Dialectical behavior therapy has been adapted and modied for self-injuring and suicidal adolescents (Miller, Rathus, & Linehan, 2006; Rathus & Miller, 2014). Miller,
Rathus, Linehan, Wetzler, and Leigh (1997) rst
described a modied DBT intervention for suicidal adolescents, which incorporated family members, reduced
the length of treatment from 1 year to 12 weeks, and
simplied the skills to make them more developmentally
appropriate, compared to the adult protocol. This was
followed by Rathus and Millers (2002) quasi-experimental pilot study which examined a modied 12-week DBT
program for suicidal adolescents with BPD features. The
ndings indicated higher treatment retention and lower
percentage of psychiatric hospitalizations compared to
the treatment as usual (TAU) group. In addition, the intervention group displayed a reduction in suicidal ideations
pre- and post-treatment, providing preliminary support for
DBT in the treatment of high-risk suicidal adolescents. Following this early work, Miller et al. (2006) published a DBT
treatment for suicidal adolescents, describing a 16-week,
developmentally appropriate DBT treatment for suicidal
adolescents that included weekly individual therapy and
family skills group, with an additional skills module, walking the middle path, addressing common dialectical dilemmas that occur between adolescents and parents. Since
then, Rathus and Miller (2014) have published a second
edition of the treatment manual.
There continues to be growing evidence for the efcacy
of modied applications of DBT for adolescents across
treatment settings, including inpatient (e.g. Katz, Cox,
Gunasekara, & Miller, 2004), forensic (e.g. Shelton, Kesten, Zhang, & Trestman, 2011; Trupin, Stewart, Beach,
& Boesky, 2002), and outpatient community settings
(e.g. Woodberry & Popenoe, 2008). Moreover, there are
multiple reviews summarizing the research on DBT to
date. Groves, Backer, van den Bosch, and Miller (2012)
conducted a narrative review on 12 DBT outcome studies among adolescents from 19972008. They concluded
treatment acceptability and retention among adolescents, as well as reduction in behavioral problems associated with BPD, comorbid depression, impulsivity,
disordered eating pathology and bipolar disorder. In
addition, MacPherson, Cheavens, and Fristad (2013)
provided a summary of 18 studies that examined empirical outcomes of DBT interventions for adolescents and
concluded overall positive treatment effects for DBT to
address suicidality, depression, and oppositional behavior, among other mental health outcomes. Of note, no
meta-analyses have been conducted on this emerging
literature base.
2015 Association for Child and Adolescent Mental Health.

doi:10.1111/camh.12112
As with the adult literature, research studies investigating DBT interventions for adolescents have focused
on its potential to reduce nonsuicidal self-injury (NSSI).
While there is tremendous variability within the literature in the usage of standard denitions, NSSI has been
dened as direct, deliberate destruction of ones own
body tissue in the absence of intent to die (Nock, Joiner,
Gordon, Lloyd-Richardson, & Prinstein, 2006; p. 65).
NSSI occurs in alarmingly high rates (Nock, 2010). In a
systematic review of 52 empirical studies on the international prevalence of NSSI and deliberate self-harm, a
mean NSSI lifetime prevalence rate of 18.0% and 16% for
deliberate self-harm was found (Muehlenkamp, Claes,
Havertape, & Plener, 2012). It is likely that the incidence
rates of self-harm are variable, given the lack of standardized conceptualization and assessment measures
(Nock, 2010).
More recently, Ougrin, Tranah, Stahl, Moran, and
Asarnow (2015) conducted a review and meta-analysis
of a variety of therapeutic interventions in reducing both
suicidal and nonsuicidal self-harm in adolescents. In
doing so, they reviewed 19 RCTs with self-harm as the
primary outcome. There was a reduction in self-harm for
adolescents in the combined intervention groups compared to the control group, when self-harm was considered globally. Yet, when self-harm, dened only as NSSI
and suicidal attempts was analyzed, results were not
signicant. The authors did not recommend a specic
intervention for the treatment of self-harm, due to the
limited evidence; however, the authors emphasized the
importance of standard denitions and assessments of
self-harm and replication of therapeutic interventions,
specically DBT, CBT, and Mentalization-Based Therapy (MBT) as they had the largest effect sizes.
To date, there are two published RCTs targeting adolescents with BPD, one in DBT and one in MBT. Mehlum
et al. (2014) examined the efcacy of DBT in adolescents
meeting at least three of nine BPD criteria (Mehlum
et al., 2014). This was a single-blind randomized trial of
77 adolescents with recent and repetitive self-harm. The
study compared a 16-week outpatient DBT treatment
intervention to an enhanced usual care (EUC), which
consisted of psychodynamic or cognitive-behavioral
individual therapy. The results indicated that the DBT
intervention was superior to EUC in reducing frequency
of depressive symptoms, suicidal ideations, and NSSI.
Rossouw and Fonagy (2012) examined the efcacy of a
1-year mentalization-based treatment program adapted
for adolescents (MBT-A) who had self-harmed, compared
to TAU, among 80 adolescents. MBT-A utilized once a
week individual therapy and monthly family sessions.
The treatment is psychodynamic in nature and works
toward increasing the adolescent and familys ability to
understand behaviors in terms of thoughts and feelings
(see Rossouw & Fonagy, 2012 for more information on
MBT-A). The results indicated a signicant reduction in
self-harm and depressive symptoms compared to TAU.
In addition to DBT and MBT, there is a preliminary
evidence of a CBT intervention specically targeted for
adolescent self-harm that may be benecial (Taylor
et al., 2011). A pilot study examining the acceptability
and feasibility of a time-limited CBT intervention
reported reduced self-harm post-treatment and at
3 month follow-up. Moreover, participants reported a
reduction in trait anxiety, and comorbid depression.
2015 Association for Child and Adolescent Mental Health.

Dialectical behavior therapy

83

Current study
This study seeks to provide the rst meta-analysis of
the developing literature base on DBT for adolescents.
The primary goal was to quantify the effectiveness of
DBT treatment for depression and NSSI with the hope
that the ndings might clarify DBTs utility in reducing NSSI behaviors and depressive symptomatology in
adolescents.

Method
Literature search
We located published studies through computer-based
searches of the reference databases PsycINFO, PsychArticles,
Academic Search Complete, Pubmed, and Medline. Key search
criteria combined the following terms: DBT, adolescents, and
teens. In addition, bibliographies of relevant research and
review articles were manually searched. Finally, articles citing
identied studies were examined for relevance. The sampling
time frame included all studies published prior to August 2014.
Inclusion criteria were: (a) the study reported an evaluation
of a DBT-based intervention, (b) with an adolescent sample (age
1218 years old), (c) included both pre- and post-treatment
measures of NSSI and/or depression, (d) and had a sample size
of at least 10 adolescents. Case studies and studies targeting
outcomes other than NSSI and depression were excluded.

Data extraction
The authors independently reviewed each potentially relevant
article to determine if it met inclusion criteria. Next, both
authors independently extracted study data including sample
recruitment, intervention setting, length of treatment, participant demographics, DBT intervention characteristics, and
effect sizes for pre- to post-treatment change in the outcome
measures of interest. Given the limited number of study characteristics extracted, agreement between raters was high and in
the few cases of discrepancy the authors reached consensus.
Study quality was assessed using the Newcastle-Ottawa
Quality Assessment Scale (NOS; Wells et al., n.d), which was
specically designed to measure quality among nonrandomized
studies. The NOS includes nine items assessing the study features including Sample Selection, Comparability between
Research Groups, and Outcome. Sample Selection items are: (a)
adequacy of case denition, (b) representativeness of cases, (c)
selection of controls, and (d) denition of controls. The Comparability item assess whether the study controls for any important factors to assure comparability of the study groups.
Finally, Outcome items are: (a) how outcomes were assessed
(e.g. by independent evaluator, self-report, etc.), (b) adequacy of
follow-up length, and (c) adequacy of follow-up cohort. For each
of the nine items, stars are earned for stronger, higher quality
design features based on criteria presented in the coding manual.1 An examination of quality assessment measures identied
the NOS as suitable for systematic reviews (Deeks et al., 2003).

Statistical analysis
Due to the predominance of within-group, repeated measures
designs, Hedges g was calculated for each individual study to
quantify gain or change from pretreatment to post-treatment
using formulas provided in Card (2012). However, g has been
shown to overestimate the population effect size, particularly in
small samples (Hedges & Olkin, 1985). Thus, a small sample size
adjustment was used in samples with less than 20 adolescents
(Card, 2012). Effect sizes were further adjusted by weighting
each data point by sample size and a 95% condence interval
was computed around each weighted effect size estimate. An
overall weighted mean effect size was calculated and tested for
statistical signicance. Finally, heterogeneity among the individual study effect sizes was examined. Given the small number of
studies included, no moderator analyses were conducted (e.g. to
examine differences between short and longer term follow-ups).

84

Nathan E. Cook & Maggie Gorraiz

Child Adolesc Ment Health 2016; 21(2): 819

Quality assessment

Results
Search results

Eligibility

Identification and Screening

Search results are summarized in Figure 1. A total of


315 abstracts were screened for eligibility. From this
screening, 28 articles were identied as potentially relevant and the full-text studies were collected for evaluation. Of those, 12 met inclusion criteria. Reasons for
exclusion included: lack of data necessary to calculate
effect sizes (n = 6), sample size less than 10 (n = 3),
non-DBT intervention (n = 1), adult sample (n = 2), no
depression or NSSI outcome (n = 4). Our nal sample
included 12 studies; all 12 studies included a depression outcome and 6 included an NSSI outcome.
Information about the studies included in this
meta-analysis (k = 12) is summarized in Table 1. Of
note, none of the studies were RCTs. The one available
RCT on adolescent DBT (Mehlum et al., 2014) was published after the close of our sampling frame. Thus, it
was not included in this study. Further, the Mehlum
et al. study is the only available RCT and all studies
included in our meta-analysis are nonrandomized trials. Thus, we decided to meta-analyze the extant nonrandomized studies and compare those results to the
ndings of the Mehlum et al. study rather than include
the RCT results in our meta-analysis. It is hoped that
as the research base continues to expand and investigators address the limitations in available studies,
there will be additional RCTs conducted which can
eventually be meta-analyzed.

As none of the studies were RCTs we used the NOS to


assess study quality given that it is specically designed
to measure quality among nonrandomized studies.
Results of the NOS are summarized in Table 2. Overall,
the studies included in this meta-analysis suffered from
signicant design limitations. Most commonly, studies
included only an active DBT treatment group with no
control group. Only ve studies included control groups.
Two of the control groups received psychodynamic psychotherapy (Katz et al., 2004; Rathus & Miller, 2002),
one study included a Mode Deactivation Therapy comparison group (Apsche, Bass, & Houston, 2006), one
study compared DBT with standard therapeutic milieu
(Wasser, Tyler, McIhaney, Taplin, & Henderson, 2008),
and one study compared DBT to a group of students
enrolled in a similar educational program who did not
receive DBT (Ricard, Lermna, & Heard, 2013). Also,
although many studies described impressive efforts to
train and prepare therapists to deliver DBT, few studies
described any efforts to assess therapist adherence to or
delivery of the DBT intervention. Regarding outcome
assessment, most studies relied on self-report measures
of both depression and/or NSSI outcomes, with one corroborating self-report with hospital records and three
others using independent evaluators. A strength of
many studies was the length of follow-up. Given that
DBT for adolescents is typically designed to be shorter
term around 1216 weeks compared to DBT for
adults around 1 year most studies employed ade-

Records identified through


database searches and
screened
(N = 315)

Full-text articles assessed for


eligibility
(N = 28)

Records excluded
(N = 287)

Full text articles


excluded due to lack of
data needed to compute
effect size, sample size
less than 10, non-DBT
intervention, adult
sample, and no NSSI or
depression outcome
(N = 16)

Included

Studies included in
meta-analysis
(N = 12)

Studies reporting
depression outcome
(N = 12)

Studies reporting NSSI


outcome
(N = 6)

Figure 1. Results of a systematic literature search conducted to identify studies of dialectical behavior therapy (DBT) interventions with
adolescents that reported either depression or nonsuicidal self-injury outcomes (NSSI)
2015 Association for Child and Adolescent Mental Health.

doi:10.1111/camh.12112

Dialectical behavior therapy

85

Table 1. Study descriptive information (listed chronologically)

Study

2002

29a

93a

16.1a

12 weeks

Outpatient

Rathus and
Miller
Katz et al.

2004

62

84

15.4

2 weeks

Inpatient

Apsche et al.

2006

10

15.9

12 months

Nelson-Gray
et al.
Goldstein
et al.

2006

31

15

12.6

16 weeks

Residential
Treatment
Outpatient

2007

10

80

15.8

12 months

Outpatient

16.4

12 months

Outpatient

% Female

Avg. age

Prepost
interval

Year

Authors

Setting

James et al.

2008

16

100

Woodberry and
Popenoe

2008

46

89

16

15 weeks

Outpatient

Wasser et al.

2008

12

25

14.7

Residential

Fleischhaker
et al.

2011

12

100

NR

Average of
14 months
6 months

10

James et al.

2011

18

83

15.5

12 weeks

Outpatient

11

Perepletchikova
et al.

2011

11

55

9.8

6 weeks

Outpatient

12

Ricard et al.

2013

125

44

4 weeks

Alternative
Education
Program

NR

Outpatient

DBT characteristics
Twice weekly individual and
multifamily skills groups
10 daily, manualized skills sessions,
twice weekly individual therapy,
diary cards, DBT milieu
Weekly individual therapy and at
least one skills group per week
16 weekly 2-hr group treatment
sessions
Weekly sessions alternating between
family skills training and individual
therapy, skills coaching by
telephone, diary cards
Once weekly skills group, 1 hr per
week individual therapy,
telephone support
Weekly individual therapy, skills
training group, and therapist
consultation team meetings,
pharmacotherapy as indicated
and telephone support
Weekly skills training group sessions
for 17-weeks
Manualized 16-week protocol, once
weekly individual therapy, family
therapy as needed, multifamily
skills group
Once weekly 2-hr long skills group,
once weekly hour-long
individual therapy, telephone
support
Twice weekly session, for 6 weeks
using detailed protocol with
session plans
Twice weekly same-gender
group sessions, for 4 weeks

NR, not reported; DBT, dialectical behavior therapy.


a
Information for DBT group only.

Table 2. Results from the Newcastle-Ottawa Quality Assessment


Scale
Study
Rathus and Miller (2002)
Katz et al. (2004)
Apsche et al. (2006)
Nelson-Gray et al. (2006)
Goldstein, Axelson,
Birmaher, and Brent
(2007)
James, Taylor, Winmill,
and Alfoadari (2008)
Woodberry and
Popenoe (2008)
Wasser et al. (2008)
Fleischhaker et al. (2011)
James, Winmill,
Anderson, and
Alfoadari (2011)
Perepletchikova
et al. (2011)
Ricard et al. (2013)

Selection

Comparability

Outcome

2015 Association for Child and Adolescent Mental Health.

quate follow-up periods to allow for treatment effect.


Further, several studies had follow-ups of 1 year, allowing for examination of longer term, and sustained treatment effects.

DBTs effect on adolescent NSSI


The overall mean weighted effect size for the six studies
reporting an NSSI outcome was g = 0.81 (95% CI = 0.59
1.03) using a xed effects model (see Table 3 and Figure 2).
These results suggest an overall large, positive effect such
that following a course of DBT adolescents engage in less
NSSI. The xed effects variance component was not statistically signicant, Q (5) = 3.51, p > .05, suggesting that the
effect sizes are homogeneous.

DBTs effect on adolescent depression


The overall mean weighted effect size for the 12 studies
reporting a depression outcome was g = 0.36 (95%
CI = 0.300.42) using a xed effects model (see Table 4 and
Figure 3). These results suggest an overall small positive
effect such that following a course of DBT adolescents experience less depression. The xed effects variance component

86

Nathan E. Cook & Maggie Gorraiz

Child Adolesc Ment Health 2016; 21(2): 819

Table 3. Effect sizes for nonsuicidal self-injury (NSSI)


Study

Sample size

SE

26
10
16
16
12
18

0.84
0.69
1.04
0.43
0.78
1.06

0.18
0.45
0.32
0.26
0.38
0.28

2
5
6
7
9
10
Total n

Lower 95% CI
0.49
0.12
0.48
0.06
0.10
0.55

Upper 95%CI

NSSI measure

1.19
1.64
1.72
0.96
1.60
1.67

Lifetime Parasuicide Count (LPC)a


K-SADS-DRSb
Deliberate self-harm incidents per week
CBCL deliberate self-harm itemc
LPC
Self-harm episodes per week

Mean ES

SE

Lower 95% CI

Upper 95%CI

0.81

0.11

0.59

1.03

7.20

<.001

98

Positive effect sizes reflect a positive treatment effect, i.e. a decrease in NSSI from pre- to post-treatment assessments.
a
LPC interview to assess lifetime history of self-injurious behaviors grouped by method, intent to die, and level of medical treatment.
b
K-SADS-DRS is a subscale from the K-SADS-PL, a semistructured diagnostic interview to assess current and past episodes of psychopathology in children and adolescents.
c
Parent reported yes/no item assessing any deliberate acts of self-harm in the past 6 months.
Mean ES, mean effect size.

Katz et al. (2004)

Goldstein et al. (2007)

James et al. (2008)

Woodberry & Popenoe (2008)

Fleischhaker et al. (2011)

James et al. (2011)

Overall

0.5

0.5

1
1.5
Effect size (g)

2.5

Figure 2. Forest plot of individual study and overall effect sizes


(Hedges g) for nonsuicidal self-injury. Error bars represent the
95% confidence interval. Thick vertical line represents the mean
weighted effect size

was statistically signicant, Q (11) = 34.04, p < .001, suggesting that the effect sizes are heterogeneous and not all estimates of a single population value. To characterize the
magnitude of heterogeneity we computed the I2 index, which
is interpreted as the ratio of between-study variability relative
to the total variability, expressed as a percentage ranging
from 0% to 100% (Card, 2012). Among these 12 studies the
I2 index was 67.7%. Using available interpretive guidelines
(Huedo-Medina, S
anchez-Meca, Marn-Martnez, & Botella,
2006), this represents a medium amount of heterogeneity.

Discussion
The overall large positive effect size for NSSI and small
positive effect size for depression suggest improvement
in treatment outcomes among adolescents engaged in a
modied DBT intervention. Specically, adolescents
exhibited less NSSI following a course of DBT, compared
to pretreatment assessment. Also, adolescents exhibited

decreased depressive symptoms following a course of


DBT. These ndings are similar to those found in adult

populations (e.g. Ost,


2008; Tarrier et al., 2008). This
suggests that DBT-based interventions modied for adolescents may be as efcacious as those for adult populations. Although these results are encouraging, it is
important to note that the extant literature base
includes notable methodological limitations and, therefore, our results are considered preliminary and highly
tentative pending the availability of more RCTs and outcome studies with stronger designs.
It is important to note that the studies examined in
this meta-analysis used a range of modied DBT interventions, across a range of treatment lengths and settings. Given that the DBT treatments were not
standardized across studies, it is uncertain what role
moderators (e.g. patient gender or treatment setting) and
mediators (e.g. perceived family support) may contribute
in producing changes in pre- and post-treatment outcomes for NSSI and depression. Providing additional
support for DBT for treating adolescents, the only available RCT found similar, positive improvement in both
NSSI (g = 0.66) and depression (self-report: g = 0.79;
interviewer rating: g = 0.87). It is notable that the effect
sizes reported in the RCT are larger for the depression
outcome than the mean weighted effect sizes from metaanalyzing the available nonrandomized studies but
slightly smaller for the NSSI outcome. Still, these results
are encouraging and provide preliminary, albeit highly
tentative support for the use of DBT to treat adolescents
with symptoms of depression and/or NSSI.

Limitations
The literature base available for meta-analysis presented
several notable methodological limitations. The majority
of the studies used in this meta-analysis were based on
small samples, which limits the precision in estimating
the individual study effect sizes. Indeed, our ndings
suggested a considerably larger effect size for the NSSI
(g = 0.81) outcome compared to depression (g = 0.36).
This difference could be due to the much smaller sample
size for the NSSI outcome. However, the condence
intervals for the overall mean weighted effect sizes for
each of the two outcomes demonstrated that there was
enough power across studies to offer a preliminary, ten 2015 Association for Child and Adolescent Mental Health.

doi:10.1111/camh.12112

Dialectical behavior therapy

87

Table 4. Effect sizes for depression


Study

Sample Size

SE

1
2
3
4
5
6
7
8
9
10
11
12

10
26
10
31
10
16
25
12
11
18
11
125

1.09
0.92
1.26
0.47
0.07
0.76
0.77
0.65
1.37
0.81
0.95
0.30

0.52
0.19
0.56
0.14
0.40
0.29
0.18
0.37
0.53
0.26
0.45
0.03

Total n

Mean ES

SE

Lower 95% CI

Upper 95% CI

0.36

0.03

0.30

0.42

12.02

<.001

305

Lower 95% CI

Upper 95%CI

0.07
0.55
0.16
0.20
0.71
0.20
0.41
0.07
0.32
0.30
0.08
0.24

Depression measure

2.11
1.29
2.36
0.74
0.85
1.32
1.13
1.37
2.42
1.32
1.82
0.36

SCL-90
BDI-13
BDI-II
CDI
K-SADS-DRS
BDI
RADS
BPRS-C
SCL-90 R
BDI
MFQ
YOQ-30.2

Positive effect sizes reflect a positive treatment effect, i.e. a decrease in depressive symptoms from pre- to post-treatment assessments.

Rathus & Miller (2002)


Katz et al. (2004)
Apsche et al. (2006)
Nelson-Gray et al. (2006)
Goldstein et al. (2007)
James et al. (2008)
Woodberry & Popenoe (2008)
Wasser et al. (2008)
Fleischhaker et al. (2011)
James et al. (2011)
Perepletchikova et al. (2011)
Ricard et al. (2013)
Overall

0.5

0.5
1
Effect size (g)

1.5

2.5

Figure 3. Forest plot of individual study and overall effect sizes (Hedges g) for depression. Error bars represent the 95% confidence interval. Thick vertical line represents the mean weighted effect size

tative estimate of the population effect size for DBT with


regard to both NSSI and depression. Still, the condence
intervals for each individual study were fairly wide. It will
be important for future research to report correlations
between time points to allow for more precision in effect
size calculations.
Secondly, the meta-analysis used only pre- and posttreatment comparisons for DBT interventions, using
within-group repeated measures designs. This was due
to the predominance of such designs in the extant literature. Thus, it is unclear, whether any TAU would have
produced comparable changes in pre- and post-treatment measures of NSSI and depression. Given that there
were few control groups and the studies were not RCTs,
the efcacy of DBT interventions compared to other
interventions remains uncertain.
2015 Association for Child and Adolescent Mental Health.

Moreover, the studies available for meta-analysis have


considerably varied follow-up periods. Follow-up periods
for studies included in this meta-analysis ranged from
2 weeks to roughly 1 year. Ideally these differing followup periods would be accounted for through moderator
analyses, however, given the limited number of available
studies, we did not have the power to conduct such
analyses.

Future directions
This is the rst meta-analysis to examine the efcacy of
DBT interventions among adolescent populations for
depression and NSSI. These preliminary ndings suggest that further development and evaluation of DBT
interventions to treat adolescent depression and NSSI is
warranted. The ability to quantify treatment effective-

88

Nathan E. Cook & Maggie Gorraiz

ness with regard to serious outcomes such as NSSI will


hopefully encourage the renement and implementation
of DBT-based interventions for youth. In addition, it is
hoped that by providing preliminary meta-analytic support for DBT to address adolescent NSSI and depression,
additional research efforts will be undertaken to advance
clinically relevant knowledge regarding the treatment of
such signicant mental health problems in youth.
In addition, this meta-analysis provides an initial estimate of the expected effect sizes for intervention
research. Thus, investigators are provided with a more
accurate means of estimating necessary sample size for
future studies. As the research base expands, further
meta-analytic investigation will be crucial to examine
potential moderators of effect size, particularly those
that might foster more precise assignment of youth to
interventions most likely to decrease potentially lifethreatening mental health problems.

Acknowledgements
This study did not receive any external funding. The authors
thank Joseph Rossi for providing guidance and offering his
methodological expertise in support of this project. The authors
have declared that they do not have any potential or competing
conicts of interest.

Notes
1

Interested readers are encouraged to access the NewcastleOttawa Quality Assessment Scale manual for more details
regarding scoring criteria (http://www.ohri.ca/programs/clini
cal_epidemiology/nos_manual.pdf).

References
Articles denoted with an asterisk below were included in
the meta-analysis.
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th edn). Washington, DC:
Author.
*Apsche, J.A., Bass, C.K., & Houston, M.A. (2006). A one year
study of adolescent males with aggression and problems of
conduct and personality: A comparison of MDT and DBT.
International Journal of Behavioral Consultation and Therapy,
2, 544552.
van den Bosch, L., Koeter, M.W., Stijnen, T., Verheul, R., & van
den Brink, W. (2005). Sustained efcacy of dialectical behaviour therapy for borderline personality disorder. Behaviour
Research and Therapy, 43, 12311241.
Card, N.A. (2012). Applied meta-analysis for social science
research. New York: The Guilford Press.
Deeks, J.J., Dinnes, J., DAmico, R., Sowden, A.J., Sakarovitch,
C., Song, F., . . . & Altman, D.G. (2003). Evaluating nonrandomised intervention studies. Health Technology Assessment, 7, 1173.
Dimeff, L., & Linehan, M.M. (2001). Dialectical behavior therapy
in a nutshell. The California Psychologist, 34, 1013.
*Fleischhaker, C., B
ohme, R., Sixt, B., Br
uck, C., Schneider, C.,
& Schulz, E. (2011). Dialectical behavioral therapy for adolescents (DBT-A): A clinical Trial for patients with suicidal and
self-injurious behavior and borderline symptoms with a oneyear follow-up. Child and Adolescent Psychiatry and Mental
Health, 5, 110.
*Goldstein, T.R., Axelson, D.A., Birmaher, B., & Brent, D.A.
(2007). Dialectical behavior therapy for adolescents with
bipolar disorder: A 1-year open trial. Journal of the American Academy of Child and Adolescent Psychiatry, 46,
820830.

Child Adolesc Ment Health 2016; 21(2): 819


Groves, S., Backer, H.S., van den Bosch, W., & Miller, A. (2012).
Dialectical behaviour therapy with adolescents. Child and
Adolescent Mental Health, 17, 6575.
Hedges, L.V., & Olkin, I. (1985). Statistical methods for metaanalysis. San Diego, CA: Academic Press.
Huedo-Medina, T.B., S
anchez-Meca, J., Marn-Martnez, F., &
Botella, J. (2006). Assessing heterogeneity in meta-analysis:
Q statistic of I2 index? Psychological Methods, 11, 193206.
*James, A.C., Taylor, A., Winmill, L., & Alfoadari, K. (2008).
A preliminary community study of dialectical behaviour therapy (DBT) with adolescent females demonstrating persistent,
deliberate self-harm (DSH). Child and Adolescent Mental
Health, 13, 148152.
*James, A.C., Winmill, L., Anderson, C., & Alfoadari, K. (2011).
A preliminary study of an extension of a community dialectic
behaviour therapy (DBT) programme to adolescents in the
looked after care system. Child and Adolescent Mental Health,
16, 913.
*Katz, L.Y., Cox, B.J., Gunasekara, S., & Miller, A. (2004). Feasibility of dialectical behavior therapy for suicidal adolescent
inpatients. Journal of the American Academy of Child and
Adolescent Psychiatry, 43, 276282.
Kliem, S., Kr
oger, C., & Kosfelder, J. (2010). Dialectical behavior
therapy for borderline personality disorder: A meta-analysis
using mixed-effects modeling. Journal of Consulting and Clinical Psychology, 78, 936951.
Koons, C.R., Robins, C.J., Lindsey Tweed, J., Lynch, T.R., Gonzalez, A.M., Morse, J.Q., . . . & Bastian, L. A. (2001). Efcacy of
dialectical behavior therapy in women veterans with borderline personality disorder. Behavior Therapy, 32, 371390.
Linehan, M. (1993a). Cognitive-behavioral treatment of borderline personality disorder. New York: The Guilford Press.
Linehan, M. (1993b) Skills training manual for treating borderline personality disorder. New York: The Guilford Press.
Linehan, M. M. (2014). DBT skills training manual (2nd edn).
New York: Guilford Publications.
Linehan, M.M., Armstrong, H.E., Suarez, A., Allmon, D., &
Heard, H.L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General
Psychiatry, 48, 10601064.
Linehan, M.M., Comtois, K.A., Murray, A.M., Brown, M.Z., Gallop, R.J., Heard, H.L., . . . & Lindenboim, N. (2006). Two-year
randomized controlled trial and follow-up of dialectical
behavior therapy vs therapy by experts for suicidal behaviors
and borderline personality disorder. Archives of General Psychiatry, 63, 757766.
Linehan, M.M., Dimeff, L.A., Reynolds, S.K., Comtois, K.A.,
Welch, S.S., Heagerty, P., & Kivlahan, D.R. (2002). Dialectical
behavior therapy versus comprehensive validation therapy
plus 12-step for the treatment of opioid dependent women
meeting criteria for borderline personality disorder. Drug and
Alcohol Dependence, 67, 1326.
Linehan, M.M., Heard, H.L., & Armstrong, H.E. (1993). Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients. Archives of General Psychiatry,
50, 971974.
Linehan, M.M., Schmidt, H., Dimeff, L.A., Kanter, J.W., Craft,
J.C., Comtois, K.A., & Recknor, K.L. (1999). Dialectical
behavior therapy for patients with borderline personality disorder and drug-dependence. American Journal on Addiction,
8, 279292.
Lynch, T.R., Morse, J.Q., Mendelson, T., & Robins, C.J. (2003).
Dialectical behavior therapy for depressed older adults: A
randomized pilot study. The American Journal of Geriatric
Psychiatry, 11, 3345.
Lynch, T.R., Trost, W.T., Salsman, N., & Linehan, M.M. (2007).
Dialectical behavior therapy for borderline personality disorder. Annual Review of Clinical Psychology, 3, 181185.
MacPherson, H.A., Cheavens, J.S., & Fristad, M.A. (2013). Dialectical behavior therapy for adolescents: Theory, treatment
adaptations, and empirical outcomes. Clinical Child and Family Psychology Review, 16, 5980.
Mehlum, L., Trmoen, A.J., Ramberg, M., Haga, E., Diep, L.M.,
Laberg, S., . . . & Grholt, B. (2014). Dialectical behavior therapy for adolescents with repeated suicidal and self-harming

2015 Association for Child and Adolescent Mental Health.

doi:10.1111/camh.12112
behavior: A randomized trial. Journal of the American Academy of Child & Adolescent Psychiatry, 53, 10821091.
Miller, A. L., Rathus, J. H., & Linehan, M. (2006). Dialectical
behavior therapy with suicidal adolescents. New York, NY:
Guilford Publication.
Miller, A.L., Rathus, J.H., Linehan, M.M., Wetzler, S., & Leigh,
E. (1997). Dialectical behavior therapy adapted for suicidal
adolescents. Journal of Practical Psychiatry and Behavioral
Health, 3, 7886.
Muehlenkamp, J.J., Claes, L., Havertape, L., & Plener, P.L.
(2012). International prevalence of adolescent non-suicidal
self-injury and deliberate self-harm. Child and Adolescent
Psychiatry and Mental Health, 6, 19.
*Nelson-Gray, R.O., Keane, S.P., Hurst, R.M., Mitchell, J.T.,
Warburton, J.B., Chok, J.T., & Cobb, A.R. (2006). A modied
DBT skills training program for oppositional deant adolescents: Promising preliminary ndings. Behavior Research
and Therapy, 44, 18111820.
Nock, M.K. (2010). Self-injury. Annual Review of Clinical Psychology, 6, 339363.
Nock, M.K., Joiner, T.E., Gordon, K.H., Lloyd-Richardson, E., &
Prinstein, M.J. (2006). Non-suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide
attempts. Psychiatry Research, 144, 6572.

Ost,
L.G. (2008). Efcacy of the third wave of behavioral therapies: A systematic review and meta-analysis. Behaviour
Research and Therapy, 46, 296321.
Ougrin, D., Tranah, T., Stahl, D., Moran, P., & Asarnow, J.R.
(2015). Therapeutic interventions for suicide attempts and
self-harm in adolescents: Systematic review and meta-analysis. Journal of the American Academy of Child & Adolescent
Psychiatry, 54, 97107.
Palmer, R.L., Birchall, H., Damani, S., Gatward, N., McGrain,
L., & Parker, L. (2003). A dialectical behavior therapy program for people with an eating disorder and borderline personality disorder description and outcome. International
Journal of Eating Disorders, 33, 281286.
*Perepletchikova, F., Axelrod, S.R., Kaufman, J., Rounsaville,
B.J., Douglas-Palumberi, H., & Miller, A.L. (2011). Adapting
dialectical behavior therapy for children: Towards a new
research agenda for paediatric suicidal and non-suicidal selfinjurious behaviours. Child and Adolescent Mental Health,
16, 116121.
*Rathus, J.H., & Miller, A.L. (2002). Dialectical behavior therapy adapted for suicidal adolescents. Suicide and Life-Threatening Behavior, 32, 146157.
Rathus, J. H., & Miller, A. L. (2014). DBT Skills Manual for
Adolescents. New York: Guilford Publications.
*Ricard, R.J., Lermna, E., & Heard, C.C.C. (2013). Piloting a dialectical behavioral therapy (DBT) infused skills group in a disciplinary alternative education program (DAEP). The Journal
for Specialists in Group Work, 38, 285306.
Robins, C.J., & Chapman, A.L. (2004). Dialectical behavior
therapy: Current status, recent developments, and
future directions. Journal of Personality Disorders, 18, 73
89.

2015 Association for Child and Adolescent Mental Health.

Dialectical behavior therapy

89

Rossouw, T. I., & Fonagy, P. (2012). Mentalization-based treatment for self-harm in adolescents: A randomized controlled
trial. Journal of the American Academy of Child & Adolescent
Psychiatry, 51, 13041313.
Safer, D.L., Robinson, A.H., & Jo, B. (2010). Outcome from a
randomized controlled trial of group therapy for binge eating
disorder: Comparing dialectical behavior therapy adapted for
binge eating to an active comparison group therapy. Behavior
Therapy, 41, 106120.
Safer, D.L., Telch, C.F., & Agras, W.S. (2001). Dialectical behavior therapy for bulimia nervosa. American Journal of Psychiatry, 158, 632634.
Shelton, D., Kesten, K., Zhang, W., & Trestman, R. (2011).
Impact of a dialectic behavior therapycorrections modied
(DBT-CM) upon behaviorally challenged incarcerated male
adolescents. Journal of Child and Adolescent Psychiatric
Nursing, 24, 105113.
Tarrier, N., Taylor, K., & Gooding, P. (2008). Cognitive-behavioral interventions to reduce suicide behavior a systematic
review and meta-analysis. Behavior Modication, 32, 77108.
Taylor, L.M., Oldershaw, A., Richards, C., Davidson, K.,
Schmidt, U., & Simic, M. (2011). Development and pilot evaluation of a manualized cognitive-behavioural treatment
package for adolescent self-harm. Behavioural and Cognitive
Psychotherapy, 39, 619625.
Telch, C.F., Agras, W.S., & Linehan, M.M. (2001). Dialectical
behavior therapy for binge eating disorder. Journal of Consulting and Clinical Psychology, 69, 1061.
Trupin, E.W., Stewart, D.G., Beach, B., & Boesky, L. (2002).
Effectiveness of a dialectical behaviour therapy program for
incarcerated female juvenile offenders. Child and Adolescent
Mental Health, 7, 121127.
Verheul, R., van den Bosch, L.M., Koeter, M.W., De Ridder,
M.A., Stijnen, T., & Van Den Brink, W. (2003). Dialectical
behaviour therapy for women with borderline personality disorder 12-month, randomised clinical trial in The Netherlands. The British Journal of Psychiatry, 182, 135140.
*Wasser, T., Tyler, R., McIhaney, K., Taplin, R., & Henderson, L.
(2008). Effectiveness of dialectical behavior therapy (DBT)
versus standard therapeutic milieu (STM) in a cohort of adolescents receiving residential treatment. Best Practices in
Mental Health, 4, 114125.
Wells, G. A., Shea, B., OConnell, D., Peterson, J., Welch, V., Losos,
M., & Tugwell, P. (n.d). The Newcastle-Ottawa Scale (NOS) for
assessing the quality of nonrandomised studies in meta-analyses.
Available from: Ottawa Hospital Research Institute website:
http://www.ohri.ca/programs/clinical_epidemiology/ oxford.asp
[last accessed 20 October 2014].
*Woodberry, K.A., & Popenoe, E.J. (2008). Implementing dialectical behavior therapy with adolescents and their families in a
community outpatient clinic. Cognitive and Behavioral Practice, 15, 277286.

Accepted for publication: 6 May 2015


Published online: 8 July 2015