Does Dialectal Behavioral Therapy (DBT) Actually Change the Way the Brain Works?


Ruocco, Anthony 2011Background
Dialectical Behavior Therapy (DBT) is a treatment that focuses on helping patients to better manage their emotions, and develop skills to cope with problems and negative feelings. A primary aim is to lead the patient to stop or reduce behavior that is harmful. DBT was initially created for people with borderline personality disorder (BPD), and its effectiveness has been proven multiple times with that population.

Research has shown that over 60% of individuals with BPD engage in self-harm. While DBT is effective for reducing self-harm in many patients, some do not improve, or end treatment prematurely. It is therefore important to identify any factors that might predict which patients are most likely to remain in treatment and benefit from DBT.

The Study
Previous studies have established that the area of the brain that helps with emotional and behavioral control — the prefrontal cortex — shows lower activity levels in people with BPD than in the brains of those without BPD.

In a study funded by AFSP, Dr. Ruocco sought to investigate whether there is a change in brain activity after DBT. To do so, he worked with 29 actively self-harming outpatients with BPD at a clinic in Toronto. Participants ranged in age from 18 to 65, had been diagnosed with BPD for at least five years, and had engaged in seven episodes of self-harm in the previous year (e.g., cutting, overdose, burning). Most were White/Caucasian (64%), and nearly all were women (90%); the median age was 29.

For the study, before undergoing DBT therapy, participants completed a standard computerized go/no-go task that measures motor control inhibition—that is, the ability to stop from performing an action. In this case, the task consisted of pressing a button. The theory is that this type of task is analogous, in the brain, to what happens when someone stops or prevents a behavior such as self-harm.

While engaging in the task, participants underwent brain-imaging procedures that probed the activation of the prefrontal cortex (PFC). Specifically, they completed functional near-infrared spectroscopy (fNIRS) neuroimaging procedures, which is an emerging technology that offers a relatively non-invasive, safe, portable, and low-cost method of monitoring brain activity.

The patients then engaged in DBT therapy. Following seven months of treatment, the patients once again completed the computerized go/no-go task while being monitored using fNIRS.

The results showed great promise. Most patients had substantial declines in their self-harm behavior after treatment. Improvement was associated with increased activity in the PFC demonstrating that brain activity had changed. Furthermore, the patients benefiting the most from treatment showed less activation in the PFC prior to beginning treatment, and showed a substantial increase in activation in this region after treatment. Thus, those with the most need for change were the ones who improved the most.


  • DBT was effective in reducing self-harm behavior.
  • This research breaks new ground by showing that impulse control-related brain activity may predict which high-risk patients are most likely to remain engaged and benefit from DBT.
  • Brain activity had indeed changed after DBT.
  • Assessment of potential benefit from specific treatments may now be possible, allowing for more precision in selecting the best treatments for people with self-harm behavior.

Publications from AFSP grant

  • Williams, G., Daros, A. R., Graves, B., McMain, S. F., Links, P. S., & Ruocco, A. C. (2015). Executive functions and social cognition in highly lethal self-injuring patients with borderline personality disorder. Personality Disorders: Theory, Research, and Treatment, 6, 107-116. doi:10.1037/per0000105
  • Ruocco, A. C., Rodrigo, A. H., Page-Gould, E., Ayaz, H., McMain, S. F., & Links, P. S. (2016). Predicting treatment outcomes from prefrontal cortex activation during response inhibition for self-harming patients with borderline personality disorder: A preliminary study. Front. Hum. Neurosci. 10:220. doi: 10.3389/fnhum.2016.0020