Contingencies Create Capabilities: Adjunctive Treatments in Dialectical Behavior Therapy That Reinforce Behavior Change

Dialectical behavior therapy (DBT) has been shown to be effective in the treatment of borderline personality disorder (BPD), a disorder associated with poor functional outcomes and high utilization of behavioral health services. Contingency management strategies are one of the four primary change procedures in DBT. This paper provides an overview of the use of contingency management strategies in DBT with a particular focus on how adjunctive treatments can be utilized as a reinforcer for positive behavior change. We focus specifically on two adjunctive DBT treatments with evidence of efficacy, including the DBT Prolonged Exposure protocol (DBT PE), which targets PTSD, and DBT-Accepting the Challenges of Exiting the System (DBT-ACES), which targets getting off of psychiatric disability by obtaining and maintaining employment. This paper describes how contingency management strategies are used to help clients make the changes necessary to become eligible to receive these adjunctive treatments, as well as the process of clarifying and managing contingencies to maintain and increase adaptive behaviors as these treatments are implemented. Considerations for how DBT therapists and larger health systems can apply contingency management strategies to enhance behavioral capabilities in the treatment of individuals with BPD are discussed.