Overview of Dialectical Behavior Therapy

Mindfulness meditating

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Dialectical behavior therapy (DBT) is a type of cognitive behavioral therapy. Its main goals are to teach people how to live in the moment, cope healthily with stress, regulate emotions, and improve relationships with others.

It was originally intended for people with borderline personality disorder (BPD) but has since been adapted for other conditions where the patient exhibits self-destructive behavior, such as eating disorders and substance abuse. It is also sometimes used to treat post-traumatic stress disorder.

History

DBT was developed in the late 1980s by Dr. Marsha Linehan and colleagues when they discovered that cognitive behavioral therapy (CBT) alone did not work as well as expected in patients with BPD. Dr. Linehan and her team added techniques and developed a treatment that would meet the unique needs of these patients.

DBT is derived from a philosophical process called dialectics. Dialectics is based on the concept that everything is composed of opposites and that change occurs when one opposing force is stronger than the other, or in more academic terms—thesis, antithesis, and synthesis. 

More specifically, dialectics makes three basic assumptions:

  • All things are interconnected.
  • Change is constant and inevitable.
  • Opposites can be integrated to form a closer approximation of the truth.

In DBT, the patient and therapist are working to resolve the seeming contradiction between self-acceptance and change in order to bring about positive changes in the patient.

Another technique offered by Linehan and her colleagues was validation. Linehan and her team found that with validation, along with the push for change, patients were more likely to cooperate and less likely to suffer distress at the idea of change. The therapist validates that the person's actions "make sense" within the context of his personal experiences without necessarily agreeing that they are the best approach to solving the problem.

How It Works

DBT has now evolved into a standard type of cognitive behavioral therapy. When a person is undergoing DBT, they can expect to participate in three therapeutic settings: 

  • A classroom where a person is taught behavioral skills by doing homework assignments and role-playing new ways of interacting with people. Typically, the class meets for two to three hours on a weekly basis.
  • Individual therapy with a trained professional where those learned behavioral skills are adapted to a person's personal life challenges. Running concurrently with the classroom work, individual therapy sessions usually last for 60 minutes, once a week.
  • Phone coaching in which a person can call their therapist in between sessions to receive guidance on coping with a difficult at-the-moment situation.

In DBT, individual therapists also meet with a consultation team to help them stay motivated in treating their patients and help them navigate difficult and complex issues.

While each therapeutic setting has its own set structure and goals, the following characteristics of DBT are found in group skills training, individual psychotherapy, and phone coaching:

  • Support: You'll be encouraged to recognize your positive strengths and attributes and develop and use them.
  • Behavioral: You'll learn to analyze any problem or destructive behavior patterns and replace them with healthy and effective ones.
  • Cognitive: You'll focus on changing thoughts and beliefs, and behavior, or actions that are not effective or helpful.  
  • Skill sets: You’ll learn new skills to enhance your capabilities.
  • Acceptance and change: You’ll learn strategies to accept and tolerate your life, emotions, and yourself as well as skills to help you make positive changes in your behaviors and interactions with others.
  • Collaboration: You'll learn to communicate effectively and work together as a team (therapist, group therapist, psychiatrist).

DBT Strategies

People undergoing DBT are taught how to effectively change their behavior using four main strategies:

Core Mindfulness

Mindfulness skills, which is perhaps the most important strategy in DBT, teaches you to focus on the present or “live in the moment.” By doing so, you can learn to pay attention to what's going on inside of you (thoughts, feelings, sensations, impulses) as well as what's outside of you (what you see, hear, smell, and touch). These skills will help you to slow down so you can focus on healthy coping skills in the midst of emotional pain. Mindfulness can help you to stay calm and avoid engaging in automatic negative thought patterns and impulsive behavior.

Sample Exercise: Observe Mindfulness Skill

Pay attention to your breath. Take note of the sensation of inhaling and exhaling, observing your belly rise and fall as you breathe.

Distress Tolerance

Distress tolerance teaches you to accept yourself and the current situation. More specifically, you learn how to tolerate or survive crises using four techniques: distraction, self-soothing, improving the movement, and thinking of pros and cons. By learning distress tolerance techniques, you'll be able to prepare in advance for any intense emotions and cope with them with a more positive long-term outlook.

Sample Exercise: Putting Your Body in Charge

Run up and down the stairs. If you're inside, go outside. If you're sitting, get up and walk around. The idea is to distract yourself by allowing your emotions to follow your body.

Interpersonal Effectiveness

Interpersonal effectiveness helps you to become more assertive in a relationship (for example, expressing needs and saying "no") while still keeping that relationship positive and healthy. This happens by learning to listen and communicate effectively, deal with difficult people, and respect yourself and others.

Sample Exercise: GIVE

Use the acronym GIVE to improve relationships and positive communication:

  • Gentle: Don't attack, threaten, or judge
  • Interest: Show interest with good listening skills (don't interrupt to speak)
  • Validate: Acknowegle the person's thoughts and feelings
  • Easy: Try to have an easy attitude (smile and stay light-hearted)

Emotion Regulation

Emotion regulation provides a set of skills that help to keep your emotional system healthy and functioning. It teaches you to adjust your emotions, including the intensity, when you have it, and how you react to it. By recognizing and coping with negative emotions (for example, anger), you can reduce your emotional vulnerability and have more positive emotional experiences.

Sample Exercise: Opposite Action

Identify how you're feeling and do the opposite. If you're sad and feel like withdrawing from friends and family, do the opposite. Make plans to see family and friends and stay social.

Is DBT Right for You?

While the majority of research to date has focused on the effectiveness of DBT for people with borderline personality disorder, as well as co-occurring thoughts of suicide and self-harm, post-traumatic stress disorder, and substance use disorders, DBT has also been shown to work for a variety of mental health conditions including:

  • ADHD
  • Binge eating disorder
  • Bipolar disorder
  • Bulimia
  • Generalized anxiety disorder
  • Major depressive (including treatment-resistant major depression and chronic depression)
  • Post-traumatic stress disorder
  • Substance use disorder
  • Suicidal and self-harming behavior

Researchers have also found that DBT is effective regardless of age, gender, sexual orientation, and race/ethnicity.

The best way to figure out if DBT is right for you is to talk with a mental health professional, who will evaluate your symptoms, treatment history, and therapy goals to determine the best next step.

A Word From Verywell

If you believe that you or a loved one may benefit from DBT, please seek guidance from a doctor or healthcare professional trained in this treatment approach. DBT therapists aren't always easy to locate.

You can begin your search with the Clinical Resource Directory maintained by Behavioral Tech, an organization founded by Dr. Linehan, to train mental health professionals in DBT. This directory allows you to search by state for clinicians and programs that have gone through DBT training with Behavioral Tech, LLC, or the Behavioral Research and Therapy Clinics at the University of Washington. Another option is to ask your physician, therapist, or psychologist to refer you to someone who specializes in DBT.

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