What Is Dialectical Behavior Therapy (DBT)?

What Is Dialectical Behavioral Therapy?

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

DBT was originally intended to treat borderline personality disorder (BPD), but it has been adapted to treat other mental health conditions. It can help people who have difficulty with emotional regulation or are exhibiting self-destructive behaviors (such as eating disorders and substance use disorders). This type of therapy is also sometimes used to treat post-traumatic stress disorder (PTSD).

Dialectical Behavior Therapy Techniques

DBT has evolved to become an evidence-based psychotherapy approach that is used to treat many conditions. Settings in which DBT are often used include:

• Group therapy where patients are taught behavioral skills in a group setting.
• Individual therapy with a trained professional where a patient's learned behavioral skills are adapted to their personal life challenges.
• Phone coaching in which patients can call the therapist between sessions to receive guidance on coping with a difficult situation they are currently in.

Some of the strategies and techniques that are used in DBT include the following.

Core Mindfulness

One important benefit of DBT is the development of mindfulness skills. Mindfulness helps you focus on the present or "live in the moment." This helps you pay attention to what is happening inside you (your thoughts, feelings, sensations, and impulses) as well as using your senses to tune in to what's happening around you (what you see, hear, smell, and touch) in nonjudgmental ways.

Mindfulness skills help you slow down and focus on using healthy coping skills when you are in the midst of emotional pain. The strategy can also help you stay calm and avoid engaging in automatic negative thought patterns and impulsive behavior.

Distress Tolerance

Distress tolerance skills help you accept yourself and your current situation. DBT teaches several techniques for handling a crisis, including:

• Distraction
• Improving the moment
• Self-soothing
• Thinking of the pros and cons of not tolerating distress

Distress tolerance techniques help prepare you for intense emotions and empower you to cope with them with a more positive long-term outlook.

Interpersonal Effectiveness

Interpersonal effectiveness helps you to become more assertive in a relationship (for example, expressing your needs and be able to say "no") while still keeping a relationship positive and healthy. You will learn to listen and communicate more effectively, deal with challenging people, and respect yourself and others.

Emotion Regulation

Emotion regulation lets you navigate powerful feelings in a more effective way. The skills you learn will help you to identify, name, and change your emotions.

When you are able to recognize and cope with intense negative emotions (for example, anger), it reduces your emotional vulnerability and helps you have more positive emotional experiences.

Stages of DBT

Dialectical behavior therapy is also divided into four stages of treatment. 

• Stage 1: During the beginning of treatment, the most serious and self-destructive behaviors are the first things addressed. This may include issues such as self-injury or suicidal behaviors.
• Stage 2: Next, treatment moves on to address issues that affect a person's quality of life, such as their interpersonal effectiveness, emotional regulation skills, and ability to tolerate distress.
• Stage 3: The next step is to focus on issues related to self-esteem and interpersonal relationships.
• Stage 4: At this point, treatment is focused on helping people get the most out of their lives, including finding ways to experience greater happiness, strengthen their relationships, and pursue their life goals.

What Dialectical Behavioral Therapy Can Help With

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 to meet the unique needs of these individuals.

Though developed with BPD in mind, DBT might also be an effective treatment for:

• Attention-deficit/hyperactivity disorder (ADHD)
• Bipolar disorder
• Borderline personality disorder (BPD)
• Eating disorders (such as anorexia nervosa, binge eating disorder, and bulimia nervosa)
• Generalized anxiety disorder (GAD)
• Major depressive disorder (including treatment-resistant major depression and chronic depression)
• Non-suicidal self-injury
• Obsessive-compulsive disorder (OCD)
• Post-traumatic stress disorder (PTSD)
• Substance use disorder
• Suicidal behavior

Benefits of Dialectical Behavioral Therapy

In DBT, the patient and therapist work to resolve the apparent contradiction between self-acceptance and change to bring about positive changes in the individual in treatment. Part of this process involves offering validation, which helps people become more likely to cooperate and less likely to experience distress at the idea of change.

In practice, the therapist validates that an individual's actions "make sense" within the context of their personal experiences without necessarily agreeing that the actions are the best approach to solving a problem.

Each therapeutic setting has its own structure and goals, but the characteristics of DBT can be found in group skills training, individual psychotherapy, and phone coaching.

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

Effectiveness of Dialectical Behavior Therapy

Because this approach to therapy is able to help people successfully improve their coping skills, they are able to develop effective ways to manage and express strong emotions. Researchers have also found that DBT is effective regardless of a person's age, sex, gender identity, sexual orientation, and race/ethnicity.

• For BPD: Studies have found that DBT is effective in the treatment of borderline personality disorder (BPD) and reducing suicide risk in individuals with BPD. One study found that after a year of treatment, more than 75% of people with BPD no longer met the diagnostic criteria for the condition.
• For suicidal behavior: Another study found that interventions that incorporated skills training as a treatment component appeared to be more effective in reducing suicidality than DBT without skills training.
• For other conditions: Most DBT research has focused on its effectiveness for people with borderline personality disorder who have thoughts of suicide and self-harm, but the method could also be a successful treatment for other mental health conditions. For example, research has found that this type of therapy also appears to be effective in the treatment of PTSD, depression, and anxiety.

Things to Consider About Dialectical Behavior Therapy

DBT requires a significant commitment of time. In addition to regular therapy sessions, people are also required to do "homework" to work on skills outside of the individual, group, and phone counseling sessions. This may pose a challenge for people who have difficulty keeping up with these assignments on a regular basis.

Practicing some of the skills may also be challenging for some people. At different stages of treatment, people explore traumatic experiences and emotional pain, which may be upsetting.

Can You Do Dialectical Behavior Therapy On Your Own?

DBT is complex, and it's generally not something that people can do on their own without the guidance of a trained therapist. 

However, there are some things you can do on your own to help you develop new coping skills. For example, mindfulness, breathing exercises, and progressive muscle relaxation are all skills you can utilize to improve your ability to tolerate distress.

It is important to remember that this should not be used in place of professional help. If you're struggling with a mental health condition, it's always best to seek out the help of a qualified mental health professional.

How to Get Started With Dialectical Behavior Therapy

The best way to find out if DBT is right for you is to talk with a professional who is trained in the method. They will evaluate your symptoms, treatment history, and therapy goals to see if DBT might be a good fit.

If you or a loved one might benefit from DBT, it's important to talk with a healthcare provider or mental health professional who is trained in the approach. That said, it's not always easy to find DBT therapists.

You can start your search with the Clinical Resource Directory, which is maintained by Behavioral Tech (an organization founded by Dr. Linehan to train mental health professionals in DBT). The directory lets you search by state for clinicians and programs with DBT training through Behavioral Tech, LLC, or the Behavioral Research and Therapy Clinics at the University of Washington.

You can also ask your provider, current therapist, or another trusted mental health professional to refer you to a colleague who specializes in DBT. You may also find online therapists who offer DBT therapy.