Dialectical Behavior Therapy (DBT): A Complete Guide

What Is Dialectical Behavior Therapy?

DBT helps patients learn skills in four key areas:

1. Mindfulness

Mindfulness improves your ability to stay in the moment. When you can accept your present situation in this way, you can reduce your struggling, take control of your life, and improve your overall health.

2. Distress Tolerance

Distress tolerance helps you get through an extremely stressful situation without making it worse. These skills help you get “back to baseline” so you can problem solve with a clear mind.

3. Emotion Regulation

Emotion regulation helps you manage intense changes in emotions. Once you learn these skills, you can decrease the distress such shifts can cause. Emotion regulation skills give you tools to use in the moment, as well as tools that can help boost resilience.

4. Interpersonal Effectiveness

Interpersonal effectiveness helps you communicate with others. By learning these skills, you can strengthen your relationships and improve self-respect.

What Makes Dialectical Behavior Therapy Different

Dialectical behavior therapy is a combination of cognitive behavior therapy (CBT), humanism, and dialectics.

CBT helps people identify unhelpful ways of thinking and behaving and then substitutes these ways with new patterns. A humanistic outlook stresses the value of human beings. Dialectics is the idea of two concepts being true at once. An example of a dialectic is acknowledging the importance of both acceptance and change.

Taken together, DBT operates on the assumptions that people are doing the best they can, want to do better, and need compassionate support in learning skills to create the lives they want to live.

Dialectical behavior therapy combines these three things to help patients manage emotions, cope with unexpected obstacles, and overcome stressors.

DBT helps patients cope with their situations and their emotions. For example, people with suicidal ideation can learn to address the emotions, thoughts, and situations that contribute to such thinking.

In this way, DBT provides patients with the skills they need to control their emotions. A professional therapist is unable to stand by someone’s side every minute of every day. Dialectical behavior therapy helps patients cope with their thoughts and feelings even when they leave the therapist’s office.

Who Will Find Dialectical Behavior Therapy Helpful?

Dialectical behavior therapy is one of the most versatile mental health treatment options.

It was developed to help patients with borderline personality disorder. BPD is a personality disorder that is marked by all-or-nothing thinking, severe mood swings, emotional instability, and, in some cases, suicidal ideation.

To this day, dialectical behavior therapy is the most effective treatment for personality disorders, including BPD.

Since DBT’s initial development, its application has expanded. DBT is used to help those who struggle with depression, binge eating disorder, bipolar disorder, bulimia, PTSD, and substance use disorders.

The skills related to dialectical behavior therapy can help anyone who wishes to improve their ability to tolerate stress, regulate emotions, respond to negative situations, and remain present in any given moment. In this way, it can help people communicate and interact with others.

Many people will find DBT helpful and effective, whether they have a mental health diagnosis or just need help navigating a tricky situation.

What Is DBT Treatment Like?

DBT treatment generally consists of therapy in individual and group settings, practicing skills outside of sessions (e.g., “phone coaching,” homework), and working with a therapist who participates in a consultation team.

Many DBT programs can last six months or longer because behavior changes, as well as the skills taught in DBT, take a while to become go-to thoughts and actions.

Getting Started: Pre-Treatment

DBT begins with “pre-treatment” sessions with your therapist. Your therapist asks you about your background and your goals for therapy. You collaborate in developing a treatment plan.

Individual Therapy

Individual therapy focuses on the patient’s motivation to change, as well as adapting behaviors to be consistent with what the patient perceives to be a life worth living. This is done both in and out of the therapist’s office.

Each week, the patient must complete a self-monitoring form—sometimes called a “diary card”—that tracks treatment targets and daily mood ratings. The therapist uses it to prioritize session time, where behavior that is life-threatening gets the highest priority.

Behavior that disrupts DBT—like tardiness or skipping sessions—would be addressed next, followed by behavior that impacts quality of life. Behaviors that impact quality of life could include anything from arguing with loved ones to dangerous substance use to procrastination.

You and your therapist personalize your diary card based on your goals and revise it over time as you progress in therapy. The diary card helps create consistently productive individual therapy sessions.

Once behaviors and session time are prioritized, the provider and patient discuss causes and consequences of each behavior. This way patients can learn how to understand behavioral patterns, manage their emotions, and solve problems faster and with less stress.

Group Therapy

The group therapy component of DBT is less like what you’d imagine a group therapy session to be. It’s more like a weekly class. It typically starts with a mindfulness exercise and a review of the past week’s homework. The session continues with a lesson on a new skill and activities or hands-on practice for that skill.

In DBT group therapy, new skills are learned, and patients have a chance to work on practicing these skills before they’re put into action out in the “real world.” Just like a class, there is weekly homework so the skills taught can be practiced in everyday life.

Phone Coaching

An important part of DBT is ensuring that patients can use the skills regularly in their daily lives. While patients get into a routine of completing their diary cards and homework assignments, it can still be hard to apply new skills independently—especially in highly stressful situations.

“Phone coaching,” an essential component of DBT, is designed for just that. Phone coaching helps patients apply skills when they are having trouble doing so in the moment. It involves the therapist being available by phone for support. Patients and therapists develop plans for when and how to use phone coaching.

Therapist Consultation Team

Standard DBT also includes a therapist team meeting. Several DBT therapists meet weekly to help one another problem-solve, adapt, and implement treatment when faced with unique clinical challenges—for example, if a patient is regularly skipping therapy sessions.

In the team meeting, therapists are encouraged to remain compassionate and nonjudgmental toward patients, especially when in difficult circumstances.

Support, encouragement, and monitoring for therapist burnout may also be provided in the team meeting. This allows for therapists to continue to learn from one another and ultimately provide the best care for you or your loved one.

What DBT Can (And Can’t) Do

People have different needs when it comes to their mental health. Therapies vary in how they are structured and how they are employed. Some people see greater benefits from some types of therapy than from others.

DBT is often paired with another type of therapy, so patients get the most out of their mental health care.

Many mental health disorders are managed with an approach that includes both medications and therapy. Some mental health disorders can’t be treated with therapy alone.

Some people think that DBT involves turning a person’s attention exclusively toward their faults. Others believe DBT involves intentionally exposing people to painful situations. Neither is true.

During sessions, the patient and therapist conduct a behavioral analysis to understand the causes and consequences of certain target behaviors. These thorough assessments give a clear picture of behavior patterns. This gives the patient choices about what they would like to try to do differently in the future, and how they would like to do it (e.g., what types of skills they want to practice to reduce target behaviors).

Similarly, the therapist and patient celebrate skillful and effective behavior. Similar behavior assessments are conducted to reflect on what a person did well and how they achieved positive changes.

DBT encourages you to pay attention to current emotions, which can be uncomfortable and yet incredibly helpful. DBT therapists discuss with you the purpose of any “exposures” to thoughts and feelings that may cause an uncomfortable reaction.

While some parts of DBT focus on a person’s past, the primary focus is to help people get better. Patients have the final say in everything that happens in treatment. A professional is there to guide the way.

It’s important to remember that DBT may not work for you—every person’s treatment for mental health is as unique as they are. That’s why we encourage you to be open and honest with your providers about what’s working—and what isn’t—as you explore treatment options.

Research Shows That DBT Works

One of the most consistent findings across research studies is that dialectical behavior therapy reduces suicidal behavior and ideation when compared to control conditions.

A randomized controlled trial from 1991 applied DBT to women with borderline personality disorder. The research found that DBT outperformed other standard treatments at the time. Participants who received DBT had fewer and less severe suicide attempts, fewer inpatient hospital stays, and fewer symptoms, as well as improved social functioning.

A study from 2006 attempted to replicate the research from the 1991 study. It had a larger study population and more rigorous control conditions. The new study also found that patients who underwent DBT had a greater reduction in their suicide attempts.

It also showed reductions in the length of psychiatric hospitalization, risky behaviors, negative emotions, and the frequency of emergency room visits.

Several more studies have shown that DBT is an effective treatment for mental health disorders. New medications and many behavioral interventions have been developed since DBT was created, but DBT is a mainstay in mental health treatment.

Find a Dialectical Behavior Therapy Provider

The easiest way to get started is to contact your primary care provider (PCP). Together, you and your PCP can discuss your symptoms. Your PCP can then refer you to a trained mental health professional. You should look for a licensed therapist who is specifically trained in DBT.

You can also ask your current mental health care team if they use DBT. If they don’t, you can ask for a referral or find a provider near you.

Your therapist reviews any referral notes and meets with you. The therapist does a thorough intake assessment to learn about the history of your mental health. After this, they review the information, look at your symptoms, and come up with a diagnosis. Then, the treatment process begins.

Even if DBT is part of your treatment plan, you might not start with it on the first day of your treatment. A licensed mental health professional may recommend another type of therapy first and incorporate DBT as part of treatment later.

DBT usually occurs in an outpatient clinical setting. DBT is also sometimes delivered as part of more intensive treatment programs, like residential or partial hospitalization day programs.

The goal of DBT is to provide patients with coping skills to manage negative situations and emotions on their own. With the right team and the right approach, DBT may help transform your mental health treatment.

It is important for patients to follow the guidance of the trained mental health professional(s) they work with. That way, patients can maximize the therapy’s benefits both inside and outside treatment sessions.

History of DBT

Dr. Marsha Linehan developed the modern form of DBT in the 1970s. Linehan, a psychologist with a personal history of mental health challenges, knew she could use her experience and skills to develop a new therapy that would help people with mental health challenges.

While treating patients, she experienced her own challenges, but worked with her care team to manage her conditions.

Linehan found that behavioral therapy alone wasn’t effective for helping people with BPD. She also tried humanistic therapy, and it wasn’t helpful for her patients either.

Ultimately, she blended components of both approaches to offer patients a balance of support in creating the changes they desired and a compassionate and validating stance. This balance of change and acceptance is a core component of DBT.

As a result, DBT was the first type of Western treatment that formally used mindfulness. Mindfulness helps people focus on the current moment. Because of this, the practice allows people to overcome many of the issues that contribute to their mental health condition.

Dialectical behavior therapy has been fine-tuned since it was first developed. While originally designed to treat borderline personality disorder, DBT is now used to treat a variety of conditions, including depression, anxiety, and eating disorders.

Finding Your Approach to DBT

DBT has helped many people better manage their mental health, and research backs up its effectiveness.

Whether you’re navigating a diagnosed mental health condition or simply looking for better ways to handle stress and connect with others, the skills taught in DBT can be explored on your own or as part of formal treatment.

If you’re considering formal treatment, a doctor or licensed therapist can help determine the approach that best fits your situation. With the right support, DBT can make a meaningful difference in your emotions, relationships, and daily life.

Contributors

Arielle Gartenberg, PsyD