What is dialectical behavior therapy (DBT)?

A brief overview of DBT

Dialectical behaviour therapy (DBT) was originally developed to help manage symptoms of borderline personality disorder.

The use of ‘dialectical’ means this therapy aims to help someone bring together two things that seem opposite - that they can accept who and how they behave while also trying to achieve change.

In DBT, you will work with a therapist, on your own or in a group, to develop skills to cope with distressing or difficult life situations and learn how to cope with negative emotions that unsettle you when they come up.

It tends to be prescribed for people with more complex treatment plans, including those with multiple mental health problems. Most people who enter DBT will also be on a course of medication, which should help them to engage in the therapy.

What is the goal of dialectical behavior therapy (DBT)?

The goal of DBT is for the person entering it to learn to manage their feelings and behaviors, particularly risky ones like self-harm or suicide attempts. As well as this aim being helpful for the person to stay safe and get better, this should help them to engage with the therapy for a longer time.

As with other types of talking therapy, the goals are also set by the person entering it. Your therapist should work with you to identify your obstacles to leading a fulfilling life and how you can tackle them. These obstacles could be anything from symptoms of a severe mental illness, like hallucinations, to an issue in a close relationship.

Ultimately, DBT should help you gain emotion regulation skills and minimize your unhelpful behaviors to make these goals realistic and achievable.

What is dialectical behaviour therapy (DBT) used to treat?

This type of therapy was initially developed for people with a diagnosis of borderline personality disorder (BPD), who often experience intense emotions as one of their symptoms. Evidence shows DBT is an effective treatment for people with this diagnosis. ^[1]

DBT is now being offered by some healthcare providers for different groups of people, including:

• Young people and children ^[2]
• People with eating disorders
• People experiencing alcohol or substance use disorders ^[3]

There is also some similarity between BPD symptoms and other mental health conditions concerning emotional regulation, difficulty with how you view yourself, behavior and moods, often leading to unhelpful coping mechanisms. For this reason, DBT can be a good treatment option for anyone who is self-harming, having thoughts about or making suicide attempts, or experiencing severe depression. ^[4]

Some research also shows that DBT is effectively treats people with complex post-traumatic stress disorder (CPTSD). This diagnosis is not recognized in the most recent Diagnostic and Statistical Manual of Mental Disorders. Still, it is understood by many clinicians as a separate diagnosis from PTSD and often involves suicidal behavior and thoughts. ^[5]

Because DBT seeks to help someone accept themselves and work on changing their thinking and behaviors, you might be more likely to be offered DBT if you accept the diagnosis you have been given. This can be particularly hard if you have been diagnosed with a personality disorder, as many feel this suggests their mental health condition is innate to who they are.

What are common dialectical behavior therapy techniques?

The use of ‘dialectical’ means this therapy aims to help someone bring together two things that seem opposite - that they can accept who and how they are while also trying to achieve change. That means the techniques used mirror these two things.

As part of learning to accept yourself, you will work with your therapist to better understand of the kind of person you are and why you are that way. Through this, you will also learn more about why you do behaviors that are risky or harm yourself.

As part of learning to change your behaviors, you might work on why you think certain things and challenge the underlying assumptions that come with them. You could also try different ways to cope with distressing feelings.

Most DBT involves a curriculum of skills training, often carried out in groups. ^[6] This includes:

Mindfulness

Mindfulness practice and meditation are rooted in religious traditions to do with contemplation. By slowing your mind down and focusing on the present, from physical sensations to colors, you learn not to get caught up in worrying about things that happened in the past or might happen in the future.

Distress tolerance

In distress tolerance, you learn skills to cope with distressing events without resorting to unhelpful coping behaviors like self-harm. This might include self-soothing by focusing on the things you can hear around you or using touch. Some people also find distraction techniques work to build up their tolerance to coping with distress or listing the upsides and downsides of a situation to keep it in perspective.

Emotion regulation

This skill should help you manage strong emotions without feeling overwhelmed. A key part of this is recognizing and naming your feelings at any given moment and then working out ways to keep them in check, for example, rationalizing the feeling. 

By naming positive emotions, you should also build resilience for dealing with difficult ones and consider how to incorporate those positive feelings as part of your coping in hard situations. You might also use the mindfulness skills you have gained to regulate your emotions.

Interpersonal effectiveness 

This skill should equip you to have better interpersonal relationships with others by maintaining respect for yourself and them. This could include learning how to ask for help or saying no when people ask you to do things you don’t want to do to maintain your boundaries. A key part of this skill is also learning how to manage conflict with other people well.

Is dialectical behavior therapy (DBT) effective?

There is evidence to show that DBT can effectively treat borderline personality disorder, which has led to the American Psychiatric Association endorsing it as a treatment for this diagnosis. ^[7] Some studies showed that people were less likely to be hospitalized, experienced fewer and less extreme suicidal thoughts, engaged better in treatment, were less angry and had better social interactions as a result of DBT. ^[8]

Other studies are less clear-cut. A study of various pieces of research found that DBT only had a moderate impact on people with BPD. ^[9] Overall, it is commonly prescribed for this diagnosis, but more research is needed on its effectiveness for other mental health diagnoses. ^[10]

What should you expect in a dialectical behavior therapy (DBT) session?

First session

Before you begin treatment, your first DBT session should be for you and your therapist to work out if it’s the right talking therapy for you. During this session, you will talk about what DBT involves and the model it follows. 

You might also agree to a crisis plan in case your mental health deteriorates at any point while you are in therapy. If you agree to continue, you will then go on to have regular sessions that can last up to an hour.

Following sessions

A common task that a DBT therapist might ask you to do is to complete diary cards as homework to use as prompts for discussion in sessions. Your therapist should help you with a list of more than 40 feelings, actions and impulses you can note down. ^[11]

The aim is to keep a log of how you feel and your behaviors to determine if there are sequences you can spot and any particular things that trigger you. In addition, these diary cards will help to determine each session’s structure.

If you are working with a group, you might work on similar exercises spotting your feelings together and even role-play to re-enact situations that have come up that triggered a response from you. In both group and individual therapy sessions, your therapist will give you work to do outside the sessions, so you can keep implementing your learning.

Many DBT therapists will offer crisis telephone coaching outside of your sessions. Still, within the boundaries you agree together about when to call, how long the calls can be and whether you need to wait some time and sit with the situation before calling them.

Therapy settings

Different types of talking therapy now happen in various settings, and there is a greater diversity of therapists available. In addition, many people now engage in therapy through apps, video calls, on the phone, or in office. However, more research is needed into whether DBT can be effective when carried out this way.

Research also suggests that DBT is not as effective if carried out alone, unlike CBT which can produce similar results by following online resources as an individual. However, finding online material about DBT might help you to determine whether it is the right kind of therapy for you.

Many people also find that doing DBT with a therapist, alone or in a group, can help them stay motivated to work on their treatment and understand that others are going through similar things.

How do I know if dialectical behavior therapy is right for me?

Before deciding whether DBT is right for you, it is important to know that accessing this kind of therapy can be quite difficult, so it might take some time before you enter treatment.

Before starting DBT, it is important to consider your mental health and which type of therapy best fits your goals. If you have a specific diagnosis, you might want to try a therapy commonly used to treat it. For example, dialectical behavior therapy is commonly used to treat borderline personality disorder.

You should find the right therapist to work with because you will need to trust them enough to talk about your feelings and any harmful behaviors you do. Most people entering DBT will also be receiving other treatments alongside it, including taking medication. You will discuss with your therapist how your different treatments interact. 

It is important to be aware that your therapist might need to work with your healthcare provider to discuss how your care is progressing and agree on ways to keep you motivated to engage in treatment. If this concerns you, ask your therapist if you can discuss the details of your confidentiality agreement early on.

If your therapist is not sure you can make progress the way you want to with DBT or with them, they should recommend that you work with somebody else or try a different approach.

What is the difference between CBT and DBT?

Dialectical behaviour therapy (DBT) is a sub-type of cognitive behavioral therapy (CBT) typically prescribed for people with more severe mental health diagnoses. It was developed in the late 1970s after a series of failed attempts to use CBT with suicidal individuals. ^[12]

While CBT primarily focuses on changing patterns of thought and behavior, DBT has an equal emphasis on self-acceptance. You are also more likely to explore your feelings and close relationships in greater depth in DBT than in CBT.

Similarly to CBT, DBT is a highly structured type of talking therapy, which moves through stages from addressing someone’s most risky behavior to learning life skills, building self-belief and healthy relationships and finding greater fulfilment.