What is Dialectical Behavior Therapy (DBT)?

Dialectical Behavior Therapy (DBT) is a cognitive behavioral treatment developed by Marsha Linehan, PhD, ABPP. It emphasizes individual psychotherapy and group skills training classes to help people learn and use new skills and strategies to develop a life that they experience as worth living. DBT skills include skills for mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness.

The UCSF DBT Program for Adolescents and Young Adults created a fun, easy-to-understand overview of Dialectical Behavior Therapy.

DBT was originally developed to treat chronically suicidal individuals diagnosed with borderline personality disorder (BPD). It is now recognized as the gold standard psychological treatment for this population. In addition, research has shown that it is effective in treating a wide range of other disorders such as substance dependence, depression, post-traumatic stress disorder (PTSD), and eating disorders.

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What are the components of DBT?

The goal of DBT is to help clients build a life that they experience as worth living. In DBT, the client and the therapist work together to set goals that are meaningful to the client. Often this means they work on ways to decrease harmful behaviors and replace them with effective, life-enhancing behaviors.

DBT has five components that work together that make up a standard DBT program. This is different than many other psychotherapies that consist of just one mode or aspect of treatment (such as individual therapy). Each component or mode of treatment is intended to meet a specific function (see Figure 1).

Function = Objective or aim of DBT | Mode = Therapy component that supports each objective
 

Figure 1
1 – Enhance Capabilities with DBT Skills Training
DBT skills training focuses on enhancing clients’ capabilities by teaching them behavioral skills. Skills training is frequently taught in groups; the group is run like a class where the group leaders teach the skills and assign homework. The homework helps clients practice using the skills in their everyday lives. Groups meet on a weekly basis for approximately 2.5 hours, and it takes 24 weeks to get through the full skills curriculum, which is often repeated to create a 1-year program. Briefer schedules that teach only a subset of the skills have also been developed for particular populations and settings.

There are four modules in skills training:

  • Mindfulness: the practice of being fully aware and present in this one moment
  • Distress Tolerance: how to tolerate pain in difficult situations, not change it
  • Interpersonal Effectiveness: how to ask for what you want and say no while maintaining self-respect and relationships with others
  • Emotion Regulation: how to change emotions that you want to change

2 – Enhance Motivation with Individual Therapy
DBT individual therapy is focused on enhancing client motivation and helping clients to apply the skills to specific challenges and events in their lives. In the standard DBT model, individual therapy takes place once a week for as long as the client is in therapy, and it runs concurrently with DBT skills training.

3 – Ensure Generalization with Coaching
DBT uses telephone coaching and other in vivo coaching to provide in-the-moment support. The goal is to coach clients on how to use their DBT skills to effectively cope with difficult situations that arise in their everyday lives. Clients can call their individual therapist between sessions to receive coaching at the times when they need help the most.

4 – Structure the Environment with Case Management
Case management strategies help the client manage his or her own life, such as their physical and social environments. The therapist applies the same dialectical, validation, and problem-solving strategies in order to teach the client to be his or her own case manager. This lets the therapist consult to the patient about what to do, and the therapist will only intervene on the client’s behalf when absolutely necessary.

5 – Support Therapists with the DBT Consultation Team
The DBT consultation team is focused on the people who provide DBT, including individual therapists, skills training group leaders, case managers, and others who help treat the client or patient. The consultation team is intended to support DBT providers in their work; it’s almost like therapy for the therapist. The consultation team is designed to help therapists stay motivated and competent so they can provide the best treatment possible. This is especially important when they are treating people with severe, complex, difficult-to-treat disorders so the team can help one another manage burnout and share their knowledge.

Why does DBT teach skills?

Problematic behaviors evolve as a way to cope with a situation or attempt to solve a problem. While these behaviors might provide temporary relief or a short-term solution, they often are not effective in the long-term. DBT assumes that clients are doing they best they can, AND they need to learn new behaviors in all relevant contexts. DBT helps enhance a client’s capabilities by teaching behavioral skills in areas like mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. These skills help people develop effective ways to navigate situations that arise in everyday life or manage specific challenges.

Here, Dr. Linehan explains how skills are an important part of helping individuals build a life that they experience as worth living.

Why does DBT require the therapist to be on a consultation team?

A therapist’s work can be difficult for many reasons, so DBT uses the DBT consultation team (“team”) to help therapists monitor their fidelity to the treatment, develop and increase their skills, and sustain their motivation to work with high-risk, difficult-to-treat clients.

Therapists work together to help one another treat clients, and DBT recommends that they meet weekly for a consultation team meeting. A typical meeting might start with a mindfulness practice, reading a team agreement, reviewing the minutes of the previous meeting, reviewing any new clients under the care of a therapist, and completing therapist-focused consultation.

The therapist-focused consultation prioritizes assistance from the team for anyone with a client who has high risk behaviors; then the team helps one another assess, problem-solve, or provide emotional support for an issue that is important to any team member who needs it. DBT teams use the same principle of focusing on the behaviors of the individual in order to define and assess the problem and identify, troubleshoot, and implement a solution.

Learn more about the role of the DBT consultation team on our Training FAQs page.

How does DBT prioritize treatment targets?

Clients who receive DBT typically have multiple problems that require treatment. This can mean that they have multiple diagnoses, or they may have problem behaviors that fall under one diagnosis. How does a therapist figure out where to start treatment? A DBT therapist uses a hierarchy to determine the order in which problems should be addressed. The treatment targets, in order of priority, are:

Life-threatening behaviors: First and foremost, behaviors that could lead to the client’s death are targeted, including all forms of suicidal and non-suicidal self-injury, suicidal ideation, suicide communications, and other behaviors engaged in for the purpose of causing bodily harm.

Therapy-interfering behaviors: This includes any behavior that interferes with the client receiving effective treatment. These behaviors can be on the part of the client and/or the therapist, such as coming late to sessions, cancelling appointments, and being non-collaborative in working towards treatment goals.

Quality of life behaviors: This category includes any other type of behavior that interferes with clients having a reasonable quality of life, such as mental disorders, relationship problems, and financial or housing crises.

Skills acquisition: This refers to the need for clients to learn new skillful behaviors to replace ineffective behaviors and help them achieve their goals.

Within a session, presenting problems are addressed in the above order. For example, if the client is expressing a wish to commit suicide and reports recurrent binge eating, the therapist will target the suicidal behaviors first. The underlying assumption is that DBT will be ineffective if the client is dead or refuses to attend treatment sessions.

What are the stages of treatment in DBT?

DBT is divided into four stages of treatment. Stages are defined by the severity of the client’s behaviors, and therapists work within this frame to support clients in achieving his or her individual goals. There is no set timeframe allotted to each stage; instead, a therapist and client will spend a much or as little time as needed, based on the client’s goals.

In Stage 1, the client is often miserable and their behavior is out of control: they may be trying to kill themselves, self-harming, using drugs and alcohol, and/or engaging in other types of self-destructive behaviors. When clients first start DBT treatment, they often describe their experience of their mental illness as “being in hell.” The goal of Stage 1 is for the client to move from being out-of-control to achieving behavioral control.

In Stage 2 , clients may feel they are living a life of quiet desperation: their life-threatening behavior is under control, but they continue to suffer, often due to past trauma and invalidation. Their emotional experience may be inhibited. The goal of Stage 2 is to help the client move from a state of quiet desperation to one of full emotional experiencing. This is the stage in which post-traumatic stress disorder (PTSD) would be treated if part of the client’s diagnosis.

In Stage 3, the challenge is to learn to live: to define life goals, build self-respect, and find peace and happiness. The goal is that the client leads a life of ordinary happiness and unhappiness.

Stage 4: For some people, a fourth stage is needed: finding a deeper meaning through a spiritual existence. Dr. Marsha Linehan has posited a Stage 4 specifically for those clients for whom a life of ordinary happiness and unhappiness fails to meet a further goal of spiritual fulfillment or a sense of connectedness of a greater whole. In this stage, the goal of treatment is for the client to move from a sense of incompleteness towards a life that involves an ongoing capacity for experiences of joy and freedom.

How effective is DBT?

DBT is one of several evidence-based treatments. Research has shown DBT to be effective in reducing suicidal behavior, non-suicidal self-injury, psychiatric hospitalization, treatment dropout, substance use, anger, and depression and improving social and global functioning. For a review of the key research on DBT and its effectiveness, visit our Research section.

To learn about other evidence-based treatments, visit the National Registry of Evidence-Based Programs and Practices and search their registry.

How is DBT different than Cognitive Behavioral Therapy?

DBT is a modification of standard cognitive behavioral treatment. When first developing DBT, Dr. Linehan and her team of therapists used standard CBT techniques, such as skills training, homework assignments, behavioral rating scales, and behavioral analysis in addressing clients’ problems. While these worked for some people, others were put off by the constant focus on change. Clients felt the degree of their suffering was being underestimated, and that their therapists were overestimating how helpful they were being to their clients. As a result, clients dropped out of treatment, became very frustrated, shut down, or all three. Linehan’s research team, which videotaped all their sessions with clients, began to notice new strategies that helped clients tolerate their pain and worked to make a “life worth living.” As acceptance strategies were added to the change strategies, clients felt their therapists understood them much better. They stayed in treatment instead of dropping out, felt better about their relationships with their therapists, and improved faster.

The balance between acceptance and change strategies in therapy formed the fundamental “dialectic” that resulted in the treatment’s name. “Dialectic” means ‘weighing and integrating contradictory facts or ideas with a view to resolving apparent contradictions.’ In DBT, therapists and clients work hard to balance change with acceptance, two seemingly contradictory forces or strategies. Likewise, in life outside therapy, people struggle to have balanced actions, feelings, and thoughts. We work to integrate both passionate feelings and logical thoughts. We put effort into meeting our own needs and wants while meeting the needs and wants of others who are important to us. We struggle to have the right mix of work and play.

In DBT, there are treatment strategies that are specifically dialectical; these strategies help both the therapist and the client get “unstuck” from extreme positions or from emphasizing too much change or too much acceptance. These strategies keep the therapy in balance, moving back and forth between acceptance and change in a way that helps the client reach his or her ultimate goals as quickly as possible.

What does “dialectical” mean?

The term “dialectical” means a synthesis or integration of opposites. The primary dialectic within DBT is between the seemingly opposite strategies of acceptance and change. For example, DBT therapists accept clients as they are while also acknowledging that they need to change in order to reach their goals. In addition, all of the skills and strategies taught in DBT are balanced in terms of acceptance and change. For example, the four skills modules include two sets of acceptance-oriented skills (mindfulness and distress tolerance) and two sets of change-oriented skills (emotion regulation and interpersonal effectiveness).

How and when was DBT developed?

In the late 1970s, Dr. Linehan attempted to apply standard Cognitive Behavior Therapy (CBT) to the problems of adult women with histories of chronic suicide attempts, suicidal ideation, urges to self-harm, and self-mutilation. Trained as a behaviorist, she was interested in treating discrete behaviors; however, through consultation with colleagues, she concluded that she was treating women who met criteria for Borderline Personality Disorder (BPD). In the late 1970s, CBT had gained prominence as an effective psychotherapy for a range of serious problems. Linehan was keenly interested in investigating whether or not it would prove helpful for individuals whose suicidality was in response to extreme pain and distress. As she and her research team applied standard CBT, they encountered numerous problems with its use. Three were particularly troublesome:

  1. Clients receiving CBT found the unrelenting focus on change inherent to CBT invalidating. Clients responded by withdrawing from treatment, by becoming angry, or by vacillating between the two. This resulted in a high drop out rate. And, obviously, if clients do not attend treatment, they cannot benefit from treatment.
  2. Clients unintentionally positively reinforced their therapists for ineffective treatment while punishing their therapists for effective therapy. In other words, therapists were unwittingly under the control of consequences largely outside their awareness, just as all humans are. For example, the research team noticed through its review of audio taped sessions that therapists would “back off” pushing for change of behavior when the client’s response was one of anger, or emotional withdrawal, or shame, or threatened self-harm. Similarly, clients would reward the therapist with interpersonal warmth or engagement if the therapist allowed them to change the topic of the session from one they didn’t want to discuss to one they did want to discuss.
  3. The sheer volume and severity of problems presented by clients made it impossible to use the standard CBT format. Individual therapists simply did not have time to both address the problems presented by clients – suicide attempts, urges to self-harm, urges to quit treatment, noncompliance with homework assignments, untreated depression, anxiety disorders, etc, — AND have session time devoted to helping the client learn and apply more adaptive skills.

Adding Dialectics and Validation

In response to these key problems with standard CBT, Linehan and her research team made significant modifications to standard CBT. They added in new types of strategies and reformulated the structure of the treatment (see below, next section). In the case of new strategies, Acceptance-based interventions, frequently referred to as validation strategies, were added. Adding these communicated to the clients that they were both acceptable as they were and that their behaviors, including those that were self-harming, made real sense in some way. Further, therapists learned to highlight for clients when their thoughts, feelings, and behaviors were “perfectly normal”, helping clients discover that they had sound judgment and that they were capable of learning how and when to trust themselves.

The new emphasis on acceptance did not occur to the exclusion of the emphasis on change: Clients also must change if they want to build a life worth living. Thus, the focus on acceptance did not occur to the exclusion of change based strategies; rather, the two enhanced the use of one another.

In the course of weaving in acceptance with change, Linehan noticed that a third set of strategies – Dialectics – came into play. DBT therapists and patients aim to adopt a dialectical world view, with its emphasis on holism and synthesis of opposing perspectives. This worldview enables the therapist to blend acceptance and change in a manner that results in therapeutic movement, speed, and flow in individual sessions and across the entire treatment. This counters the tendency, found in treatment with clients diagnosed with BPD, to become mired in arguments, polarizing positions, and extreme positions. Beyond the dialectical worldview, specific dialectical strategies used in session, such as the devil’s advocate technique, irreverence, and the use of metaphor can help to prevent the therapist and client from becoming stuck in the rigid thoughts, judgments, feelings, and behaviors that can occur when emotions run high, as they often do in the treatment of clients diagnosed with BPD. Thus, these three sets of strategies and the theories on which they are based form the foundations of DBT.