Understanding Dialectical Behavior Therapy
Dialectical behavior therapy (DBT) defined
Dialectical behavior therapy (sometimes spelled dialectical behaviour therapy), or DBT, is a type of psychotherapy that aims to teach group skills to help people learn and utilize skills that they need to create a more fulfilling life. It was developed by Marsha Linehan, who used it initially for those who had borderline personality disorder (BPD), and it now can be used for many mental health conditions, especially those that cause self-destructive behaviors. DBT aims to give a person new skills that they can use to manage intense negative emotions.
DBT tends to focus on four key elements:
- Mindfulness, which focuses on improving someone's ability to be present in the moment
- Distress tolerance, which is geared toward increasing tolerance for negative emotion, rather than trying to escape it
- Emotional control, which is a strategy used to manage and change emotions that are intense and create problems in a person's life
- Interpersonal effectiveness, or behavioral skills that allow someone to communicate with others in a way that's assertive while maintaining self-respect and strengthening relationships.
When is DBT used?
DBT was originally used to treat BPD. But, it can help treat those who experience depression, post-traumatic stress disorder (PTSD), binge eating, generalized anxiety disorder, bulimia, bipolar disorder, eating disorders, and substance use. DBT is similar to cognitive behavioral therapy (CBT), but it is specially adapted for the needs of people with intense, often uncontrollable emotions.
Rather than trying to change the emotions, DBT teaches strategies for coping with them in healthy ways. DBT skills are taught in telephone crisis coaching because the coping skills learned in DBT therapy can be applied immediately to prevent harmful behavior like self-injury*.
One study on the benefits of comprehensive DBT for patients with bulimia found that the participants had significantly decreased bulimia nervosa symptoms after learning emotional control skills. However, more research needs to be done on how suitable DBT is for eating disorders.
If you are experiencing a crisis text HOME to 741741 to contact Crisis Text Line.
DBT and skill development
DBT as a cognitive behavioral treatment
- Mindfulness, which focuses on improving someone's ability to be present in the moment
- Distress tolerance, which is geared toward increasing tolerance for negative emotion, rather than trying to escape it
- Emotional control, which is a strategy used to manage and change emotions that are intense and create problems in a person's life
- Interpersonal effectiveness, or behavioral skills that allow someone to communicate with others in a way that's assertive while maintaining self-respect and strengthening relationships.
When is DBT used?
DBT for borderline personality disorder
Dr. Marsha Linehan originally developed DBT in the late 1970s to treat borderline personality disorder (BPD). The original goal of this type of therapy was for a patient’s treatment team to give a patient radical acceptance as they are (using elements of comprehensive validation therapy), then help them build a “life worth living” through DBT skills training. According to the study Mechanisms of change in dialectical behavior therapy: theoretical and empirical observations, the goal of DBT is to help a patient “engage in functional, life-enhancing behavior, even when intense emotions are present.”
With a combination of individual DBT therapy, group therapy, and phone coaching with a licensed mental health professional, patients are able to learn emotion control strategies and communication skills that lead to the ability to tolerate feelings of distress, accept their situations, and change their behaviors.
DBT for other mental health conditions
Although DBT was originally used to treat BPD, it can help treat other mental health conditions* as well, such as depression, post-traumatic stress disorder (PTSD), binge eating disorder, generalized anxiety disorder, bulimia, bipolar disorder, eating disorders, drug and alcohol dependence, substance use disorder, and self-harm. Additionally, one study found DBT to be successful in reducing substance use of opioid-dependent women. DBT is similar to cognitive behavioral therapy (CBT), but it is specially adapted for the needs of people with intense, often uncontrollable emotions.
Rather than trying to change the emotions, DBT teaches strategies for coping with them in healthy ways. DBT skills are taught in telephone crisis coaching because the coping skills learned in DBT therapy can be applied immediately to prevent harmful behavior like self-injury**.
One study on the benefits of comprehensive DBT for patients with bulimia found that the participants had significantly decreased bulimia nervosa symptoms after learning emotional control skills. However, more research needs to be done on how suitable DBT is for eating disorders.
Another study performed a systematic review of DBT’s treatment outcome literature and discovered “preliminary evidence supporting the use of DBT skills training as a method of addressing a range of behaviors.”
Dialectical behavior therapy skills training can help people control their emotions, develop more tolerance of distress and negative emotions, remain present in the moment, improve communication, and interact with others better. Anyone can benefit from learning the skills taught in DBT, but especially people who experience intense emotions.
* Please note that the term “other mental health problems” is no longer used and should instead be replaced with “other mental health conditions”.
** If you are experiencing a crisis text HOME to 741741 to contact Crisis Text Line.
DBT and skill development
To provide effective treatment, DBT assumes that clients are trying as best as possible but that they need to learn behaviors in different contexts. The word “dialectical” means to combine opposites. DBT therapy can teach people how to accept their intense emotions without reacting to them in a maladaptive way. People with borderline personality disorder and other mental health conditions may engage in self-injury and other harmful behaviors. DBT teaches skills to stop unwanted behaviors and replace them with positive coping skills.
DBT focuses on helping people make positive changes in their life by controlling intense emotional reactions. DBT aims to teach these different skills, which may allow a person to navigate situations in everyday life or manage challenges that get too big. These skills, according to Linehan, can be a huge part of building a fulfilling life. Being fully aware of their emotions can help people with a personality disorder manage intense emotions in day-to-day life.
People who have BPD can have extreme emotions, which can be difficult to manage. These can be intense, uncontrollable emotions that become a problem when someone with BPD is interacting with other people, including friends, romantic partners, and even their own family.
Individual therapy sessions in a DBT program tend to be influenced by the philosophy of dialectics, which often focuses on balancing opposites. A therapist might work with you to find different ways to balance different perspectives that are influencing you. This work may help you to avoid extremes in the way you think. In clinical psychology, DBT training may provide you with distress tolerance skills, coping skills, and thought reframing.
This type of therapy may consist of both group work and one-on-one sessions. The therapist may occasionally seem like a coach to the client. The goal of individual sessions is to keep the person motivated, help them apply the learned skills in their life, and address any obstacles that might arise during treatment. Therapists may use a variety of methods, including role-playing, experiments, and homework assignments. Doing any homework assignments, the therapist assigns can help you get the most out of DBT.
There may be one or more licensed mental health professionals involved in treatment. Some facilities offer a consultation team to provide comprehensive DBT treatment. The DBT consultation team may include a primary healthcare provider, behavioral tech, nurses, therapists, and other professionals. The following are some skills that you may work on during DBT.
Mindfulness
During DBT sessions, a therapist may help a client become more mindful of any triggers that cause emotional distress or any situations that can cause a desire to lash out and an inability to accept change. Accepting change tends to be a significant part of this type of therapy.
Distress tolerance
When it comes to the skill of distress tolerance, the therapist may focus on helping the person try to tolerate negative emotions. Oftentimes, a person may flee negative situations or lash out, which tends to breed more negativity. With DBT, a therapist may help the client tolerate their current emotions and handle distress more skillfully.
Emotion control skills
Emotion control skills consist of strategies that can be used to help a person become more emotionally balanced. This part of the treatment targets one’s ability to manage emotions in order to help prevent blowups, allowing them to harness control over their emotions.
Interpersonal effectiveness
Interpersonal effectiveness training aims to help a person become more assertive in their relationships. This component of DBT may help them to get better at communicating and have a stronger, healthier relationship not just with themselves but also with other people.
Group sessions with a therapist
This group aspect of dialectical behavior therapy focuses mostly on learning how to practice these skills. The one-on-one aspect of training tends to focus on the why, but group work allows you to practice your skills. Other people have their own experiences, and they may know of something that can help you cope with challenging situations better. Also, group work can give you a better, more reliable support network. Usually, one trained therapist leads all of this work, and they practice different skills and exercises with group participants.
The group component of DBT usually lasts about two hours, with the group meeting weekly for approximately six months, depending on the needs that people have. DBT can be conducted in different ways, depending on the participants and the therapist. Some people don't need skills groups, but others may find that they work better with others.
Group sessions can have many benefits, including social support and encouragement from the other group members. Practicing the skills learned in DBT with others can help increase self-esteem and confidence. However, how suitable DBT group sessions are for people may depend on several factors. People with social anxiety may feel uncomfortable in a group setting and prefer individual DBT. The effectiveness of group sessions may depend on the participant’s willingness to participate.
If you’re interested in trying DBT, you can search for "DBT therapy near me" with an experience in this therapeutic modality. Alternatively, you might try DBT through online therapy, which research has shown to be just as effective as in-person sessions. With an online platform like BetterHelp, you can speak with a licensed therapist without leaving home, which may be more comfortable than going to a therapist’s office if this is your first time speaking with a therapist.
With BetterHelp, you can communicate with a DBT therapist via phone or video chat at a time that suits your schedule. Also, you can contact your therapist in between sessions via in-app messaging, and they’ll get back to you as soon as they can.
Takeaway
Dialectical behavior therapy (DBT) often involves thoughtful validation of the client’s thoughts and feelings by the therapist. This validation can be classified into six specific levels, encompassing various ways to reassure the client that they’re being seen, heard, and accepted.
The six levels of validation in DBT are:
- Wakefulness and Attentiveness. This includes “active listening” techniques such as eye contact, nodding, using verbal cues like “I see,” and prompting the individual with questions.
- Accurate Reflection. Practicing this level involves paraphrasing and summarizing what the client has said to let them know they’ve been understood.
- Stating the Unarticulated. In level 3 validation, the therapist attempts to identify and acknowledge things the patient might feel but have trouble expressing.
- Placing Behavior in Context. This type of validation involves showing the individual that you recognize how their personal history or physical health may have influenced their choices, even if that’s led to bad outcomes.
- Normalizing Feelings. Validation of this type can involve acknowledging that the person’s emotional reactions are understandable (without condoning inappropriate actions or confirming a distorted worldview).
- Radical Genuineness. This approach involves treating the other person as a rational adult, not condescending to them or tiptoeing around their feelings. In the context of therapy, it may require the therapist to be honest about their own reactions to the client’s words and behavior.
Validation is designed to enable a client to bring difficult emotions to the surface and deal with them directly, rather than avoiding them through unhealthy coping strategies. Research suggests that the effective use of validation strategies by therapists can have important positive effects.
The four key elements of DBT skills training include:
- Core Mindfulness: Often considered the most important skill learned in DBT, mindfulness involves learning to pay attention to the present moment, be aware of your reactions, and assess yourself accurately but non-judgmentally.
- Interpersonal Effectiveness: These skills focus on effective ways to relate to other people, such as setting healthy boundaries, articulating needs, and managing conflict without catastrophizing.
- Emotion Control: This type of skills training centers on learning healthy strategies for coping with negative emotions, replacing dysfunctional responses like self-harming behavior.
- Tolerating Distress: An individual with borderline personality disorder or a similar mental health condition may have difficulty handling conflict, loss, or unpleasant emotions. Distress tolerance skills are meant to help these individuals make peace with their pain while moving forward.
Dialectical behavior therapy often involves a balance between self-acceptance and self-improvement. Here are a few examples of how that can work in practice:
- A person with binge eating disorder might be encouraged to see how their episodes of overeating serve as self-soothing techniques in response to difficult emotions. While providing a non-judgmental space to discuss their feelings, a therapist might also suggest healthier coping mechanisms or outlets, such as exercise, listening to music, or creating artwork.
- Someone with a history of suicidal behavior may be encouraged to recognize their actions as dysfunctional emotion control strategies. Their therapist may help them practice accepting and living with negative feelings, while also assisting them in developing a strong motivation to survive.
- A client with substance use disorder may learn a variety of strategies to change their behavior, from techniques for handling cravings to relationship skills that can help them cultivate a supportive social circle.
Dialectical behavior therapy is partially based on the principles of cognitive-behavioral therapy (CBT). However, while they have some similarities, these two therapeutic approaches tend to have different areas of emphasis.
CBT often focuses heavily on the connections between thoughts and feelings, targeting distorted beliefs, worldviews, or habitual ways of thinking that tend to reinforce mental health disorders. DBT tends to place a greater focus on managing difficult emotions, often through radical and non-judgmental acceptance based on mindfulness practice. Since it was originally developed to help patients with high suicide risk, this approach may also involve a significant amount of pragmatic behavioral strategies for avoiding self-harm.
CBT is intended to be a short-term technique targeting particular symptoms, generally encompassing between 8 and 20 weekly sessions. DBT often involves a significantly longer treatment plan. Many patients use DBT to manage long-term, chronic mental illnesses like personality disorders or substance use disorders. This generally requires at least a year, and may involve ongoing coaching and communication after the initial course of treatment.
DBT has several advantages and drawbacks that may make it better suited for some people than others. The pros of DBT therapy include:
- Highly effective at reducing suicidal behaviors, including in adolescents and young adults
- Practical training in interpersonal and crisis management skills
- Good evidence for effectiveness in treating chronic conditions like borderline personality disorder and post-traumatic stress disorder
- Group-based learning provides interpersonal support
- Affirming and non-judgmental approach may benefit patients who often feel invalidated or dismissed
Potential disadvantages of DBT include:
- Requires a substantial commitment of time and effort
- Some people may find the number of skills to learn overwhelming
- Treatment availability is often limited
- May be less effective at reducing symptoms of depression and anxiety compared to traditional CBT
Dialectical behavior therapy consists of four core components:
- Group skills training: Clients learn, discuss, and practice interpersonal and emotion control skills together.
- Individual therapy: A licensed mental health professional works one-on-one with each patient to address specific emotional and behavioral challenges.
- Phone coaching and consultation: Patients can reach out by phone to their treatment providers for help in times of crisis.
- Therapist team consultations: DBT therapists meet regularly to discuss patients, give strategies, and provide mutual support.
Dialectical behavior therapy is a highly structured, multi-stage outpatient therapy combining elements of CBT and mindfulness training. It’s focused on building emotion control and behavior management skills. In the best-case scenario, DBT results in better behavior management, improved self-awareness, and a greater feeling of wholeness and purpose.
DBT was originally developed to treat patients with substantial suicide risk and has since demonstrated effectiveness in relieving conditions like:
- Borderline personality disorder
- Eating disorders, especially bulimia and binge eating disorder
- Unhealthy substance use
- Post-traumatic stress disorder
- Bipolar disorder
DBT is structured into four specific stages:
- Therapist and client work to stabilize behavior and reduce the risk of self-harm or major life disruptions
- Clients learn to experience and accept their varied emotions while controlling their behavior.
- Persistent difficulties that get in the way of important life goals are addressed, such as habitual relationship conflict.
- Clients work on finding sources of meaning, purpose, and joy in their lives to aid their long-term flourishing.
DBT skill training begins with learning mindfulness — a nonjudgmental observation and acceptance of your perceptions, sensations, habits, and emotions. This type of clear attentiveness is considered fundamental to many of the other skills and techniques involved in this treatment.
Can DBT be used for anxiety?
Some studies suggest that DBT techniques may help relieve symptoms of anxiety disorders. However, the evidence for this approach to treating anxiety is not yet very strong compared to methods like cognitive-behavioral therapy.
Most treatment providers still regard CBT as the gold standard for psychotherapy in anxiety disorders. That said, if you’ve tried CBT and found it doesn’t work well for you, it may be worthwhile to talk with your treatment provider about DBT.
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