DBT: What to Know
Learning how to live in the moment, practice distress tolerance, and enjoy meaningful relationships are essential skills for healthy living. However, these skills may feel incredibly challenging for people struggling with certain mental illnesses. Likewise, many people do not learn these skills in childhood- instead, they must identify and practice them routinely.
DBT is a well-known, evidence-based therapy model that can treat borderline personality disorder and many other mental health conditions. Let’s get into what you need to know.
What is DBT?
DBT (short for dialectical behavior therapy) is a manualized treatment approach that consists of four different modules.1 DBT is widely researched and accepted as a standard method for treating various mental illnesses and behavioral issues.
The ‘D’ stands for dialectical, which refers to integrating opposite concepts. Many people struggle with extreme, all-or-nothing thinking. Such thought patterns can trigger unpleasant emotions and act as a driving force for self-destructive behaviors. Learning how to tolerate different thoughts- and accept them more radically- allows for healthier coping.
The ‘B’ stands for behavioral, which refers to how therapists help clients target unwanted behaviors and learn to problem-solve and change unwanted patterns. The behavioral component entails linking the connection between certain behaviors and the subsequent thoughts and feelings.
Who Developed DBT?
DBT integrates concepts from cognitive-behavioral therapy, group therapy, attachment-based principles, and spirituality.
In the 1970s, Dr. Marsha Linehan first began applying standard cognitive-behavioral therapy (CBT) to female clients with extensive histories of chronic suicide attempts and self-harm. She was trained as a behaviorist and suicide researcher, but she eventually concluded she was meeting with women who met the criteria for borderline personality disorder- and not depression or anxiety.2
In her initial work, Linehan found that standard CBT wasn’t working with some of her clients. They didn’t respond as treatment protocol predicted they would. Instead, she discovered that some of her clients frequently withdrew from treatment (due to being angry at their therapist) and subconsciously rewarded or punished their therapists for different behaviors. She also found that CBT could not address all the presenting acute problems while also adequately devoting time to helping clients learn new coping skills.
Linehan has identified as having a mental illness herself, which she now refers to as borderline personality disorder. In recent work, she has described a tumultuous history of suicide attempts, inpatient hospitalization, and self-harm.3
Linehan began developing the foundations of DBT in the 1980s. Today, thousands of clinicians practice DBT helping clients with numerous issues.
What Is DBT Used For?
DBT is a standard recommendation in treating borderline personality disorder (BPD), a complex mental health condition characterized by:
- Extreme mood swings.
- Frantic efforts to avoid real or perceived abandonment.
- Chronic patterns of unstable relationships.
- Alternating between idolizing someone and devaluing them.
- Engaging in reckless, impulsive behaviors like self-harm, overeating, drug use, or sex.
- Experiencing recurrent thoughts of suicide and acting on those thoughts.
- Feeling a persistent sense of emptiness.
- Having difficulty trusting others.
- Feeling detached or dissociated from reality.
Although people are becoming more aware of BPD, it is still largely misunderstood and stigmatized. People often mistake this condition for other diagnoses like bipolar disorder, depression, substance use disorders, or narcissistic personality disorder. Subsequently, many individuals with BPD also meet the criteria for other diagnoses.
BPD tends to be relatively rare, with approximately 1.6% of the population meeting criteria for it. The lifetime prevalence is estimated to be 5.9%. In standard clinical settings, the ratio of women to men has been reported as 3:1.4
In addition to supporting people with BPD, DBT can also treat:
How Long is DBT?
Structured DBT requires a long-term commitment. Because patterns can be challenging to break, it’s important to give yourself time to practice new ways of coping.
Most DBT therapists ask that potential clients offer at least six months to participate in comprehensive treatment. Many DBT programs provide services that range anywhere from six months to over two years. In its standard form, this treatment often includes weekly individual therapy, TeleMental Health, and weekly skills groups.
Furthermore, in its manualized approach, it takes 24 weeks to complete the full skills curriculum. It should be noted that DBT can be used as either a standalone or conjunctive treatment. The type of treatment will affect the length of time needed to participate.5
What Are the Four Modules of DBT?
DBT emphasizes four behavioral skills modules. Practicing and integrating these modules ideally improves emotional well-being.
Mindfulness refers to remaining present and ‘living in the moment.’ When you are acting mindfully, you are focused on the right now. You are not thinking about something that already happened or planning something in the future.
Distress tolerance refers to learning how to cope and even embrace difficult situations without trying to change them. To practice this skill, you must learn how to self-soothe. You must also understand viable crisis survival skills to address problematic triggers when they arise.
Interpersonal effectiveness refers to strengthening relationships. This skill includes identifying personal needs and setting appropriate boundaries. It also entails practicing self-respect and learning how to validate yourself if facing relationship problems.
Emotion regulation refers to understanding your feelings, becoming more aware of your triggers, and learning how to cope with them. By learning how to ‘ride’ strong emotions, you can feel more empowered to deal with challenging times.
What Does a DBT Session Look Like?
DBT may vary between different providers and locations. However, here are some common themes you can expect during your treatment.
Therapists will conduct a comprehensive intake to evaluate your mental health history. During this intake, you will share important details about your current symptoms and past treatment.
If a therapist determines you are a good fit for DBT, they will initiate the informed consent process. This process entails reviewing the structure of DBT and discussing limitations and risks. If you have any questions about what to expect, feel free to ask your therapist.
Individual therapy usually entails weekly, one-on-one sessions that last between 45-60 minutes. These sessions address a specific hierarchy of goals6:
- Reduce immediate crisis behaviors (self-harm, suicidal thoughts)
- Reduce behaviors that may interfere with the therapeutic process
- Address specific barriers affecting your quality of life
- Learn new skills to replace maladaptive behaviors
Most therapists have their clients complete DBT diary cards in between sessions. These cards allow you to track your emotions and behaviors. Having this information can raise awareness of specific triggers and patterns. Such insight can be invaluable for both you and your therapist in deciding what to work on in subsequent sessions.
Therapists use skills-based groups to reinforce the four skills modules. This is not a process-based group- it’s educational and follows a specific curriculum.
During these group sessions, your therapist may encourage you to practice specific role-plays or exercises. In addition, they will typically assign homework for clients to practice skills during the week.
Phone Crisis Coaching
DBT often integrates phone calls for routine support, such as needing help with an immediate crisis, wanting advice on using specific skills, or repairing an issue with your therapist.
That said, therapists implement strict parameters around these calls. For instance, they may require the calls to be brief and only during certain hours. They might also request that the client waits a certain number of hours before calling. These boundaries may feel frustrating, but they are designed to help clients understand healthy relationships and practice self-soothing exercises.
What Are the DBT Skills?
DBT therapists teach their clients numerous skills to strengthen skills within the four modules. Therefore, it’s important to learn many different techniques. Some will work better than others, and it’s best to have a toolbox full of coping skills to refer to when needed.
Mindful activity: Choose an activity where you notice your mind typically wanders, like your commute or while brushing your teeth. Aim to focus on doing this activity mindfully- focus on each of your five senses and avoid judging any external thoughts that may arise.7
Mindful meditation: Create an intention to meditate. Find a quiet place to sit or lie down. Focus on your breath and notice how the breath feels moving in and out of your body. Whenever your mind wanders, aim to be neutral- tell yourself, I’m having a thought right now. As it passes, focus on returning to the breath. Start doing this practice for five minutes at a time and work your way up to longer spans.
TIPP: TIPP stands for temperature, intense exercise, paced breathing, and progressive muscle relaxation. TIPP can help you feel grounded when you feel emotionally aroused. To practice this skill, focus on one area at a time. For instance, change the temperature by jumping into a cold shower. Or, practice paced breathing by inhaling deeply for five counts and then exhaling for five counts.
Accepting Reality: Accepting reality means understanding what you can and cannot change. Many times, we want to fix things that are beyond our level of control. For example, we want other people to act in certain ways or want specific events to unfold with desired outcomes. Accepting reality means making the most of the situation without trying to alter it.
DEAR MAN: Dear Man is an acronym that stands for describe, express, assert, reinforce, mindful, appear, negotiate. Each of these points allows you to practice healthier and more transparent communication. Describe situations objectively, express your feelings, assert your needs transparently, reinforce people who respond positively, be mindful of your intentions, appear confident, and be open to negotiation.8
GIVE: GIVE stands for ‘gentle, interested, validate, easy.’ In other words, don’t attack. Instead, show a genuine desire to care about the other person’s feelings. Validate their experiences and aim to have an easygoing, friendly attitude.
FAST: FAST stands for ‘fair, apologize, stick to values, truthful.’ Aim to be fair to others and yourself, avoid apologizing unless an apology is warranted, stay true to your morals and values, and aim to be truthful in your disclosures.
Opposite action: Aim to engage in an opposite behavior to your emotions. For example, you might typically isolate yourself from loved ones if you feel sad. If you practice the opposite action, you will make an effort to reach out to your friends and spend time with them.
Check the facts: Focus on the evidence when understanding your emotions. To check the facts, you can ask yourself, what specific situation triggered my emotion? What assumptions might I be making about the event right now?
Paying attention to positive events: We tend to focus more on adverse circumstances than positive ones. Strive to add more positivity to your life by implementing self-care activities that feel enjoyable. For example, make a plan to take a bath and relax or schedule having coffee with a favorite friend.9
What Is the Difference between DBT and CBT?
DBT and CBT focus on behavioral changes and understanding the relationship between thoughts, feelings, and responses. Both treatments are a form of ‘talk therapy,’ where you build a relationship with your therapist to facilitate sustainable change.
However, CBT clinicians typically focus on:
- Identifying and changing cognitive distortions.
- Providing brief, specific, collaborative therapy.
- Understanding logic and rationale to understand behavior.
CBT, in its structured form, tends to be factual and objective. Therefore, by changing X, you may start to feel Y, which can lead to Z. Over time, this pattern allows for positive behavioral change and improved quality of life.
DBT is rooted in CBT principles, but it emphasizes spiritual, emotional, and relationship aspects. DBT tends to focus more on identifying (and coping with) extremities, particularly when it comes to emotions.
DBT also integrates concepts of mindfulness and distress tolerance. While these are also introduced in CBT, this integration tends to focus more on internal validation and radical acceptance.10
Finally, DBT is a more comprehensive approach, and it can be highly beneficial for individuals with severe mental illness. If you are participating in a formal DBT treatment, you will be attending individual and group therapy, and you will be allowed to contact your therapist in between sessions. This may be an option in CBT, but it is not inherently part of the process.
Is DBT Effective?
Yes, empirical data shows that DBT can be highly effective in treating crisis problems like suicidal behavior, self-harm, depression, anger issues, disordered eating, ADHD, emotional dysregulation, and anxiety.11
Furthermore, research on DBT with adults also demonstrates lower dropout rates. Premature dropouts can be a serious problem in mental health treatment. If a client ends treatment abruptly, they may be at an increased risk for emotional distress. Commitment to treatment remains an ongoing challenge for many therapists and clients alike.
Finally, research on youths with histories of suicide attempts and self-harm participating in DBT showed they engaged in more individual and group treatment sessions than those attending other supportive therapies. DBT also yielded better results for family involvement, which can be a crucial component for treatment success.12
DBT is an effective treatment for people struggling with moderate or severe mental health issues. It can support you in understanding your feelings, managing your reactions, and improving your interpersonal skills.
To learn more about how DBT can help you or a loved one, contact us today.