Dialectical Behavior Therapy (DBT)

What is DBT?

DBT, short for dialectical behavior therapy, is a structured treatment with four modules.1 It's been widely studied. It's accepted as a common therapy for various mental health 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 negative emotions and harmful behaviors. Learning to tolerate and accept different thoughts promotes healthier coping.  

The 'B' in DBT stands for behavioral and focuses on: 

• helping clients address unwanted behaviors 

• teaching problem-solving skills 

• changing pattern 

DBT is a standard recommendation for treating Borderline Personality Disorder (BPD). It's 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. 

More people are becoming aware of BPD. But it is still largely misunderstood and stigmatized. People often confuse it with other conditions like:  

• bipolar disorder  

• depression 

• substance use disorders 

• 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: 

• Eating disorders like anorexia, bulimia, or binge eating disorder 

• Substance use disorders 

• Mood disorders, such as major depression and bipolar disorder 

• Post-traumatic stress disorder (PTSD)  

• Severe behavioral and emotional issues 

DBT History

DBT integrates concepts from cognitive-behavioral therapy, group therapy, attachment-based principles, and spirituality.  

In the 1970s, Dr. Marsha Linehan started using  cognitive-behavioral therapy (CBT). She used it with female clients who had long e histories of chronic suicide attempts and self-harm. Dr. Linehan was trained as a behaviorist and suicide researcher. She recognized that these women met the criteria for borderline personality disorder.  Not  depression or  anxiety.

In her initial work, Linehan found that standard CBT wasn’t working with some of her clients. They didn’t respond as the treatment protocol predicted they would. Instead, she found that some of her clients often withdrew from treatment because they were angry at their therapist. They were unconsciously rewarding or punishing them for different behaviors. She also realized that CBT couldn't effectively address all the immediate issues. There wasn't enough time to help clients learn new coping skills. 

Linehan had a mental illness herself. She now refers to it as borderline personality disorder.. In recent work, she has described a tumultuous past. It was often marked with suicide attempts, inpatient hospitalization, and self-harm.

Linehan began developing the foundations of DBT in the 1980s. Today, thousands of clinicians practice DBT helping clients with numerous issues. 

What to Expect in DBT

DBT may vary between different providers and locations. But, here are some common themes you can expect during your treatment. 

Pre-Assessment  

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 start 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 

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 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. It can help decide what to work on in later sessions. 

Group Therapy  

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. 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 DBT Skills?

DBT therapists teach their clients many skills to strengthen skills within the four modules. Therefore, it’s important to learn many different techniques. Some will work better than others. It's best to have a toolbox full of coping skills to refer to when needed. 

Mindfulness 

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.

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. 

Distress Tolerance 

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, you can practice paced breathing. Take a deep breath for five counts, then exhale 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.  

Interpersonal Effectiveness 

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 clearly. Share your feelings and state your needs directly. Appreciate positive responses and be aware of your intentions. Show confidence and be willing to negotiate. 

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.  

Emotion Regulation  

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 doing self-care activities.le. For example, make a plan to take a bath and relax or schedule having coffee with a favorite friend.

What Are the Benefits of DBT?

Empirical data shows that DBT can be highly effective in treating crisis problems. These include: 

•  suicidal behavior  

• self-harm 

• depression  

• anger issues  

• disordered eating  

• ADHD  

• emotional dysregulation  

• anxiety 

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. 

Research on youths with histories of suicide attempts and self-harm in DBT revealed that they attended more individual and group treatment sessions. As compared to those in other supportive therapies. DBT also produced better results for involving families. This is crucial for treatment success.

How Long Does It Take for DBT to Work?

Structured DBT requires a long-term commitment. Patterns can be challenging to break. It's important to give yourself time to practice new ways of coping.  

Most DBT therapists ask that clients offer at least six months to take part in treatment. . Many DBT programs provide services that range anywhere from six months to over two years. In its standard form, this treatment often includes: 

• Individual therapy 

• TeleMental Health therapy 

• Weekly skills groups 

In its structured approach, completing the full skills curriculum takes 24 weeks.  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. 

What Is the Difference Between DBT and CBT?

DBT and  CBT both focus on behavioral changes. As well as understanding the relationship between thoughts, feelings, and responses. Both treatments are a form of ‘talk therapy’. You build a relationship with your therapist to help sustainable change.  

But, CBT clinicians typically focus on: 

• Identifying and changing cognitive distortions. 

• Providing brief, specific, collaborative therapy. 

• Understanding logic and rationale to understand behavior. 

In its structured form, CBT tends to be factual and objective. By changing X, you may start to feel Y, which leads to Z. Over time, this encourages positive behavioral change. It enhances the quality of life. 

DBT is based on CBT principles but emphasizes spiritual, emotional, and relational aspects. It particularly focuses on identifying and coping with extremes, especially about emotions. 

DBT also integrates mindfulness and distress tolerance concepts. While these are also introduced in CBT, this integration tends to focus more on internal validation and radical acceptance.

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. You will be allowed to contact your therapist between sessions. This may be an option in CBT, but it is not inherently part of the process.  

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  

• improving your interpersonal skills 

To learn more about how DBT can help you or a loved one, contact us today.