Dialectic behavior therapy (DBT) is a therapeutic method used to treat many mental health conditions. It includes emotion management skills training, individual and group therapy, and guidance for building healthy social relationships.
This method works slowly and methodically to bring about positive changes and well-being. This deep dive into DBT will give you a better idea of what this method is, how it’s used, and the mental health conditions it’s used for.
What Is DBT?
The “dialectic” part of DBT refers to this method’s use of opposites to help bring the person receiving treatment out of extreme positions or thoughts. For example, a therapist may challenge someone with thoughts of self-harm using the opposite view or idea. However, DBT also requires that DBT therapists push themselves away from extreme positions by acknowledging where the client is in their journey and validating their feelings.
DBT also includes behavior change strategies and exercises borrowed from cognitive behavior therapy (CBT). However, a key tenant of DBT is that you set your goals, not the therapist. A DBT therapist may help you figure out your goals. Then, they help you achieve them by teaching strategies and coping skills that support your goals.
To help clients deal with intense emotions, DBT therapists function under a few important assumptions that include:
- The person they’re working with has difficulty regulating emotions
- Fair or unfair, this person may not have caused their problems, but it is their responsibility to solve them
- Treat the client where they are without assigning blame
- Clients set their goals
These key assumptions underlie the alliance between the therapist and the person they’re treating to build trust further.
The History and Development of DBT
Dr. Marsha Linehan developed DBT in the 1970s as a treatment for borderline personality disorder (BPD) and those with thoughts of self-harm. Dr. Linehan recognized that other methods, such as the highly adaptable and successful CBT, didn’t quite meet the needs of people with BPD. She began by integrating problem-solving strategies into treatment. However, these first problem-solving strategies led to strong pushback because they forced difficult life changes on people, invalidating their feelings and experiences.
The therapists then added warmth and acceptance, yet it didn’t bring about the needed changes in and of itself, and those getting treatment were still frustrated in their difficult situations. With time and practice, DBT began to include a shift in mindset for both the client and therapist. For therapists, that meant:
- Accepting patients as and where they are
- Slowly progressing, even knowing that self-harm was possible
- Approaching each client with humility and acceptance
Modern DBT incorporates these acceptance-based treatment assumptions and positive acknowledgment. However, the therapist approaches it with accepting each person’s past and present with realistic limits on the future. The acceptance of the present comes from mindfulness training, one of four training modules in DBT that’s become an integral part of DBT treatment.
Today, after extensive DBT study, there are three specific goals, which include:
- Problem-solving
- Regulating emotions
- Learning and developing coping skills
However, the therapist works with the person seeking treatment to determine how to reach these goals.
Who Should Get DBT?
According to John’Neiska Williams, a licensed professional counselor with Grow Therapy, “DBT is most often used with women with a BPD or suicidal behaviors or self-harm. It was initially designed for these disorders and still has the highest percentage amongst several populations with these disorders at 67%. Undiagnosed bipolar is growing more common as a prognosis for BPD, and for that reason, the use of DBT is growing as well with that population.”
Over the last couple of decades, DBT has also been used in treating patients with mental health disorders that involve powerful emotions and problematic thought patterns, such as:
- Borderline personality disorder
- Depression
- Anxiety
- Those with self-harming behavior
- Post-traumatic stress disorder (PTSD)
- Eating disorders
- Substance use disorders
- Trauma survivors
However, Williams says, “Anyone with any type of mood disorder, behavior, or conduct disorder, or difficulty with regulating emotions can be a good candidate for DBT. CBT teaches one how to change that negative thinking and push for more positive behaviors, but if you can’t get to the action of change and are stuck in the contemplation or preparation stage of change, DBT may be more appropriate. It will help bring acceptance and change together to put more action behind changing unhealthy behaviors.”
DBT is also an option for those who have multiple disorders, like someone with eating disorders who also has also attempted suicide or someone with bipolar disorder and PTSD.
Benefits of DBT
For many people, DBT offers immediate acceptance and validation of their feelings. But DBT goes beyond acceptance to include practical skills training that:
- Improves daily functioning
- Increases hope of continued improvement
- Works for those with suicidal thoughts
- Utilizes a professional group or team approach to therapy
- Helps people control and adjust to strong and quickly changing emotions
- Offers practical skills to improve interpersonal communication and relationships
- Assist people with managing anger more effectively
- Communicate more assertively
- Set boundaries to make their relationships healthier
Additionally, DBT works through four very specific stages, offering structure, and serves as a long-term outpatient treatment option.
The Four Modules of DBT
The DBT framework creates a hierarchy of what to treat and when, with the first stage decreasing any immediate harm or interfering behaviors. You then progressively move through the steps, incorporating what you’ve previously learned as you progress.
Module One: Mindfulness
Mindfulness, a core DBT skill, builds present-moment awareness or attention to build acceptance and distress intolerance. Mindfulness, as used in DBT, encourages:
- Acceptance
- Curiosity
- Friendliness
- Openness
- Non-judgment
- Compassion
- Kindness
Mindfulness helps people to accept contradictions in their lives. They can accept themselves while still working to change destructive thoughts and distressing emotions. For example, they can have a bulimia diagnosis without beating themselves up mentally while working on developing healthy eating habits.
DBT mindfulness training uses shorter, less formal exercises than some mindfulness-centric methods, like mindfulness-based stress reduction (MBSR) or mindfulness-based cognitive therapy (MBCT).
However, mindfulness persists throughout the other DBT modules. For example, a therapist may focus on being mindful of your current emotions while building emotional awareness or emphasizing mindfulness of your current thought patterns when developing distress tolerance.
Module Two: Distress Tolerance
Distress tolerance is a person’s ability to tolerate or withstand negative or uncomfortable emotional states, like stress, sadness, or anger. It’s designed to develop coping and self-soothing skills that don’t include problematic or destructive behaviors. However, it’s important to understand that improving distress tolerance doesn’t make distress disappear. Rather, it’s designed to prevent you from feeling overwhelmed.
Therapists can teach you new tolerance-related skills based on what you need. There may be time spent developing skills for work, then developing skills for home or in public. It’s also a process of learning about yourself and what works for you, and when. Some skills, for example, may work at home but not at your job. Over time, improved distress tolerance can result in increased stability.
Module Three: Emotion Regulation
Emotion regulation, the third stage of DBT, typically includes three goals:
- Understand your emotions
- Reduce emotional vulnerability
- Decrease emotional suffering
The first step is usually learning to identify and name your emotions. This part of DBT doesn’t label emotions as good or bad. It emphasizes that emotions, even negative ones, are part of life and can’t nor should be avoided.
Understanding and regulating emotions can help you reduce avoidance behaviors when you feel stressed. Avoidance can lead to unhealthy self-soothing or self-medicating, such as substance abuse or self-harming behavior. Understanding and regulating your emotions can break those habits and replace them with healthier ones.
Module Four: Interpersonal Effectiveness
This fourth stage helps people understand and handle conflict, develop new relationships, and end or maintain old ones. It focuses on strengthening interpersonal relationships through the following:
- Objective effectiveness
- Relationship effectiveness
- Self-respect effectiveness
Objective effectiveness involves identifying the purpose or goal of your interactions. Understanding the plan can help adjust interactions to reach your desired end-result. Relationship effectiveness involves setting goals for specific relationships, whether with a spouse, parent, or coworker. You may even find some relationships are harmful, at which point you can adjust goals to protect yourself.
Self-respect effectiveness, as the name implies, focuses on strengthening self-respect. It includes activities to help you set healthy boundaries, confidently say no, and make effective requests.
The Evidence-Based Effectiveness of DBT
Dialectic behavior therapy has a strong evidence-based foundation. There are repeatable links between what research studies show and the results from practical applications in real-life therapy settings with clinicians and therapists.
DBT, like other evidence-based practices, has extensive scientific studies behind it, with measurable evidence to support the modules and steps described in DBT. The evidence is so strong for DBT’s use in treating BPD that it’s the go-to therapy for people with this condition.
Aside from BPD, its ability to strengthen understanding and regulation of emotions and make behavior changes has led to its use for many other disorders. DBT’s use with other disorders isn’t as heavily researched at this point as its use with BPD. But the evidence for its successful use with other disorders continues to grow.
The evidence favoring DBT rests on the framework with the four modules. Additionally, it relies on using a mix of:
- Individual therapy
- Group skills training/therapy
- In-between session coaching/phone coaching
- Consultation with a health team
A therapist trained in DBT will be familiar with this framework and can help put it in place in ways that fit each individual. Everyone is different, and while DBT has a definitive framework, it’s adaptable.
Integrating DBT with Other Therapies
“In my practice, I integrate DBT techniques often with CBT techniques. CBT helps clients become aware of thoughts and feelings [that] ordinarily they aren’t able to express or that are troublesome or difficult. It also helps redirect those thoughts and puts them into words and verbalizations,” says Williams. “I integrate this with DBT because DBT helps regulate those emotions and make healthier, less self-destructive and -sabotaging decisions, such as safety and self-acceptance.”
Williams is not alone in using CBT with DBT. Cognitive behavior therapy focuses on thought patterns and emotions and how they relate to our choices and actions. It naturally fits within DBT’s goals to learn emotion regulation and successful personal relationships.
There are many types of therapy, and a licensed therapist can work with you to determine which ones will help you. They may use DBT along with more detailed mindfulness therapies or motivational interviewing to help you narrow down your goals.
Final Thoughts
DBT was designed and has become an effective treatment for BPD, but it’s proven helpful in many circumstances when intense emotions and harmful behaviors are present. It provides a strong framework with definitive stages that build a structured but adaptable therapy approach. This skill-building, emotion-regulating method takes time, patience, and a strong alliance with a therapist, and that’s where we can help.
Grow Therapy connects you with licensed therapists from many disciplines, with many trained in DBT and other therapeutic techniques. Our platform helps you find providers that are in-network with your insurance for both online and/or in-person therapy so you can get the affordable help you need.
