Dialectical Behavior Therapy (DBT)

A comprehensive therapy designed to help individuals manage intense emotions, improve interpersonal relationships, and enhance overall mindfulness and well-being.

Overview

Dialectical Behavior Therapy (DBT) is a specialized form of Cognitive Behavioral Therapy (CBT) created by Dr. Marsha Linehan initially to treat borderline personality disorder (BPD) and chronic suicidality. It has since been adapted to treat a wide range of conditions involving emotional dysregulation. DBT balances acceptance and change strategies, teaching clients to accept their experiences while working to change behavioral patterns and develop new skills.

Combined Top-Down & Bottom-Up Approach

Is This You?

"I'm so tired of being completely overwhelmed by my emotions—they seem to control my entire life."

"One minute I'm fine, and the next I'm in complete emotional crisis with no middle ground."

"My relationships keep falling apart because I can't regulate my reactions."

"I've tried traditional therapy, but nothing has helped me manage these intense feelings."

Who Benefits Most

DBT was originally designed for individuals with borderline personality disorder, but has shown effectiveness for many conditions characterized by emotional dysregulation:

  • Borderline Personality Disorder (BPD) - the condition for which DBT was specifically developed and has the strongest evidence base
  • Chronic suicidal ideation and self-harm behaviors - DBT directly addresses these behaviors with specific protocols
  • Emotional dysregulation disorders - including mood disorders with intense emotional swings
  • Eating disorders - particularly those involving impulsive behaviors like binge eating and purging
  • Substance use disorders - especially when emotional dysregulation drives substance use
  • Post-traumatic stress disorder (PTSD) - particularly complex trauma with emotional regulation difficulties
  • Individuals with multiple treatment failures - who haven't responded to other therapeutic approaches
  • Adolescents with multiple problems - self-harm, suicidality, and emotion regulation difficulties

Especially Effective For:

DBT is particularly well-suited for individuals who:

  • Experience emotions as overwhelming or out of control
  • Engage in impulsive or self-destructive behaviors to cope with distress
  • Have difficulty maintaining stable relationships
  • Struggle with black-and-white thinking
  • Have a history of multiple unsuccessful treatment attempts
  • Are committed to making significant life changes and willing to engage in skills practice

How It Works

DBT combines cognitive-behavioral techniques with mindfulness principles derived from Eastern practices. It utilizes both top-down (cognitive) and bottom-up (experiential) approaches to help clients regulate emotions and develop healthier behavioral patterns. Standard DBT includes four treatment components:

Treatment Components:

  • Individual therapy - weekly sessions focused on applying DBT skills to personal challenges and life events
  • Group skills training - structured weekly classes teaching specific DBT skills
  • Phone coaching - between-session support for applying skills in crisis moments
  • Therapist consultation team - support for therapists to maintain the DBT model and approach

Mindfulness

The core skill upon which all other skills are built. Mindfulness in DBT involves developing awareness of thoughts, emotions, physical sensations, and the environment without judgment.

Key skills include:

  • "What" skills (observing, describing, participating)
  • "How" skills (non-judgmentally, one-mindfully, effectively)
  • Practices for strengthening the "wise mind" (balance between emotional and rational mind)

Distress Tolerance

Skills for coping with painful emotions and difficult situations without making things worse through impulsive reactions.

Key skills include:

  • Crisis survival strategies (TIPP, distraction, self-soothing)
  • Radical acceptance of painful realities
  • Turning the mind toward acceptance
  • Willingness vs. willfulness

Emotion Regulation

Techniques for understanding, recognizing, and managing emotional responses more effectively.

Key skills include:

  • Identifying and labeling emotions
  • Identifying functions of emotions
  • Reducing vulnerability to negative emotions (PLEASE skills)
  • Increasing positive emotions
  • Acting opposite to emotional urges when appropriate

Interpersonal Effectiveness

Strategies for navigating relationships effectively while maintaining self-respect and strengthening connections.

Key skills include:

  • DEAR MAN (getting needs met effectively)
  • GIVE (building and maintaining relationships)
  • FAST (maintaining self-respect)
  • Balancing priorities and demands
  • Identifying and setting appropriate boundaries

The DBT Process:

DBT treatment is typically structured in stages:

  1. Pre-treatment - Orientation and commitment to the DBT approach
  2. Stage 1 - Achieving behavioral control and safety (reducing self-harm, suicidality, and therapy-interfering behaviors)
  3. Stage 2 - Addressing emotional experiencing (processing trauma, grief, and previously avoided emotions)
  4. Stage 3 - Tackling ordinary problems of living and building a life worth living
  5. Stage 4 - Finding joy and completeness (for some clients)

DBT typically requires a significant time commitment (often a year or more), with clients attending both individual therapy and skills group each week, plus practicing skills between sessions.

Example Case: Dog Bite Phobia

The Situation:

Olivia was bitten by a dog when she was 10 years old. Now at 35, she experiences intense anxiety around all dogs, regardless of size or breed. She crosses the street when she sees someone walking a dog, avoids visiting friends with pets, and experiences panic symptoms (racing heart, sweating, difficulty breathing) when a dog approaches her. This phobia has significantly limited her social life and ability to enjoy outdoor activities. When faced with dogs unexpectedly, she sometimes lashes out at the dog owner or has emotional meltdowns that affect her relationships.

How DBT Would Approach This:

  1. Assessment and case conceptualization: The DBT therapist would evaluate how Olivia's dog phobia fits into her overall pattern of emotional and behavioral dysregulation. They would examine how her fear-based behaviors (avoidance, emotional outbursts) impact her life and relationships, and identify her personal goals.
  2. Chain analysis: For specific incidents (like a recent emotional meltdown after encountering a dog), the therapist would conduct a detailed chain analysis to understand the sequence of events, thoughts, emotions, and behaviors, identifying points for potential intervention.
  3. Core mindfulness skills: Olivia would learn to observe and describe her physical and emotional reactions to dogs without judgment. Mindfulness practices would help her notice when she's entering a state of panic and stay present rather than becoming overwhelmed by fear.
  4. Emotion regulation skills: The therapist would help Olivia:
    • Identify the components of her fear response
    • Recognize how her thoughts intensify her emotional reaction
    • Learn to check the facts about the actual danger present
    • Practice opposite action by gradually approaching safe dogs while managing her fear response
    • Reduce vulnerability to intense emotions by maintaining adequate sleep, nutrition, and exercise (PLEASE skills)
  5. Distress tolerance skills: Olivia would develop strategies to manage intense fear when unexpectedly confronted with dogs:
    • TIPP skills (Temperature change, Intense exercise, Paced breathing, Progressive muscle relaxation) to reduce physiological arousal
    • Distraction techniques for temporary relief until she can use more adaptive coping
    • Self-soothing using her five senses
    • Radical acceptance of the fact that dogs are a part of everyday life
  6. Interpersonal effectiveness skills: Olivia would learn to:
    • Communicate effectively with dog owners using DEAR MAN skills
    • Explain her needs in dog-related situations assertively but without hostility
    • Maintain relationships with friends who have dogs by negotiating comfortable arrangements
  7. Gradual exposure combined with skills use: With her new DBT skills as support, Olivia would create a hierarchy of dog-related situations and gradually expose herself to them, applying appropriate skills at each step.

Expected Outcomes:

Through DBT, Olivia would likely develop a more nuanced and managed response to dogs. While she might still experience fear, she would have skills to prevent it from controlling her behavior. She would learn to tolerate distress without avoidance or outbursts, maintain relationships despite her fear, and gradually expand her comfort zone. The comprehensive approach of DBT would address not just the specific phobia but also the broader patterns of emotional response and interpersonal functioning affected by her fear.

Clinical Research

DBT is one of the most extensively researched treatments for borderline personality disorder and has accumulated substantial evidence for other conditions as well.

Key Findings:

  • Significant reductions in suicidal behavior and self-harm
  • Decreased psychiatric hospitalizations and emergency visits
  • Improvements in emotional regulation and distress tolerance
  • Better treatment retention compared to other therapies
  • Effective adaptations for teens, eating disorders, substance use

Strengths:

  • Comprehensive approach addressing multiple problem areas
  • Strong evidence base, particularly for BPD and suicidality
  • Balances acceptance and change strategies
  • Practical skills that can be used in everyday life

Limitations:

  • Intensive time commitment (weekly individual and group sessions)
  • Limited availability in some geographic areas
  • Requires significant client commitment to skills practice
  • May be challenging for clients with cognitive limitations

Key Research Papers:

Professional Organizations and Resources: