Dialectical behavior therapy (DBT) helps treat emotional dysregulation, self-harming behavior, suicidal ideation, and other mental health and/or behavioral issues. It is a structured, skills-based approach that helps people live “a life worth living.” This means a trained DBT therapist teaches patients the skills they need to accomplish their goals and reduce behaviors that get in the way of achieving these goals.
There are four core modules of DBT skills:
- Mindfulness: Increasing awareness and focus in the present moment
- Emotion Regulation: Navigating up-and-down emotions
- Interpersonal Effectiveness: Managing relationships
- Distress tolerance: Tolerating difficult emotions safely, reduce suffering through reality acceptance
These skills are the core pillars of DBT. Therapists use them during individual sessions, group sessions, and one-on-one coaching during crises.
For adolescents, therapists add a fifth DBT module called Walking the Middle Path. These skills teach teens how to find balance between two extremes.
History of DBT
Dr. Marsha Linehan developed dialectical behavior therapy in the late 1980s. As a clinician, she was trained in cognitive behavioral therapy (CBT), but found that CBT wasn’t working effectively for her patients diagnosed with borderline personality disorder (BPD). Many of them did not make progress in treatment. They displayed extreme emotions, engaged in self-harming behavior, and frequently attempted and completed suicide.
Linehan realized these patients needed a heavy dose of self-acceptance first, before they began trying to change their behavior. This insight evolved into her theory of “radical acceptance.” She saw that people were more willing to change when immersed in an atmosphere of affirmation from the beginning of treatment. After establishing this atmosphere of acceptance and affirmation, she worked on helping them stop their unhealthy behaviors.
As she wrote in her book Cognitive Behavioral Treatment of Borderline Personality Disorder:
“DBT is very simple. The therapist creates a context of validating rather than blaming the patient, and within that context the therapist blocks or extinguishes bad behaviors, drags good behaviors out of the patient, and figures out a way to make the good behaviors so reinforcing that the patient continues the good ones and stops the bad ones.”
DBT is based on evidence and data derived from peer-reviewed research, which means DBT skills are scientifically proven to work. Every aspect of DBT is formalized. DBT techniques evolve over time, based on the latest research developments. DBT’s efficacy and effectiveness have been verified by random-controlled trials (RCT) in both academic and community settings since the 1980s.
What’s the Difference Between CBT and DBT?
Many people have questions about the differences between CBT and DBT.
We’ll clarify those differences now.
During CBT, patients work with a therapist to change their thinking patterns in order to change their emotions and behavior. In DBT, therapists work with patients to change negative behaviors first. Patients learn practical, actionable skills they can apply immediately. This is a primary difference between DBT and CBT: DBT focuses on behavior first, whereas CBT focuses on thoughts first.
That’s why DBT – in lieu of CBT – has gained widespread recognition as an effective treatment for self-injurious behavior, suicidal behavior, and other behaviors or symptoms that pose an immediate danger to the person experiencing them. The main priority of DBT is to get the patient to stop life-threatening behaviors immediately. Once the dangerous behaviors are under control, a DBT therapist works with a patient on changing the maladaptive thoughts at the root of those behaviors.
In contrast to CBT, DBT emphasizes accepting life circumstances, as they are now, in the present moment, while working to improve them. DBT is based on the idea that persistent difficulties in regulating emotion influences all aspects of behavior. CBT, on the other hand, is based on the idea that thoughts impact and influence feelings and behavior. That’s why some therapists call CBT “inside-out” therapy, while they refer to DBT as “outside-in” therapy.
What Does Dialectical Mean?
The word “dialectical” means “acting through opposing forces.” It also means the ability to hold two opposing thoughts in the mind at the same time. Dialectical behavior therapy asks patients to do just that: consider two opposing ideas in their mind at once.
For example – if an anxious teen frequently says, I do everything wrong. I can’t get anything right, DBT encourages them to replace that with I am proud of myself, and I must still try to improve. Note that DBT discourages the use of the conjunction “but,” as it negates, rather than affirms, the first half of the sentence.
That’s how the concept of acceptance works hand-in-hand with the concept of the dialectic.
DBT discourages all-or-nothing thinking patterns. Instead, it encourages finding the middle path between two extremes. This philosophy was inspired by Zen practices, which Linehan was studying when she created DBT.
The dialectical perspective is specifically beneficial for teenagers, whose extreme, all-or-nothing thinking often influences their impulsive adolescent behavior. That’s why adolescent DBT includes a fifth core skill, Walking the Middle Path, which is not included in standard DBT for adults. Middle Path skills help adolescents balance extreme thinking patterns, behaviors, and approaches to life.
Applying a Dialectical Approach
Consider how DBT can help someone change extreme emotions and thoughts. Instead of thinking I’m all good or I’m all bad, dialectical behavior therapy encourages replacing those two extremes with Sometimes I do things that aren’t effective, and other times I do things that are. This helps increase self-acceptance and serves as an effective method for changing behavior.
This dialectical way of thinking also applies in cases of relapse. If an adolescent who struggles with alcohol use breaks their sobriety with a drink at a party, they may immediately think “I relapsed – I’m a terrible person.” Overwhelmed by waves of guilt and failing to place this one drink in the context of their overall progress, they may continue their behavior with binge-drinking and engage in an escalating pattern of life-interrupting behavior.
This illustrates DBT’s key philosophy: a person can learn to step out of an extreme, all-or-nothing pattern of thought and instead take a dialectical perspective. It’s all about accepting yourself– flaws and all – while telling yourself you can change. It’s radical acceptance and acknowledgment to improve. It’s validating yourself and solving the problems in your life.
The Biosocial Theory
Dialectical behavior therapy is based on the theory that emotional dysregulation is a result of both nature and nurture. Some teens are born highly emotionally sensitive and highly emotionally reactive, with a slow return to a stable emotional baseline. But this alone does not typically result in mental health or behavioral issues. Problems with mental health or behavior may be a result of biological vulnerabilities interacting with an invalidating environment.
An invalidating environment may include one or more of the following:
- Emotional, physical or sexual abuse
- Instability and/or family conflict
- Emotional neglect from a parent or caregiver
- Parent or caregiver mental health or substance use issues
- Parent chronically minimizing, dismissing, or negating their emotions
When a parent invalidates a child, they do not affirm their emotional needs. For example, they may tell a child to stop crying if the child is upset, rather than comfort them. Or they might ignore the child and retreat into themselves because they cannot handle the neediness. Continuous, repeated invalidation teaches a child not to trust themselves or their emotions. They stop expressing their feelings and instead learn to bury, repress, and hide their emotions.
When an invalidating environment interacts with a naturally reactive disposition, it can result in mental health issues. DBT assumes that this interaction is the root of most emotional and mental health problems.
Core Assumptions of DBT
All DBT therapists approach their clients while operating under a specific set of assumptions created by Dr. Linehan. These assumptions are divided into two categories.
Assumptions about Clients:
- People are doing the best that they can.
- People want to improve.
- People must learn new behaviors both in therapy and in the context of their day-to-day life.
- People cannot fail in DBT.
- People may not have caused all of their problems, but they have to solve them anyway.
- People need to do better, try harder, and be more motivated to change.
- The lives of people who are suicidal are unbearable as they are currently being lived.
Assumptions about DBT Therapists:
- The most caring thing a therapist can do is help people change in ways that bring them closer to their own ultimate goals.
- Clarity, precision, and compassion are of the utmost importance.
- The treatment relationship is a real relationship between equals.
- Principles of behavior are universal, affecting clinicians no less than clients.
- DBT therapists can fail.
- DBT can fail even when therapists do not.
- Therapists treating BPD patients need support.
These two lists are adapted from the book Dialectical-behavioral therapy for borderline personality disorder by Dr. Marsha Linehan.
The DBT House of Treatment
The DBT House of Treatment model, created by Dr. Linehan for treating children and adolescents, delineates four levels of dialectical behavior therapy. As behaviors and goals change over time, teens can move through all these stages of treatment, starting from the “basement” and finally climbing up to the “roof.”
DBT Stage 1
If a teen chronically engages in life-threatening behaviors, they’re in Stage 1 of DBT. Stage 1 is otherwise known as “the basement” or “hell.” A teen in Stage 1 may be addicted to alcohol or drugs, engaging in self-harming behaviors, and/or attempting suicide. Teens in this stage are in so much internal pain and suffering that they cannot cope with life. They’re in distress 24/7.
This stage corresponds to treatment at a residential treatment center or psychiatric hospital, where teens receive supervised care 24/7. Inpatient treatment focuses on eliminating all life-threatening behaviors, removing treatment-interfering behaviors, and reducing behaviors that severely impact functioning. The number one focus is crisis management and stabilization.
DBT Stage 2
In Stage 2 of DBT, otherwise known as “the first floor,” teens are still in pain, but in “quiet desperation.” Their behaviors are not life-threatening. However, they still need substantial support in regulating their emotional volatility.
Therapy in Stage 2 of DBT focuses less on eliminating life-threatening behavior and more on emotional stability. DBT helps adolescents increase emotional self-awareness, replace negative thinking patterns with positive ones, and become more comfortable living with themselves. Stage 2 of DBT is also the stage when teens work more comprehensively on recovering from trauma or posttraumatic stress disorder (PTSD).
DBT Stage 3
During this stage – the “second floor” – teens learn more and more about DBT skills and begin applying those skills to cope with everyday issues in life. In Stage 3, DBT addresses ways to help teens solve daily problems and issues. Teens learn to identify their values and maintain positive behaviors and thinking patterns. At this point, teens may live at home and go to school. However, they still need help managing emotions on a day-to-day basis and support in accomplishing their life goals.
DBT Stage 4
In the House of DBT, Stage 4 – the “Roof” – symbolizes life after leaving the four walls of structured treatment. During Stage 4, teens should continue applying their DBT skills to seek out opportunities that fulfill them and make them happy. When life presents routine challenges and obstacles, teens in Stage 4 should be able to apply DBT skills to cope independently and “achieve a life worth living.”
Four Components of Treatment
When Dr. Linehan developed DBT in the 1980s, she delineated four components of treatment. These four treatment delivery requirements were originally meant to be implemented in a standard outpatient setting. However, since then, many residential treatment centers and intensive outpatient programs have adapted them to fit the needs and constraints of their specific settings. DBT therapists typically receive formal training for this purpose. At Behavioral Tech, for instance, the DBT training institute for clinicians, founded and run by Dr. Linehan herself, this training requires weeks of intense coaching and instruction.
Below are the four components of DBT treatment, as delineated by Dr. Linehan:
- Individual therapy
Treatment providers offer weekly individual and family DBT therapy sessions. In 1:1 sessions, therapists use dialectical behavior therapy as the primary (or exclusive) therapeutic modality. In between sessions, the therapist will instruct clients to track their own emotions and behavior. For example, using Daily Diary Cards.
- Skills training
Teen treatment centers should offer DBT skills-training groups. In these groups, clients learn the five core modules of DBT together with peers. Each group session focuses on one of the five modules. After each session, the facilitator will assign homework. This homework usually consists of practicing and applying a certain DBT skill independently before the next class.
- Skills coaching
Teen treatment centers should offer DBT skills-coaching between sessions. When a teen needs immediate help, they should be able to contact their therapist at any given time – day or night – and receive relatively instant coaching. This is especially beneficial when a teen has an urge to engage in negative behaviors or needs help implementing a coping skill. The coaching may include instructing the client to problem-solve, for example, by using a Behavior Chain Analysis, another DBT tool.
- Consultation teams
Every week, all DBT-trained staff should meet to evaluate their treatment administration and patient progress. The primary goals of the consultation team are to enhance the motivation and capabilities of the DBT providers. DBT emphasizes that the relationship between therapist and patient is an equal one. Therapists practice DBT skills in their own lives so they can authentically model them for their patients.
A DBT-comprehensive teen treatment center includes all the standard treatment components described above, while a DBT-informed program includes only one, two, or three from the list.
Typically, DBT-informed programs choose to include the skills-training groups component. Research shows that a DBT skills group by itself can reduce suicidality, self-harming behavior, depression, and anxiety.
What Does DBT Treat?
While Dr. Linehan saw success using DBT with her patients diagnosed with borderline personality disorder, this evidence-based treatment is effective in many other populations: patients with depression, anxiety, posttraumatic stress disorder, substance use disorder, eating disorders, and other mental health issues.
Studies show how patients with high emotional sensitivity and high reactivity, especially teens who frequently self-harmed and attempted suicide, responded better to DBT than to other therapies. In many instances, DBT was the only therapy that worked.
According to Behavioral Tech, Dr. Linehan’s training institute, DBT effectively helps:
- Suicidal and self-harming adolescents
- Pre-adolescent children with severe emotional and behavioral dysregulation
- Major depression
- Posttraumatic stress disorder related to childhood sexual abuse
- Borderline personality disorder/symptoms
- Narcissistic/antisocial/histrionic personality disorders
- Attention deficit hyperactivity disorder (ADHD)
- Bipolar disorder
- Trans-diagnostic emotion dysregulation
- Binge eating disorder
- Bulimia nervosa
While DBT can help anyone, it’s especially helpful for adolescents. Puberty brings dramatic changes in the developing brain, especially in the prefrontal cortex, the decision-making part of the brain that controls impulses and evaluates the consequences of actions. As the prefrontal cortex develops, teenagers may be more impulsive, emotional, reckless, and/or aggressive. These behaviors begin around the age of 12 and may continue through young adulthood.
Teens with typical levels of emotional reactivity have difficulty controlling their impulses during adolescence. Teens who have pre-existing emotion dysregulation, such as high reactivity and a slow return to baseline, or a mental-health disorder, have even more difficulty controlling impulses and managing emotions.
Children referred for DBT treatment due to emotion dysregulation may have displayed high sensitivity and reactivity from a young age. The environment around them, such as their family or school environment, may have reinforced or punished these emotional reactions, which may have caused them to turn to substances like alcohol or drugs, or engage in problematic behaviors such as self-injury suicide attempts. Over time, these behaviors or substances become their go-to coping mechanisms, even when common, day-to-day emotions or emotional challenges come up.
DBT treatment is beneficial for these teens and children because it:
- Eliminates ineffective, life-interrupting, problem behaviors
- Teaches adolescents skills for coping with their emotions safely, e.g. without hurting themselves and without resorting to substance use.
- Empowers them with skills they can apply in a variety of circumstances and situations throughout adolescence
These skills promote the successful accomplishment of the overall goal of DBT:
To live a life worth living.