Dialectal Behavior Therapy (DBT)

Dialectical behavior therapy (DBT) is an evidence-based treatment designed to treat emotional dysregulation, suicidal thoughts and behaviors, self-harm, and other mental health and/or behavioral issues. It is a structured, skills-based approach that helps people reach their goals and create a life that is experienced as worth living.  

The full DBT treatment model includes the four components below. While there is benefit in utilizing some aspects of DBT on their own (standalone skills training, for example), a program isn’t truly providing DBT unless all four essential treatment components are implemented. 

1. DBT Skills Training Groups  

General goal: “To learn how to change your own behaviors, emotions, and thoughts that are linked to problems in living and are causing misery and distress.” 

2. DBT Individual and Family Therapy 

In DBT, individual sessions always start with a review of the DBT Diary Card and incorporate the use of DBT’s core treatment strategies, including skill reinforcement, restructuring thought patterns, behavior shaping, exposure to difficult emotions, etc. Behavior Chain Analysis is often used to help clients analyze problem behaviors and plan for how to prevent them in the future. DBT therapists balance acceptance strategies with change strategies to help clients stay motivated for treatment while doing the hard work of changing their behaviors.  

DBT is similarly incorporated into the family therapy work for teen clients. Parents are oriented to the structure and philosophies of DBT at the start of treatment and provided with resources on DBT skills and concepts so that they can learn alongside their teen. Parent involvement in skills training is an essential part of treatment and is reinforced in each family session. Behavior Chain Analysis is incorporated into family therapy as well, often with “double chains,” where parents reflect on their behavior during a crisis while the teen client does the same.  

3. Skills Coaching 

In standard outpatient DBT, phone coaching is provided as a method of helping clients strengthen and generalize the skills they are learning, particularly in times of crisis. In residential settings, this is implemented as milieu-based skills coaching. Teens newer to treatment typically do not know how to cope with intense emotions effectively yet. They may experience difficult emotions and urges for Target Behaviors but not yet know what skill to use or how to use it effectively. In these cases, they can reach out for skills coaching so that they can receive guidance around what skills to use and how to use them. Over time, clients are pushed to identify skills and use them more and more independently so that they will be able to cope effectively in their everyday lives.   

4. DBT Consultation Team 

When developing DBT, Marsha Linehan understood the importance of a built-in support network to the success and efficacy of DBT providers. This led to the creation of the DBT consultation team as a required part of the full DBT treatment model. The goal of the consultation team is to enhance the motivation and capabilities of all members of the DBT team so that they can continue to apply the treatment effectively. Members of the consultation team problem solve together, validate each other, assess, and push one another to maintain empathy in the work they are doing, often using DBT skills themselves and with one another in the process.  

DBT Strategies and Concepts  

DBT therapists pull from four core treatment strategies and apply several key concepts when working with their clients. 

Core Strategies 

1. DBT skills training à learn and apply skills  

2. Behavioral contingency management à apply rewards to increase desired behaviors and consequences to decrease unwanted behaviors 

3. Cognitive restructuring à work towards thinking more dialectically  

4. Informal exposure à face things that are difficult instead of avoiding them  

Balancing Acceptance and Change 

Change can be difficult, especially when behavioral patterns have been in place for many years and have often felt beneficial to the client. It is essential for the DBT therapist to understand the function of a client’s problem behaviors and validate how hard it is to leave these behaviors behind. For example, when someone engages in self-harm, it is often to cope with intense and painful emotions. A DBT therapist would start by validating hesitance to let go of a behavior that has helped them cope, especially when they don’t have any other alternatives yet. This step represents acceptance, which is an essential part of DBT and helps to keep clients motivated to change. A careful dance is done in DBT therapy to balance acceptance and change so that clients feel motivated to change and are pushed to change when ready.  

Thinking Dialectically  

Balancing things that appear in opposition to one another, like acceptance and change, is an essential component of DBT. Dialectical thinking refers to the balancing of opposites while finding the middle path, or synthesis, between two opposing sides. DBT therapists help clients to think dialectically—rather than remain stuck in black and white, all or nothing thinking, learn to acknowledge the kernels of truth that exist on each opposing side. This helps clients think more flexibly and avoid the emotional reactivity that comes with all or nothing thinking. DBT therapists often highlight this important “dialectic”: it is very hard to change, and it must be done so that you can reach your goals in life.   

The Biosocial Theory 

When DBT therapists think about a client’s history and current presenting problems, they do so through the lens of the Biosocial Theory. This theory states that some people are born with biologically based heightened emotion sensitivity, meaning that they are more sensitive to triggers in the environment, experience emotional responses more intensely, and take a longer time to return to baseline when emotionally activated. When in a supportive, validating environment, these individuals can learn to understand their emotions and cope with them effectively. When in an unsupportive, invalidating environment, these individuals don’t learn how to cope with difficult emotions and may end up using unhealthy methods of coping (self-harm, substance use, etc.) or trying to avoid their emotions altogether.  

An invalidating environment may involve one or more of the following: 

• Emotional, physical, or sexual abuse 
• Intense 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  

Even without biologically based emotion sensitivity, children in invalidating environments may ending up learning unhealthy ways of coping and communicating their distress. Sometimes the home environment is stable and abuse is not present, yet the parents or caregivers simply don’t have the tools they need to support a child with high emotion sensitivity. They may make good faith attempts to support their child that end up feeling invalidating. For example, when a highly sensitive child gets flooded with emotions and loudly cries after plans change, a parent might say, “try not to be so sensitive, it’s not a big deal, there’s nothing to cry about.” While it might be well-meaning, this communicates to the child that their emotional responses are wrong, or that emotion expression should be avoided.  

DBT therapists pay close attention to the how a child’s biology transacted with their environment in childhood to create the problems bringing them to treatment today. DBT therapy would focus on applying the core treatment strategies to fit the needs of each client.  

For example: if a teen client was ignored or punished when expressing intense emotions as a child, they learn to act out in big ways (self-harming, threatening suicide) so that others will take their emotional pain seriously. The DBT therapist would need to teach the client interpersonal effectiveness skills to help them communicate their needs and experiences in safer ways, and emotion regulation skills to help them manage difficult emotions. They would then need to teach the parents how to respond more effectively to their child’s emotions.  

The DBT Assumptions 

All DBT providers are asked to maintain the following assumptions in working with each client and family. While no one can prove whether these things are true, assuming that they are helps each DBT provider to remain effective in applying the treatment. For example, if members of the DBT team don’t believe that each client truly wants to feel better and improve their lives, then their motivation to help that client goes down significantly, especially when the client is feeling stuck or willful. 

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 their problems, but they must 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. 

*These lists are adapted from Cognitive Behavioral Treatment of Borderline Personality Disorder, by Marsha Linehan.  

The DBT Treatment Hierarchy 

Since teens seeking DBT often have multiple problems to address, DBT providers utilize the DBT Treatment Hierarchy to guide when and how each problem is addressed. This hierarchy guides the agenda for individual and family therapy sessions.  

Life-Threatening Behaviors are always addressed first since clients must be alive and out of the hospital to participate in treatment. These behaviors may include: 

• Suicidal behaviors 
• Non-suicidal self-injury 
• Severe Anorexia or Bulimia 
• IV drug use 

Treatment-Interfering Behaviors are addressed next, or alongside life-threatening behaviors, because they get in the way of working towards a client’s goals and building a life that is experienced as worth living. Examples may include: 

• Dishonesty 
• Refusing to participate in individual or family therapy 
• Avoiding discussion of target behaviors 
• Not doing skills training homework 

Behaviors that severely impact quality of life are addressed once life-threatening behaviors and treatment-interfering behaviors have been eliminated or significantly reduced. Along with life-threatening behaviors, these behaviors often play a big role in necessitating the need for residential treatment. Examples may include: 

• Severe depression and anxiety 
• Non-life-threatening eating disorder behaviors 
• Non-life-threatening substance use 
• Impulsivity  
• Anger 
• Opposition, defiance 
• Conflict with peers and/or family 
• etc. 

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. 

Cognitive Behavioral Therapy (CBT) is an evidence-based treatment that has shown to be effective at treating depression, anxiety, substance use disorders, and eating disorders. It is based on the belief that these problems are caused by unhelpful ways of thinking and behaving, and that treatment should involve changing these unhelpful thinking and behavioral patterns. In essence, once an individual starts to think about themselves and the world differently, they will then start to feel and act differently as well. For example, a client utilizing CBT for social anxiety would need to challenge negative assumptions about what others are thinking of them while also challenging themselves to not avoid social situations. Over time, they will start to feel less anxious in social situations as a result.  

CBT is a change-oriented treatment—focus is largely placed on changing thoughts. This differs from DBT in that DBT incorporates acceptance strategies as an essential treatment component. Rather than jump to pushing for immediate change, the DBT therapist pauses in acceptance first by validating the valid of the client’s experience.  As Linehan 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.” 

While many clients can benefit from the change-focused approach of CBT, particularly those primarily experiencing depression and anxiety, clients with high emotion sensitivity and difficulties with emotion dysregulation may find CBT less helpful. In these cases, the acceptance strategies and the biosocial lens of understanding their problems are key to helping these clients move towards change.  

What Does DBT Treat? 

DBT was originally created as an alternative treatment method for chronically suicidal adults. In working with this population, Marsha Linehan found that the primary treatments at the time, Cognitive Behavioral Therapy and Psychoanalytic Therapy, did not seem to fully meet the needs of these clients and that many would drop out of treatment or continue attempting suicide or ending up in psychiatric hospitals. She developed DBT as an alternative to these treatments and went on to demonstrate its efficacy for adults with chronic suicidality, self-harm, and severe emotion dysregulation. Over time, DBT has become the gold standard for evidence-based treatment of borderline personality disorder. 

In the decades since its development, research has shown DBT’s efficacy in treating a variety of populations and presenting problems, including teens with suicidal behaviors, self-harm, substance use, and eating disorders. While many teens with thoughts of suicide, depression, and/or anxiety may benefit from DBT skills training alone, some teens require a more comprehensive approach that applies all aspects of the DBT treatment model.  

According to Behavioral Tech, Dr. Linehan’s training institute, DBT effectively treats: 

• Suicidal and self-harming adolescents 
• Severe emotional and behavioral dysregulation 
• Depression 
• Posttraumatic stress disorder  
• Borderline personality disorder/symptoms 
• Attention deficit hyperactivity disorder (ADHD) 
• Bipolar disorder 
• Eating disorders 

Research Backing for DBT 

There is strong evidence that supports the efficacy of DBT as a treatment for adults and teens with a variety of mental health and substance use struggles. Here are some highlights of the research available: 

Randomized Controlled/Comparative Trials 

• In a study of teens age 12-18 with bipolar disorder, standard DBT was shown to be more effective than treatment as usual in decreasing depressive symptoms (Goldstein et al., 2015) 
• In a study of adults with borderline personality disorder and recent self-harm or suicide attempts, standard DBT was shown to decrease the frequency and severity of suicide attempts, suicidal ideation, and use of crisis services due to suicidality (Linehan et al., 2015) 
• In a study of teens age 12-18 with a history of self-harm or suicide attempts, DBT was shown to decrease self-harm, the severity of suicidal thoughts, and depressive symptoms, compared enhanced usual care (Mehlum et al., 2014) 
• In a study of adults with borderline personality disorder, PTSD, and a history of self-harm or suicide attempts, DBT was shown to result in improvements in PTSD symptoms and increases in remission of symptoms (Harned, Korslund, & Linehan, 2014) 

For more information on peer-reviewed research related to DBT, please refer to the Behavioral Tech website: 

Sources: 

Goldstein, T. R., Fersch-Podrat, R. K., Rivera, M., Axelson, D. A., Merranko, J., Yu, H., … & Birmaher, B. (2015). Dialectical behavior therapy for adolescents with bipolar disorder: results from a pilot randomized trial. Journal of child and adolescent psychopharmacology, 25(2), 140-149. 

Linehan, M. M., Korslund, K. E., Harned, M. S., Gallop, R. J., Lungu, A., Neacsiu, A. D., … & Murray-Gregory, A. M. (2015). Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: A randomized clinical trial and component analysis. JAMA psychiatry, 72(5), 475-482. 

Mehlum, L., Tørmoen, A. J., Ramberg, M., Haga, E., Diep, L. M., Laberg, S., … & Grøholt, B. (2014). Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial. Journal of the American Academy of child & adolescent psychiatry, 53(10), 1082-1091. 

Harned, M. S., Korslund, K. E., & Linehan, M. M. (2014). A pilot randomized controlled trial of dialectical behavior therapy with and without the dialectical behavior therapy prolonged exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD. Behaviour research and therapy, 55, 7-17.