Dialectical Behavior Therapy (DBT)

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Dialectical Behavior Therapy (DBT)

What is dialectical behavior therapy?

Dialectical behavior therapy (DBT) is a comprehensive, evidence-based treatment for borderline personality disorder (BPD). It balances a client’s acceptance of their challenges and struggles while working to change negative patterns of behavior and thinking. It combines elements of cognitive behavioral therapy with learning new skills such as practicing mindfulness, developing healthy ways to deal with stress, regulating emotions when encountering stressful situations, and improving relationships with others. The therapy uses the term dialectical, which means integrating opposites, to emphasize the importance of balancing self-acceptance with its opposite – changing negative behaviors. 

What is borderline personality disorder?

BPD causes acute emotional distress. Patients can have intense bursts of anger and aggression, moods that shift rapidly, and extreme sensitivity to rejection. Their intense and seemingly uncontrollable negative emotions often occur when the patient is interacting with others – family, friends, romantic partners. They have difficulty regulating emotions, and are often unstable in their moods, behavior, self-image, and thinking. Impulsive behaviors (substance abuse, risky sex, self-injury), and repeated life crises are common.

Who developed dialectical behavior therapy?

DBT was developed in the late 1980s by Marsha Linehan, PhD, and her colleagues. They were looking for a way to create a treatment method for multiproblematic, suicidal women who had not found relief from other types of therapy. She studied treatments for emotion-related difficulties, and assembled a package of cognitive-behavioral interventions that directly target suicidal behavior and patients with BPD. Initially, these interventions were so focused on changing cognitions and behaviors that many patients felt criticized, misunderstood, and dropped out of treatment. 

Linehan subsequently developed treatment interventions that were designed to convey acceptance of the patient and help the patient accept her/his emotions and thoughts. Linehan’s work culminated in a comprehensive, evidence-based, cognitive-behavioral treatment for BPD. Standard DBT treatment consists of weekly individual therapy sessions of one hour, a weekly group skills training session of about two hours, telephone consultations as the need arises, and team meetings for therapists. 

Eight published, well-controlled, and randomized clinical trials have demonstrated DBT’s effectiveness with patients who have BPD and/or related problems. One study found that after a year of treatment, more than 75% of people with BPD no longer met the diagnostic criteria for the condition. DBT has been endorsed by The American Psychiatric Association as effective in treating BPD. Patients undergoing DBT treatment have seen these improvements:

  • Less frequent and less severe suicidal behavior
  • Less anger
  • Shorter hospitalizations
  • More likely to stay in treatment
  • Better social functioning

What sets dialectical behavior therapy apart from other therapies?

DBT emphasizes validation and the development of coping skills and distress tolerance. Acceptance and commitment therapy (ACT), focuses specifically on increasing flexibility in thinking, and acceptance of challenging thoughts and feelings. 

Cognitive behavioral therapy (CBT) helps an individual identify and change negative thought patterns and push for positive behavior changes. DBT includes elements of CBT, but focuses on validating the patient’s emotions, developing mindfulness skills, improving interpersonal skills, acceptance-oriented interventions, and learning how to tolerate emotional distress. 

Which patients are most helped by dialectical behavior therapy?

Researchers have found that DBT is effective with people of any age, gender or race. It’s most often used with high-risk, hard-to-treat patients, who often have multiple diagnoses. DBT is most effective with suicidal women with BPD. 

Additionally, it’s used with patients who have other disorders where mindfulness, interpersonal skills, stress tolerance, and relief from intense emotions are needed. They include: 

DBT can also be effectively combined with other treatment methods when needed. 

How does dialectical behavior therapy work?

DBT focuses on developing skills to help the individual tolerate intense and overwhelming emotions, and improve their relationship with themselves and others. It can be done individually or in group skills training.

Individual psychotherapy sessions work to resolve the contradiction between self-acceptance and the desire to change problem behaviors. By validating the patient’s behaviors, the therapist can reduce their stress at the idea of change, and motivate them to cooperate with making changes. For example, the therapist can validate that the patient’s actions make sense within the context of their life and personal experiences. However, they don’t concur that the behaviors are the best approach to solving a problem.

Individual psychotherapy serves two of DBT’s functions:

  • Increase patient motivation to apply newly learned skills when meeting specific challenges and stressful events in their lives. 
  • Learn case management strategies and problem-solving methods so the individual can become their own case manager and better manage their physical and social environments. While the therapist can consult with the patient about what to do, the therapist intervenes only when absolutely necessary. 

Group sessions teach new coping skills over a period of about six months, although shorter versions are available. Problem behaviors usually develop as a way to cope with a difficult situation. Although they may help temporarily, problem behaviors are not effective in the long-term. The group is led by a therapist and group members are encouraged to share experiences and provide mutual support. DBT teaches new behaviors for all relevant situations.​ Patients are taught four important skills, which they practice every day:

  • Mindfulness is learning how to be fully aware and present in each moment, including self-awareness and awareness of others. This helps the patient slow down and focus on using healthy coping skills when encountering emotional or difficult situations. Mindfulness helps the person stay calm and avoid falling back into old habits of negative thought patterns and impulsive behavior. 
  • Distress tolerance is learning how to tolerate pain in difficult situations, not try to change it. It teaches self-acceptance and acceptance of the current situation. Patients learn to recognize destructive behavior patterns and unhelpful thoughts, and replace them with healthier ones. Techniques include distraction, self-soothing, improving the moment, and thinking of the good and bad consequences of not tolerating distress. These techniques empower the patient to cope with problems to enhance a positive, long-term outlook. 
  • Interpersonal effectiveness or assertiveness means learning how to ask for what you need, and to say “no” to other people when needed. These skills help maintain healthy and positive relationships by learning to listen and communicate more effectively, and respecting yourself and others. 
  • Emotional regulation teaches ways to identify and change powerful emotions the patient wants​ to change or control. This can reduce emotional vulnerability, giving the patient more effective responses and more positive emotional experiences. ​

In-the-moment coaching may be provided via telephone to provide immediate support at stressful times.

Consultation sessions for therapists provide peer support to monitor adherence to treatment methods, increase therapy skills, and sustain motivation to work with difficult-to-treat patients. DBT therapists must make some assumptions about their patients that guide their work. They include:

  • Patients are suffering from difficulties that regulate or control their emotions.
  • Although patients have not caused all their problems, it’s up to them to solve them.
  • Therapists must help patients toward the goals that the patient wants to achieve. 

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References

Chapman, A.L. (2006 Sept) Dialectical Behavior Therapy Current Indications and Unique Elements. National Institutes of Health, U.S. National Library of Medicine Psychiatry. Retrieved 2-16-22, {https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2963469/}
Behavioral Tech. (n.d.) What is Dialectical Behavior Therapy (DBT)? A Linehan Institute Training Company. Retrieved 2-16-22, {https://behavioraltech.org/resources/faqs/dialectical-behavior-therapy-dbt/}
Schimelpfening, N. (2021, Nov.) What is Dialectical Behavioral Therapy? verywell mind. Retrieved 2-16-22, {https://www.verywellmind.com/dialectical-behavior-therapy-1067402}
Taylor, R.B. (2020, Feb.) Dialectical Behavioral Therapy. WebMD Mental Health. Retrieved 2-16-22, {https://www.webmd.com/mental-health/dialectical-behavioral-therapy}
Psychology Today. (n.d.) Dialectical Behavior Therapy. Retrieved 2-16-22, {https://www.psychologytoday.com/us/therapy-types/dialectical-behavior-therapy}

Information

Medically reviewed by:

Dr Roy Kedem, MD

Dr Roy Kedem started his premedical studies at Harvard, and research in genetics and gene sequencing at Harvard, Beth Israel. He attended medical school in the UK at the Cambridge Overseas Medical Program in 1998. Dr Kedem then completed his residency in Internal Medicine at Columbia College of Physicians and Surgeons in Stamford, Connecticut and his fellowship in Hospital Medicine at the Cleveland Clinic in Cleveland, Ohio.

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Affordable –
with or without insurance

With Insurance

Therapy

Your copay
Depending on insurance

Without Insurance

Therapy

$99

Initial Visit

$99

Follow Up