What Is Dialectical Behavior Therapy (DBT)? Techniques & Effectiveness

Definitions

The D in DBT, dialectical, relates to two seemingly opposite viewpoints that can be true simultaneously.

The dialectical philosophy is that all things are connected, and change is constant and inevitable.

Dialectical strategies in DBT help the individual and their therapist to get unstuck from extreme positions, balance out viewpoints, and view situations from multiple perspectives to reach a logical viewpoint.

The B in DBT, behavioral, means that DBT aims to adjust behaviors.

During sessions, the DBT therapists learn to assess the situations and target behaviors that are relevant to the client’s goals in order to figure out how to solve problems in their lives.

How DBT Was Developed

Marsha Linehan developed DBT in the 1980s to help people with suicidal thoughts who often had a diagnosis of borderline personality disorder (BPD).

Individuals with BPD often experience the following symptoms:

• Experience intense emotions

• Have difficulties with their relationships

• Their actions can be very impulsive

• Their thinking can be very black and white

Thus, DBT was developed to help people with DBT manage these core symptoms by providing them with skills to reach their goals.

This way, people with DBT would know how to respond to challenging situations or manage relationships so that they can have a better quality of life overall.

What DBT Can Help With

Although DBT was developed with borderline personality disorder in mind, the techniques used in DBT can be effective for many of the following mental health conditions:

• Major depressive disorder

• Bipolar disorder

• Generalized anxiety disorder (GAD)

• Posttraumatic stress disorder (PTSD)

• Attention deficit hyperactivity disorder (ADHD)

• Eating disorders

• Substance use disorders

People who feel the symptoms of their mental health condition negatively impact their quality of life may wish to seek help through DBT.

As well as helping individuals who have mental health conditions, DBT does not need to be limited to those with a diagnosed condition. People who experience any of the following may also benefit from DBT:

• Those who struggle with intense emotions that they feel they cannot control.

• Those who find it difficult to manage challenging situations.

• Those who are experiencing negative consequences from encountering a lot of stress.

• Those who struggle to maintain healthy relationships; may describe their relationships as unstable or like a rollercoaster.

• Those who experience negative and recurring thought patterns.

• Those who experience a lot of anger or get into many conflicts with others.

• Those who are experiencing negative consequences after a traumatic life event.

• Those who may feel hopeless or empty.

• Those who have tried other therapies and found they have not worked for them.

• Those who feel as if their life is out of control.

• Those who believe their life is not fulfilling.

• Those who have suicidal thoughts or show self-injurious behaviors.

DBT Techniques

The idea of DBT is to teach important skills and techniques through the four following components:

Mindfulness

The premise of mindfulness is to teach the individual to be focused on the present moment and feel grounded. This technique is useful for those struggling with an unstable sense of self and/or those with difficulties focusing on the present.

This technique encourages the individual to pay attention to what is happening around them as well as inside, such as their thoughts and feelings. People completing mindfulness will learn to focus on their thoughts in a non-judgemental way and notice any negative thoughts that may arise.

For example, a mindfulness exercise may involve paying close attention to the physical sensations while slowly eating a raisin and noticing any thoughts or feelings that arise. This teaches being present with the current experience.

After focusing on the present moment, the idea is that the automatic negative thoughts are not engaged with, resulting in feeling more settled.

This, therefore, teaches healthy coping skills to those struggling with negative thoughts.

Emotion regulation

Learning to regulate emotions is a component of DBT that aims to help individuals be more comfortable and accepting of their own emotions.

This technique helps people to learn how to manage their difficult emotions, which may arise so that the intense emotions they experience do not end up controlling the situation.

For instance, if someone feels mounting anger during a disagreement with a friend, they can be taught to take some deep breaths, consciously relax their body, and consider the situation more objectively before responding.

Through emotional regulation, people are taught that they may experience intense emotions, but they can choose how to react to them in a healthy way.

They can also learn to avoid situations that they know will trigger strong emotions, helping them to have more positive emotional experiences overall.

Distress tolerance

As people experiencing issues with their mental health may encounter a lot of distress, the component of distress tolerance in DBT is important to learn how to manage upsetting situations.

This technique aims to help individuals think about some of the helpful things they can do to manage their behavior and emotions so that they do not act impulsively or risky, with potentially negative consequences.

For example, when stuck in traffic, rather than getting angry, one can practice distraction by listening to music or imagery by imagining being in a favorite relaxed setting.

This component can help with challenging negative thought patterns. For instance, instead of thinking, ‘It’s not fair,’ they may ask themselves instead, ‘Can I control the situation?’.

If they realize the situation cannot be controlled, they learn to accept it for what it is.

This skill can help individuals prepare for intense emotions they may experience and use distraction techniques to help decrease feelings of distress (e.g., listening to music or going for a walk).

Interpersonal effectiveness

The final component of DBT is interpersonal effectiveness, which aims to teach individuals to communicate in healthy and respectable ways.

To demonstrate interpersonal effectiveness, clients are often given roleplay scenarios to practice assertiveness skills. This may involve refusing an unreasonable request or asking to have a need met appropriately.

Clients learn to express themselves clearly while respecting others’ boundaries.

This technique can also help build listening skills and conflict resolution skills and help build trust with others, which can be a big issue for those with BDP.

Individuals can also learn to deal with challenging people in a healthy manner, acknowledge others’ thoughts and feelings, and learn to ask for what they need in a clear way.

What DBT Sessions Involve

There are different modes of treatment for DBT, which makes it different from other psychotherapies, which may typically consist of just one mode of treatment. Each mode of treatment is intended to meet a specific function.

Individual psychotherapy

The function of one-to-one sessions with a therapist is to enhance the client’s motivation to apply learned DBT skills to specific challenges and events in their lives.

These sessions are usually once a week and run for the duration of the therapy. The clients will be asked to complete homework tasks outside the individual sessions.

An example of this is daily ‘diary cards,’ which are used to track emotions, behaviors, and thoughts.

Another goal of individual therapy is for the therapist to help the client structure their own lives, becoming managers of their lives.

The therapist does this by applying dialectical, validation, and problem-solving skills to enable the clients to learn to be their own managers of personal life challenges.

Group skills training

Group skills training typically runs once a week for two-hour sessions for the duration of the therapy.

Within these sessions, the group will learn skills in the four components of DBT: mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness.

As these are in a group setting, the clients have opportunities to interact with others and roleplay scenarios.

The group leaders will also assign homework to aid the clients in practicing the skills they have been taught in their everyday life.

Phone Coaching

Another mode of treatment that is unusual for other therapies for mental health is phone coaching.

This means that the DBT therapist will be available to contact by phone for any incidents where the client may face a challenging moment.

The therapist can give guidance on how to cope with a situation as it is happening. The overall goal of this contact is to coach the client on how to put their DBT skills into practice whenever required.

DBT Treatment stages

Dialectical behavior therapy progresses through four stages:

Stage 1 prioritizes life-threatening behaviors, teaching suicide prevention and crisis survival strategies so clients can function safely.

Stage 2 builds emotion regulation skills to better tolerate distress and reduce mood instability and loneliness. Clients learn to identify emotions and increase positive experiences.

Stage 3 focuses on self-management to achieve stability in self-concept and emotions through self-care, decision-making, and meaning-creation.

Stage 4 aims to fulfill relationship needs by expanding social connections, building intimacy abilities, and balancing priorities. Assertiveness and conflict-resolution training help achieve interpersonal effectiveness.

Each phase builds on the last, guiding the client from crisis stabilization to enhanced life meaning and satisfaction. The progression equips clients with layered skills for safety, emotional control, self-efficacy, and social fluency so they can pursue life goals.

Benefits of DBT

Below are some of the positive changes that can arise as a result of completing DBT:

• Individuals notice behavioral changes – they should be more able to identify when harmful behavior patterns threaten to occur and should be able to adjust these with healthier ones.

• The learning of new skill sets to deal with any challenging situation in life.

• Cognitive changes including the alteration of negative thoughts and beliefs about the self.

• The acceptance that some situations cannot be controlled but can be responded to in healthy ways.

• Finding new, healthy methods of coping with distress.

• Being able to work collaboratively with others (especially during the group skills training).

• Being able to communicate more effectively with others resulting in healthier relationships.

How Effective Is DBT?

Linehan et al. (1991) conducted the first randomized controlled trial of the effectiveness of DBT on women with BPD.

It was found that after completion of DBT, participants showed significant improvements in chronically suicidal and self-injuring behaviors.

A more recent meta-analysis found that most studies reported significant reductions in suicidal ideation, self-injurious behaviors, depression, and anxiety after DBT (Bloom et al., 2012).

One study found that after a year of therapy, around 77% of the patients no longer met the criteria for a diagnosis of BPD (Stiflmayr et al., 2014).

Evidence also indicates that DBT skills reduce depressive symptoms and improve affective control and mindfulness self-efficacy for those with bipolar disorder (Van Dijk et al., 2013).

DBT also helps treat PTSD symptoms. One study found reduced feelings of shame, anxiety, and trauma-related guilt for individuals with PTSD after DBT (Harned et al., 2014).

Recent research further supports the effectiveness of DBT across diagnoses.

For example, DBT skills training alone led to significant improvements in binge eating disorder for adolescents (Kamody et al., 2019).

When integrated into family-based treatment for adolescents with anorexia nervosa and avoidant restrictive food intake disorder, DBT resulted in improvements in eating disorder symptoms, emotion regulation, coping skills and depression (Peterson et al., 2020).

DBT has also shown success delivered concurrently with trauma-focused therapy for women with childhood abuse histories and PTSD/borderline symptoms (Bohus et al., 2020), and several studies have found post-DBT treatment, abstinence from self-harm, binge eating, and purging was maintained at follow-up across diagnoses (Fischer & Peterson, 2015; Salbach-Andrae et al., 2008).

Overall, DBT demonstrates efficacy in reducing dysfunctional behaviors and improving emotion regulation across disorders.

However, more randomized controlled trials are needed to compare DBT to first-line treatments for particular conditions. As DBT adaptations continue, studies must evaluate if DBT outperforms existing evidence-based approaches.

Considerations

While DBT has shown promising results for many individuals, it’s important to acknowledge that it may not be effective for everyone.

Factors such as individual differences, treatment adherence, and the complexity of certain mental health conditions can contribute to varying outcomes.

Additionally, DBT requires a significant commitment of time and effort, and some individuals may struggle to fully engage or find it challenging to implement the skills learned in therapy into their daily lives.

It’s crucial to consider personalized treatment plans and explore alternative therapeutic approaches for those who may not respond optimally to DBT. Consulting with a mental health professional can help determine the most suitable treatment path for each individual’s unique needs.

References

Bloom, J. M., Woodward, E. N., Susmaras, T., & Pantalone, D. W. (2012). Use of dialectical behavior therapy in inpatient treatment of borderline personality disorder: a systematic review. Psychiatric Services, 63(9), 881-888.

Bohus, M., Kleindienst, N., Hahn, C., Müller-Engelmann, M., Ludäscher, P., Steil, R., … & Priebe, K. (2020). Dialectical behavior therapy for posttraumatic stress disorder (DBT-PTSD) compared with cognitive processing therapy (CPT) in complex presentations of PTSD in women survivors of childhood abuse: a randomized clinical trial. JAMA psychiatry, 77(12), 1235-1245.

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.

Kamody, R. C., Thurston, I. B., Pluhar, E. I., Han, J. C., & Burton, E. T. (2019). Implementing a condensed dialectical behavior therapy skills group for binge-eating behaviors in adolescents. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity, 24, 367-372.

Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of general psychiatry, 48(12), 1060-1064.

Peterson, C. M., Van Diest, A. M. K., Mara, C. A., & Matthews, A. (2020). Dialectical behavioral therapy skills group as an adjunct to family-based therapy in adolescents with restrictive eating disorders. Eating disorders, 28(1), 67-79.

Salbach-Andrae, H., Bohnekamp, I., Pfeiffer, E., Lehmkuhl, U., & Miller, A. L. (2008). Dialectical behavior therapy of anorexia and bulimia nervosa among adolescents: A case series. Cognitive and behavioral practice, 15(4), 415.

Stiglmayr, C., Stecher-Mohr, J., Wagner, T., Meiβner, J., Spretz, D., Steffens, C., Roepke, S., Fydrich, T., Salbach-Andrae, H., Schulze, J. & Renneberg, B. (2014). Effectiveness of dialectic behavioral therapy in routine outpatient care: the Berlin Borderline Study. Borderline personality disorder and emotion dysregulation, 1(1), 1-11.

The Linehan Institute Behavioural Tech (2017) What is dialectical behaviour therapy (DBT)? https://behavioraltech.org/resources/faqs/dialectical-behavior-therapy-dbt/

Van Dijk, S., Jeffrey, J., & Katz, M. R. (2013). A randomized, controlled, pilot study of dialectical behavior therapy skills in a psychoeducational group for individuals with bipolar disorder. Journal of affective disorders, 145(3), 386-393.