DBT for Anxiety: How It Works, Effectiveness, & How to Begin

How Does DBT Help With Anxiety?

Dialectical behavior therapy (DBT) works by helping a person recognize their anxiety triggers and develop coping skills to handle their anxiety.¹ The majority of research has focused on DBT’s effectiveness in treating generalized anxiety disorder, but therapists trained in DBT can apply DBT principles to all types of anxiety disorders.  DBT for anxiety is also recommended for people who develop unhealthy coping mechanisms for their anxiety (i.e., self-harm, substance use, disordered eating).

Here is how the four DBT modules can help with anxiety:

1. Mindfulness

Mindfulness encourages a non-judgmental and open perspective of experiencing the present just as it is, without needing it to change. Anxiety often involves to a sense of panic about what’s to come. There’s a feeling of impending doom, and the body and mind react to that fear. Mindfulness can help someone with anxiety to avoid ruminating on the past or obsessing about the future. It can also support greater gratitude and a sense of purpose.

DBT introduces many mindfulness skills, including the ‘Wise Mind’, which refers to a blended state of one’s rational, reasonable mind and one’s mood-dependent, emotional mind. Being in ‘Wise Mind’ often allows people to feel more present and calm. Other mindfulness techniques may include observing physical sensations, noticing breath, doing single tasks at a time, and engaging in meditation practices for anxiety.

2. Emotional Regulation

Everyone experiences fluctuating emotions, but people with anxiety can feel consumed by their emotional state. Learning emotional regulation includes identifying emotions, coping with the intensity of difficult emotions, and detaching from excessive emotional suffering. This work can reduce and stabilize anxiety symptoms.

DBT introduces several acronyms for emotional regulation. For example, the S.T.O.P skill consists of ‘stop, take a break, observe, and proceed mindfully. A.B.C. Please focuses on accumulating pleasant emotions by doing pleasant things, building mastery, and coping ahead to prepare for difficult situations. Opposite action encourages people to respond differently than they normally would to an emotion.

3. Interpersonal Effectiveness

Individuals with anxiety often struggle to set boundaries, form friendships, assert their needs, or enjoy interactions with others. The interpersonal effectiveness module in DBT focuses on understanding triggers and practicing new ways to strengthen connections with others. This, in turn, can result in reduced anxiety and improved self-confidence.

One of the most popular interpersonal effectiveness skills in DBT is D.E.A.R M.A.N, which stands for describe (the situation), express (your feelings), assert (what you want), reinforce (reward the person for respecting your needs/wants), mindful (stay focused on your specific goal or boundary), appear (confident and competent), and negotiate (be open to compromise).

4. Distress Tolerance

Distress tolerance skills teach a person with anxiety to identify that they are in crisis, such as having a panic attack, and learning how to tolerate the distress. Many people with anxiety struggle to tolerate uncertainty, which can cause significant distress and panic in daily life. DBT’s distress tolerance skills help a person to manage these negative emotions effectively. Distress tolerance isn’t about getting rid of the situation that is making the person anxious – it’s about being able to tolerate the high levels of anxiety without going into an anxiety spiral.

In DBT, distress tolerance can include T.I.P.P (tip the temperature, intense exercise, paced breathing, paired muscle relaxation). These physical interventions can help to calm an anxiety attack quickly. Therapists will also often explore the cost-benefit analysis, where you assess the risks and benefits of engaging in a certain behavior. In addition, radical acceptance can be a significant part of distress tolerance.

How Effective Is DBT for Anxiety?

Research shows that DBT can be effective in treating anxiety. One study showed that DBT reduced symptoms of anxiety and depression in people with generalized anxiety disorder.² Another study showed that DBT was associated with reduced anxiety in medical students during the COVID-19 pandemic.³ Radically-open DBT (RO DBT) is sometimes used successfully for patients with treatment-resistant anxiety.

That said, there aren’t many specific studies examining DBT on various types of anxiety disorders. For example, research consistently shows that exposure and response prevention (ERP) is the gold standard of treatment for specific phobias. It’s likely that DBT is best for people who want to feel more empowered with their emotions and in control of their responses.

DBT Vs. CBT for Anxiety

DBT for anxiety is an offshoot of cognitive behavior therapy (CBT) for anxiety. Many therapists use skills from CBT and DBT in their treatment process. CBT focuses more on changing negative thoughts (i.e., reframing the anxious situation), whereas DBT focuses on accepting negative thoughts, embracing them, and releasing them.

What to Expect During DBT for Anxiety

In DBT for anxiety, participants learn and practice DBT’s four core modules: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. To begin DBT for anxiety, a person would typically find an all-inclusive program that includes group therapy, individual therapy, and DBT phone coaching. These programs last six months. Some DBT therapists work solo and provide only individual therapy sessions.

In a DBT program, group therapy sessions focus on learning the DBT modules and skills. The group sessions also allow a person to be surrounded by people who understand their anxiety struggles and can provide empathy as well as suggestions of what works for them. Group therapy sessions are typically 2 hours long and occur once a week.

In individual sessions, a therapist explores the person’s unique anxiety triggers and provides specific DBT skills for them to try. Individual therapy sessions are typically around 45-60 minutes.  The individual therapist will also assign homework, where the person will be encouraged to apply the skills they are learning in the real world, as well as using diary cards that track emotions and behavioral patterns.

Examples of DBT for Anxiety

DBT for a College Student Experiencing Social Anxiety

Abe is a college student who experiences social anxiety that prevents him from answering questions in class, making friends, and joining events at school. He sometimes experiences so many worries about people judging him that he skips class, which only makes him feel even more embarrassed and anxious the next day.

A DBT therapist might first teach Abe how to use mindfulness strategies, like breathing and grounding techniques for anxiety. The therapist might ask him to use these techniques in his dorm room before heading out for the day. The therapist might help him practice and roleplay how to start conversations to try and make friends. They might also provide Abe with distress tolerance skills for when he feels embarrassed but cannot avoid the situation that embarrasses him.

DBT for a Single Mother Experiencing Panic Attacks

Sarah is a young single mother who has high stress levels and experiences panic attacks. She often worries about the well-being of her child, leading to difficulties sleeping that triggers overuse of caffeine, irritability in relationships, and panic attacks at her job as a waitress.

A DBT therapist might first help Sarah gain some easily accessible mindfulness skills, such as the 5-4-3-2-1 method, as she is playing with her child. This can help her to appreciate the present moment with her child without getting lost in future worries. The therapist might encourage Sarah to use the emotion regulation skill of P.L.E.A.S.E., where she focused on limiting her use of caffeine and increasing a healthy sleep routine. Finally, the therapist might increase Sarah’s distress tolerance skills, such as radical acceptance of the moment, to refocus on feelings of gratitude.

How to Know If DBT for Anxiety Is Right for You

DBT for anxiety may be a good therapy option for you if anxiety is causing many future-focused thoughts, problems in relationships, difficulty tolerating physical anxiety symptoms, or a lack of general coping skills for anxiety. DBT for anxiety may also be beneficial for someone who needs more accountability since it generally requires tracking through the use of diary cards and sometimes involves group sessions.

When Is DBT for Anxiety Not Right For Someone?

DBT for anxiety may not be appropriate for someone who is actively in a physical crisis or who has a co-occurring active addiction or eating disorder. DBT for anxiety may also not be appropriate for individuals who have a primary diagnosis of schizophrenia or an intellectual disability because the skills may be too hard to understand or ineffective.

How to Find DBT Treatment for Anxiety

If you are interested in exploring DBT for anxiety, it’s important to find a DBT therapist who meets your needs. A therapist professionally certified in DBT has the highest knowledge of the model with a demonstration of clinical excellence. Insurance may cover therapy sessions, and it’s important to review mental health options with your individual healthcare provider. Therapists may offer both in-person and online DBT therapy sessions. You can use therapist directory to look for a professional near you.

Other Treatment Options for Anxiety

Treatment for anxiety generally includes learning to tolerate the distress of anxiety, increasing positive coping skills and relational supports, learning about anxiety and triggers, and sometimes roleplaying in sessions. A comprehensive treatment plan may involve therapy, anti-anxiety medication, therapy, or both. Sometimes, group therapy is recommended, especially for individuals with social anxiety.

Other therapy options for anxiety include:

• Cognitive behavioral therapy (CBT): CBT for anxiety helps the individual understand the connection between thoughts, emotions, and behaviors that may contribute to their anxiety symptoms. A CBT therapist might help a person target negative thinking patterns or challenge them to minimize unhelpful coping strategies, like avoiding social events.
• Exposure and Response Prevention (ERP): If anxiety is caused by obsessive-compulsive disorder or related tendencies, ERP may be helpful to target core fears. An ERP therapist would help a person develop an exposure hierarchy, which slowly helps them confront the trigger(s) for anxiety.
• Acceptance and commitment therapy (ACT): ACT for anxiety helps the individual learn to become more psychologically flexible, meaning they are able to respond to life circumstances adaptively. An ACT therapist may help a person identify core values and commit to living through the values despite anxiety symptoms.
• Psychodynamic therapy: Psychodynamic therapy for anxiety encourages a person to examine past relationships and childhood attachment issues that may be root causes for experiences of anxiety. Psychodynamic Therapy is appropriate for long-term and chronic experiences of complex anxiety, especially if it is rooted in trauma or attachment concerns.
• Interpersonal therapy (IPT): If anxiety is rooted in issues with family and friends, interpersonal therapy may be a good option. An IPT therapist can help a person examine the role of relationships in their life and how anxiety impacts those roles.