DBT for Depression: How It Works, Examples, & Effectiveness

What Is Dialectical Behavior Therapy?

Dialectical behavior therapy (DBT) aims to assist clients in “building a life worth living.”⁴ “Dialectical” refers to acting with oppositional forces, which, in this case, is the balance that DBT seeks to create in teaching clients both skills for change and skills for radical acceptance.

The key elements of dialectical behavior therapy include:

• Interpersonal effectiveness
• Emotional regulation
• Mindfulness
• Distress tolerance

What Is Depression?

Depression is a medical illness that, if left untreated, can become life-threatening. Twenty-one percent of Americans will experience depression during their lifetime, with a higher risk among women (25%) than men (16%).⁵ Distress caused by depression can range from mild to severe and, in the latter case, may lead to an inability to function in one or more areas of a person’s life.

Symptoms of depression can include:⁶

• Significant fatigue
• Sleep issues
• Noticeable loss/increase in appetite and/or weight
• Crying
• Agitation.
• Concentration difficulties
• Memory and decision-making issues
• Increased pessimism and self-criticism
• Suicidal thoughts.
• Feelings of guilt
• Hopelessness
• Irritability

How Does DBT Help With Depression Symptoms?

DBT interventions for depression can provide a toolkit of skills to help manage and reduce some of the distress caused by depression while coming to accept aspects of life that one cannot change. Access to such a toolkit can provide some individuals with immediate relief and reduce feelings of hopelessness and helplessness.

DBT is a unique approach to depression that involves identifying any maladaptive skills clients use to cope with the pain of depression (e.g., social withdrawal, substance/alcohol use, self-injury). Clients learn skills for radical acceptance of what they cannot change (e.g., their past, other people) and adaptive change skills for what they can control.

DBT Vs. CBT for Depression

DBT is a type of cognitive behavioral therapy (CBT). Both DBT and CBT for depression focus on the interrelatedness of thoughts, emotions, and behaviors. Therapists work with individuals to identify, understand, and replace maladaptive or destructive thoughts and behaviors with more supportive and healthy ones. DBT also includes specific skill development modules focused on mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness.

Does DBT Effectively Treat Depression?

Research suggests that DBT can significantly reduce depressive symptoms. One study found that participants with medication-resistant depression showed notable improvements with DBT therapy compared to individuals in a control group.¹

Among older adults with predominantly chronic depression, 71% of those in the antidepressant plus DBT group were in remission at the end of treatment, compared to 47% in the medication-only group.⁷ DBT can also reduce suicidal ideations and self-harm incidents.^2,8

DBT Skills Training Applied to Depression

DBT was originally a treatment for individuals with a high risk of suicide, specifically those with borderline personality disorder.⁴ Since then, DBT has been applied as an effective treatment for depression and other mental illnesses. The four foundational DBT skills are generally relevant to individuals suffering from depression.

Here is how the DBT skills training modules are applied to depression:

Mindfulness Skills

DBT mindfulness skills are intended to help individuals focus on the present moment. A common experience associated with depression is a negative thinking spiral, often resulting in increased physical, cognitive, and emotional distress.

DBT mindfulness skills used in depression treatment include:

• Mindful breathing: Practice mindful breathing by paying attention to your breath and notice your inhale. Follow the breath in through your nose, into your lungs, and then out again as your exhale.
• Mindful observation: Use your senses to consciously observe your surroundings. Being mindful means taking time to notice colors, sounds, or smells and how you physically and emotionally react to them.
• Body scan: Starting at the top of your head, slowly scan each body part down to your toes. Notice, without judgment, any physical sensations that are occurring in different areas,
• Grounding anchors: If negative thought spirals are causing you distress, use grounding techniques like deliberately draw your attention to the present moment and identify five things you can see, four things you can touch, three things you can hear, two things you can smell, and one thing you can taste.
• Yoga: Practicing gentle yoga for mental health can be a very mindful experience because you focus on your breath, physical sensations, and physical form in the present moment.
• Focus on this moment: If you have a lot to do and are feeling overwhelmed, choose one thing, and one thing only, to focus on “in this moment” (a moment is 20 minutes).

Distress Tolerance Skills

Distress tolerance skills can assist you in dealing with intense emotional distress without resorting to destructive or self-harming behaviors. This distress can stem from painful negative emotions (e.g., guilt, shame, rage, hopelessness) or an unbearable feeling of numbness or disconnection from yourself, others, or life purpose.

DBT distress tolerance skills help you expand the window of how much distress you can tolerate, making it less likely that you will turn to self-injury, substances, or high-risk behaviors to distract from, manage, and/or survive the pain.

Distress tolerance also includes radical acceptance of aspects of life that cannot change. Hyperfocusing on these unmoveable aspects can contribute to maintaining a high level of distress and keep one stuck in negativity and feelings of helplessness.

Distress tolerance skills can add to and free up your energy and strength reserves so you safely experience your emotions and make conscious, rational decisions about your responses.

DBT distress tolerance skills used in depression treatment may include:

• Self-soothing: Wear comfortable clothes, wrap yourself in a warm blanket, or take a hot bath or shower.
• Radical acceptance: This involves acknowledging your current situation as it is, without judgment or self-criticism. Instead of trying to change things out of your control, focus on what is within your power. Tell yourself, “This is what the situation is. How do I want to go forward from here?”
• Engaging in physical activity: Physical activity can allow your body to release stress along with endorphins (the body’s natural pain relievers).
• Spending time with a loved one: Is there someone you enjoy being with? If so, make time to see them.
• Eating regularly: Your body needs fuel to deal with your illness. Even if you have little appetite, try to eat small meals a few times throughout the day (e.g., an apple, a piece of cheese, yogurt, raw vegetables, nuts, and berries). It can make a significant difference in how you feel and your ability to manage distress.
• Participating in a guided progressive muscle relaxation: Many guided relaxation meditations online can help you train your muscles to relax.
• Engaging in creative activity: Engaging in art, music, or writing can be a way to release stress and increase energy and good feelings.

Emotion Regulation Skills

DBT emotion regulation skills allow one to identify, acknowledge, observe, and experience the full range of emotions without getting overwhelmed by them.

DBT emotion regulation skills that are used in depression treatment include:

• Remove yourself from the situation: Where possible, take a break to give yourself time to stabilize emotionally so you are in a better mindset.
• Count to 10: Counting to 10 or focusing on your breathing for 60 seconds creates time to think more rationally and interrupt an impulsive response that might make things worse and lead to regret.
• Debrief with a friend or colleague: Debriefing the situation with a trusted friend or colleague might provide a wider perspective and adaptive ways to handle a situation.
• Focus on the outcome you want: Sometimes, reacting without thinking can jeopardize the final positive outcomes you want. Consider your ultimate goal and the response that yields the highest probability of success.
• Journal: For some individuals, writing out their feelings and thoughts allows them to clarify and process these emotions, creating a more objective perspective.
• Talk to your therapist: Bringing the issue and your honest emotional reactions to therapy offers an opportunity to understand yourself and your reactions. You also have a chance to explore possible healthy responses to the situation.

Interpersonal Effectiveness Skills

DBT interpersonal effectiveness skills for depression focus on developing healthy, assertive, and mutually respectful relationship skills. These skills often involve learning to communicate emotions, needs, and wants in relationships and how to address conflicts.

DBT interpersonal effectiveness skills used in depression treatment include:

• Identify and honor your personal values in relationships
• Ask open-ended non-judgemental questions to better understand another person’s perspective.
• Say “no” and set personal boundaries with others.
• Shift from judgment to curiosity when struggling to understand another person’s beliefs or choices.
• Express emotions and needs assertively in a conflict without verbally attacking the other person.
• Stop apologizing for your feelings, opinions, and beliefs

What to Expect During DBT Treatment for Depression

DBT treatment tends to have a structured format that varies depending on whether the treatment is in a group or individual setting. Some clients participate in both group and individual DBT therapy sessions. To adapt the original treatment for depression, emphasis is placed on information and skills that tend to be negatively impacted by depression.¹

For individual therapy, clients may attend 28 weekly 50-minute sessions before tapering sessions to meet their needs. Group therapy often involves a minimum of 28 weekly two-hour sessions.⁹ DBT allows for flexibility based on the client’s needs.

The following provides a general overview of DBT for depression:

• If the client is in crisis (e.g., engaging in life-threatening behaviors, significant self-harm, or reporting suicidal/homicidal intentions) the therapist will immediately engage in crisis intervention to help stabilize the client.
• Therapists will work with clients to identify their stressors and strategies the client has been using to cope. Unhelpful or destructive techniques (i.e., harmful to the client, others, relationships, etc.) are identified. Interfering behaviors are highlighted and will be addressed in skills training.
• Mindfulness practice is often interwoven throughout the skill development learning sessions. Clients are typically given homework after learning a particular skill to allow for the transfer of learning to their daily lives. Assigned homework is reviewed at the next session.

How to Find a DBT Therapist for Depression

Therapists who utilize DBT often list their approaches on their profiles in an online therapist directory, an online therapy platform, or professional websites. Consider asking your primary care doctor, friends, or family members for recommendations if you are unsure about choosing a provider.

Alternative Treatment Options for Depression

Alternative depression treatment options are available. A comprehensive treatment plan typically includes a medical assessment to rule out other potential symptom causes. Physicians and patients may also discuss whether or not medication is an option. Therapy with a qualified therapist (i.e., social worker, psychotherapist, clinical counselor, or psychologist) is usually recommended as part of a treatment plan.

Alternative treatment options for depression include:

• Medications: SSRIs and SNRIs are the most commonly prescribed medications for depression. These medications increase levels of certain neurotransmitters in the brain to reduce depressive symptoms.
• Cognitive behavioral therapy (CBT): CBT leverages the connections between thoughts, behaviors, and emotions. By shifting maladaptive thoughts and behaviors, individuals often experience a significant reduction in emotional distress.
• Acceptance and commitment therapy: ACT focuses on living in the present moment and accepting the pain and challenges part of depression (and life).
• Interpersonal therapy: Interpersonal therapy focuses on resolving interpersonal conflicts and increasing healthy connections.
• Internal family systems therapy (IFS): IFS for depression focuses on the many parts of the self and identifying and releasing the pain from the part(s) holding the depression.
• Psychodynamic therapy: Psychodynamic therapy involves examining the unconscious mind. Psychodynamic therapy helps the therapist better understand the clients’ challenges to support the development of more adaptive responses.

In My Experience

In my experience, DBT is a helpful intervention for clients dealing with depression. It provides access to skills that can immediately help manage distress. I ask clients to do a body scan for physical and emotional sensations before and after we try a new skill. Doing so allows clients to notice immediate impacts on their feelings when they change a behavior, increasing the chances they will continue to use these skills when they leave the session.

Radical acceptance is another very effective intervention. When clients realize they are squandering their time and energy on things that are outside of their influence, they are more likely to redirect their focus to areas of their lives where they can make meaningful changes. Accepting that some things as unchangeable will often initially elicit grief but can also provide a sense of freedom and relief.