Dialectical Behavioral Therapy (DBT) and Cognitive-Behavior Therapy (CBT) are psychotherapies rooted in a philosophy that suggests healthy thinking can reduce distress and promote well-being. Both DBT and CBT can be used to effectively treat depression, anxiety, personality disorders, addiction, eating disorders, PTSD, and some other problems. CBT tends to work well in short-term therapy, 5 – 20 sessions. DBT offers better results combining individual therapy sessions with weekly groups over six months to a year.
It is easy to take various parts of DBT and put them to use in a variety of settings targeted at an array of problems. I call these practices modified, abbreviated or abridged Dialectical Behavioral Therapy.
Core Concepts of Cognitive-Behavior Therapy (CBT)
Basic Cognitive-Behavior Model9
Since the 1950’s Cognitive-Behavior Therapy has been refined into two central beliefs: thoughts have a controlling influence on emotions and behaviors, and these behaviors can strongly affect both thought patterns and emotions. CBT requires a new way of thinking about one’s self and acting on it.
CBT is not “talk” therapy where the client might spend 45 minutes talking to the therapist
Sessions have a structure with set segments presented in this order:
- Greeting
- Symptom check
- Set agenda
- Review homework
- Conduct CBT work on issue from the agenda
- New CBT concept
- Develop new homework
- Review key points
- Provide feedback
- Close
CBT sessions are usually 45 – 50 minute sessions weekly, or every two weeks. They are short-term, usually lasting 5 – 20 sessions. Sessions focus on present-day problems without delving deeply into the past. CBT aims to change negative thoughts as ways to improve and manage emotions and behavior.
CBT teaches effective problem-solving skills, by focusing on a specific problem, and working towards a healthy resolution. The process is collaborative, in which there is a working partnership between the therapist and client. This requires the client to set specific goals and “do the work” by learning in session and later practicing outside of session to master new thinking and new behaviors.
Core Concepts of Dialectical Behavior Therapy (DBT)
Dr. Marsha Linehan established Dialectical Behavior Therapy as the effective treatment for borderline personality disorder.4,7 In her research, Linehan found that CBT offered an excellent foundation for learning problem-solving skills; however, it did not focus enough on regulating intense emotions and preventing intentional self-harming behavior.4 Linehan’s population required something more, so she added a foundation in dialectics to CBT. Over time, DBT has been empirically established as an effective treatment for many disorders besides borderline personality disorder.
Linehan’s application of dialectics sets DBT apart from all other treatments. Dialectics is both a holistic worldview, and a way of interacting in a relationship.
The dialectic perspective of reality has four characteristics:
- It is a systems view in which all parts relate to the whole; everything and everyone is connected.
- Reality consists of opposing forces that stand side by side; two opposite things can be true at the same time. For example, “I like the way I am, and I need to change.”
- The interconnectedness of (1), and oppositional reality of (2) leads to continuous change; change is the only constant
- Change is transactional.
The environment and people influence me and I influence people and the environment.4 Dialectics requires a new way of seeing and understanding the world.
There are some elements of talk therapy in DBT. Discussions take place about what happened, why it happened, and what skills to use for change The client will sign a written contract with the therapist agreeing to treatment. It is oriented towards dialectical processes in sessions that can be both flexible and structured. DBT uses individual therapy along with an education group and coaching calls.
DBT takes place weekly with 45 – 50 minute sessions along with 2 or 2.5 hours weekly group sessions. Clients can call their therapist to coach them through a crisis which are usually short, 5 – 10 minutes with set rules. Emphasis is placed on problem solving using new effective skills.
Validation is a key aspect of therapy. Validation is affirming that thoughts, emotions, and behaviors make sense in context even though they may not be effective, or a good choice
The therapeutic relationship in DBT is essential. DBT is a long-term treatment, usually lasting six months, a year, or more.
There are four distinct skill building modules which take six months to complete:
- Mindfulness
- Interpersonal effectiveness
- Emotion regulation
- Distress tolerance
Additionally, there is an extra “Walking the Middle Path” module may be added. Each module is taught in a weekly group setting for 6 – 8 weeks and homework is assigned each meeting; groups are two or more, but less than 12 people.
DBT works through three stages of therapy targeting specific types of behaviors to decrease or increase in each stage, and behavioral change is measured over time and tracked on diary cards by the client.
DBT works well with disorders that share the following characteristics with borderline personality disorder:
Key Differences in DBT vs. CBT
Here are the main differences between DBT and CBT.
Dialectical Behavioral Therapy vs. Cognitive-Behavior Therapy
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DBT vs. CBT for Treating Different Disorders
DBT and CBT are used to treat different disorders. CBT is primarily used for mental health issues such as anxiety and depression disorders, and DBT is mainly used for personality disorders and overwhelming emotional disorders.
Disorders Typically Treated With CBT
Since the 1980’s CBT has become the most common, best-studied form of therapy. There have been hundreds of random controlled trials finding it effective for many disorders. CBT is the an effective treatment for the following:
- Major depressive disorder
- Anxiety disorders
- Eating disorders5
- Obsessive compulsive disorder
- Substance use disorders
- Bipolar disorder
- Impulse control disorders
- Insomnia
- Menopause
- Post-traumatic stress disorder
- Suicidal ideation
- Trauma3,6
There is some debate over the effectiveness of CBT treatment for psychosis, schizophrenia, chronic pain, and ADHD.1,8 CBT can be used for treating children, adolescents, and adults.
There are established guidelines for evaluating clients for CBT therapy.
A therapist will generally assess for a client’s:
- Disorder complexity and duration (chronic, complicated disorders may not be treatable with CBT)
- Optimism for treatment relief
- Acceptance of change
- Cognitive ability to assess one’s thoughts and identify emotions
- Capacity to engage with the therapist
- Ability to stay within the problem-oriented focus of treatment
These characteristics are beneficial for CBT to be completely effective. CBT is not effective for the following:
- Dementia
- Amnesia disorders
- Confused states
- Some traumatic brain injuries
- Antisocial personality disorder9
Disorders Typically Treated With DBT
DBT is the only empirically supported treatment for borderline personality disorder. Modified DBT skills training has also been found to be an effective treatment for substance use disorders, mood disorders, posttraumatic stress disorder, suicidal ideation, and eating disorders.2,7
DBT focuses on modulating intense emotions that negatively impact everyday life. Disorders that include intense, overwhelming emotions are good candidates for DBT treatment.
Intense emotions can be described as:
- overwhelming, uncontrollable and exceedingly painful
- rapid changes in mood over the course of the day
- feeling like everything is a constant crisis
- being unable to keep emotions in check or the having the feeling of “spinning out of control”
- feeling compelled to engage in extreme behaviors to stop or avoid emotions
- angry all the time, even when there isn’t a cause
- emotions that have a long duration—hours or days
- being so emotional that thinking or decision making is impaired
- feeling empty and numb, or an absence of self
- causing chaos and crisis in interpersonal relationships
- feeling like suicide is an option to stop the misery
These features of intense emotion can be found in the disorders listed above and in trauma experiences. DBT is often modified, adapted, or abbreviated to help clients regulate emotions. DBT can make the difference between life and death, figuratively and literally. DBT can be used effectively with adolescents and adults.
How Do I Know if DBT or CBT Is Right for Me?
Whether DBT or CBT is effective for a person depends on the individual’s needs, issues, and emotional state.
There isn’t an exact answer, but here are some tips:
- Look first to the problem. Is it specific and in the present? For example, “I can’t make myself eat lunch in the cafeteria. I am afraid I will drop my tray and look stupid.” CBT would be great. Is it chronic and pervasive, “I cry and scream every time I lose at my video game, or can’t do my homework. I only feel better if I punch the wall.” DBT would be the best answer.
- Insurance, time and money. Does your insurance only allow for 12 sessions per year? Try CBT to solve the current problem. Can you afford to put your teenager, or yourself, in a six month program for anger and self-harm? Then DBT is the best solution. If you don’t have the time to invest in DBT therapy and groups, then try CBT first or modified DBT treatment.
- Are your emotions uncontrollable and causing daily misery? Read the intense emotions list above. If you are experiencing emotional dysregulation that interferes with your work, relationships, sense of self, or causes frequent suicidal thoughts. The answer is definitely DBT.
- Are you feeling depressed, sad, or somewhat worthless? “I just can’t get out of bed in the morning.” This would be a good problem to solve with CBT.
As with all behavioral and mental health issues, it is best to meet with a professional and define problems and goals. Doing so will be the best way to understand all of the options to make an informed decision.
DBT vs. CBT Therapy Goals And First Sessions
DBT and CBT address different issues for patients, and as a result have different goals. The first sessions for each type of therapy will also differ based on those goals the individual’s needs for attending therapy.
Goals of CBT therapy
CBT goals are S.M.A.R.T. The mnemonic acronym SMART stands for Specific, Measurable, Achievable, Relevant, and Time-bound. Goals will be based on client’s reported ineffective behaviors that make life difficult. For someone suffering with panic attacks an
example might be, “I want to be able to go to work events (parties, fundraisers, award ceremonies) without suffering panic attacks when meeting new people. The annual company dinner is in two months and I want to be comfortable going.”
What To Expect At Your First CBT Session
As with most therapy, the first session is a review of paperwork completed before the session otherwise known as an “intake.” The therapist collaborates with the client to assess symptoms and problems, and how they affect one’s life. This is the time to set SMART goals that will guide therapy. CBT is focused on solving problems in the present. Don’t be surprised if the therapist doesn’t ask for a deep personal history. CBT treatment assumes that negative thoughts are having an unwanted impact on behavior and emotions. Emphasis in therapy will be placed on challenging and changing burdensome thoughts, emotions and behaviors to improve one’s quality of life.
In additional sessions, the therapist will guide the work based on the current session’s agreed upon agenda. In the first few sessions, it will feel like the therapist is talking a lot. The CBT model has to be explained and understood for the treatment to be productive. Moving forward, there is less education and more CBT work on current problem situations. This will include practice using the skills, rehearsal for future situations, feedback and new homework.
Success with CBT relies on committing to all of the CBT work. The therapist will expect and review completed homework and skills practice every session. Talking through a session will not achieve the established goals. Changing thoughts, emotions, and behaviors is the most difficult work one can confront. It takes dedication to change. Optimism, desire to change, commitment to learning, hard work, and a very good relationship with the therapist will greatly impact CBT treatment results.
Goals of DBT Therapy
DBT’s end goal is changing one’s overall quality of life. The initial stage focuses on decreasing harmful behaviors (therapy) and increasing effective behavior skills (group). The second stage is processing trauma. The third stage targets increasing self-respect and meeting personal goals.
What To Expect At Your First DBT Session
The first session with a DBT therapist will include a thorough “intake” to:
- gauge the depth of problems;
- gain a history of maladaptive (ineffective) behaviors;
- understand current symptoms;
- assess fitness for DBT treatment;
- understand the client’s motivations and current environment.
Boundaries, treatment procedures and goals of treatment are set immediately. DBT requires a thorough understanding of what is expected from therapist and client. If an agreement is reached, the orientation process begins, and a written contract will be signed for treatment. Without this contractual agreement, there is no treatment.
The complete orientation process may take four sessions, or more. It is educational and dynamic, moving with the dialectical tension of acceptance and change. It is a time to build a solid, positive therapeutic relationship. The therapist accepts and validates the client’s thoughts, emotions and behaviors in context. At the same time, the therapist insists on problem-solving to change behaviors that are ineffective and cause misery. The therapist believes in the client’s inherent ability to change and works with the client’s strengths.4
Once the orientation is complete, the client will be started in an educational skills training group and continue weekly therapy sessions. The group meets for 2.5 hours per week and requires attendance. New concepts and skills are presented each week. Group will end with new practice homework to reinforce skills and to help generalize skills to all settings. The groups are structured. Group follows the same agenda each week: Mindfulness activity, homework review, new learning, and homework assignment. It takes six months of adherence to weekly meetings to complete the skills training group and graduate.
How Do I Find A CBT Therapist?
Finding a CBT therapist is fairly easy since it is a widely used treatment. Therapists generally publish their education and training on their professional websites. Their credentials also appear when they list themselves on searchable online directories. Searching can be done by provider’s name or simply by location.
How To Find A DBT Therapist
Finding a qualified DBT therapist is a bit trickier. There are many therapists who take short courses in DBT therapy, but have not completed certification. First try Dr. Linehan’s website search at: DBT – Linehan to find a DBT therapist with certification. Please read the article Certification versus a Certificate on Dr. Linehan’s website to understand the different levels of training and how it affects DBT treatment.
Do not be afraid to ask therapists about their education, training, certifications, work history, experience and their personal treatment philosophy. The relationship between therapist and client is paramount. It is important to have the right fit. With a good therapist, treatment goals can be accomplished within a safe, honest, trusting environment in a timely manner.
