DBT Vs. CBT: Understanding the Differences

What Is Dialectical Behavioral Therapy?

Dr. Marsha Linehan established dialectical behavior therapy as the effective treatment for borderline personality disorder (BPD).^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 for those with BPD.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, including trauma, addiction, and suicidality.

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.

Similarities Between DBT & CBT

CBT and DBT share many similarities. Both treatments help clients to better manage their thoughts, feelings, and behaviors, and work with clients to replace maladaptive patterns. CBT and DBT teach positive coping skills and often engage clients in homework assignments. Both of these therapeutic modalities are evidence-based and frequently used as a first-line intervention for a variety of mental health concerns.

Key Differences in DBT Vs. CBT

Despite the similarities, DBT and CBT differ in many important ways. One treatment may be more effective than the other for certain clients based on the session format, time frame of treatment, or the overall philosophy behind each intervention.

The Types of Sessions

CBT sessions will focus on the client’s thoughts, feelings and behaviors, and work toward establishing new patterns. Most often CBT is delivered in individual therapy sessions and can progress quickly. CBT is a collaborative effort between client and therapist.

DBT, on the other hand, includes mindfulness, emotion regulation, and distress tolerance skill-building in a group setting in addition to individual therapy sessions. One-on-one therapy spends time on processing trauma and establishing safety so that the client is emotionally prepared for the skill-building component of treatment. DBT also includes a focus on interpersonal relationships in the client’s life. In DBT, the therapist takes the lead as they instruct the client in developing skills to help them reach their goals.

The Time Frame

While CBT works well in a brief course of therapy, usually 5 – 20 sessions, DBT typically takes 6 – 12 months of individual therapy and group skills training sessions in order to be most effective. CBT is often more cost-effective and may provide faster symptom relief for some clients.

The Philosophies

CBT focuses on the present, while DBT makes space to process past trauma in order to facilitate healing. DBT encourages acceptance, whereas CBT is primarily concerned with changing maladaptive thinking and behavioral patterns. DBT also incorporates principles like distress tolerance and seeking joy and spiritual meaning, which are beyond the scope of CBT.

The Goals of Treatment

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 the client’s reported ineffective behaviors that make life difficult. For someone suffering from 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.”

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.

CBT Vs. DBT 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, and DBT is mainly used for personality disorders and overwhelming emotional disorders, but DBT for depression is also an option.

Disorders Typically Treated With CBT

Since the 1980s, 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 can be used for treating children, adolescents, and adults.

CBT is the an effective treatment for the following:^3,5,6

• Major depressive disorder
• Anxiety disorders
• Eating disorders
• Obsessive compulsive disorder
• Substance use disorders
• Bipolar disorder
• Impulse control disorders
• Insomnia
• Menopause
• Post-traumatic stress disorder
• Suicidal ideation
• Trauma

There is some debate over the effectiveness of CBT treatment for:^1,8

• Psychosis
• Schizophrenia
• Chronic pain
• ADHD

CBT is not effective for the following:⁹

• Dementia
• Amnesia disorders
• Confused states
• Some traumatic brain injuries
• Antisocial personality disorder

Disorders Typically Treated With DBT

DBT is the only empirically supported treatment for borderline personality disorder. DBT focuses on modulating intense emotions that negatively impact everyday life. Disorders that include intense, overwhelming emotions are good candidates for DBT treatment.

Modified DBT skills training has also been found to be an effective treatment for:^2,7

• Substance use disorders
• Mood disorders
• Posttraumatic stress disorder
• Suicidal ideation
• Eating disorders

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.

Here are some tips for determining whether CBT or DBT is the right treatment for you:

1. 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.
2. Insurance, time, and money: Does your insurance only allow for 12 sessions per year? Try CBT to solve the current problem. Can you afford 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 a modified DBT treatment.
3. Are your emotions uncontrollable and causing daily misery? If you are experiencing emotional dysregulation that interferes with your work, relationships, sense of self, or causes frequent suicidal thoughts, the answer is likely DBT.
4. 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, and as a result have different goals. The first sessions for each type of therapy will also differ based on those goals and the individual’s needs for attending therapy.

What To Expect At Your First CBT Session

As with most forms of 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 are affecting their life. This is the time to set SMART goals that will guide the therapy process. CBT is focused on solving problems in the present, so 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, and the emphasis in therapy will be placed on challenging and changing burdensome thoughts, emotions and behaviors to improve one’s quality of life.

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 will be less education and more CBT work on current problems. 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.

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 the therapist and client. If an agreement is reached, the orientation process begins, and a written contract will be signed for 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 attendance is required. New concepts and skills are presented each week. Group will end with new practice homework to reinforce skills and help people practice them in a variety of settings. The groups are structured, following 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 to 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 tool to find a DBT therapist with certification.

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.