Dialectical Behavior Therapy (DBT): How It Works & What To Expect

What Is DBT Therapy?

DBT involves employing self-reflection, analyzing behaviors and possible solutions, challenging dysfunctional thought and behavior patterns, and skills training for managing emotional dysregulation. It was initially developed as a treatment for highly suicidal individuals, but has been adapted to treat clients dealing with a variety of issues related to managing emotional distress.

DBT Vs. CBT

Cognitive behavioral therapy (CBT) is often considered the gold standard of therapeutic interventions due to the large body of research that supports it. In CBT, the link between thoughts, feelings, and behaviors is explored, and unhealthy patterns are identified and replaced. CBT is used for a wide range of mental health concerns, including depression, anxiety disorders, ADHD, substance use, and bulimia, among others.²⁴

DBT is based on CBT principles but focuses on mindfulness, distress tolerance, and relationship skills. DBT was developed to treat borderline personality disorder and has also been shown to be effective in treating clients dealing with self-harm or difficulties regulating emotions.²⁵ While some evidence exists for the efficacy of DBT in treating anxiety, depression, and other mental health concerns, the body of research is limited in comparison to CBT.

Core Concepts of DBT

The two main concepts of DBT involve dialectics, recognizing the complexity of life and how individuals both influence and are influenced by their environment, and biosocial theory, the idea that both environmental and biological factors influence the way in which humans regulate their emotions.

Dialectics

Dialectics recognizes that reality is complex, ever-changing, and interrelated; when change occurs in one area of one’s life, its influences are felt in other areas.² It acknowledges that people are influenced by their environment, and also have an influence on their environment. It further acknowledges that opposite forces are part of this reality, and each have their place.

For example, acceptance and change, which appear to be opposites, have a central role to play in DBT. The dialectical perspective involves seeing issues in shades of gray rather than black and white. For example, although people might have very different perspectives regarding an event or situation, dialectics presupposes that each of those perspectives will contain some part of the truth—and that no one perspective can claim the “absolute truth.”

Biosocial Theory

DBT is based on the theory that both biology and environment have significant influences on the development of the central nervous system, which regulates emotions in humans. It is thought that differences in the way the central nervous system functions—due to genetics, fetal development, or trauma exposure at an early age—might make it more difficult for some people to manage or regulate extreme emotions.³

Further, when a person who is biologically vulnerable lives within an environment in which they are led to believe that their emotional responses are inappropriate or wrong, and/or their emotional responses are minimized, punished, or belittled, that person does not learn how to successfully manage distressing emotions. Instead, they will learn to shut down their expression of emotions entirely, and/or to express emotions in extreme ways(e.g., verbal attacks, angry outbursts, self-injury, etc.).

DBT views client issues as stemming from maladaptive behaviors.² Emotions, thoughts, sensations, and actions are considered to be components of behavior. DBT therapists operate from the belief that the inability to manage or regulate painful emotions is often at the core of a number of mental illnesses such as borderline personality disorder, anxiety, depression, substance use, and eating disorders, as well as suicidality. Thus, clients and therapists focus on identifying and replacing behaviors that are a source of distress with more adaptive behaviors.⁴

What Is DBT Used For?

Goals for DBT are determined by the client in conjunction with the therapist and thus are individualized. Examples for how DBT is used and potential goals could include stopping self-injury behavior whenever there is a conflict in a significant relationship, learning how to deal with anger without resorting to violence, or learning how to work through conflicts at work.

More generally, the goals of DBT typically include enhancing awareness and use of adaptive skills or behaviors in the following areas:^5,6

• Emotional regulation: Understanding and naming emotions, changing responses to emotions, managing extreme emotions
• Distress tolerance: Crisis survival, acceptance of distressing emotions or situations
• Interpersonal effectiveness: Building healthy relationships, how to manage conflict effectively
• Control of attention: Being able to shift the focus of attention away from thoughts, sensations, or situations that increase emotional distress, and instead choosing to focus attention on those that reduce distress and/or increase positive thoughts, sensations and emotions.
• Coping skills: Increased use of effective and adaptive coping and problem-solving strategies

What Can DBT Help With?

DBT was originally developed to treat clients who were highly suicidal. Over the years, DBT, and the DBT skills components have been adapted to treat many mental health concerns. DBT for anxiety helps people recognize their triggers and develop better coping skills.

DBT can help with the following:⁶

• Borderline personality disorder (DBT for BPD is one of the only evidence-based BPD treatments)
• Self-injury behaviors
• Substance dependency
• Eating disorders
• Depressive symptoms
• Post-traumatic stress disorder
• Anger management
• ADHD
• Intimate partner violence

Dialectical Behavior Therapy Components

There are four main components to DBT: pre-assessment, individual therapy, skills training groups, and consultation.

Here is a brief overview of what to expect at each step in the DBT process:

DBT Pre-Assessment

Before beginning DBT, a therapist will conduct a pre-assessment to learn more about your concerns and ensure that DBT is the best course of treatment for you. They will likely discuss what DBT is, and what to expect during treatment.

Individual DBT Therapy

Individual DBT therapy sessions are typically held weekly for 40-60 minutes. During these sessions the therapist will help you create a plan for safety, if applicable, and learn new skills to help improve symptoms.

DBT Skills Training Groups

DBT skills training groups are an integral piece of this intervention model. Unlike group therapy, DBT groups are focused on learning skills rather than sharing experiences and receiving peer support.

Four main skills are taught in DBT skills training groups:

• Mindfulness
• Distress tolerance
• Interpersonal effectiveness
• Emotion regulation

Learning these skills will help you cope better in daily life.

Ongoing DBT Coaching Outside of Formal Sessions

DBT often involves crisis coaching in between sessions to help you integrate the skills you are learning to achieve symptom reduction, particularly in stressful moments. This may look like having an on-call therapist available to walk you through challenging moments over the phone. It is important to respect the therapist’s boundaries regarding these calls, which are usually during agreed upon hours for a brief time.²⁶

DBT Skills

Given that DBT views one of the primary sources of client distress to be a lack of adaptive skills, the focus is on identifying problem behaviors and replacing them with the skills they need to reach their goals.

Acceptance Skills

Clients are taught acceptance skills through which they learn how to accept the world, themselves, and others as they are.

Acceptance skills include mindfulness and distress tolerance:

• Mindfulness: Mindfulness skills are fundamental to DBT. These skills focus on teaching how to observe oneself and one’s environment from a non-judgemental and curious perspective—to witness oneself and one’s environment in a more objective way, and to be able to describe what is happening inside and outside one’s body from this perspective.
• Distress Tolerance: Therapists work with clients to identify and consciously choose behaviors that will help manage impulses that would previously have led to self-destructive or relationship-destructive behaviors, and replace these with self-soothing and distraction behaviors that will help them to survive a crisis.

Change Skills

DBT clients are also taught skills that will bring about change in their lives by allowing them to more effectively manage their own emotions, behaviors, and relationships.

Change skills in DBT include emotional regulation and interpersonal skills:

• Emotional Regulation: Emotional regulation skills development focuses a variety of cognitive and behavioral strategies that can be used to reduce distress caused by negative emotions, and to increase the experience of positive emotions.
• Interpersonal Effectiveness: Difficulties managing extreme emotions can have a negative impact on important relationships in one’s life. Clients are taught communication, assertiveness, and conflict resolution skills that will provide them with the means to more effectively address issues in relationships, including their own needs, in a manner that is respectful of themselves and the relationship.

Contingency Management

Contingency management refers to the therapist providing praise and acknowledgement to clients when they demonstrate a desired adaptive behavior in an effort to increase the likelihood that these behaviors will continue to occur.² It can also involve the therapist using negative consequences or withholding praise for client behaviors that are identified as being dysfunctional in the client’s life.

Exposure

Exposure refers to consciously choosing to pay attention to thoughts, behaviors, emotions, and related situations that one would typically take steps to avoid or escape the pain associated with them. In therapy sessions, with the assistance of the therapist, the client is encouraged to analyze and allow these experiences to occur instead of avoiding them.

The therapist works with the client to activate strategies of mindful acceptance, distress tolerance, and emotional regulation, so that the client learns how to more effectively tolerate and/or reduce the pain associated with these experiences – and thus no longer has to resort to maladaptive behaviors to avoid these experiences.⁶

Cognitive Modification (Changing Ways of Thinking)

Cognitive modification skills are also taught as part of DBT, to assist the client in changing unhelpful or destructive ways of thinking. Contingency clarification focuses on teaching clients to see how their behaviors impact their environment and others’ responses to them. Cognitive restructuring helps clients to learn to check their beliefs and assumptions regarding a situation, and how to change ways of thinking that are maladaptive.

Chain Analysis

One of the primary strategies used to help clients to understand their behaviors is chain analysis. Chain analysis is a very detailed analysis of the client’s thoughts, sensations, emotions, and actions that led up to a problem behavior.⁶

For example, if the client identifies that missing work is a problem, the therapist would help the client to identify all of the links or events that led up to the problem behavior.

The links might look something like this:

• This morning I woke up at 7:00 a.m. and immediately thought, “I have to go to work today. I don’t want to lose this job.” 
• I felt a knot in my stomach and my head started to hurt.
• I took a shower and got dressed for work.
• During my shower I started thinking about how much I hate my job.
• I started to feel a little nauseous.
• I walked into the kitchen to make coffee.
• I started thinking about my roommate who has been laid off from work and is able to stay home. I felt envious.
• I thought that it would be nice to hang out with my roommate and get high instead of dealing with the stress of work.
• I started to worry about not meeting quotas at work.
• My headache got worse.
• I thought about the meeting I had with my supervisor last week. She said she was concerned about how much work I missed during the past few weeks. 
• I started to feel angry when I remembered the meeting. 
• I was thinking, “It’s fine for her. She likes the job. I hate it.”
• My roommate came into the kitchen and asked if I was going to work. 
• My answer was, “I don’t know.”
• He pointed out that if I didn’t go into work, I could have a long weekend, and start back on Monday.
• I thought about how my stomach hurt, and I had a headache. I felt miserable.  
• I felt relief when I heard myself say, “You’re right. I’ll call in and say I’m sick.”
• I called work and left a message for my supervisor, saying I was sick and wouldn’t be in.
• I stayed home and got high with my roommate.
• Now, I can’t stop thinking about Monday. I’m afraid to go to work. What if I get fired? 

Therapist and client work together to identify each link (i.e., behaviors, thoughts, feelings) leading up to the decision to stay home from work. They then identify the links that they need to focus on to interrupt or break the chain and support the client in making the desired changes in behavior.

The 4 Stages of DBT

There are four stages in DBT, but these stages are not necessarily linear – at times, a client and therapist may go back to a previous stage as needed to revisit the tasks in that stage of treatment.²⁷

Here are the four stages of DBT:

• Stage 1: Behavioral stabilization involves getting problem-reducing behaviors under control. Safety is the most important component addressed in this stage, putting measures in place to prevent any imminent danger to self or others. Any behavioral patterns that might interfere with therapy are also addressed here.
• Stage 2: In this stage, traumatic experiences are processed, and maladaptive thoughts, beliefs and behaviors are addressed.
• Stage 3: The third stage focuses on helping the client trust themselves, reach their personal goals, and solve the problems of everyday life.
• Stage 4: This final stage aims to work with the client toward spiritual meaning and joy.

Benefits of DBT

Research has demonstrated many benefits for clients who engage in DBT:

• Reduces self-harm²⁸
• Helps clients to better face challenges²⁹
• Improves relationships
• Decreased substance use³⁰
• Reduces symptoms of depression³¹
• Increases coping skills
• Improves quality of life

Are There Any Risks?

DBT is considered a safe and effective treatment, though it may have a few drawbacks for potential clients to consider:

• DBT is time-intensive and can be costly
• DBT has a high drop-out rate³²
• Overwhelming emotions, flashbacks, and fatigue are possible side effects at various stages in the therapeutic process

How to Find a DBT Therapist

It is important to find a DBT therapist who is licensed to work in your state. The Linehan Board of Certification is a non-profit organization which provides a directory of mental health professionals who have completed rigorous knowledge-based and clinical requirements. You can also ask your primary care provider for a referral, or use an online therapist directory with experience in DBT and your specific mental health concerns.

Can You Get DBT Online?

Online DBT therapy is often available, and attendance is sometimes better in an online environment as many clients find it to be more convenient and cost-effective. Considerations regarding safety, confidentiality, access, and engagement are notable, and elements that therapists and researchers are bearing in mind as online therapy becomes more prevalent. Overall, studies show that DBT is just as safe and effective when delivered online as it is in person.³³

Key Questions to Ask a Therapist Who Offers DBT

Before beginning DBT treatment, here are several questions to ask your potential therapist:

• What is your educational background? Are you licensed to provide mental health therapy in this state?
• What advanced training have you completed in DBT?
• Do you offer individual and group DBT therapy? If so, how do you structure treatment?
• Do you offer a sliding scale of fees (i.e., based on client ability to pay)? If so, what is the range and how is it determined?
• Do you accept payment directly from health insurance plans?
• Do you offer DBT only, or do you use DBT interventions with other therapeutic approaches? If so, what other approaches do you use?

What to Expect at Your First Appointment

During the first appointment, you and your therapist will work together to identify goals for the first few sessions. Your therapist will also ask about your history (particularly with respect to high-risk behaviors such as self-injury and suicide attempts, since these would need to be addressed first).

Standard information about therapy will also be provided so that clients know what to expect. One of the goals of providing this information is to reduce client apprehension and emotional distress related to the unknown.

Types of information typically addressed in the first appointment will include:

• Therapist and client roles
• Confidentiality and its limits
• Structure of sessions
• Frequency and length of sessions
• Duration of treatment
• Fees for session and if there are fees for missed or canceled appointments
• What crisis supports or resources are available

How Long Will I Need Dialectical Behavior Therapy?

The length of DBT treatment can vary depending on the client’s needs. However, most clients complete DBT in about 6-12 months.³⁴ For some clients, just the first stage of treatment will take several months, while others will move through the stages more quickly. Once treatment is considered complete, a client may still face challenges and return to therapy again in the future.

Is DBT Effective? 

Research has demonstrated that DBT has been effective with clients who are dealing with borderline personality disorder (BPD), suicidal behaviors, substance dependency, and post-traumatic stress disorder (due to childhood sexual abuse).^{8,9,20,11,12,13} It has also been proven to be effective in situations regarding suicidal and/or self-injurious behaviors, eating disorders, and depressive symptoms.^{14,15,16,17,18,19,20,21}