Dialectical Behavioral Therapy (DBT) primarily involves skills training (i.e., mindfulness, interpersonal effectiveness, emotional regulation, and distress tolerance) to assist clients to better manage and tolerate emotional distress, as well as problem-solving strategies to support clients in learning how to identify extreme or maladaptive behaviors and replace them with more effective and helpful behaviors.1
While the treatment timeline varies depending upon the severity of the issues being addressed, the cost of DBT usually ranges between $100 to $200 per session. Your out-of-pocket costs could be significantly lower if your therapist is in-network for your insurance plan.
What is DBT?
DBT is a type of Cognitive Behavioral Therapy (CBT). It uses many of the same strategies of CBT in terms of employing self-reflection, analyzing behaviors and possible solutions, challenging dysfunctional thought and behavior patterns, and skills training. 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.
Core Concepts of DBT
The two main concepts of DBT involve Dialectics (recognizing the complexity of life and how individuals influence/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 is a way of viewing the world, whereby it is recognized that reality is complex, ever-changing, and interrelated; when change occurs in one area of one’s life, it’s influences are felt in other areas.2 It acknowledges that individuals 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 individuals 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.”
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 individuals 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 are the Goals of DBT and Who Determines Them?
Goals for DBT are determined by the client in conjunction with the therapist and thus are individualized (e.g., stopping self-injury behavior whenever there is a conflict in a significant relationship; learning how to deal with anger without resorting to violence; 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.
- 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 component alone, have been adapted to treat the following:7
- Borderline personality disorder
- Self-injury behaviors
- Substance dependency
- Eating disorders
- Depressive symptoms
- Post-traumatic stress disorder
- Anger management
- Attention-Deficit/Hyperactivity Disorder
- Intimate partner violence
Common Types of DBT Interventions
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. Clients are taught acceptance skills through which they learn how to accept the world, themselves, and others as they are. They 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.
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.
An inability to manage and tolerate intense emotions can lead to high risk behaviors that have the potential to effectively reduce the intensity of one’s emotions when one is feeling them too deeply, or to feel something when one is feeling unbearably numb or shut down. 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.
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.
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 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 which are identified as being dysfunctional in the client’s life.
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.9
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.
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.9
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.
DBT Skills Training Examples
DBT training may include working with a therapist to develop skills such as mindfulness and self-soothing. Here are some examples of what these practices entail:
Take a few moments to bring your attention inward. You might want to close your eyes or focus them gently on a point in front of you. Notice your breathing. Don’t do anything to change it. Just observe your breath. Notice the pattern. Notice the filling and emptying of your lungs. Notice how the breath comes into your body. Notice how it leaves.
Scan your body, starting at the top of your head, working slowly through all areas, right down to the bottom of your feet. Notice any physical sensations along the way… feelings of pressure, pain, relaxation, tightness, heaviness, or lightness… Try not to judge these sensations or think about them too much. Just notice them the way you might notice scenery passing by when you are looking out of the window of a car, a bus, or a train. Are there any areas that feel tight? Any that feel relaxed? Do you notice any painful, achy or heavy spots? Are there any areas that feel healthy, light, or at peace?
Increasing Distress Tolerance through Self-Soothing
During times when you notice that you are feeling emotionally distressed or overwhelmed you might find self-soothing strategies, which use your senses, to be helpful in reducing your level of distress so that you can continue to function and cope.
Some examples of self-soothing are:
- Sight: Looking at nature; looking into the eyes of a loved one; placing a picture of loved ones or a favorite place in a place you can see it.
- Sound: Listening to music that has a calming or relaxing influence on you; singing a song that you find inspiring; playing an instrument.
- Touch: Wear comfortable clothes; pet an animal; have a hot bath or shower.
- Smell: Breathe in the scents of nature; use a favorite scented hand or body lotion; bake cookies or bread.
- Taste: Make your favorite meal; have a warm comforting drink; allow a piece of chocolate to melt in your mouth.
Self-soothing strategies are not likely going to eliminate all of your distress, but if one action reduces your distress by 5%, another by 10%, and another by 10%, that might add up to just enough distress reduction to allow you to effectively cope.
Cost of Therapy* 10,11
|Possible DBT Providers||Range (per one-hour session)||Average cost (per one-hour session)|
A psychiatrist is a licensed medical doctor who has completed specialized training in psychiatry. Psychiatrists can diagnose mental illness, prescribe and monitor medication, and provide therapy.
A licensed psychologist has completed a doctoral degree, typically in clinical, counseling or educational psychology. Psychologists can assess and diagnose mental illness. They can also offer individual and/or group therapy.
|Counselors, Clinicians, Social Workers, and
These mental health professionals have completed a master’s degree (typically a M.A., M.Ed., or M.S.W.) in a mental health related field such as psychology, counseling, social work, or marriage and family therapy). They can provide individual and/or group therapy.
*If your health insurance plan covers mental health services from any of these professionals, your cost might be significantly lower, possibly as low as $20-$50 per session. Check with your plan first to see what types of mental health professionals are covered. Additionally, some hospitals, medical centers, colleges, and community agencies might offer therapy at no charge.
How to find a Therapist who offers DBT
It is important to look for a mental health professional who is licensed to work in your state. (Note: Titles of mental health professionals may vary by 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.
Key Questions to Ask a Therapist Who Offers DBT:
- 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 cancelled appointments
- What crisis supports or resources are available
Is DBT Effective?
Research has demonstrated that DBT has been effective with clients who are dealing with Borderline Personality Disorder (BPD),12 suicidal behaviors,13,14 substance dependency,15,16 and post-traumatic stress disorder (due to childhood sexual abuse).17 It has also been proven to be effective in situations regarding suicidal and/or self-injurious behaviors,18,19,20,21 eating disorders,22,23,24 and depressive symptoms.18,25,26,27