Learn more about dialectical behavior therapy, how it works, when it’s used, and its core skills.
What Is Dialectical Behavior Therapy?
In the 1980s, psychologist Dr. Marsha Linehan noticed that CBT was not working well with patients who experienced suicidal behaviors, self-harm tendencies, or had borderline personality disorder. CBT’s focus on improving feelings by changing thoughts and behaviors overwhelmed them. Patients felt invalidated, misunderstood, and criticized, which led many to drop out of therapy.
Realizing some patients needed a different kind of emotional support and skills training, Linehan created dialectical behavioral therapy.
What Does Dialectical Mean?
In DBT, dialectical means two opposing ideas being true at the same time. Patients who have all-or-nothing or black-and-white attitudes are sometimes unable to think in other ways.
DBT emphasizes the dialectic of acceptance and change.
How Does It Work?
DBT requires a fundamental shift in thinking. DBT therapists work to teach patients necessary skills, such as mindfulness and distress tolerance, to balance their emotions and change their thinking.
DBT creates shifts in thinking by teaching acceptance of the present moment and acknowledging the feelings a person may be currently having, while still working toward the change that is needed to improve their life.
Here are some examples of DBT thinking:
Instead of: I can’t get out of bed. I’m too tired. I can’t go to work today. In DBT: I don’t feel like getting out of bed (acceptance). Or: I can still get up and go to work. My thoughts don’t control my life—I do (change). Instead of: I am a failure. I am worthless. I will never be successful. In DBT: Sometimes I may fail (acceptance). Or: Sometimes I succeed, and I’m sure I will do better next time (change). Instead of: I’m an idiot. I never get anything right. In DBT: I made a mistake (acceptance). Or: I can learn from my mistakes and do better next time. This mistake doesn’t define me as a person. Nobody’s perfect (change).
Core Skills of DBT
There are four main core skills with DBT. These include distress tolerance, mindfulness, emotion regulation, and interpersonal effectiveness.
Distress Tolerance Skills
Often, when people are overwhelmed with emotions, they may deal with the distressing feelings in ways that help them feel better in the moment. This can include substance abuse to numb the feelings or some type of immediate self-destructive action.
But in the long-term, these methods may cause even deeper emotional pain. Distress tolerance is about learning to manage those overwhelming feelings in healthier ways.
DBT skills to improve distress tolerance include:
Distraction: Distracting yourself from unhelpful thoughts and emotionsRadical acceptance: Accepting what you cannot change and focusing on what you can changeSelf-soothing strategies: Relaxing and soothing yourself using your five sensesSafe-place visualization: Imagining a safe, peaceful place, such as the beach or mountainsSpirituality: Empowering yourself with your own sense of spirituality
Mindfulness Skills
The practice of mindfulness is to be aware and focused on the present moment instead of the past.
Some DBT skills to practice mindfulness include:
Focus more fully on this present moment. Observe your thoughts, emotions, and physical sensations without judgment. Mindful breathing exercises, which can bring you into the present moment. Being kind and compassionate to yourself during mindful meditation.
Emotion Regulation Skills
Some people experience emotional extremes they cannot regulate, often when there is a history of trauma or when they feel threatened or abandoned. This is known as emotional dysregulation.
When they become triggered or emotionally overwhelmed, they may become highly reactive and self-destructive. Using magnetic resonance imaging (MRI), brain researchers have found that people with emotional dysregulation may have issues with the neurocircuitry that regulates emotion in the brain.
Some DBT emotion regulation skills include:
Recognizing your emotionsRecognizing how your thoughts and behaviors influence your emotionsRecognizing self-destructive behaviorsIncreasing positive emotions
Interpersonal Effectiveness Skills
Interpersonal effectiveness is about improving relationship skills. Managing emotions and emotional reactivity in relationships requires setting limits and managing conflict, while also respecting others.
Some DBT interpersonal effectiveness skills include:
Mindful attention to others to understand their thoughts and feelingsUsing assertive behavior instead of passive-aggressive behaviorMaking simple requests for what you want while also protecting your relationshipsActively listening instead of passive listening
How Do Dialectical Behavioral Therapy Sessions Work?
The traditional format for DBT is intensive and requires that the patient do work between sessions. The four major components of DBT sessions include:
Individual therapy once a week. Skills-training sessions, usually in a group therapy format for one to two hours weekly. Consultation check-ins between patient and therapist outside of the weekly session, as needed. The therapist meets weekly with other DBT-trained therapists for clinical case supervision. They discuss their DBT cases and gain guidance, which also helps the client, for one to two hours weekly.
When Is DBT Used?
DBT was originally created for borderline personality disorder (BPD) and those with suicidal behavior and non-suicidal self-injury who may be experiencing extreme emotions. But it has also been found to be an effective treatment for other mental health issues, including:
Post-traumatic stress disorder (PTSD) Bipolar disorder Attention-deficit hyperactivity disorder (ADHD) Eating disorders such as binge eating disorder and bulimia Major depressive disorder (MDD) Substance use disorder
How Does DBT Help?
In one study of DBT, as the participants developed more effective skills to manage their emotions, their substance use decreased too. Researchers believe this happened because their emotional coping skills increased and they had less of a need to use substances to numb their emotions.
In another study, after the first year of DBT treatment, 77% of the patients no longer met the criteria for a borderline personality diagnosis.
Summary
Dialectical behavior therapy is a type of therapy that was developed from cognitive behavioral therapy. It involves distress tolerance, mindfulness, emotional regulation, and interpersonal effectiveness skills. Although designed for people with suicidal behaviors, self-harm behaviors, and borderline personality disorder, it is an effective treatment for many other mental health disorders.
A Word From Verywell
If you are suffering from suicidal ideation, self-harm behaviors, or another mental health condition, you are not alone. Resources are available to help. If you are interested in exploring or think you could benefit from dialectical behavior therapy, talk with a healthcare provider or mental health professional about getting a referral to a DBT therapist in your area.
