DBT (Dialectical Behavior Therapy (DBT)

Overview
Dialectical Behavior Therapy (DBT) is a cognitive behavioral treatment that was originally
developed to treat chronically suicidal individuals diagnosed with borderline personality disorder
(BPD) and it is now recognized as the gold standard psychological treatment for this population.
In addition, research has shown that it is effective in treating a wide range of other disorders such
as substance dependence, depression, post-traumatic stress disorder (PTSD), and eating
disorders.
What are the components of DBT?
In its standard form, there are four components of DBT: skills training group, individual
treatment, DBT phone coaching, and consultation team.
1. DBT skills training group is focused on enhancing clients' capabilities by teaching them
behavioral skills. The group is run like a class where the group leader teaches the skills
and assigns homework for clients to practice using the skills in their everyday lives.
Groups meet on a weekly basis for approximately 2.5 hours and it takes 24 weeks to get
through the full skills curriculum, which is often repeated to create a 1-year program.
Briefer schedules that teach only a subset of the skills have also been developed for
particular populations and settings.
2. DBT individual therapy is focused on enhancing client motivation and helping clients to
apply the skills to specific challenges and events in their lives. In the standard DBT
model, individual therapy takes place once a week for as long as the client is in therapy
and runs concurrently with skills groups.
3. DBT phone coaching is focused on providing clients with in-the-moment coaching on
how to use skills to effectively cope with difficult situations that arise in their everyday
lives. Clients can call their individual therapist between sessions to receive coaching at
the times when they need help the most.

4. DBT therapist consultation team is intended to be therapy for the therapists and to
support DBT providers in their work with people who often have severe, complex,
difficult-to-treat disorders. The consultation team is designed to help therapists stay
motivated and competent so they can provide the best treatment possible. Teams typically
meet weekly and are composed of individual therapists and group leaders who share
responsibility for each client's care.

What skills are taught in DBT?

DBT includes four sets of behavioral skills.

Mindfulness: the practice of being fully aware and present in this one moment

Distress Tolerance: how to tolerate pain in difficult situations, not change it

Interpersonal Effectiveness: how to ask for what you want and say no while maintaining
self-respect and relationships with others

Emotion Regulation: how to change emotions that you want to change

There is increasing evidence that DBT skills training alone is a promising intervention for a wide
variety of both clinical and nonclinical populations and across settings.

What does "dialectical" mean?

The term "dialectical" means a synthesis or integration of opposites. The primary dialectic within
DBT is between the seemingly opposite strategies of acceptance and change. For example, DBT
therapists accept clients as they are while also acknowledging that they need to change in order
to reach their goals. In addition, all of the skills and strategies taught in DBT are balanced in
terms of acceptance and change. For example, the four skills modules include two sets of
acceptance-oriented skills (mindfulness and distress tolerance) and two sets of change-oriented
skills (emotion regulation and interpersonal effectiveness).

How does DBT prioritize treatment targets?

Clients who receive DBT typically have multiple problems that require treatment. DBT uses a
hierarchy of treatment targets to help the therapist determine the order in which problems should
be addressed. The treatment targets in order of priority are:
1. Life-threatening behaviors: First and foremost, behaviors that could lead to the client's
death are targeted, including all forms of suicidal and non-suicidal self-injury, suicidal
ideation, suicide communications, and other behaviors engaged in for the purpose of
causing bodily harm.
2. Therapy-interfering behaviors: This includes any behavior that interferes with the client
receiving effective treatment. These behaviors can be on the part of the client and/or the
therapist, such as coming late to sessions, cancelling appointments, and being noncollaborative in working towards treatment goals.
3. Quality of life behaviors: This category includes any other type of behavior that interferes
with clients having a reasonable quality of life, such as mental disorders, relationship
problems, and financial or housing crises.
4. Skills acquisition: This refers to the need for clients to learn new skillful behaviors to
replace ineffective behaviors and help them achieve their goals.
Within a session, presenting problems are addressed in the above order. For example, if the client
is expressing a wish to commit suicide and reports recurrent binge eating, the therapist will target
the suicidal behaviors first. The underlying assumption is that DBT will be ineffective if the
client is dead or refuses to attend treatment sessions.
What are the stages of treatment in DBT?
DBT is divided into four stages of treatment. Stages are defined by the severity of the client's
behaviors, and therapists work with their clients to reach the goals of each stage in their progress
toward having a life that they experience as worth living.
1. In Stage 1, the client is miserable and their behavior is out of control: they may be trying
to kill themselves, self-harming, using drugs and alcohol, and/or engaging in other types

of self-destructive behaviors. When clients first start DBT treatment, they often describe
their experience of their mental illness as "being in hell." The goal of Stage 1 is for the
client to move from being out of control to achieving behavioral control.
2. In Stage 2, they're living a life of quiet desperation: their behavior is under control but
they continue to suffer, often due to past trauma and invalidation. Their emotional
experience is inhibited. The goal of Stage 2 is to help the client move from a state of quiet
desperation to one of full emotional experiencing. This is the stage in which posttraumatic stress disorder (PTSD) would be treated.
3. In Stage 3, the challenge is to learn to live: to define life goals, build self-respect, and
find peace and happiness. The goal is that the client leads a life of ordinary happiness and
unhappiness.
4. For some people, a fourth stage is needed: finding a deeper meaning through a spiritual
existence. Linehan has posited a Stage 4 specifically for those clients for whom a life of
ordinary happiness and unhappiness fails to meet a further goal of spiritual fulfillment or
a sense of connectedness of a greater whole. In this stage, the goal of treatment is for the
client to move from a sense of incompleteness towards a life that involves an ongoing
capacity for experiences of joy and freedom.

How effective is DBT?

Research has shown DBT to be effective in reducing suicidal behavior, non-suicidal self-injury,
psychiatric hospitalization, treatment dropout, substance use, anger, and depression and
improving social and global functioning. For a review of the research on DBT. In this video,
DBT Developer and Behavioral Tech founder Dr. Marsha Linehan describes the amazing
changes she's seen in people who have received DBT and gotten out of hell.

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Dive Deeper
Philosophy and Principles of DBT
DBT is based on three philosophical positions. Behavioral science underpins the DBT bio-social
model of the development of BPD, as well as the DBT behavioral change strategies and
protocols. Zen and contemplative practices underpin DBT mindfulness skills and acceptance
practices for both therapists and clients. DBT was the first psychotherapy to incorporate
mindfulness as a core component, and the Mindfulness skills in DBT are a behavioral translation
of Zen practice. The dialectical synthesis of a "technology" of acceptance with a "technology" of
change was what distinguished DBT from the behavioral interventions of the 1970s and 1980s.
Dialectics furthermore keeps the entire treatment focused on a synthesis of opposites, primarily
on acceptance and change, but also on the whole as well as the parts, and maintains an emphasis
on flexibility, movement, speed, and flow in the treatment.
True to dialectics, DBT strategies are designed in pairs representing acceptance (validation,
reciprocal communication, environmental intervention on behalf of the client) and change
(problem solving, irreverence, consultation-to-the-patients about how they can change their own
environment). Strategies are further divided into procedures; a set of principles guides the
selection of strategies and procedures depending on the needs of the individual client. Clients are
also taught a series of behavioral skills designed to promote both acceptance and change. A focus
on replacing dysfunctional behaviors with skillful behaviors is woven throughout DBT.
DBT is a principle-based treatment that includes protocols. As a principle-based treatment, DBT
is quite flexible due to its modular construction. Not only are strategies and procedures
individualized, but various aspects of the treatment, such as disorder-specific protocols, can be
included or withdrawn from the treatment as needed. To guide therapists in individualizing
priorities for targeting disorders and behavioral problems, DBT incorporates a concept of levels
of disorder (based on severity, risk, disability, pervasiveness, and complexity) that in turn guides
stages of treatment and provides a hierarchy of what to treat when for a particular patient. In

contrast, skills training is protocol based. Once a skills curriculum is determined, what is taught
in a session is guided by the curriculum, not by the needs of a single client during that session.
The Development of DBT
In the late 1970s, Marsha M. Linehan attempted to apply standard Cognitive Behavior Therapy
(CBT) to the problems of adult women with histories of chronic suicide attempts, suicidal
ideation, and non-suicidal injury. Trained as a behaviorist, she was interested in treating these
and other discrete behaviors. Through consultation with colleagues, however, she concluded that
she was treating women who met criteria for Borderline Personality Disorder (BPD). In the late
1970s, CBT had gained prominence as an effective psychotherapy for a range of serious
problems. Dr. Linehan was keenly interested in investigating whether or not it would prove
helpful for individuals whose suicidality was in response to extremely painful problems. As she
and her research team applied standard CBT, they encountered numerous problems with its use.
Three were particularly troublesome:
1. Clients receiving CBT found the unrelenting focus on change inherent to CBT to be
invalidating. Clients responded by withdrawing from treatment, by becoming angry, or by
vacillating between the two. This resulted in a high drop-out rate. If clients do not attend
treatment, they cannot benefit from treatment.
2. Clients unintentionally positively reinforced their therapists for ineffective treatment
while punishing their therapists for effective therapy. For example, the research team
noticed through its review of taped sessions that therapists would "back off" pushing for
change of behavior when the client's response was one of anger, emotional withdrawal,
shame, or threats of self-harm. Similarly, clients would reward the therapist with
interpersonal warmth or engagement if the therapist allowed them to change the topic of
the session from one they did not want to discuss to one they did want to discuss.
3. The sheer volume and severity of problems presented by clients made it impossible to use
the standard CBT format. Individual therapists simply did not have time to both address
the problems presented by clients (suicide attempts, self-harm, urges to quit treatment,
noncompliance with homework assignments, untreated depression, anxiety disorders, and

more) and have session time devoted to helping the client learn and apply more adaptive
skills.
In response to these key problems with standard CBT, Linehan and her research team made
significant modifications to standard CBT.
They added acceptance-based or validation strategies to the change-based strategies of CBT.
Adding these communicated to the clients that they were both acceptable as they were and that
their behaviors, including those that were self-harming, made real sense in some way. Further,
therapists learned to highlight for clients when their thoughts, feelings, and behaviors were
"perfectly normal," helping clients discover that they had sound judgment and that they were
capable of learning how and when to trust themselves. The new emphasis on acceptance did not
occur to the exclusion of the emphasis on change: clients must change if they want to build a life
worth living.
In the course of weaving in acceptance with change, Linehan noticed that another set of
strategies dialectics came into play. Dialectical strategies give the therapist a means to
balance acceptance and change in each session. They also serve to prevent both therapist and
client from becoming stuck in the rigid thoughts, feelings, and behaviors that can occur when
emotions run high, as they often do in the treatment of clients diagnosed with BPD. Dialectical
strategies and a dialectical world view, with its emphasis on holism and synthesis, enable the
therapist to blend acceptance and change in a manner that results in movement, speed, and flow
in individual sessions and across the entire treatment. This counters the tendency, found in
treatment with clients diagnosed with BPD, to become entrenched in arguments and polarizing or
extreme positions.
Significant changes were also made to the structure of treatment in order to solve the problems
encountered in the application of standard CBT.
In her original treatment manual, Cognitive-Behavioral Treatment of Borderline Personality
Disorder (1993), Linehan hypothesizes that any comprehensive psychotherapy must meet five
critical functions. The therapy must:

1. Enhance and maintain the client's motivation to change

2. Enhance the client's capabilities
3. Ensure that the client's new capabilities are generalized to all relevant environments
4. Enhance the therapist's motivation to treat clients while also enhancing the therapist's
capabilities
5. Structure the environment so that treatment can take place
As already described, the structure of DBT includes four components: skills group, individual
treatment, DBT phone coaching, and consultation team. These components meet the five critical
functions of a comprehensive psychotherapy in the following ways:
1. It is typically the individual therapist who maintains the client's motivation for treatment,
since the individual therapist is the most prominent individual working with the client.
2. Skills are acquired and strengthened, and generalized through the combination of skills
groups and homework assignments.
3. Clients capabilities are generalized through phone coaching (clients are instructed to call
therapists for coaching prior to engaging in self harm), in vivo coaching, and homework
assignments.
4. Therapists' capabilities are enhanced and burnout is prevented through weekly
consultation team meetings. The consultation team helps the therapist stay balanced in his
or her approach to the client, while supporting and cheerleading the therapist in applying
effective interventions.
5. The environment can be structured in a variety of ways. For example, the home
environment could be structured by the client and therapist meeting with family members
to ensure that the client is not being reinforced for maladaptive behaviors or punished for
effective behaviors in the home.

References
Allmon, D., Armstrong, H. E., Heard, H. L., Linehan, M. M., &.Suarez, A. (1991). CognitiveBehavioral Treatment of Chronically Parasuicidal Borderline Patients. Archives of General
Psychiatry, 48, 1060-1064.
Koons, C. R., Robins, C. J., Tweed, J. L., Lynch, T. R., Gonzalez, A. M., Morse, J. Q., Bishop, G.
K., Butterfield, M. I., & Bastian, L. A. (2001). Efficacy of Dialectical Behavior Therapy in
Women Veterans with Borderline Personality Disorder. Behavior Therapy, 32, 371-390.
Linehan, M. M. (1993). Cognitive Behavioral Treatment of Borderline Personality Disorder.
New York: Guilford Press.
Linehan, M. M., Schmidt, H., Dimeff, L. A., Kanter, J. W., Craft, J. C., Comtois, K. A., &
Recknor, K. L. (1999). Dialectical Behavior Therapy for Patients with Borderline Personality
Disorder and Drug-Dependence. American Journal on Addiction, 8, 279-292.
Verheul, R., Van Den Bosch, L. M. C., Koeter, M. W. J., De Ridder, M. A. J. , Stijnen, T., & Van
Den Brink, W. (2003). Dialectical Behaviour Therapy for Women with Borderline Personality
Disorder, 12-month, Randomised Clinical Trial in The Netherlands. British Journal of Psychiatry,
182, 135-140.