National Alliance on Mental Illness
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[Download the NAMI DBT fact sheet.]

Dialectical Behavior Therapy

What is dialectical behavior therapy?

Dialectal behavior therapy (DBT) was invented by Marsha Linehan, a psychologist, who modified traditional cognitive behavioral therapy (CBT) for the treatment of chronically suicidal and self-injurious individuals with borderline personality disorder (BPD). Dr. Linehan recently revealed her own struggles with BPD and how her own insights from living successfully with the condition contributed to developing this novel and creative therapy.

What is different about DBT?

In standard DBT, different types of psychosocial therapies (e.g., individual psychotherapy, group skills training and even phone consultations) may be used as part of treatment. DBT differs from traditional CBT in its emphasis on validation—a powerful tool whereby the therapist and the patient work on “accepting” uncomfortable thoughts, feelings and behaviors rather than struggling with them. Once an identified thought, emotion or behavior has been validated, the process of change no longer appears impossible, and the goals of gradual transformation become reality. The term dialectics refers to the therapist’s goal of establishing a balance between acceptance and change and effectively integrating these two fundamental principles of successful therapy. DBT also focuses on the development of coping skills—specific behavioral techniques used to combat the disabling symptoms of mental illness.

As part of the skills-based element of DBT, emphasis is often placed on the development of mindfulness practice and other relaxation techniques. Mindfulness has its roots in Eastern meditation practices (e.g., yoga) and teaches individuals to become increasingly conscious of their thoughts and feelings through observation of bodily sensations. Through this practice, an individual develops the ability to accept distressing thoughts without self-criticism and to tolerate self-destructive urges (e.g., the desire to cut oneself) without acting upon them. Deep breathing and progressive muscle relaxation are examples of specific mindfulness techniques. People in DBT will frequently be asked to use their “wise mind” to help them make better choices.

Like CBT, DBT can involve the use of “homework” in between sessions. A common exercise is the use of diary cards or journaling for individuals to track their progress by noting the presence of symptoms (e.g., self-destructive urges) as well as successes (e.g., proper utilization of coping skills).

Since its development, DBT has been the best researched of the treatments for BPD. In particular, DBT has been shown in research to reduce suicidal outcomes in person with BPD. There are a few other psychotherapies to help with BPD. One of these is mentalization-based therapy in which individuals learn to become increasingly conscious of their own internal states and to develop empathy for other people’s experiences. These skills are then used to explore their own emotions as well as their interactions with others—specifically seeking alternative explanations for negative interpersonal experiences.

Who will benefit from DBT?

While DBT was initially developed to treat chronically suicidal individuals with BPD, it has evolved into a treatment for individuals with multiple different disorders. Although many people who are treated with DBT have BPD as a primary diagnosis, DBT has also been adapted for behavioral disorders involving emotional dysregulation (such as substance dependence in individuals with BPD and binge eating disorder) and for treating people with severe depression and associated suicidal thoughts.

How Do I know if my therapist is trained in DBT?

Training in DBT is rigorous and involves a considerable investment of time, effort and supervision. Dr. Linehan developed to lay out the rigorous qualifications to ensure therapists are using her model and to organize training sessions for therapists who want formal training. If you are seeking DBT, ask where the clinician received training in the model.

What can DBT accomplish?

As a comprehensive treatment, DBT can:

  • Decrease the frequency and severity of self-destructive behaviors.
  • Increase the motivation to change by providing positive reinforcement.
  • Teach new “coping skills” that generalize to a person’s natural environment.
  • Provide a treatment environment that emphasizes the strengths of both individuals and their treatments.
  • Enhance the therapist's motivation and ability to treat their clients effectively.

Recent research—based on long-term studies of people utilizing DBT—suggests that the majority will experience significant and long-lasting periods of symptom remission in their lifetime. Many people will not experience a complete recovery (e.g., problems with self-esteem and the ability to form and maintain relationships may linger) but nonetheless will be able to live meaningful and productive lives.

For individuals actively involved in DBT, family members and friends can be most helpful in providing nonjudgmental support of their loved one and by encouraging their loved one to continue with treatment.

Reviewed by Jacob L. Freedman, M.D., and Ken Duckworth, M.D., February 2013