Dialectical behaviour therapy (DBT), explained

By Team TherapyRoute

DBT is a structured talking therapy built around skills. It belongs to the third wave of behaviour therapy.² That wave treats the setting a behaviour happens in as part of the problem, not just the behaviour itself. The four skill sets it teaches cover mindfulness, relationships, emotions and distress.

Where DBT comes from

Behaviour therapy developed from learning theory. That is the study of how behaviour is learned: classical conditioning, where two things become linked, and operant conditioning, where the consequences of an action shape whether it is repeated. Its methods treat symptoms as learned patterns that can be reshaped.

Behaviour therapy emerged in the mid-1950s. It began in three countries, one of them South Africa, through the work of Joseph Wolpe.²

The field then moved in waves. The first focused on conditioning and learning.² The second came in the 1970s, added a focus on information processing, and produced cognitive behavioural therapy, or CBT.

DBT belongs to that third wave.² Third-wave therapies pay close attention to context, and to what a behaviour does. They aim to build broad, flexible skills, not only to remove symptoms.

What "dialectical" means here

DBT is based on a dialectical world view.¹ The word describes how the therapy sees reality: as made of opposing forces.¹ The tension between those forces can move towards a synthesis, a position that takes in what is true on both sides.

Rigid, all-or-nothing thinking is seen as a dialectical failure.¹ Only one side of a tension is held, and the other is dropped. The four skill sets follow from this view.

The four skills modules

DBT skills training is organised into four modules.¹ Each builds a different set of skills.

• Mindfulness. Paying attention to what is happening now, on purpose, without judging it. Mindfulness comes first, and its skills are used in all the others.¹
• Interpersonal effectiveness. Asking other people for change, and setting limits with them.¹
• Emotion regulation. Built on the idea that emotional responses can change.¹
• Distress tolerance. Getting through pain that cannot be fixed now.¹ It includes crisis survival skills for the hardest moments.¹

Every skill comes with handouts, and each handout has a worksheet to practise with.¹ DBT is a hands-on, practice-based therapy.

What a full DBT programme involves

Full DBT is more than a class. It combines individual therapy, a skills group, phone coaching, and a therapist consultation team.¹

The skills are usually taught in a group. A standard group has six to eight members, and up to ten, plus two leaders.¹ It tends to meet once a week for about two and a half hours.¹

Working through all four modules once takes about six months.¹ Each core module runs over several weeks, and mindfulness is repeated before each new one. A one-year programme repeats the cycle over twelve months.¹

Who DBT tends to suit

DBT was developed alongside work on borderline personality disorder.¹ Its foundational text is titled Cognitive-Behavioral Treatment of Borderline Personality Disorder.¹

Marsha Linehan developed the therapy. The first randomised controlled trial of it, published in 1991, was conducted in women with borderline personality disorder who had a recent history of suicide attempts and self-injury.³

Its skills are used for problems beyond BPD too. The modules deal with intense emotions, distress and relationships, so it may suit you if those are your hardest areas. A therapist can help you judge the fit.

What the evidence shows

DBT was built and tested first for borderline personality disorder in people at high risk of suicide, and that is where the evidence is strongest. For this group it is the only therapy with enough good-quality research behind it to have been assessed as effective by the Cochrane Database of Systematic Reviews.¹

Compared with treatment as usual, and with treatment by experienced community clinicians, adults with borderline personality disorder at risk of suicide have shown greater improvement on measures of suicidal thinking and suicidal behaviour, hopelessness and anger outbursts, along with fewer emergency and inpatient admissions for suicidality.¹

Self-injury has been measured directly. In one trial, non-suicidal self-injury fell in the DBT group and rose in the group receiving usual treatment.¹

An independent review in a psychiatry textbook rated DBT well established for borderline personality disorder on the strength of nine well-designed randomised trials run by four separate research groups, while treating its use for other diagnoses as still experimental pending further evidence.⁴

What none of this says is that DBT works for everyone, or that it ends risk. These trials compare average outcomes between groups over months or a year. A reduction in suicide attempts and self-injury is a reduction, not a guarantee, and it is not a substitute for emergency help when someone is in danger.

One further limit is worth knowing. The trials that built the case for DBT in borderline personality disorder were conducted almost entirely with women, so less is known about how well the findings carry to men.³

Where DBT has been adapted

Shortened versions that teach the skills without the individual therapy have been tested for other problems, usually in smaller studies. Adapted skills groups were found effective for eating disorders in three trials, with less binge eating and less bingeing and purging, and they reduced depression across nine separate studies.¹

For substance use the picture is narrower and the claim should be narrower with it. Trials in women who had borderline personality disorder alongside a drug problem found reductions in illicit drug use.³ That finding belongs to a particular group and does not generalise to addiction treatment at large.

Researchers working on DBT say plainly that more work is needed to establish which of the skills are doing the work and which could be left out.¹

DBT and CBT: how they differ

CBT belongs to the second wave, and is built around information processing. DBT belongs to the third. It adds close attention to context, alongside the skills it teaches.

Finding DBT and taking a next step

Availability varies from one place to another, and a full programme is not offered in every setting. Some services run the whole programme; others offer only parts of it.

Some people start with a skills group. Others start with individual therapy that draws on DBT.

If you are weighing DBT, a therapist can help you decide. Our guide on how to find the right therapist is a good place to start.

This article is general information, not personal clinical advice. For guidance about your own situation, please consult a qualified mental health professional.

Common questions

Is DBT the same as CBT?

No. CBT belongs to the second wave, built around information processing. DBT belongs to the third wave and adds close attention to context.

How long does DBT skills training take?

Working through all four modules once takes about six months. A one-year programme repeats the cycle over twelve months.

Do I have to join a group?

Standard skills training happens in a group. Full DBT also includes individual therapy, phone coaching, and a consultation team.

How strong is the evidence that DBT works?

Strongest for borderline personality disorder with suicidal behaviour and self-injury, where randomised trials support it. Thinner, though promising, for adapted skills groups in eating disorders, depression and drug use, where the studies are smaller and fewer.¹

What will I actually practise?

You work through four modules: mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. Every skill comes with handouts and a worksheet.

References

1. [1] Linehan MM. DBT Skills Training Manual. 2nd ed. Guilford Press; 2015.
2. [2] Hopko DR, Clark CG, Shorter R. Behavior Therapy. In: Kaplan & Sadock's Comprehensive Textbook of Psychiatry. 10th ed. 2017.
3. [3] Chapman AL, Linehan MM. Dialectical Behavior Therapy for Borderline Personality Disorder. In: Zanarini MC, ed. Borderline Personality Disorder. Taylor & Francis; 2005.
4. [4] Rosenthal MZ, Lynch TR. Dialectical Behavior Therapy. In: Kaplan & Sadock's Comprehensive Textbook of Psychiatry. 9th ed. Lippincott Williams & Wilkins; 2009.