Dialectical Behavioral Therapy (DBT)

The 2014 National Survey on Drug Use and Health found that around 43.6 million American adults suffered from some form of mental illness and 20.2 million had a substance abuse disorder—7.9 million had both, which is known as a dual diagnosis.¹ Although substance abuse and mental health disorders can be debilitating, professional treatment can help people recover and lead happier and healthier lives.

Various treatment methods provide different ways of helping people heal from trauma, mental health disorders, and substance abuse issues. Depending on their unique needs, people suffering from these problems may benefit from undergoing treatment that uses several therapeutic methods, including cognitive behavioral therapy (CBT), motivational enhancement therapy (MET), the Matrix Model, and—as the topic of this discussion—dialectical behavioral therapy (DBT).^2,3

What Is DBT?

The term dialectic refers to the concept of bringing together or integrating two opposing forces or concepts.⁴ Originally developed by Marsha Linehan, an American psychologist who sought to find an effective form of treatment for people with Borderline Personality Disorder (BPD), DBT has also been adapted to treat trauma, substance abuse disorders, and certain mental illnesses, such as depression or binge-eating disorders.^5,6 It is a highly structured form of therapy that blends CBT and acceptance-based practices such as mindfulness. DBT involves a combination of 4 strategies that include:⁷

• Weekly individual therapy to help you maintain and improve your motivation to work toward a happier and healthier life.
• DBT skills training groups to help you learn new coping skills and to draw out and fortify your pre-existing life skills, such as acceptance or a nonjudgmental attitude.
• As-needed telephone consultation to provide support and to offer you the opportunity to discuss how you’ve implemented the strategies you’ve learned.
• Weekly consultation team meetings for therapists to help them maintain their own motivation and ability to best treat their patients.

DBT is designed to fulfill 5 specific functions, 4 of which directly involve you:⁶

• Learning the 4 essential principles:
  • Emotional regulation.
  • Mindfulness.
  • Interpersonal effectiveness.
  • Distress tolerance.
• Generalizing these capabilities. That is, learning to apply these skills to your daily life.
• Improving motivation and decreasing dysfunctional behavior to help you establish healthier behaviors and feel that your life is worth living.
• Structuring the environment. Creating an environment that is conducive to healing and that does not encourage negative behaviors (e.g., a person in recovery from substance abuse must learn to avoid associating with people with whom they used, or must try to stay away from certain places where drugs are easily available).
• Enhancing and maintaining therapist capabilities and motivation so that therapists can continue to help their patients.

When Is It Used?

Although Dialectical Behavior Therapy was originally developed to treat BPD, research has shown that it can be effective for people suffering from other issues, such as: ^4-6,8-10

• Substance abuse. One study demonstrated the effectiveness of DBT for treating people with opiate addiction, and while further research is needed, DBT is promising for people with other forms of substance addiction.
• Women with BPD and substance abuse disorders. Studies have shown that women with BPD and a co-occurring substance abuse disorder experience decreased substance abuse, less suicidal tendencies, and improvement in impulsive behaviors when treated with DBT.
• Eating disorders. A study reported that women with binge-eating disorder who were treated with DBT exhibited less binge-eating, improved body image, and decreased anger. Another study also showed that DBT was effective in helping patients with bulimia decrease binging and purging behaviors.
• Depression in the elderly. One study demonstrated that DBT was effective in reducing depression in elderly people who also met criteria for a personality disorder. It’s possible that this benefit may also apply to the general population suffering from depression, although more studies are needed to confirm this assertion.
• Suicidal adolescents with BPD. Researchers found DBT to be helpful for reducing suicidal and self-injurious behaviors (such as self-mutilation) in adolescents who met the criteria for BPD. Adolescents suffering from suicidal tendencies often have underlying trauma, so DBT may be useful for people with trauma issues too.
• Post-traumatic stress disorder. One study showed that DBT helped to reduce depression in people who suffered childhood sexual abuse–related PTSD.
• Bipolar disorder. Another study demonstrated the effectiveness of DBT in reducing severe depressive symptoms in adolescents suffering from bipolar disorder.

DBT may also be useful for additional syndromes or conditions, but further research is needed to fully validate its effectiveness for those purposes.

How Does It Work?

According to the Linehan Institute, DBT is divided into 3 (or for some people, 4) stages:¹¹

• The first stage. In this stage, you usually feel awful and out of control. You don’t know how to live a happy life without a substance or without feeling controlled by your destructive and harmful behaviors. The goal of stage one is to help you feel more in control and to help you experience less suffering.
• The second stage. When you move on to the second stage, you feel more in control but often still feel emotionally tormented or distraught due to your inner emotional experience. Linehan explains that “this is the stage where post-traumatic stress disorder (PTSD) would be treated.” The goal is to help you fully—and safely—feel your emotions.
• The third stage. This stage promotes the idea of coming to terms with day-to-day life with all its mundanities and learning to live with the normal ups and downs of happiness and unhappiness. It is a period of integration.
• The fourth stage. Some people benefit from a fourth stage, which involves finding a sense of spiritual connection or fulfillment.

People are often curious about what a typical DBT session might look like. Because there are 3 main components in which a client participates, the way a standard DBT session looks depends on the component in which a person is currently engaged:^6,11,12

• Weekly individual therapy. During a weekly individual therapy session, you meet one-on-one with your therapist for about an hour. You discuss the problematic behaviors you experienced in the past week and work on improving your problem-solving and coping skills with the therapist. You participate in individual therapy for the entire length of treatment.
• Group skills training. In addition to individual therapy, you attend group skills training on a weekly basis. Group sessions run for around 2-1/2 hours and are led by a facilitator who teaches skills and shows you how to apply them in your daily life through homework. You are required to attend the group skills training for 24 weeks, which may be recorded so that you can re-listen between sessions and gain more insights.
• As-needed phone consultations. Additionally, you may call your therapist for phone consultations in between sessions to discuss problem areas or challenges that arise.

In individual and group sessions, you learn to apply the principles of DBT to your everyday life largely through education and role-playing:¹¹

• The principle of mindfulness. You learn how to be more mindful and accepting of the present moment, instead of reacting or acting out through negative behaviors.
• The principle of interpersonal effectiveness. You learn how to ask for what you want from others and how to set effective boundaries.
• The principle of distress tolerance. You learn how to better manage and tolerate experiences involving emotional pain, instead of trying to manipulate situations or people.
• The principle of emotional regulation. You learn ways to change dysfunctional emotional reactions.

Through role-playing, you practice these principles in imaginary situations that mimic those you encounter in everyday life. With the guidance of the therapist and the participation of group members (depending on whether you are in a group or individual session), you learn healthier and more appropriate ways to respond to and handle these scenarios by acting them out in advance.
With the guidance of the therapist, you learn healthier and more appropriate ways to respond to and handle these scenarios by acting them out in advance.

You also learn principles and skills through homework, which is an important component of DBT that:¹²

• Helps a therapist assess your skill level.
• Allows you to learn and strengthen skills.
• Gives your therapist the opportunity to provide constructive feedback.

Four types of homework assignments are employed, including:¹²

• Discrete homework in which you are assigned a specific task to practice a certain skill. For example, you might be instructed to practice mindfulness by paying attention to your breathing patterns during a specific time of day for a certain length of time.
• Self-monitoring homework in which you are instructed to monitor and keep track of certain behaviors. You might be asked to record on a diary card how many times you engaged in self-harm or substance abuse so you can develop insight into the frequency and severity of these behaviors.
• Skills practice in which you practice new skills at home. You might receive a handout that instructs you on the process of accepting your emotions instead of immediately acting on them when you become upset.
• Conditional homework is primarily used in individual therapy. You and your therapist examine the detrimental behaviors you engaged in over the past week based on your diary card. Your therapist might work with you to help you develop new ways to manage those behaviors and assign homework to practice coping skills should those behaviors arise in the next week.

DBT is an effective method of alleviating the distress and pain caused by trauma and other disorders. It is a practical method to help you manage and regulate your emotions and to teach you how to make healthier and improved choices as you move forward in your life.¹³

How to Find Treatment

Finding a qualified DBT therapist can help you start down the road to recovery from trauma, substance abuse issues, and mental health disorders. Some of the ways you might find one include:^13,14

• Getting a referral from your insurance provider, specifically asking for therapists qualified to practice DBT.
• Searching the list of providers on the Behavioral Tech website. Therapists listed on this site have completed specialized training in DBT through Behavioral Tech, a DBT training institute founded by Dr. Linehan.
• Asking for a recommendation from people you know who have been in therapy, if you feel comfortable doing so. Ask if the provider’s approach includes DBT.
• Consult your doctor for a referral to a provider who practices DBT.
• Contact your local university’s psychology or psychiatry department for a recommendation.