Dialectical Behavior Therapy (DBT)

What is dialectical behavior therapy?

Dialectical behavior therapy (DBT) is a mental health talking therapy. It was developed by psychologist Marsha M. Linehan, based on her experiences trying to treat chronically suicidal and self-harming women with cognitive behavioral therapy (CBT) in the late 1970s. While treating them, Linehan realized that many of these patients met the diagnostic criteria for borderline personality disorder (BPD).

She and her researchers found the traditional CBT was inadequate to treat these patients, who were often alienated and angered by CBT’s insistent on the necessity of change, dropping out of the program or pushing the therapist away from sensitive topics, and had complex problems that overwhelmed the standard CBT format.^[1]

Linehan developed an alternative method, which paired the cognitive restructuring of CBT with acceptance and mindfulness, drawn from Zen and contemplative practices. She called it dialectical behavior therapy (DBT). Dialectics is the synthesis of opposites. Specifically in DBT, it's the balancing of the outwardly opposing strategies of accepting distressing experiences and your behavior while also making changes to manage emotions and lead a happier, healthier life.^[2][3]

How does DBT work?

DBT treatment programs have five functions:

• Motivate patients to change, by understanding their goals; identifying their strengths and resources, and the obstacles to these goals; and highlighting the way their current behaviors and emotions are interfering with their achievement of these goals. To motivate patients, therapists use a mix of validation, coaching, positive reinforcement, and cheerleading.
• Teach the patients behavioral skills that make them more physically and psychologically resilient and functional and replace unhealthy, self-defeating, and self-destructive habits. There are four sets of skills in DBT: mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness (see below).
• Generalize those skills to their everyday lives so they can apply them across situations, people, and settings.
• Motivate therapists so they stay motivated to work with clients, especially those with challenging behaviors; can deliver the best therapy possible; and don’t suffer from burnout, which would impair treatment.
• Structure the treatment environment, by setting clearly defined rules, expectations, and tasks that are agreed upon by the patient and the therapist.^[4]

The four skills modules taught in DBT are:

1. Mindfulness: focusing on the present moment and becoming aware of your emotions, thoughts, sensations, and impulses at that moment. Mindfulness will teach you to separate your emotions and sensations from your rational thoughts to stay calm and avoid negative patterns of behavior and thinking.
2. Distress tolerance: recognizing and accepting intense emotions without reacting in an impulsive way that can make the situation worse and without turning to self-destructive coping strategies such as substance use, self-harm, angry outbursts, and isolation. Rather, you’re taught healthier strategies including self-soothing activities, distraction, and radical acceptance of the situation.
3. Emotional regulation: recognizing, labeling, and moderating your emotions so they don’t control your thoughts and behaviors and you can solve your problems rationally and effectively.
4. Interpersonal effectiveness: enhancing your ability to communicate effectively and form healthy relationships. You’ll learn to ask for what you need, say no, maintain your self-respect, and work through interpersonal conflicts.

DBT treatment components

There are four components of a comprehensive DBT program. These programs typically involve biweekly appointments and last a year.

1. Skills training: the four DBT skills (mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness) are taught by a therapist in a group setting. The skills are taught using instructions, handouts and worksheets, stories, and behavioral rehearsal. Participants are given homework assignments, in which they must practice applying one of the skills independently in their everyday lives. Typically, groups meet weekly.
2. Individual psychotherapy: during one-on-one appointments with a psychotherapist, the patient learns to apply the skills to specific challenges in their life and gain motivation to make positive changes. These appointments are usually offered weekly and run concurrently with skills training classes.
3. In-the-moment coaching: The patient can contact the therapist between sessions to receive phone or video coaching on how to cope with difficult situations that arise in their personal lives and how to apply the DBT skills to their immediate problems.
4. Consultation team for therapists: This part of the program effectively provides therapy for the therapists delivering DBT, supporting them in their work with patients who have complex needs and may display challenging behaviors. The therapists meet weekly to improve their motivation and skills in order to provide the best treatment possible. They practice applying DBT skills to their own lives so they can model them for their patients.^[5]

DBT may be offered in residential treatment programs, intensive outpatient programs, or community-based programs.

Not all DBT is delivered in comprehensive programs like that described above. Sometimes treatment is simply DBT-informed, meaning it delivers some aspects of the DBT program, such as skills training, but is more flexible and can be personalized to individual clients.

What conditions is DBT used to treat?

In addition to borderline personality disorder and suicidal behavior, DBT is also used to treat people with:

• substance use disorders
• eating disorders
• depression
• self-harm
• post-traumatic stress disorder (PTSD).^[3]

DBT for addiction treatment

DBT has been used as an addiction therapy for more than twenty years, both to treat the significant proportion percentage of people with substance use disorders who have BPD (which studies suggest may be as high as 50%) and others whose drug use is fed by their intense and unstable emotions.^[6]

The change and acceptance dialectic at the heart of DBT is easily applied to addiction treatment. DBT pushes for the immediate and permanent cessation of substance use (change), while also acknowledging that relapse is possible and doesn’t mean the patient can’t achieve their goal of abstinence in the future (acceptance).

To promote change, at the first appointment, the therapist asks the patient to commit to abstinence for what they believe is an achievable period of time, even if it’s as short as a few hours. Eventually, long-term sobriety is achieved by piecing together these discrete periods of abstinence.

Patients are also taught to “cope ahead,” to anticipate future triggers and high-risk situations they may encounter and to prepare responses to them. The therapist also encourages the patient to disconnect themselves from their drug-using past, for example by changing their phone number, telling friends they've stopped using, and developing a social life distant from drugs and those who still use.

To promote acceptance, DBT frames a relapse not as a failure but rather as a problem to solve. The therapist helps the patient analyze the events that led up to the relapse in order to learn from it and gain information that can help them avoid future relapses.^[7]

Effectiveness of DBT for addiction treatment

DBT has been found to be an effective treatment for people who have borderline personality disorder and substance abuse disorder—a common comorbidity.

In a study of polysubstance-dependent women with BPD, those who received DBT rather than standard community-based treatment were more likely to remain in treatment (64% vs 27%), achieved greater reductions in drug use as measured by interviews and urine testing, and attended more individual therapy sessions. In the DBT group, these improvements were sustained at the 16-month follow-up.^[7]

Another study evaluated DBT in the treatment of opiate-dependent patients with BPD, comparing it to a control of comprehensive validation therapy (in which some acceptance-based strategies from DBT are combined with warm validation from a therapist) and a 12-step program (Narcotics Anonymous). The study found that while both treatment programs led to a reduction in opiate abuse, as confirmed by urine testing, only the subjects treated with full DBT maintained the reduction during the last four months of the year-long treatment. Both groups saw an overall reduction in BPD symptoms during the treatment and at the 16-month follow-up. However, dropout rates were higher in the DBT group (64% completed the program, compared to 100% in the other group).^[7]

If you’re struggling with addiction, you may very well have BPD, even if you haven’t been diagnosed yet, and could benefit from DBT. A review of numerous studies, covering more than 10,000 people with substance abuse disorders, found that 22% had BPD. The review also found that people with borderline personality have rates of lifetime substance abuse of between 45% and 86%.^[6]

It’s unclear if DBT has a benefit for patients with substance use disorders who don’t have BPD. Linehan herself argues that it can help patients whose substance use emerges from emotional dysregulation, even if they don’t meet the diagnostic criteria for BPD. But it may not be helpful for those who use drugs for other reasons. ^[7]