The Basics of Dialectical Behavior Therapy

This guide covers basic information on how dialectical behavioral therapy works and how it may be used to treat mental health conditions, including those co-occurring with substance use disorders. Details are also provided on how dialectical behavioral therapy is administered, the cost of therapy, potential side effects, and other considerations of using this type of therapy as part of a comprehensive treatment plan.

Dialectical behavior therapy is a comprehensive, evidence-based treatment that focuses on high-risk patients who are difficult to treat and often have multiple issues. Although DBT was initially designed to treat suicidal behavior and borderline personality disorder, it’s been adapted to help with other mental health problems and self-destructive behaviors that threaten your safety, relationships, and emotional and physical well-being. Some of the conditions that have seen promising results include depression, bipolar disorder, and eating disorders.

Generic Treatment Name Dialectical Behavioral Therapy
Other Names Subset of Cognitive Behavioral Therapy
Conditions Commonly Treated Borderline personality disorder, ADHD, bipolar disorder, depression, eating disorders, mood disorders, post-traumatic stress disorder, substance abuse, suicidal and self-harming behavior
How to Receive Therapy DBT may be recommended by your doctor or mental health provider and should be administered by a licensed therapist, counselor, psychologist, or another mental health professional.
Clinician Certification Requirements Mental health professionals, notably licensed psychologists, may pursue specialized training and certification through the Linehan Board of Certification or other similar programs.
Five Functions of Treatment 1. Enhancing capabilities
2. Generalizing capabilities
3. Improving motivation and reducing dysfunctional behaviors
4. Enhancing and maintaining therapist capabilities and motivation
5. Structuring the environment
Four Parts of Therapy 1. Individual therapy
2. Group skills therapy
3. Phone coaching, if necessary, during crises between sessions
4. Consultation group, intended for health care providers
Behavioral Skills Covered Mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation
Treatment Targets Life-threatening behaviors, therapy-interfering behaviors, quality-of-life behaviors, and skills acquisition
Potential Side Effects Depressed mood, overwhelming emotions, agitation, flashbacks, frustration, and fatigue

DBT was originally developed by Dr. Marsha Linehan in the 1980s as a more comprehensive way to treat borderline personality disorder and suicidal women with multiple problems. Her efforts evolved to potentially treat other disorders, such as depression and anxiety disorders, and other difficulties triggered by emotions. DBT culminated in an evidence-based, cognitive-behavioral treatment that presently includes numerous randomized clinical trials that demonstrate its effectiveness for the treatment of a wide array of conditions and disorders in patients of all ages and genders.

How Dialectical Behavior Therapy Works

According to the National Center for Biotechnology Information, U.S. National Library of Medicine, DBT has many similarities with other cognitive-behavioral approaches but with several critical, unique elements. Some of these elements include the five functions of treatment, consistent dialectical philosophy, mindfulness, and acceptance-oriented interventions.

DBT works though a four-stage approach that includes treating the most self-destructive behavior first, which is generally suicide attempts or other self-injury behavior. The next stage addresses life skills, which may include distress tolerance, emotional regulation, and interpersonal effectiveness. Step three focuses on improving self-esteem and relationships, and the final step promotes better relationship connections and greater happiness.

DBT is primarily influenced by the philosophical concepts of dialectics, which are essentially about balancing opposites. Your therapist works to find ways to help you promote balance, instead of an all-or-nothing way of thinking. The goal is to balance acceptance and change. Because many people seeking DBT treatment suffer from multiple problems, it also targets specific behaviors in order of priority. These targets include life-threatening behaviors, therapy-interfering behaviors, quality-of-life behaviors, and acquiring new behaviors to replace ineffective ones.

What Dialectical Behavior Therapy Is Used For

The American Psychiatric Association endorsed DBT as an effective treatment for borderline personality disorder. People engaging in DBT may see marked improvements, such as fewer and less severe suicidal behavior, less anger, improved social function, and a lower likelihood of dropping out of treatment. Those with borderline personality disorder and substance use disorders also found that DBT led to reductions in drug use during the treatment and follow up periods and lowered likelihood of quitting treatment.

DBT has also been found to be effective for a wide array of other conditions. Some of these include suicidal and self-harming behavior, post-traumatic stress disorder, attention deficit hyperactivity disorder (ADHD), major or chronic depression, and emotion dysregulation. Research has also shown that DBT may help with bipolar disorder, which affects an estimated 4.4% of U.S. adults age 18 or older at some time in their lives; eating disorders, which is estimated to affect at least 30 million people of all ages and genders; and substance use disorders, which affected more than 2.7 million people who abused alcohol, illicit drugs, and/or prescription drugs in 2017.

How Dialectical Behavioral Therapy Is Administered

A standard DBT treatment program includes weekly individual therapy sessions lasting about an hour, weekly group skills training sessions lasting approximately 1.5 to 2.5 hours, and therapist consultation meetings. Phone coaching may also be provided between therapy sessions, if necessary, due to a crisis.

A comprehensive DBT program focuses on four ways to enhance life skills, including distress tolerance, emotion regulation, mindfulness, and interpersonal effectiveness. DBT treatment also includes numerous aspects of other cognitive behavioral therapies, cognitive restructuring, and other interventions. However, the essential aspects are very specific and unique to DBT, which includes five functions of treatment:

1. Enhancing capabilities to improve important life skills, including regulating emotions, tolerating distress, surviving crises, practicing mindfulness that focuses on paying attention to the present moment, and navigating interpersonal situations. This function is typically worked on during weekly skills group sessions that include homework assignments to practice skills between sessions.

2. Generalizing capabilities to transfer the skills learned in therapy sessions to your daily life. This function is accomplished during group skills training with homework assignments that focus on improving skills and during individual therapy sessions in which your therapist helps you apply your new skills in your natural environment.

3. Improving motivation and reducing dysfunctional behaviors to improve motivation and change and reduce behaviors that aren’t consistent with living a worthwhile life. This function is primarily accomplished during individual therapy, in which you complete a weekly self-monitoring diary to track treatment targets. Your therapist uses this diary to prioritize behaviors that threaten your life, interfere with therapy, and interfere with your quality of life. The therapist then helps you figure out what led to these behaviors and find ways to apply effective behavior to solve problems and regulate emotions.

4. Enhancing and maintaining therapist capabilities and motivation to help maintain the motivation and skills of your therapist. This function is accomplished through weekly therapist consultation/team meetings. During these meetings, therapists work together to provide support, feedback, encouragement, motivation, and skill-building to ensure the most taxing patients receive the best, most comprehensive treatment.

5. Structuring the environment reinforces effective behavior and progress while discouraging problematic behavior. This function may also involve helping you modify your environment to ensure you avoid situations and behaviors that impact the progress you’ve made during therapy.

Besides these vital functions, DBT is primarily powered by dialectical philosophy, which promotes balance throughout treatment. Basically, this means promoting change without creating tension, which requires promoting change and acceptance. To help ensure the most effective treatment, the focus on change and acceptance must be equal to keep everything balanced.

Cost and Side Effects

DBT includes a per session cost for individual therapy sessions and group therapy sessions, with individual sessions costing more than group sessions. Per session costs vary greatly by treatment center and mental health care provider, but you can expect to pay anywhere between $75 to $300 per session. Group therapy sessions are usually about 1/2 to 1/3 of the cost of individual sessions. Cost can be greatly affected by where you live, the therapist’s experience, the number of sessions required, and various other factors.

While cost has a wide range, many professional organizations agree that the cost-effectiveness of DBT is worth it. For example, the American Psychiatric Association reported that yearly treatment costs decreased by $26,000 per patient when treatment included DBT compared to previous years without DBT treatment. These cost reductions included reductions in hospitalizations and emergency room contacts. Linehan and Heard also reported that DBT treatment resulted in a $9,000 cost savings compared to treatment-as-usual (TAU).

Because dialectical behavior therapy doesn’t require medicines as part of the treatment process and therapy may allow you to cut down on some of the medications you currently use for specific conditions, adverse medication-related side effects may be reduced. However, never stop taking any medication without consulting your doctor, even if you feel you no longer need it.

DBT side effects are uncommon. However, while some members of a patient-based website who underwent dialectical behavior therapy reported no side effects, others reported varying side effects, including depressed mood, overwhelming emotions, agitation, flashbacks, frustration, and fatigue.

How to Get Help & Additional Resources

Learn more about the signs and symptoms associated with depression, which can be brought on by alcohol or substance addiction disorders, and how it may be helped with dialectical behavioral therapy.

Learn more about the symptoms and treatment methods for bipolar disorder and eating disorders, which may also be helped with dialectical behavioral therapy.

  • Behavioral Tech, a Linehan Institute Training Company, offers a detailed breakdown of what dialectical behavioral therapy is and the components included in treatment.

Disclaimer: The information contained in this guide is for informational purposes and only intended to educate the public on how this therapy is used. It is not recommending a specific treatment or giving medical advice. Always consult with your doctor or other qualified medical, addiction, and mental health professionals before beginning any type of treatment.