Dialectical Behavior Therapy (DBT)

Dialectical Behavior Therapy (DBT) is a structured form of cognitive-behavioral therapy that teaches people practical skills for managing intense emotions, surviving crises without making things worse, and building more stable relationships. It was developed by psychologist Marsha Linehan at the University of Washington in the 1980s and early 1990s, originally for chronically suicidal women with borderline personality disorder (BPD). Its defining idea is balancing acceptance and change: accepting a person as they are while helping them change behaviors that cause suffering.

Standard DBT combines individual therapy, a weekly skills training group, between-session phone coaching, and a consultation team for therapists. Randomized trials have found that it reduces self-harm, suicide attempts and psychiatric hospitalizations compared with usual care, and adapted versions are now used for adolescents, substance use, eating problems and trauma. This guide covers the theory, structure, skills, evidence and limitations of DBT. It is educational information, not a substitute for professional care.

Understanding DBT

Origins

In the late 1970s and 1980s, Linehan tried applying standard behavior therapy to people with repeated suicidal behavior. She found that a relentless focus on change often left clients feeling criticized and misunderstood, and many dropped out. A purely accepting approach, on the other hand, did not help them build the skills they needed. Drawing on behavioral science, dialectical philosophy and her own practice of Zen, she combined the two. Her first randomized trial was published in 1991, and her treatment manual and skills manual followed in 1993. In 2011 Linehan publicly described her own experience of severe mental illness as a young woman, which she said shaped her commitment to developing a treatment for people others considered "untreatable."

The Dialectical Philosophy

"Dialectical" refers to the idea that two seemingly opposite things can both be true, and that progress comes from finding a synthesis rather than choosing one side. In DBT the central dialectic is between acceptance and change: "You are doing the best you can, and you need to do better." This stance helps loosen the all-or-nothing thinking that often accompanies intense emotional distress.

DBT therapists work from a set of assumptions about clients, including:

• People are doing the best they can.
• People want to improve.
• People need to do better, try harder, and be more motivated to change.
• People may not have caused all their problems, but they have to solve them anyway.
• New behaviors must be learned in all relevant contexts.
• All behaviors, including thoughts and feelings, have causes.
• Figuring out and changing those causes works better than judging and blaming.

Biosocial Theory

DBT is based on a biosocial theory of emotion dysregulation. It proposes that some people are born with heightened emotional sensitivity: they react quickly and strongly and take longer to return to baseline. If they grow up in an invalidating environment, where their emotional experiences are dismissed, punished or treated as wrong, they do not learn to understand, trust or regulate their emotions. Over time this transaction between temperament and environment can produce pervasive emotion dysregulation. The theory is meant to reduce blame: it explains problems as the result of understandable causes rather than character flaws. It has been influential but is difficult to test directly, and research on it is still developing.

DBT vs. Standard CBT

DBT uses many CBT techniques, but differs in important ways (see our CBT vs DBT comparison for more detail):

• Validation and acceptance: equal emphasis on accepting current reality and working toward change.
• A skills curriculum: a structured, class-like program teaching specific coping skills.
• A hierarchy of targets: life-threatening behaviors are always addressed first.
• Phone coaching: brief between-session support to help use skills in real situations.
• A consultation team: therapists support one another, which matters when working with high-risk clients.
• Dialectical strategies: holding opposing perspectives and searching for synthesis.

Four Components of DBT

1. Individual Therapy

Clients usually meet a DBT therapist weekly for about an hour. Sessions are organized around a hierarchy of treatment targets:

1. Life-threatening behaviors (suicidal and self-harming behavior)
2. Therapy-interfering behaviors (by client or therapist, such as missed sessions)
3. Quality-of-life-interfering behaviors (such as substance misuse, unstable housing, or problems at work)
4. Increasing behavioral skills

Clients complete a diary card each day, recording emotions, urges and the skills they used, and the therapist uses it to set the agenda. When a target behavior has occurred, the pair work through a chain analysis to understand what led to it and where a different response could have been used.

2. Skills Training Group

The skills group meets weekly, typically for two to two and a half hours, and runs more like a class than traditional group therapy. Each session usually includes a short mindfulness practice, review of the past week's practice assignments, and teaching of a new skill. In the standard adult program the full curriculum takes around 24 weeks and is often completed twice over a year.

3. Phone Coaching

Clients can contact their individual therapist between sessions for brief coaching on how to use skills in the moment. Calls are short and focused on what skill to use now, not on extended therapy. Coaching also helps with repairing the relationship after a rupture. Programs set clear limits to protect both client and therapist; for example, the original model asks clients to reach out before acting on urges to self-harm, so that coaching reinforces skillful behavior rather than crisis behavior.

4. Therapist Consultation Team

DBT therapists meet weekly as a team. The team helps them stay faithful to the model, solve difficult problems, and manage the stress of working with people at high risk. Linehan described this as "therapy for the therapists."

The Four DBT Skills Modules

The skills are the most widely known part of DBT. Two modules focus on acceptance (mindfulness and distress tolerance) and two on change (emotion regulation and interpersonal effectiveness).

1. Mindfulness Skills (Core Skills)

Mindfulness is the foundation for all other skills and is revisited between each of the other modules. DBT describes three states of mind: "reasonable mind" (cool, logical), "emotion mind" (hot, mood-driven), and "wise mind," the integration of the two that allows a person to act on what they know to be true and important.

The "what" skills describe what to do when practicing mindfulness: observe (notice experience without words), describe (put words to it factually), and participate (enter fully into an activity). The "how" skills describe how to do it: non-judgmentally, one-mindfully (one thing at a time), and effectively (doing what works rather than what feels "right"). See our guide to mindfulness meditation for the wider background.

2. Distress Tolerance Skills

Distress tolerance skills are for getting through painful moments without acting in ways that make things worse.

• TIPP aims to bring down very high physiological arousal quickly: Temperature (for example, cold water on the face), Intense exercise (brief vigorous activity), Paced breathing (slowing the breath, with a longer exhale), and Paired muscle relaxation. People with heart conditions or other medical concerns are advised to check with a doctor before using the temperature or exercise components.
• ACCEPTS describes ways to distract: Activities, Contributing, Comparisons (for example, to a time one coped with something hard), Emotions (creating a different emotion), Pushing away, Thoughts, and Sensations.
• Self-soothe uses the five senses (vision, hearing, smell, taste and touch) to bring comfort.
• IMPROVE the moment includes Imagery, finding Meaning, Prayer, Relaxation, One thing in the moment, a brief Vacation, and Encouragement.
• Radical acceptance means fully acknowledging reality as it is, especially when it cannot be changed, as a way to reduce the extra suffering that comes from fighting it. Related skills include "turning the mind" and choosing willingness over willfulness.

3. Emotion Regulation Skills

Emotion regulation skills help people understand what emotions do, reduce vulnerability to painful emotions, and change emotions when that would be helpful.

• Understanding and naming emotions: recognizing the prompting event, interpretation, body sensations, urges and actions that make up an emotion.
• Check the facts: asking whether the intensity of an emotion fits the actual situation.
• Opposite action: when an emotion does not fit the facts, or acting on it is not effective, acting opposite to its urge. For example, approaching rather than avoiding when fear is unjustified, or gently avoiding a person rather than attacking when anger does not fit.
• ABC PLEASE: Accumulate positive experiences, Build mastery, and Cope ahead of difficult situations, plus taking care of the body: treat PhysicaL illness, balanced Eating, Avoid mood-altering substances, balanced Sleep, and Exercise.

4. Interpersonal Effectiveness Skills

These skills help people ask for what they need, say no, and handle conflict while keeping relationships and self-respect intact.

• DEAR MAN (getting an objective met): Describe the situation, Express feelings, Assert the request, Reinforce (explain the benefits), stay Mindful, Appear confident, and Negotiate.
• GIVE (keeping the relationship): be Gentle, act Interested, Validate, and use an Easy manner.
• FAST (keeping self-respect): be Fair, no unnecessary Apologies, Stick to values, and be Truthful.

Key DBT Techniques

Chain Analysis

A chain analysis is a detailed, step-by-step look at a specific problem behavior. Therapist and client identify vulnerability factors (such as poor sleep), the prompting event, each link in the chain of thoughts, emotions, body sensations and actions, the behavior itself, and its consequences. They then carry out a solution analysis, identifying where a different skill could have broken the chain.

Diary Cards

Diary cards are daily tracking sheets recording emotions (often rated 0 to 5), urges, target behaviors, the skills used, and anything likely to interfere with therapy. They help both client and therapist see patterns and set priorities for each session.

Validation Strategies

Validation means communicating that a person's emotions, thoughts or actions make sense in some way. Linehan described six levels:

1. Paying attention and staying awake to what the person says
2. Accurate reflection
3. Articulating what has not been said
4. Validating in terms of past history or biology
5. Validating in terms of the present context, or as normal
6. Radical genuineness: treating the person as an equal, not as fragile

Validation is not agreement. A therapist can validate that someone's anger makes sense while still helping them change how they act on it.

Dialectical Strategies

DBT therapists use strategies designed to unstick rigid positions, such as entering the paradox, using metaphor and storytelling, playing devil's advocate, "extending" (taking a client more seriously than they expected), and "making lemonade out of lemons" (finding the usable part of a difficulty).

Conditions Treated with DBT

Primary Applications

• Borderline personality disorder: the original target and the most researched use.
• Recurrent self-harm and suicidal behavior: DBT was designed for people at chronic high risk and is one of the few treatments with trial evidence specifically for reducing self-harm.
• Severe emotion dysregulation: intense, rapidly shifting emotions that drive impulsive behavior.

If anyone is in immediate danger or thinking about suicide, see crisis resources for urgent support.

Expanded Applications

DBT and its skills have been adapted and studied for:

• Binge eating and bulimia: adaptations focus on emotion regulation as an alternative to disordered eating.
• Substance use disorders: combined with addiction treatment (see addiction).
• PTSD: particularly when trauma co-occurs with self-harm or severe dysregulation (see PTSD).
• Depression: especially where emotion dysregulation is prominent.
• Bipolar disorder: skills groups as an addition to standard care, with early evidence.
• ADHD: DBT-based skills groups targeting impulsivity and emotional reactivity, with mixed evidence.

Adaptations

• DBT-A: for adolescents, developed by Alec Miller, Jill Rathus and colleagues; includes family members and an extra "walking the middle path" skills module.
• DBT-C: for preadolescent children with severe emotion dysregulation, with simplified skills and heavy parent involvement.
• DBT-PE: integrates prolonged exposure for PTSD once self-harm is under control, developed by Melanie Harned.
• DBT-SUD: adds strategies targeting substance use.
• RO-DBT: Radically Open DBT, developed by Thomas Lynch for problems of emotional over-control, such as chronic depression and anorexia, rather than under-control.

The DBT Process

Pre-Treatment Stage

Before treatment begins, the therapist orients the client to DBT, explains its structure and expectations, assesses whether it fits the client's needs, and works with them to build commitment, typically agreeing to a defined period of treatment and to working on reducing self-harm.

Stage 1: Stabilization

Stage 1 aims to move from behavioral dyscontrol to behavioral control. It focuses on decreasing life-threatening, therapy-interfering and quality-of-life-interfering behaviors and on building skills. Most research on DBT concerns this stage.

Stage 2: Post-Traumatic Stress

Stage 2 moves from "quiet desperation" toward full emotional experiencing. For many clients this involves processing trauma, for example with an integrated exposure protocol, once behavior is stable enough to do so safely.

Stage 3: Individual Goals

Stage 3 addresses ordinary problems in living: building self-respect, working toward personal goals, and creating a life with ordinary happiness and unhappiness.

Stage 4: Capacity for Joy

Linehan later added a fourth stage, moving from a sense of incompleteness toward connection, meaning and a capacity for sustained joy, sometimes with a spiritual dimension.

Research and Effectiveness

Evidence Base

DBT has been tested in dozens of randomized controlled trials, more than any other psychological treatment for BPD. Key findings include:

• The first trial (Linehan et al., 1991) found that women with BPD and recurrent self-harm who received a year of DBT had fewer and less medically serious self-harm episodes, fewer days in hospital, and better retention than those receiving treatment as usual.
• A two-year trial (Linehan et al., 2006) compared DBT with therapy by community experts. DBT participants were about half as likely to make a suicide attempt (roughly 23% vs 46%) and had fewer psychiatric hospitalizations and emergency visits.
• Adolescents: a multi-site trial (McCauley et al., 2018) found that DBT reduced suicide attempts and self-harm in teenagers at high risk more than an individual and group supportive therapy over the treatment period, although differences narrowed by the one-year follow-up.
• Systematic reviews: a 2020 Cochrane review of psychological therapies for BPD found DBT reduced BPD severity and self-harm compared with usual treatment, while rating the certainty of the evidence as low to moderate.

In head-to-head trials, other structured therapies for BPD, including mentalization-based treatment, schema therapy, transference-focused psychotherapy and general psychiatric management, have often produced broadly similar improvements. DBT is therefore best described as one of several effective treatments, with particularly strong evidence for reducing self-harm.

Long-Term Outcomes

Follow-up studies suggest many gains are maintained for at least one to two years after treatment, and naturalistic research on BPD shows that symptoms tend to improve over time for many people. Improvements in social and work functioning have generally been smaller and slower than reductions in self-harm, which has led to growing interest in later-stage DBT goals such as building a life worth living.

Mechanisms of Change

Research on how DBT works is still developing. Studies suggest that increased use of DBT skills partly explains reductions in suicidal behavior, depression and anger. Validation appears to help reduce emotional arousal, and the therapeutic alliance is linked to staying in treatment. Which of DBT's many components are essential remains an open question; a 2015 dismantling trial found that versions including skills training produced better outcomes on several measures than individual DBT without skills training.

Limitations and Criticisms

• Resource demands: comprehensive DBT requires a trained team, weekly groups and phone coaching, which makes it expensive and hard to access in many areas.
• Dropout: although retention is better than in many comparison treatments, a meaningful share of clients leave early.
• "DBT-informed" variation: many services offer partial versions, such as skills groups only, whose effects may differ from the tested model.
• Evidence quality: many trials are small, and reviews rate certainty as moderate or low.
• Theory: parts of the biosocial theory are difficult to test, and the label "invalidating environment" can be misread as blaming families.

Finding DBT Treatment

Types of DBT Programs

• Comprehensive DBT: all four components; this is the model tested in most research.
• DBT skills groups only: skills training without individual DBT therapy, sometimes alongside other therapy.
• DBT-informed therapy: individual therapy that uses DBT principles and skills.
• Intensive outpatient and day programs: several skills groups per week.
• Inpatient and residential DBT: programs in hospital or residential settings.

Finding Qualified Providers

In the US, clinicians can become certified through the DBT-Linehan Board of Certification, and many receive intensive training from organizations associated with Linehan's group. Useful questions to ask a provider include:

• Do you offer all four DBT components?
• What DBT training have you completed?
• Are you part of a DBT consultation team?
• How long is the program, and what is expected of participants?
• What experience do you have with the specific difficulties I am facing?

Our guide to finding a therapist and our overview of mental health professionals can help with the search.

Cost and Insurance

DBT is often covered by health insurance when delivered for a diagnosed condition, though prior authorization may be required and coverage for groups or phone coaching varies. Skills groups are usually less expensive than individual therapy, some programs offer sliding-scale fees, and online DBT groups are increasingly available. See our therapy cost guide for more options.

Self-Help Resources

Linehan's DBT Skills Training Handouts and Worksheets (2015) is the official skills material, and many workbooks are based on it. Self-help materials can introduce useful skills, but they supplement rather than replace comprehensive DBT, especially for people experiencing self-harm or suicidal thoughts.

Conclusion

Dialectical behavior therapy changed how clinicians approach people with chronic suicidal behavior and borderline personality disorder, a group once widely described as "untreatable." By pairing acceptance with change and teaching concrete skills, DBT offers a structured path toward what Linehan called "a life worth living."

The DBT skills of mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness have spread far beyond the original treatment and are now taught in schools, workplaces and general wellbeing settings. In clinical settings, the research is strongest for comprehensive DBT and for reducing self-harm. DBT is demanding and not available everywhere, and it is one of several effective approaches, but for many people it has provided practical tools and meaningful relief.