DBT Therapy
Finding Calm From Mindfulness
Understanding Dialectical Behavior Therapy
The Big Picture: What is DBT?
Dialectical Behavior Therapy (DBT) is a type of psychotherapy that was created to help people who struggle with regulating their emotions. It is a structured treatment that teaches individuals practical skills they can use in their everyday lives to manage intense feelings, improve relationships, handle distress, and avoid self-destructive behaviors. The overall goal of DBT is to help people with significant emotional challenges change the unhelpful patterns of behavior and thought that interfere with their daily lives, ultimately guiding them toward building “a life worth living”.
A central and defining principle of DBT is the term “dialectical,” which refers to the existence of two seemingly opposite ideas. In DBT, this means finding a balance between two concepts: acceptance and change. On one hand, people learn to accept themselves and their emotions and thoughts as they are, without judgment. This is a crucial element that provides validation and understanding. At the same time, the therapy teaches individuals to work toward making positive changes in their lives and behaviors. DBT is based on the idea that these two seemingly opposite truths can and must exist together. Instead of an “either/or” approach, the therapy encourages a “both/and” mindset, helping individuals move forward by both accepting themselves and committing to growth. This balance is a foundational concept that sets DBT apart from other forms of therapy.
The Roots of the Problem: The Biosocial Theory
The foundation of DBT is a model known as the biosocial theory, which helps explain why some individuals struggle so intensely with emotions. This theory suggests that the problem isn’t a person’s fault, but rather a combination of two factors. First, some people are born with a biological vulnerability that makes them more sensitive to emotional triggers. This means their emotions are often more intense and they take longer to return to a calmer state after being upset.
This biological tendency is often combined with a second factor: an invalidating environment. This refers to a situation where a person’s feelings are not understood, are dismissed as “wrong,” or are met with criticism. When a person with a high emotional sensitivity is consistently told that their feelings are inappropriate or invalid, they never learn how to properly understand, label, or manage their own emotions. This lack of emotional skills leads to a cycle of intense feelings and unhealthy behaviors, such as self-harm or substance use, which are often used as desperate attempts to cope.
The development of DBT was a direct response to this specific problem. The therapy’s creator, Dr. Marsha Linehan, found that other therapies, like standard Cognitive Behavioral Therapy (CBT), often did not work for her most challenging clients. This was because CBT’s emphasis on changing unhelpful thoughts and behaviors could feel invalidating to a person who has spent a lifetime being told that something is wrong with their emotional experience. A therapy that only focused on change would simply repeat the very environment that contributed to the problem in the first place. The inclusion of the acceptance component in DBT was a necessary and deliberate part of the treatment. It provides the validation and understanding that was missing in a person’s past, creating a safe and trusting environment where they can then engage in the difficult work of making positive changes. This unique approach is believed to be one of the reasons why DBT has a low dropout rate compared to other treatments.
The Core Skills of DBT
The skills are the foundation of DBT and are often taught in a group setting. They are practical, evidence-based tools that help people manage their thoughts, feelings, and behaviors more effectively. The skills are organized into four main areas, or “modules,” with each one designed to address a different set of life challenges.
Module 1: Mindfulness
Mindfulness is the foundational skill of DBT; it is taught first and is woven into all the other modules. At its core, mindfulness is the practice of paying attention to the present moment without judging it. It helps people slow down and become aware of what they are thinking and feeling before they act impulsively. This is done through a series of “what” and “how” skills.
The “what” skills teach a person what to do in order to be mindful:
- Observe: Simply notice what is happening around you and inside you, including your thoughts, emotions, and physical sensations.
- Describe: Put words to what you have observed, such as, “I am noticing a feeling of sadness”.
- Participate: Fully engage in what you are doing at the moment.
The “how” skills teach a person how to practice mindfulness:
- Non-judgmentally: See things as they are, without labeling them as good or bad.
- One-mindfully: Focus on one thing at a time, letting go of distractions.
- Effectively: Do what works to achieve your goals.
Mindfulness also involves the concept of Wise Mind, which is a place of balanced thinking. DBT describes two other states of mind: Emotion Mind, where feelings take over and guide all thoughts and actions, and Reasonable Mind, which is the logical, fact-focused part. Wise Mind is the middle ground between these two extremes; it is an intuitive and centered state that allows a person to make decisions based on both facts and feelings.
Module 2: Distress Tolerance
Distress tolerance skills are designed to help a person get through a crisis without making the situation worse. They teach how to handle painful or difficult situations when they cannot be immediately changed. This module is particularly important for helping people avoid impulsive and self-destructive behaviors that may provide short-term relief but create long-term problems.
The skills within this module are often divided into two main categories:
- Crisis Survival Skills: These are practical tools to use in moments of intense emotional pain to help a person calm their nervous system. Examples include the TIPP skills, which involve Tipping the body’s temperature, using Intense exercise, Paced breathing, and Paired muscle relaxation. Another example is the STOP skill: Stop, Take a step back, Observe, and Proceed mindfully.
- Reality Acceptance Skills: These skills focus on learning how to accept reality as it is, rather than fighting it, which only leads to more suffering. A core concept here is Radical Acceptance, which involves fully accepting a painful situation without approving of it or giving up.
Module 3: Emotion Regulation
Emotion regulation skills help people understand, manage, and reduce the intensity of their feelings so that they don’t feel out of control. These skills help a person make sense of their emotions and build a more balanced emotional life.
Key skills include:
- Check the Facts: A tool that helps a person pause and ask whether their emotional reaction truly fits the situation. This helps prevent overreacting or acting irrationally.
- Opposite Action: This skill teaches a person to do the opposite of what their emotion is pushing them to do. For example, if sadness is causing a person to isolate, they would choose to go out and socialize instead.
- Build Mastery: This involves taking on small challenges to build confidence and feel more capable and in control of one’s life.
- Increase Positive Emotions: This strategy focuses on increasing positive events and experiences in a person’s life to build resilience to negative emotions and improve their overall well-being.
Module 4: Interpersonal Effectiveness
Interpersonal effectiveness skills are about building and maintaining healthy relationships with others while also keeping your self-respect. These skills teach people how to get what they need, say no when necessary, and navigate conflict.
This module includes three main skill sets that are often taught using easy-to-remember acronyms:
- DEAR MAN: A step-by-step guide for asking for what you want or saying no. It stands for: Describe, Express, Assert, Reinforce, Mindful, Appear confident, and Negotiate.
- GIVE: Skills for maintaining a healthy relationship. It stands for: be Gentle, Interested, Validate, and use an Easy manner.
- FAST: Skills for maintaining your self-respect. It stands for: be Fair, no Apologies, Stick to your values, and be Truthful.
Module Name
Core Goal
Example Skills
Mindfulness
Stay in the present moment without judgment.
Wise Mind, Observe, Describe, Participate
Distress Tolerance
Get through a crisis without making things worse.
Radical Acceptance, TIPP, STOP
Emotion Regulation
Understand and manage intense emotions.
Check the Facts, Opposite Action, Build Mastery
Interpersonal Effectiveness
Build and maintain healthy relationships while keeping your self-respect.
DEAR MAN, GIVE, FAST
A Look at the Evidence: Who is DBT For?
The Story of DBT
DBT was developed in the 1980s by American psychologist Dr. Marsha Linehan. She created the therapy after realizing that standard Cognitive Behavioral Therapy (CBT) was not sufficient for treating people with chronic self-harm and suicidal behaviors. What is particularly compelling about Dr. Linehan’s story is that she herself struggled with intense emotional distress and self-harm when she was a young adult. This personal experience gave her a unique understanding of the problem and the need for a new therapeutic approach that combined two powerful, but opposing, concepts: acceptance and change. A longtime practitioner of Zen, Dr. Linehan integrated Eastern spiritual concepts and mindfulness into the core of DBT.
The Initial Target: Borderline Personality Disorder (BPD)
DBT was originally created to treat Borderline Personality Disorder (BPD) and the chronic self-harm and suicidal behaviors often associated with it. At the time, there were no effective therapies for this population, and many clients would drop out of treatment altogether.
The research has shown that DBT is the first and most-studied therapy for BPD. It is currently the only treatment for BPD that is considered “empirically supported,” which means it has strong scientific evidence to back up its effectiveness. Specific research findings from randomized controlled trials show that DBT has a significant benefit in reducing life-threatening behaviors such as suicide attempts and self-harm. The therapy is also “marginally better” at keeping people in treatment and reducing the number of people who drop out.
Beyond BPD: Other Applications
While DBT was created for BPD, its skills are a general set of life tools that can benefit almost anyone who struggles with emotional challenges. As a result, DBT has also been found to be effective for a number of other conditions, including substance use disorders, major depressive disorder, bipolar disorder, attention deficit and hyperactivity disorder (ADHD), eating disorders, and post-traumatic stress disorder (PTSD).
It is important to understand what makes DBT effective. The research shows that while it is highly successful at decreasing life-threatening behaviors and helping people stay in treatment, it is not necessarily more effective than other therapies at reducing general symptoms like depression. This is not a sign of failure but is instead a key part of the therapy’s design. The DBT model was created with a specific hierarchy of goals. The first and most critical goal is to keep the client alive and safe. Only after that is achieved can other goals, such as improving general mood and quality of life, be fully addressed. This explains why DBT is so valuable for high-risk populations, even if it does not solve every problem at once.
A Balanced View: Criticisms, Limitations, and Misconceptions
As with any treatment, DBT has its challenges and has faced some criticism within the psychological community. An expert understanding of the therapy requires acknowledging these limitations while also correcting common misunderstandings.
Acknowledging the Challenges
- Focus on Symptoms over Roots: A common criticism is that DBT focuses primarily on teaching skills for immediate symptom relief rather than exploring the deeper, underlying causes of emotional distress or past trauma. This is a point of ongoing debate within the field. The DBT model prioritizes stabilizing a person and teaching them skills to stay safe first, before deeper issues can be addressed.
- Benefits of Integration: While DBT is highly effective on its own, its focus on present and future skill-building can be used alongside other therapies to address past issues. For example, combining DBT with other therapeutic approaches, such as EMDR, can be highly beneficial. This integrated approach allows a person to use DBT skills to manage intense emotions in the present, while a therapy like EMDR can help process and heal the past trauma that is at the root of those emotions.
Dispelling Common Myths
- Myth #1: DBT is Only for BPD: This is one of the most common misconceptions about the therapy. While DBT was originally developed for BPD, its core skills are a general set of tools for life that can be useful for almost anyone who wants to improve their emotional regulation and relationships.
- Myth #2: DBT is Rigid and Inflexible: This misunderstanding stems from a lack of understanding of the “dialectical” concept at the heart of the therapy. While a full program has a rigid, procedural roadmap, the therapist’s approach is meant to be flexible and accepting. The therapy itself uses a “both/and” mindset, balancing a structured approach with a compassionate, validating attitude. This allows for both the safety of the structure and the flexibility to meet a client’s needs in the moment.
- Myth #3: DBT encourages suppressing emotions. This is a common concern because DBT places a strong emphasis on emotional regulation and distress tolerance. However, the goal is not to suppress or avoid emotions. Instead, DBT teaches healthy ways to manage emotions so they don’t lead to harmful behaviors. The skills are designed to help you understand and accept your feelings, and then choose how to respond in a way that doesn’t make the situation worse. This is about gaining control over your actions, not your feelings, and it helps you deal with emotions in a healthy way.
Building a Life Worth Living
Dialectical Behavior Therapy is a comprehensive, evidence-based treatment that was created to help people who struggle with intense and overwhelming emotions. The therapy is built on the central principle of a “dialectical” balance between two opposing ideas: accepting oneself as they are, while simultaneously working toward making positive changes.
The therapy has been shown to be uniquely effective in treating high-risk populations, particularly those with Borderline Personality Disorder, by significantly reducing self-harm and suicidal behaviors. The core skills of mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness are also valuable life tools that can benefit a wide range of individuals.
While the therapy requires a significant commitment of time and has a structured approach, these elements are essential to its effectiveness. By addressing common misconceptions and understanding the full scope of the treatment, individuals can appreciate DBT as a powerful tool. The ultimate goal is not just to reduce symptoms, but to empower people with the skills they need to build a life that feels meaningful and truly “worth living”.
Take The First Step
Starting your journey with Dialectical Behavior Therapy is a courageous and life-affirming step. Your first sessions with us will be a safe and collaborative space where you’ll begin to learn the core skills of DBT: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. We’ll work together to help you build a “life worth living,” finding a balance between acceptance and change. We will walk with you every step of the way, celebrating your progress and supporting you as you learn to navigate life’s challenges with newfound resilience.
Quick Reads Below
Personality Disorders: Diagnosis, Trauma, and Treatment
Erik Turley, LMFT
01/08/2025
Learn about the causes, symptoms, and treatments for personality disorders like BPD, NPD, HPD, and OCPD, with insights on trauma,...
Family Systems Theory: Bowen, Patterns & Family Dynamics
Erik Turley, LMFT
08/21/2024
Family Systems Theory explores how family dynamics influence individual behavior and well-being. Grounded in Bowen’s work, it remains a key...