Dialectical Behavior Therapy: Definition & Techniques

By Charlie Huntington, M. A., Ph. D. Candidate​
​Reviewed by Tchiki Davis, M.A., Ph.D.
Dialectical Behavior Therapy (DBT) can help people facing the most difficult mental health challenges. What makes it so effective? This article defines DBT and describes its techniques.
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If I asked you to tell me who you are, I bet you could answer pretty readily, telling me about your work, your relationships, your hobbies, and your family. If I pressed a little further and asked you to describe your own personality, I imagine you could tell me about your primary characteristics, your values, and the things you know to be true about yourself.
What if I told you that there are people who typically struggle to answer these questions? People with borderline personality disorder (BPD) – for reasons I will describe below – have a hard time establishing and holding on to a stable sense of self, so they naturally look to the rest of the world to provide that stability. However, as you can probably imagine, the outside world changes too much for people with BPD to experience that peace of knowing themselves for very long. This makes their lives incredibly stressful and leads them to try all sorts of (often destructive) methods to get back that sense of self.

People with BPD were not well-served by the world of psychotherapy until the invention of dialectical behavior therapy (DBT). In this article, I will describe what makes dialectical behavior therapy such an effective treatment for people who desperately need help.
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What Is Dialectical Behavior Therapy? (A Definition)

Dialectical behavior therapy (DBT) is a psychotherapy developed by the psychologist Dr. Marsha Linehan in the 1990s. Dr. Linehan developed DBT in response to seeing that other forms of cognitive-behavioral therapy (CBT) were not effective in helping therapy clients who were chronically suicidal – many of whom had diagnoses of BPD (Linehan et al., 1991). For these clients, Linehan realized, a different approach would be needed.
 
Linehan based her new therapy in biosocial theory, which states that we each have a baseline level of risk for developing psychiatric disorders that is based in our biology (Linehan et al., 1991). For example, since there is a history of depression on both sides of my family, I am more likely than the average person to have an increased genetic risk of developing depression one day. At the same time, biosocial theory tells us that whether I actually develop depression or not is a consequence of the environment I am in. If I am in a social environment that is pleasant and safe, I probably won’t develop depression, even though I have a high risk. However, if my environment is unsafe and invalidating, that may trigger my underlying vulnerability to depression.

Linehan applied this theory to patients with borderline personality disorder (BPD), noting that they probably began life with high levels of biological risk in one key category: being highly emotionally sensitive. Then, they grew up in extremely invalidating environments, where they were routinely ignored, punished, or abused, and their needs were dismissed. The combination of this emotional vulnerability and social invalidation leads people with BPD to struggle mightily to regulate themselves, so they turn to extreme behaviors, from abusing others to self-harm to considering suicide, to try to quell their emotions (Linehan et al., 1991).
 
What Is Dialectical?
You might be curious what the word dialectical means, and how it ended up in the name of this therapy. A dialectic is a situation in which two or more things that seem to be in opposition to each other need to be resolved. Clients who receive dialectical behavior therapy must reconcile with the fact that their social environments have been painfully invalidating and those environments can still be safe and rewarding once they have the skills to navigate them (Wagner & Linehan, 1997). There are many moments of dialectical thinking in DBT, and successfully thinking in dialectics is a sign of both psychological flexibility and progress in DBT (Linehan, 2014). For example, “I am doing the best I can, and I need to do better,” is a common dialectical statement in DBT.
 
Dialectical behavior therapy has been successfully used to treat people with borderline personality disorder (as well as some other disorders) for several decades now, with positive impacts for a wide range of symptoms, such as self-harming, suicidality, depression, and hopelessness (Robins & Chapman, 2004).

The 4 Dialectical Behavior Therapy Skills

Dialectical behavior therapy works by building skills in four different categories (Linehan, 2014):
 
  1. Mindfulness. An important first step for many therapy clients – and this is definitely not limited to people with BPD who are receiving DBT – is to become aware of what is happening in their bodies. Many of us do not recognize what we are feeling, so we have no way of responding effectively to our emotions. DBT uses mindfulness skills, such as visualizations and meditation, to build this awareness.
  2. Distress tolerance. Another dialectical truth of dialectical behavior therapy is that while we can change many things about our lives, some pain is inevitable and cannot be changed. Therefore, clients learn skills of distress tolerance so they can better endure the pain they experience. Indeed, a lot of suffering results from resisting, rather than acceptance of this pain.
  3. Interpersonal effectiveness. People with BPD have typically grown up in invalidating environments and have few examples of and experience with using effective communication skills. In DBT, they learn to advocate for themselves, state their needs, and draw boundaries in their lives, all in ways that will invite connection, rather than push people away.
  4. Emotional regulation. Finally, DBT teaches emotion regulation skills so that clients can skillfully reduce their experiences of negative emotions where possible.

Dialectical Behavior Therapy Techniques

Through the four skill domains I described above, dialectical behavior therapy aims to reduce clients’ use of ineffective coping mechanisms and behaviors when they are emotionally dysregulated. For example, if you grew up in a household where your parents had loud arguments and your needs were generally ignored or belittled, as an adult you might be inclined to start yelling at a friend or romantic partner when it seemed like they were not paying attention to you. You might be too upset to consider that there might be other, gentler ways to get the attention you are seeking.
 
Among the key techniques used in dialectical behavior therapy to create such changes are validation and dialectics (Lynch et al., 2006). These techniques are often used in close proximity to each other. For example, a DBT therapist might say, “You felt hurt when he said he didn’t want to go to the concert with you. You want to stay close to him even though it hurts so much sometimes. You wanted to use the skills we have been practicing here, but you were afraid he wouldn’t understand unless you yelled, so you started screaming.”
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Here are some other key techniques commonly used in dialectical behavior therapy (DiGiorgio et al., 2010):
  • Diary cards. Clients are asked to fill out diary cards, wherein they track their symptoms (such as emotions and suicidality) and their use of skills. This helps them become aware of their own patterns and provides the therapist with a useful guide for what to discuss in session.
  • Chain analysis of behavior. A technique shared by multiple cognitive-behavioral therapies, chain analysis involves writing out the stages of an interaction or situation to better understand how each thought, feeling, and behavior are related to each other. Doing this allows the client and therapist to collaboratively consider how the client could try something different at each stage. For example, perhaps a client could have used an emotion regulation skill before they initiated a conversation, or they might have remembered to use an interpersonal effectiveness skill during the conversation.
  • Target hierarchy. Since dialectical behavior therapy clients are frequently engaged in self-destructive behaviors and often have suicidal thoughts, DBT therapists maintain a hierarchy of targets for therapy. At the top of the list is any life-threatening behavior, followed by any behavior that interferes with therapy, followed by behaviors that interfere with the client’s quality of life. So if a client shows up fifteen minutes late to session but is not actively suicidal, the therapist will focus on why they arrived late before giving attention to other treatment goals.

For many more excellent examples of what dialectical behavior therapy looks like in practice, I recommend watching the following video:

Video: What a Dialectical Behavior Therapy (DBT) Session Looks Like

What Is Dialectical Behavior Therapy Used For?

As I noted above, dialectical behavior therapy is used primarily for people with borderline personality disorder, but it has also been shown to be effective for several other psychiatric disorders.

Dialectical Behavior Therapy for Borderline Personality Disorder
It is well-established that dialectical behavior therapy is an effective treatment for BPD (Lynch et al., 2007); in fact, there is no other therapy nearly as effective with this population. It is not totally clear if DBT helps all people with BPD – for example, there is little research on male clients with BPD – but it is clear that DBT is the gold standard treatment for this diagnosis.

Dialectical Behavior Therapy for Anxiety
Since dialectical behavior therapy is an extension of previously developed cognitive-behavioral therapies, it contains many of the same techniques as therapies explicitly designed to treat anxiety. So it should not come as a surprise that DBT is effective in treating anxiety as well (Chapman et al., 2011; Ritschel et al., 2012). People who receive dialectical behavior therapy experience decreases in anxiety, concurrent with increases in emotion regulation and overall skills use (Neacsiu et al., 2014). 

Dialectical Behavior Therapy for PTSD​
Dialectical behavior therapy is also effective for people with posttraumatic stress disorder (PTSD) (Steil et al., 2011). It seems to be particularly helpful for people who experienced childhood sexual abuse (Bohus et al., 2020). In addition to helping reduce their PTSD symptoms, people with PTSD who receive dialectical behavior therapy are less likely to hurt themselves or attempt suicide (Harned et al., 2014).

Dialectical Behavior Therapy for Eating Disorders​
Dialectical behavior therapy is also effective in treating people with eating disorders (Robins & Chapman, 2004; Telch et al., 2001)

History of Dialectical Behavior Therapy

Through trial and error application of some aspects of cognitive behavior therapy, along with gradual incorporation of mindfulness skills and dialectics, Marsha Linehan designed dialectical behavior therapy expressly for the clients for whom traditional cognitive behavior therapy was not helpful (Linehan & Wilks, 2015). In fact, in the first test of DBT, she recruited only the most suicidal patients she could find, because the original goal of DBT was to address this unmet need (Linehan et al., 1991). Although originally focused on the severely suicidal, DBT came to be applied to people with BPD, as they experience high rates of suicidality and are often resistant to traditional cognitive behavior therapy as well (Linehan & Wilks, 2015).

Dialectical Behavior Therapy vs Cognitive Behavior Therapy

Dialectical behavior therapy (DBT) and cognitive behavior therapy (CBT) are more similar than different – they both focus on changing feelings by changing thoughts and behaviors. However, DBT differs from CBT in that it tries to balance both acceptance and change, while CBT focuses more on change. In developing DBT, Linehan observed that focusing just on change was alienating to clients with BPD, but focusing just on acceptance of their situation was demoralizing (Linehan & Wilks, 2015). However, working towards both acceptance and change made sense to her clients.

Dialectical Behavior Therapy - Group Therapy

Dialectical behavior therapy is a highly intensive therapy. Most DBT clients not only meet weekly with their own therapist, but also attend a weekly group therapy session to learn about and practice DBT skills (Linehan & Wilks, 2015). Additionally, DBT clients typically have access to their therapists by phone as needed – an expectation not held of therapists in any other psychotherapy. DBT skills groups are essential to client progress in a traditional DBT program, but they may also be effective as a standalone intervention (Valentine et al., 2020).

Articles Related to Dialectical Behavior Therapy

​Want to learn more? Check out these articles:

Books Related to Dialectical Behavior Therapy​

If you’d like to keep learning more, here are a few books that you might be interested in.

Final Thoughts on Dialectical Behavior Therapy

I have deep admiration for everybody involved in dialectical behavior therapy, from the clients to the therapists. It is perhaps the most intensive form of psychotherapy, requiring a massive commitment of time and energy. The goal of dialectical behavior therapy is help clients have “a life worth living”, and for many clients who start from a place of active suicidality and no positive sense of who they are, this can seem like a very distant goal. If you or someone you know is having a great deal of difficulty finding meaning and grounding in life, I hope you will keep DBT in mind.

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