A Complete Guide to Dialectical Behavior Therapy (DBT)

How DBT Started

Dialectical behavior therapy (DBT) was created by Dr. Marsha Linehan in the late 1980s when she and colleagues discovered that cognitive behavioral therapy (CBT) was not an effective treatment for those suffering from borderline personality disorder (BPD) (Budak & Kocabaş, 2019). Since then, DBT has been modified and adapted to treat many disorders and behavioral issues, such as eating disorders, depression, and adolescence-related angst. 

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), BPD is diagnosed when a clear pervasive pattern of instability between relationships, self-image, emotions and impulse control issues begin in early adulthood and is clearly interfering with a person’s regular day-to-day life (American Psychological Association, 2013). Only about 1.6% of the population is diagnosed with BPD, yet many are misdiagnosed or ineffectively treated for this disorder (APA). And so DBT came to be.

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Linehan indicated four fundamental problems in patients with BPD, which are: self-confusion, impulsivity, emotional dysregulation, and interpersonal chaos. The skills needed to overcome these problems are: mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness. 

• Mindfulness is intended to decrease suffering by increasing happiness: by living in reality without passing judgement, you can experience the world in a positive way.
• Distress tolerance is focused on the ability to manage a crisis, however big or small. This is done by distraction, self-soothing, and relaxing.
• Emotional regulation aims not to ignore unpleasant feelings such as anger and pain, but to manage them in order to decrease oversensitivity towards them.
• Interpersonal effectiveness helps to achieve a matter of goals while also protecting relationships. This may mean ending a toxic relationship or learning to accept change in a growing relationship.

Essentially, Linehan created a CBT with direct focus on dialectics, meaning change and acceptance, and Zen practices, which encourage awareness of the accepted change. This was done particularly for those with BPD because these individuals, on a cognitive level, cannot maintain any of these skills that seemingly come naturally to those without BPD. 

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DBT Beyond BPD

Today DBT is used for more than effectively treating those with BPD. The following studies are a few of hundreds of examples how DBT can help a struggling individual or group get their lives to where they need to be. 

• It is fairly common for those who suffer from BPD to also suffer from some sort of eating disorder. When both disorders are experienced together, known as comorbidity, DBT has shown to be more helpful in successfully treating both more than CBT. Navarro-Haro et al. (2018) assessed 118 women with BPD and an eating disorder and placed half in a DBT treatment and the other half in CBT treatment: the women who underwent DBT reduced dysfunction behaviors like substance abuse, self-harm, and depressive symptoms way more significantly than the women who underwent CBT.

• Similar to Navarro-Haro et al., Brown et al. (2019) studied how the four skills of DBT (mindfulness, distress tolerance, emotional regulation and interpersonal effectiveness) could be used to predict improvements amongst those suffering from an eating disorder. By the first month, 30.4% of their sample population demonstrated a clinically meaningful change in managing their eating disorder with the help of DBT, and over the time spanning from admission to discharge, over half of the patients had more regulated eating habits, could successfully regulate their emotions, and had reduced depression and anxiety (Brown et al.).

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• Pardo et al. (2020) extended DBT skills and training to a group of 20 adolescents with behavioral problems. This was initially done to observe if DBT would even be useful to treat the troubled underage population, but the researchers found much more valuable results. After 16 weekly sessions of DBT, the adolescents reported direct awareness of negative behaviors and realized it stemmed from internalized issues they tried to ignore or forget. The mindfulness aspect in particular was most helpful in addressing what was truly happening in their lives, and DBT helped them accept it (Pardo et al.).

• Because treatment of suicidal behaviors is very difficult to successfully implement on those with autism spectrum disorder (ASD), Huntjens et al. (2019) are hopeful DBT will be helpful in reducing these behaviors in this population. 128 persons with ASD are currently undergoing DBT and their progress is being closely monitored, particularly their levels of suicide ideation but also anxiety, social performance, depression, and so on (Huntjens at al.). Since DBT is so effective for those with BPD, it is expected it will be just as effective for those with ASD. 

No matter the underlying cause or issue, there appears to be a common theme amongst those receiving DBT treatment: they almost always report becoming aware of their problems is the most effective aspect of DBT. This awareness, or being mindful, of their thoughts and actions is the key to overcoming any problem.

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Mindfulness and DBT

Many find focusing on mindfulness more than the other aspects of DBT to be most rewarding. Again, the purpose of mindfulness in DBT is to experience the world in a positive way to overall decrease suffering. Negative emotions such as depression, anxiety, anger, shame, and insecurities can all be addressed and changed using mindfulness.

• Mitchell et al. (2019) observed 82 client participants with BPD completed a 20 week DBT skills training program. They were interested in identifying which aspects of mindfulness would most effectively reduce the symptoms listed above, as well as the participants’ ability to avoid making judgements: in addition to decreasing the number of hospital stays, these participants reported being aware of their actions and potential consequences because of mindfulness practices. 

• Likewise, Mochrie et al. (2019) examined the changes in depression, anxiety, hopelessness, and overall suffering when participants of their study learned and used the mindfulness portion of DBT. They found that as these symptoms significantly decreased, skills such as positively observing and describing their feelings increased, as did the ability to non-react, or compose themselves. 

The most promising part of taking the mindfulness skills out of DBT and creating an isolated program solely meant to increase awareness is that it will take much less time to achieve and utilize compared to fully committing to a DBT program. Warlick et al. (2020) noted that DBT programs should typically take a few months up to a year; by directing attention to mindfulness alone, an “accelerated” course could potentially lessen this time commitment to a few weeks. That’s not to say distress tolerance, emotional regulation, and interpersonal effectiveness are not vital components to DBT, because they are. But for most of us, the simple task of truly paying attention to our own thoughts and behaviors could be just what we need to make the right kind of changes in our lives.

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Practice DBT with LIFE Intelligence

LIFE Intelligence is a science-backed self therapy app designed to help you make all the right changes in your life. Whether it’s to break a bad habit you’re unsure how you developed or to regulate your emotions, LIFE will guide you through 9 missions (topics) to better you. Mission 2.4 is designed to develop self-awareness both internally (how you view and feel about yourself) and externally (how you view and feel about others). This development of self-awareness is exactly what DBT hopes to achieve.

In addition to self-awareness, LIFE can also help you regulate your emotions, another key component of DBT. At any given time of the day, you can check in with the wheel of emotions. This tool helps you assess your current mood and record past moods. This is so eventually you may begin to notice a pattern: are you irritable in the morning? Do you feel sad just past sunset? What time of day are you most energized? Tracking these emotions and understanding the context of them is essential to regulate them. 

You don’t need a reason to make your life a happier one. Let LIFE Intelligence help you become happier.