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Dialectical Behaviour Therapy

A structured treatment combining individual therapy, group skills training and between-session coaching, developed for chronically suicidal and self-harming clients and built around balancing acceptance with change.

Definition

Dialectical Behaviour Therapy (DBT) in its full form has four components delivered together:

Individual therapy, organised by a hierarchy that puts life-threatening behaviour first.
Group skills training in mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness.
Phone coaching between sessions, for using skills in the moment.
A consultation team for the therapists, which is a treatment component rather than supervision.

A programme delivering only the skills group is not DBT, though it is frequently described as such.

History

Developed by Marsha Linehan from the late 1970s. It began as an attempt to apply standard behaviour therapy to chronically suicidal women and failed: clients experienced the relentless push to change as invalidating and dropped out.

The dialectic — holding radical acceptance of the person as they are alongside insistence on change — was the resolution, and it is the treatment's defining idea rather than a technique bolted on.

Theory

The biosocial theory proposes that the difficulties grouped under borderline personality disorder arise from a transaction between a biologically-based emotional vulnerability and an invalidating environment, each shaping the other over time.

Emotional vulnerability means high sensitivity, high reactivity, and a slow return to baseline. An invalidating environment is one that treats emotional responses as wrong, trivial or manipulative.

The theory matters clinically because it reframes behaviour usually read as manipulation as a learned solution to unbearable affect.

Research

The strongest evidence base of any treatment for borderline personality disorder. Randomised trials show reductions in suicide attempts, self-harm, hospitalisation and treatment dropout.

Evidence is weaker but present for substance use, eating disorders and adolescents.

A component analysis found the skills group carried much of the effect on self-harm, which is theoretically important and also commercially convenient, since skills-only programmes are far cheaper to run.

Applications

First-line for borderline personality disorder in most national guidelines. Adapted for adolescents, for eating disorders, and for forensic settings.

Skills-only groups are widespread. They have some evidence, and they are not the treatment that was tested in the landmark trials.

Criticism

It is expensive and demanding. A full programme is a year of weekly individual therapy plus weekly groups plus therapist consultation, which many services cannot fund.
Diluted versions are called DBT. A six-week skills group is not the treatment the trials support, and calling it DBT muddies both the evidence and the client's expectations.
The comparison conditions in early trials were often treatment as usual, which sets a low bar. Later trials against structured comparisons show narrower differences.
Therapist burnout is high, and the consultation team exists partly because of it.

References

Linehan, M. M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. Guilford Press.
Linehan, M. M., et al. (2015). Dialectical behavior therapy for high suicide risk: A randomized component analysis. JAMA Psychiatry, 72(5), 475-482.
Crowell, S. E., Beauchaine, T. P., & Linehan, M. M. (2009). A biosocial developmental model of borderline personality. Psychological Bulletin, 135(3), 495-510.
Stoffers-Winterling, J. M., et al. (2012). Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews, CD005652.

Written for PsychologyOrbit and reviewed before publishing. It is a summary for professionals and students, not clinical guidance, and it is not a substitute for the primary sources listed above.