Dialectical Behavior

Therapy
Outline
What is DBT? – Definition and historical background

• Dialectical behavior therapy (DBT) is a comprehensive, evidence-

based treatment for borderline personality disorder (BPD).
• Although DBT has many similarities with other cognitive-
behavioral approaches, several critical and unique elements must
be in place for the treatment to constitute DBT.
• Some of these elements include:
(a) serving the five functions of treatment,
(b) the biosocial theory and focusing on emotions in treatment,
(c) a consistent dialectical philosophy, and
(d) mindfulness and acceptance-oriented interventions.
Origins of DBT – Developed by Marsha Linehan,
intended for BPD treatment
• Introduced in the late 1980s to treat Borderline Personality Disorder (BPD).
• Emerged from research on Cognitive Behavioral Therapy (CBT) but adapted to address emotional
dysregulation.
• Integrates dialectical philosophy—balancing acceptance and change.

• Why Was DBT Created?

• Traditional CBT was ineffective for clients with high emotional sensitivity and chronic suicidality.
• Clients often felt invalidated by standard therapy approaches.

• Core Innovations of DBT

• Incorporates mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.
• Emphasizes validation and therapeutic acceptance alongside structured behavioral change
strategies.
• Impact on Mental Health Treatment
• Originally designed for BPD, now widely used for PTSD, depression, substance use, eating
disorders, and more.
• Recognized as an evidence-based treatment with strong empirical support.
Core Philosophy of DBT – Dialectics,
validation, and change
1. Dialectics: Balancing Opposites
• Definition: The idea that two seemingly opposite truths can coexist.
• Therapeutic Application: Balancing acceptance and change for
clients.
• Example: "You are doing the best you can, and you need to do better."
2. Validation: Acknowledging Clients’ Experiences
• Definition: Recognizing and affirming a client’s thoughts and
emotions.
• Importance: Helps clients feel understood and reduces emotional
reactivity.
• Levels of Validation: Active listening, reflecting emotions,
normalizing feelings.
Core Philosophy of DBT –
Dialectics, validation, and change
3. Change: Skill Development and Behavioral
Modification
• DBT's Goal: Empower clients with tools to regulate
emotions and improve relationships.
• Key Strategies:
• Cognitive restructuring (changing thought patterns).
• Behavioral techniques (reinforcement, exposure).
• Mindfulness and distress tolerance skills.
Populations Benefiting from DBT – BPD, PTSD,
depression, anxiety, addiction, eating disorders
• The patient populations for which DBT has the most empirical
support include parasuicidal women with borderline personality
disorder (BPD).
• There have been promising findings for patients with BPD and
substance use disorders (SUDs), persons who meet criteria for
binge-eating disorder, and depressed elderly patients.
The Biosocial Model – How
emotional dysregulation develops
1. Biological Factors
• Genetic predisposition to high emotional sensitivity and intense
emotional reactions.
• Differences in brain functioning, particularly in areas related to emotion
regulation (e.g., amygdala, prefrontal cortex).
• Difficulties with impulse control and returning to emotional baseline.
2. Environmental Factors (Invalidating Environment)
• Chronic invalidation: Caregivers dismiss or punish emotional responses.
• Unpredictable or chaotic family dynamics.
• Lack of modeling for healthy emotion regulation.
• Reinforcement of extreme emotional expressions while ignoring
moderate emotions.
The Biosocial Model – How
emotional dysregulation develops
3. Consequences of the Biosocial Interaction
• Emotional dysregulation: Difficulty managing emotions
effectively.
• Impulsivity and self-destructive behaviors as coping
mechanisms.
• Struggles with interpersonal relationships due to heightened
emotional sensitivity.
4. DBT’s Role in Addressing the Biosocial Model
• Teaches mindfulness, distress tolerance, emotion regulation,
and interpersonal effectiveness.
• Helps individuals learn self-validation and build emotional
resilience.
DBT vs. Traditional CBT – Key
differences and similarities
1. Similarities
• Cognitive-Behavioral Foundation – Both focus on
changing maladaptive thoughts and behaviors.
• Evidence-Based – Both have strong empirical support
for treating mental health disorders.
• Skill Development – Both teach coping skills for
emotional and behavioral regulation.
• Structured and Goal-Oriented – Sessions follow a
structured format with clear treatment goals.
DBT vs. Traditional CBT – Key
differences and similarities
Feature DBT Traditional CBT
Balances acceptance &
Core Focus Focuses primarily on change
change
Used for anxiety,
Designed for BPD & high
Target Population depression, and mood
emotional dysregulation
disorders
Incorporates mindfulness & Emphasizes cognitive
Therapeutic Approach
validation restructuring
Teaches distress tolerance & Focuses on modifying
Emotion Regulation
emotion management irrational thoughts
Emphasizes collaboration & Functions as an instructor or
Therapist’s Role
validation coach
Includes individual therapy,
Treatment Format group skills training, & Typically individual therapy
phone coaching
3. Takeaway
• DBT expands upon CBT by integrating mindfulness,
validation, and dialectics to help clients with intense
emotions.
• CBT is effective for many disorders, while DBT is
specialized for individuals with chronic emotional
dysregulation.
Core Assumptions of DBT –
Clients are doing their best and
want to improve
• Clients Are Doing the Best They Can
• People are trying their hardest with the skills and
resources they currently have.
• Their behaviors, even maladaptive ones, are attempts to
cope with overwhelming emotions.
• Clients Want to Improve
• Despite struggles, clients have an inherent desire to
change and build a better life.
• Motivation may be inconsistent, but it exists beneath the
surface.
Core Assumptions of DBT –
Clients are doing their best and
want to improve
Clients Need to Learn New Behaviors in All Relevant Contexts
• Emotional dysregulation is often a result of skill deficits, not a lack of effort.
• DBT teaches practical skills that must be applied across different situations.
Clients Cannot Fail in Therapy
• Progress is non-linear, and setbacks are part of the learning process.
• The therapist and client work together to find solutions rather than assigning
blame.
Therapists Must Maintain a Dialectical Stance
• Balancing acceptance (validating a client’s experiences)
and change (encouraging new behaviors).
• Avoiding extreme positions and finding a middle ground between opposing
perspectives.
Stages of DBT Treatment – Crisis survival to self-
actualization

Stage 1: Crisis Survival & Behavioral Stability

• Focus on reducing life-threatening behaviors (e.g., self-harm, suicidal
ideation).
• Build foundational skills in distress tolerance, mindfulness, and
emotional regulation.
Stage 2: Addressing Emotional Suffering & Trauma
• Work on processing past trauma and reducing emotional avoidance.
• Learn to regulate emotions without resorting to extreme behaviors.
Stage 3: Building a Life Worth Living
• Strengthen relationships, improve self-esteem, and increase independence.
• Apply DBT skills consistently across various life situations.
Stages of DBT Treatment – Crisis
survival to self-actualization
Stage 4: Self-Actualization & Fulfillment
• Focus on achieving personal goals, meaning, and long-
term well-being.
• Develop a deeper sense of purpose, self-compassion,
and emotional resilience.
• Therapeutic Progression & Individualization
• Clients move through stages at their own pace, based on
their needs.
• Each stage builds upon the last, emphasizing both
acceptance and change.
Evidence-Based Effectiveness – Research findings
on DBT outcomes

• Effective for Borderline Personality Disorder (BPD)

• Studies show 50-60% reduction in self-harm and suicidal
behaviors in individuals with BPD.
• DBT reduces hospitalization rates and
improves emotional regulation.
• Broad Applications Beyond BPD
• Proven effective for depression, PTSD, eating
disorders, and substance use disorders.
• Research supports DBT’s ability to improve interpersonal
relationships and distress tolerance.
Evidence-Based Effectiveness – Research findings
on DBT outcomes

• Long-Term Benefits & Sustained Improvement

• Follow-up studies show lasting reductions in emotional
dysregulation and impulsive behaviors.
• Clients report higher quality of life and greater
emotional stability post-treatment.
• DBT vs. Other Therapies
• DBT outperforms standard CBT for individuals with high
emotional reactivity.
• More effective in reducing suicidal
behaviors compared to treatment-as-usual (TAU).
The Four Modes of DBT – Individual therapy, skills
training, phone coaching, consultation teams

• Individual Therapy
• One-on-one sessions to address personal challenges and treatment goals.
• Focuses on applying DBT skills to real-life situations and reducing maladaptive
behaviors.
• Skills Training Group
• Weekly group sessions teaching core DBT skills: mindfulness, distress tolerance, emotion
regulation, and interpersonal effectiveness.
• Structured like a classroom, focusing on skill-building rather than emotional
processing.
• Phone Coaching
• Clients can contact their therapist for real-time support during emotional crises.
• Helps apply DBT skills in daily life to prevent impulsive or harmful behaviors.
• Consultation Team for Therapists
• A support system for DBT therapists to prevent burnout and enhance effectiveness.
• Ensures therapists remain dialectical, validating, and skillful in their approach.
DBT Skills Group – Structure, goals, and format

• Structure: DBT Skills Groups are typically held weekly,

with sessions lasting 2 hours. They are often part of a
larger DBT program, which may include individual
therapy and phone coaching.
• Goals: The primary goal is to teach clients practical
skills for managing emotions, improving relationships,
and reducing self-destructive behaviors. Key skill areas
include mindfulness, distress tolerance, emotion
regulation, and interpersonal effectiveness.
Role of the Therapist – Balancing acceptance and
change

• Format: Each session usually follows a set format,

starting with a review of homework or previous skills
practice, followed by new skill teaching, and ending with
discussion or group exercises to apply the skills.
• Group Environment: Participants are encouraged to
practice skills in real-life scenarios with support from
peers and the therapist. Group members share
experiences and provide mutual encouragement,
creating a supportive and collaborative atmosphere.
DBT and Crisis Management – Addressing suicidal
behaviors and safety planning

• Addressing Suicidal Behaviors: DBT emphasizes the importance of identifying

and addressing suicidal behaviors by teaching clients distress tolerance skills and
helping them manage overwhelming emotions in healthier ways.
• Safety Planning: DBT encourages the development of a personalized safety
plan, which includes identifying warning signs, coping strategies, and a list of
contacts for support during a crisis, ensuring that clients have immediate
resources to rely on when feeling at risk.
• Crisis Management Protocol: Therapists work with clients to establish clear
protocols for responding to crises, such as when a client is actively suicidal. This
can include emergency contacts, limiting access to harmful means, and utilizing
DBT skills to manage emotional distress in the moment.
• Validation and Support: A core principle of DBT is validation—acknowledging
the client’s feelings while reinforcing that they are capable of making safer
choices. In moments of crisis, therapists help clients feel understood while
guiding them toward taking concrete steps to protect themselves.
Homework and Diary Cards – Tracking behaviors
and skill use

• Diary Cards: Clients are asked to fill out daily diary cards to track
emotions, behaviors, and the use of DBT skills. This helps both the client
and therapist identify patterns and areas that need attention.
• Tracking Behaviors: The diary card includes sections for recording target
behaviors such as self-harm, suicidal thoughts, or impulsive actions. It also
allows clients to track the intensity of their emotions and specific triggers.
• Skill Use: Clients are encouraged to track how often and effectively they
use DBT skills like mindfulness, distress tolerance, emotion regulation, and
interpersonal effectiveness, helping to reinforce learning and increase self-
awareness.
• Homework Assignments: Each session includes homework assignments
designed to apply DBT skills in real-life situations. These assignments help
clients integrate skills into their daily lives and provide valuable insights for
therapy sessions.
Mindfulness (Overview) – Living in the present

• Living in the Present Moment: Mindfulness teaches clients to focus

on the present moment, noticing their thoughts, feelings, and sensations
without judgment, which helps reduce reactivity and stress.
• Non-Judgmental Awareness: A core principle of mindfulness is
observing experiences without labeling them as good or bad. This
encourages acceptance and reduces the tendency to criticize or avoid
feelings.
• Acceptance and Tolerance: Mindfulness promotes accepting things as
they are, helping clients cope with difficult emotions and situations by
focusing on what is happening right now rather than worrying about the
past or future.
• Improving Focus and Clarity: Practicing mindfulness helps improve
concentration and clarity of thought, allowing clients to make more
thoughtful, deliberate choices instead of reacting impulsively.
Mindfulness Skills – Observing, describing,
participating

• Observing: This skill involves paying attention to the present moment by simply
noticing thoughts, feelings, sensations, and surroundings without becoming
attached or judging them. It's about being aware without getting caught up in the
experience.
• Describing: Once something is observed, the next step is to describe it in words.
This means labeling what is happening, such as naming emotions ("I feel anxious")
or describing physical sensations ("My hands are trembling"), which helps create
clarity and detachment.
• Participating: Participating means fully engaging in the activity at hand, allowing
yourself to be immersed in the present moment without distraction. It's about being
“all in” and experiencing things as they come, without holding back or overthinking.
• Enhancing Awareness: These skills work together to increase overall mindfulness
by helping clients shift from automatic reactions to intentional, present-focused
awareness. This leads to greater emotional regulation and a deeper connection to
the moment.
Distress Tolerance (Overview) – Surviving
emotional crises

• Coping with Intense Emotions: Distress tolerance skills help individuals

manage and tolerate overwhelming emotions during crises, teaching them not
to act impulsively or engage in harmful behaviors when feeling emotionally
flooded.
• Short-Term Strategies: These skills provide immediate, short-term solutions
to help clients survive a crisis without making the situation worse. This
includes techniques like distraction, self-soothing, or grounding exercises to
reduce emotional intensity.
• Radical Acceptance: One key concept is radical acceptance, which
encourages individuals to fully accept the reality of a situation, no matter how
painful, without trying to change it in the moment. This reduces resistance and
helps clients navigate distress more effectively.
• Building Resilience: Over time, distress tolerance skills help clients build
resilience by learning to face emotional pain without resorting to maladaptive
coping mechanisms, thus strengthening their ability to handle future crises.
Distress Tolerance Skills – STOP, TIP, Self-soothing,
Radical Acceptance

• STOP: This skill involves pausing and taking a moment before reacting in a crisis. The
acronym stands for: Stop, Take a step back, Observe what’s going on (thoughts,
feelings, environment), and Proceed mindfully. It helps prevent impulsive actions and
promotes thoughtful decision-making.
• TIP: TIP stands for Temperature (changing your body temperature, such as holding ice
or splashing cold water on your face), Intense exercise (doing a quick burst of physical
activity), Paced breathing (slowing your breath down), and Paired muscle relaxation
(tensing and releasing muscles). These strategies help reduce emotional intensity by
shifting the body’s physiological state.
• Self-soothing: This involves engaging the five senses (sight, sound, touch, smell, and
taste) to calm and comfort yourself. Examples include listening to calming music, using
a soothing lotion, or enjoying a warm drink. It helps ground individuals and reduces
emotional overwhelm.
• Radical Acceptance: Radical acceptance means accepting reality as it is, without
judgment or resistance. It involves letting go of the desire to change what can't be
changed and embracing the situation fully, which can reduce suffering and increase
emotional tolerance during difficult times.
Emotion Regulation (Overview) – Managing
emotional intensity

• Understanding Emotions: Emotion regulation skills help individuals become more

aware of their emotional states, including recognizing early signs of emotional
intensity, so they can take proactive steps to manage their reactions before they
escalate.
• Increasing Positive Emotions: One goal of emotion regulation is to increase the
frequency of positive emotions by engaging in activities that are enjoyable, fulfilling,
and meaningful. This helps counterbalance negative emotions and build emotional
resilience.
• Reducing Vulnerability to Emotion Dysregulation: Emotion regulation teaches
strategies to reduce emotional vulnerability, such as maintaining a balanced routine,
getting enough sleep, eating well, and managing stress. This helps prevent intense
emotions from becoming overwhelming.
• Changing Emotional Responses: Emotion regulation involves learning to change
emotional responses by using skills like cognitive reappraisal, where individuals
reframe negative thoughts to influence how they feel, and engaging in behaviors that
are consistent with their values rather than reacting impulsively.
Emotion Regulation Skills – ABC PLEASE, Opposite
Action, Building Mastery

• ABC PLEASE: This acronym stands for strategies to build emotional

resilience:
• A: Accumulate positive experiences by engaging in enjoyable and
meaningful activities.
• B: Build mastery by practicing skills and achieving small goals.
• C: Cope ahead by planning how to handle potential future challenges.
• P: Treat physical illness, as physical well-being impacts emotional
regulation.
• L: Balance your eating habits to stabilize mood and energy.
• E: Avoid drugs and alcohol, which can destabilize emotions.
• S: Get enough sleep to maintain emotional and physical health.
• E: Exercise regularly to improve mood and reduce stress.
Emotion Regulation Skills – ABC
PLEASE, Opposite Action, Building
Mastery
• Opposite Action: This skill involves acting opposite to the emotion
you are experiencing when your emotions are not aligned with your
values or goals. For example, if feeling angry and wanting to lash out,
opposite action would be to act calm and engage in a peaceful
activity, helping to shift emotional states.
• Building Mastery: Building mastery involves engaging in activities
that provide a sense of accomplishment, confidence, and control. This
can include learning a new skill, completing a task, or participating in
a hobby, which boosts self-esteem and reduces emotional distress.
• Increasing Positive Emotions: By regularly engaging in activities
that promote mastery and pleasure, individuals can increase their
overall sense of well-being and emotional stability, making it easier to
manage intense emotions in the future.
Interpersonal Effectiveness (Overview) –
Navigating relationships

• Balancing Needs: Interpersonal effectiveness helps individuals navigate

relationships by balancing their own needs with the needs of others, ensuring
they can assert their boundaries without feeling overly selfish or neglectful.
• Assertiveness Skills: A key component is learning how to express thoughts,
feelings, and desires clearly and respectfully. This includes saying "no" when
necessary, asking for what you need, and standing up for yourself without
aggression.
• Maintaining Relationships: The skills emphasize the importance of
maintaining positive, healthy relationships through active listening, validating
others, and finding solutions that respect both your own and the other person's
needs.
• Dealing with Conflict: Interpersonal effectiveness also teaches ways to
manage conflict constructively, encouraging individuals to use skills like
compromise, calm communication, and problem-solving to resolve
disagreements and maintain relational harmony.
Interpersonal Effectiveness Skills – DEAR MAN,
GIVE, FAST

• DEAR MAN: This skill is used for assertively asking for what
you need or setting boundaries:
• D: Describe the situation clearly.
• E: Express your feelings and thoughts.
• A: Assert yourself by making a clear request.
• R: Reinforce by explaining the positive outcome.
• M: Mindful—stay focused on the issue and don’t get
sidetracked.
• A: Appear confident, using a calm and firm tone.
• N: Negotiate if necessary, being open to finding a solution.
Interpersonal Effectiveness
Skills – GIVE,
• GIVE: This skill helps maintain relationships by
promoting healthy interactions:
• G: Be Gentle in your approach, avoiding aggression or
sarcasm.
• I: Act Interested by listening and being attentive to the
other person.
• V: Validate the other person’s feelings or point of view.
• E: Use an Easy manner, keeping the conversation light
and respectful.
Interpersonal Effectiveness
Skills – FAST
• FAST: This skill is used to maintain self-respect in relationships,
ensuring you don’t compromise your values:
• F: Be Fair to yourself and others in the interaction.
• A: Avoid apologies when they aren't necessary.
• S: Stick to your values and what matters to you.
• T: Be Truthful—don’t lie or exaggerate to avoid conflict or
discomfort.
• Combining Skills: These skills are designed to be used together,
with DEAR MAN focusing on clear communication, GIVE promoting
kindness and connection, and FAST helping to preserve self-
respect, all while navigating complex interpersonal situations.
Case Study Example – Applying DBT skills in
therapy

• Client Background:
• Name: Sarah, 28-year-old female
• Presenting Issue: Chronic emotional dysregulation, frequent mood
swings, interpersonal conflicts, and self-harm behaviors.
• Diagnosis: Borderline Personality Disorder (BPD), history of trauma.
• Therapy Goal: To reduce self-harm, manage emotional crises, and
improve relationships using DBT.
• DBT Focus:
• Teaching skills for emotional regulation, distress tolerance, and
interpersonal effectiveness.
• Identifying triggers and patterns of behavior that lead to emotional
overwhelm.
• Application of DBT Skills
• Distress Tolerance – STOP Skill:
• Sarah often reacts impulsively in conflict with her partner, leading to
emotional outbursts.
• In therapy, she practices the STOP skill to pause before reacting. This
allows her to identify her emotions and make a mindful decision to
respond rather than react.
• Emotion Regulation – ABC PLEASE:
• Sarah struggles with emotional vulnerability, especially when
overwhelmed by negative emotions.
• She works on increasing positive experiences (engaging in hobbies),
taking care of physical health (regular exercise, sleep), and using self-
soothing techniques to reduce emotional intensity.
• Interpersonal Effectiveness – DEAR MAN:
• Sarah faces difficulties in asking for what she needs
from others.
• Through DBT, she learns to use the DEAR MAN skill to
assertively communicate her needs with her partner,
ensuring she expresses herself without guilt and is more
likely to receive a positive response.
Results and Progress
• Behavioral Changes:
• Reduced self-harm episodes and less impulsive emotional reactions.
• Increased ability to handle emotional distress without resorting to
unhealthy coping mechanisms.
• Improved Relationships:
• Sarah reports fewer arguments and better communication with her
partner by using DBT skills like DEAR MAN for assertive communication.
• Continued Therapy Goals:
• Deepening mindfulness practice to stay more grounded in the present
moment.
• Refining distress tolerance skills to better manage future emotional
crises.
Common Challenges in DBT – Treatment
resistance, dropout rates

• Treatment Resistance:
• Some clients may be resistant to DBT skills, particularly those with
severe emotional dysregulation or high levels of distress, making it
difficult to engage fully in the therapeutic process.
• Difficulty with Homework:
• Clients often struggle to complete homework assignments, such as
filling out diary cards or practicing DBT skills, due to emotional
overwhelm or lack of motivation.
• Stigma and Misunderstanding:
• Clients may feel stigma around having a diagnosis like Borderline
Personality Disorder (BPD) or may misunderstand DBT’s focus on
emotional regulation, making them hesitant to fully engage in the
treatment.
• Chronic Emotional Dysregulation:
• Clients with a history of trauma or chronic emotional
instability may find it challenging to trust the process,
especially when immediate results aren’t visible.
• Dropout Rates:
• DBT involves a long-term commitment (often 6 months
to a year), and some clients drop out due to the
intensity of the treatment, time commitment, or
frustration with slow progress.
• Difficulty with Radical Acceptance:
• The concept of radical acceptance—acknowledging
painful situations as they are—can be challenging for
clients who are used to rejecting or fighting against
reality, leading to resistance.
• Balancing Skills and Real-Life Application:
• Applying DBT skills in real-world situations can be
difficult, and clients may feel overwhelmed or
discouraged when they struggle to integrate the skills
effectively into their daily lives.
• Therapist Burnout and Resources:
• The demanding nature of DBT can lead to therapist
burnout, especially in settings with high caseloads or
limited resources, impacting treatment consistency and
client engagement.