What is Dialectical Behavior Therapy?

Brindusa Vanta, MD, DHMHS
Medical editor

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  1. Origins of DBT
  2. Video: What is DBT?
  3. From CBT to DBT
  4. Underlying Theory of DBT
  5. DBT Treatment Modalities
  6. The 4 Modules
  7. Who Benefits from DBT?
  8. Finding DBT Treatment
  9. DBT Resources

Dialectical Behavior Therapy (DBT) is a comprehensive cognitive-behavioral treatment developed by Marsha Linehan, Ph.D., in the early 1990s. It aims to help individuals better manage their emotions, reduce self-destructive behaviors, and improve relationships. DBT combines standard cognitive-behavioral techniques for emotion regulation and reality testing with concepts of mindful awareness, distress tolerance, and acceptance. Central to its approach is the dialectical philosophy, which emphasizes the integration of opposites—acceptance and change.


DBT has been found effective for a wide range of disorders, particularly those characterized by emotional dysregulation, such as Borderline Personality Disorder (BPD), eating disorders, substance use disorder, and depression, among others. By teaching skills in four key areas—mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness—DBT provides individuals with the tools to navigate life's challenges in a healthier, more adaptive way.

Origins of DBT

Dialectical behavior therapy (DBT) was developed in the early 1990s by Marsha Linehan, Ph.D. (1993a). Linehan, a cognitive behavioral psychologist by training, formed the principles, theory, and strategies underlying DBT while working primarily with women who were suicidal and engaged in self-harming behaviors.

Origins of DBT

Video: What is DBT?

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This video by Esme Shaller, Ph.D., a clinical psychologist at the University of California, San Fransisco (UCSF), provides an excellent overview of DBT, including who it is intended for and what being in treatment might look like.

From CBT to DBT

crying girl

In initially approaching treatment from a strict cognitive behavioral perspective, Linehan found these techniques deficient in working with people with complex, high-risk behaviors. Cognitive behavior therapy (CBT)—brief, time-limited therapy in which a therapist works with a client to identify and change problematic thoughts—led to improvements in functioning for some but caused anger or withdrawal in others.

Over time, Linehan made adaptations to her work to address these shortcomings. It is these adaptations that developed into DBT. DBT preserves the cognitive behavioral focus on changing problem thoughts and behaviors, particularly in the skills training aspect of treatment. However, it also emphasizes acceptance and validation strategies designed to recognize the difficulty of change, which can help people stay open to and engaged in the process of change.

Underlying Theory of DBT

  • DBT understands behaviors in terms of the bio-social theory. According to this theory, our thoughts, emotions, and behaviors are closely linked: A thought triggers an emotion, which influences behavior, which leads to another emotion, then another thought—in an ongoing cycle, like links in a chain. Our individual experience of this cycle or chain of feeling, thought, and behavior, particularly the emotional aspect of this cycle, is influenced by our biology, as well as our social history.

  • Linehan (1993) developed the bio-social theory to explain the intense, extreme emotions and related impulsive, high-risk behaviors some individuals experience. According to her theory, these emotions and behaviors stem from a combination of biological vulnerability and environment. Some people are simply wired to be emotionally sensitive; their environment fails to teach them to modulate emotion, and trauma or invalidating experiences reinforce emotional escalation.

DBT Treatment Modalities

DBT grew into a treatment with 5 primary modalities:

  1. Individual therapy
  2. Group skills training
  3. Coaching in crisis
  4. Structuring the environment
  5. Consultation team

Individual Therapy

  • The focus of individual therapy is on identifying and assessing problematic behaviors and their associated feelings and thoughts. Therapists generally structure treatment around the following:

  • Analyzing problematic behavior
  • Teaching and strengthening skills for cognitive modification and emotion modulation
  • Teaching effective behavior 
  • Addressing motivation
  • Continuing to commit to treatment
  • Addressing behaviors that impede treatment

Group Skills Training

  • To address emotional and behavioral skill deficits, individuals must learn new strategies for interacting with their environment. DBT skills training consists of weekly group meetings devoted to learning new skills and reviewing the application of these new skills in daily life. The skills are broken down into four categories or modules (Linehan, 1993b):

The 4 Modules

Stay Calm IconMindfulness: These skills are fundamental to DBT and often referred to as the ‘core.’ They teach how to bring awareness to everyday living. This requires focus on the present moment, a capability many people with impulsive and mood-related behaviors lack. Mindfulness is consciously bringing attention to feelings, thoughts, body sensations, behaviors, and events without judgment. It is the opposite of rejecting, suppressing, or avoiding current experiences.

Difficulty concentrating IconDistress Tolerance:  In this module, skills center on accepting and coping with pain and distressing life events. These skills answer the question, ‘How do I survive this crisis?’ They focus not on changing the moment, but rather on accepting the current situation and finding ways to get through it without engaging in problematic behavior.

Behavioral Sign IconEmotion Regulation:  Emotionally sensitive individuals often are unable to modulate the painful emotions that underlie impulsive, risky behaviors. These skills include understanding current emotions, identifying obstacles to changing emotions, checking facts related to emotional reactivity, problem-solving, increasing positive emotions, and changing emotions.

Violence IconInterpersonal Effectiveness:  Interpersonal relationships can bring joy and happiness and cause fury or despair. This module teaches skills to get what we want and need in life while maintaining relationships and self-respect. Skills include strategies for asserting your needs, saying no effectively, and coping with conflict. It also covers skills necessary for maintaining friendships, decreasing social isolation, and ending destructive relationships.

Coaching in Crisis

  • To navigate the complex world of daily stressors, interpersonal relationships, work, obligations, etc., individuals must learn to use their new skills outside of the treatment environment. Coaching in crisis is designed to allow individuals to contact treatment providers before they engage in problematic behavior. When a person recognizes they are struggling, they can access coaching to help initiate skillful and effective responses to their current situation.

Structuring the Environment

  • Principles of behavior therapy teach us that our environment significantly influences behavior. DBT maintains a focus on the environment where a person functions, and it actively works with individuals to create contingencies that reinforce adaptive and effective behaviors. Couples or family treatment can be useful in structuring an environment that supports new skill use.

Consultation Team

  • DBT assumes that effective treatment of people with high-risk behaviors and intense emotional experiences must pay as much attention to the therapist's and treatment provider's behavior as it does to the individual's. Treatment providers, like anyone, can make mistakes, take extreme positions, become vulnerable to criticism, react from emotion rather than best practices, and become burnt out.
  • The consultation team is a weekly meeting for treatment providers designed to enhance their skills and keep them in the therapeutic frame (Linehan, 1993).

DBT Today

Not all current implementations of DBT are structured with all five modalities. For example, studies on binge eating disorder were effective with the skills group alone (Telch, Agras, & Linehan, 2001), and adaptations of DBT have been effective for a variety of populations, including those with bulimia nervosa (Hill, Craighead, & Safer, 2011) and suicidal teens (Rathus & Miller, 2002).

An overview of the research examining the effectiveness of DBT skills training without individual therapy has been found effective in several areas, including reducing depression, anger, emotional dysregulation, and emotional intensity. A review of studies has also found adaptations of DBT skills to be effective for eating disorders, substance use disorders, and attention/hyperactivity disorder (ADHD) (Linehan, 2015).

Dr. Brindusa Vanta, MD, says, "Dialectical behavior therapy (DBT) is considered to be an effective treatment for mental health issues associated with high levels of emotional instability. Researchers used advanced brain scans to study how DBT affects the brain. They found specific changes in brain activity and observed positive changes in areas of the brain involved in emotion regulation and behavior among individuals who were receiving DBT."

Who Benefits from DBT?

DBT photo

In Linehan's original research study, DBT was found effective in decreasing self-injurious behavior and the number of days spent in psychiatric care in women diagnosed with borderline personality disorder (BPD).

The application of DBT has a degree of flexibility based on an underlying theory and set of principles, which has allowed it to grow into an effective treatment for people with a wide variety of diagnoses and problems. As a result, DBT has been adapted as a treatment for many disorders characterized by emotional dis-control, such as:

  • Binge eating disorder (Telch, Agras & Linehan, 2001)
  • Depression among adolescents (Miller, 1999)
  • Depression among the elderly (Lynch, 2000)
  • Individuals dually diagnosed with intellectual disabilities and mental illness (Lew, Matta, Tripp-Tebo & Watts, 2006)

DBT has also been adapted to treat drug dependence and substance use (Linehan et al. 1999). The 2nd edition of the DBT Skills Training Module includes a section in its distress tolerance module that discusses skills to use when the crisis is addiction. This module was developed based on a series of studies treating individuals with drug dependence with DBT (Linehan, 2015).

As Dr. Brindusa Vanta, MD, says, "According to a 2023 systematic review of research studies, DBT has the potential to improve key cognitive functions such as attention, memory, and response inhibition in adults with various mental health conditions, as well as in adolescents with emotional dysregulation."

Its effectiveness in helping people modulate extreme emotions and reduce impulsive and destructive behaviors makes it an attractive treatment for those with substance use disorder. DBT is also helpful in keeping individuals in treatment, a particular problem in treating people who struggle with addiction. The modular makeup of skills training, along with the different modes of treatment, allows treatment providers to intensify or reduce the components, allowing for adaptation to an array of disorders.

Finding DBT Treatment

DBT group

If you are looking for DBT treatment, you may want to consider the following options:

The Substance Abuse and Mental Health Services Administration (SAMHSA) has an excellent online treatment-finding tool. Search for providers in your area and visit their website or call to see if they offer DBT or other treatments of interest. Both outpatient and inpatient programs will be listed.

Contact your insurance company to learn about treatment providers in your area. Specify that you are looking for facilities that offer DBT.

Do an internet search for DBT providers in your area.

If you are looking for co-occurring substance use disorder and mental health (dual-diagnosis) treatment:

DBT Resources

If you are looking for resources to use on your own, you may want to consider:


  1. Lew M., Matta C., Tripp-Tebo C., Watts D. DBT for individuals with intellectual disabilities: A program description (2006). Mental Health Aspects of Developmental Disabilities, 9(1), 1–13.
  2. Linehan M. Cognitive Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press; 1993a.
  3. Linehan, M. M. 1993b. Skills Training Manual for Treating Borderline Personality Disorder. New York: Guilford Press.
  4. Linehan, M.M. 2015 DBT Skills Training Manual, Second Edition. New York: The Guilford Press.
  5. Linehan, M. M., H. Schmidt III, L. A. Dimeff, J. C. Craft, J. Kanter and K. A. Comtois. 1999. Dialectical behavior therapy for persons with borderline personality disorder and drug dependence. The American Journal of Addictions 8, 279–292.
  6. Rathus, JH & Miller, AL. (2002). Dialectical behavior therapy adapted for suicidal adolescents. Suicide and Life-Threatenino Behaviors, 32, 2, 146-157.
  7. Telch, Christy F.; Agras, W. Stewart; Linehan, Marsha M. Dialectical behavior therapy for binge eating disorder (2001). Journal of Consulting and Clinical Psychology, 69(6), 1061-1065.

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