DBT Therapy Explained: Skills, Structure and What Trials Show

DBT therapy, short for dialectical behavior therapy, is a structured form of cognitive-behavioral treatment built for people whose emotions run intensely and who respond to them with self-destructive behavior. The National Institute of Mental Health (NIMH) describes it as a treatment developed specifically for people with borderline personality disorder (BPD) that teaches skills to control intense emotions, reduce self-destructive behaviors and improve relationships^[1].

Marsha Linehan created DBT while trying to build a treatment for suicidal women with many co-occurring problems^[2]. Her first version focused almost entirely on changing thoughts and behavior, and many patients felt criticized and invalidated and dropped out^[2]. She then added strategies that convey acceptance, and the treatment came to rest on balancing acceptance with change^[2].

That balance is what "dialectical" refers to: two positions that seem to conflict, such as accepting oneself as one is and needing to change, are treated as both valid and then synthesized^[2]. This article covers how DBT works, the skills it teaches and what trials show. Prevalence data for BPD are on the BPD condition page, and a comparison of DBT with other BPD therapies is in Psychotherapy for Borderline Personality Disorder.

DBT is a program rather than a single weekly appointment. The VA describes its structure as individual psychotherapy, group skills training, in-the-moment phone coaching and a consultation team for therapists^[7]. A 2022 trial of "comprehensive" DBT delivered all four, with individual and group sessions every week^[5].

Individual sessions run about an hour, the skills group about 1.5 to 2.5 hours and the therapist team meeting about 1 to 2 hours, each once a week^[2]. Skills groups usually have about 4 to 10 members and work like a class, with teaching, practice and homework^[2].

The diary card and the target hierarchy

Each week the client fills in a self-monitoring form called a diary card, and the therapist uses it to set the session agenda^[2]. Behaviors that threaten life, such as suicidal or self-injurious behavior, come first; behaviors that interfere with therapy, such as missed sessions, come second; and problems that erode quality of life come third^[2].

For each targeted behavior, the therapist and client trace what led up to it and what consequences may be keeping it going, a step-by-step review DBT calls a chain analysis^[2][7]. Data on self-harm in the U.S. population are on the non-suicidal self-injury page.

Why therapists have their own team

The consultation team exists because repeated suicidal crises and therapy-interfering behavior can wear down clinicians^[2]. The team helps therapists problem-solve hard cases, keep a nonjudgmental stance and limit burnout^[2].

DBT skills training is organized into four modules: mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness^[7]. Each targets a set of abilities the treatment assumes clients lack or need to strengthen^[2].

• Mindfulness: observing the present experience without judgment, describing the facts of a situation and participating fully while attending to one thing at a time, which DBT calls acting "one-mindfully"^[2].
• Distress tolerance: surviving crises without making the situation worse^[2]. This module also teaches radical acceptance, accepting the present moment as it is without fighting it^[2].
• Emotion regulation: recognizing, understanding, labeling and regulating emotions^[2].
• Interpersonal effectiveness: navigating interpersonal situations effectively^[2].

The skills follow from DBT's biosocial theory, which proposes that people with BPD are born with emotional vulnerability, meaning a low threshold for emotional reactions, intense responses and a slow return to baseline^[2]. Growing up in an environment that dismisses or punishes those emotions is thought to leave the person without regulation skills and more likely to rely on fast, self-destructive ways of coping^[2]. More on this pattern is on the emotional dysregulation page.

Skills training appears to be an active ingredient. In a 2015 trial of 99 women with BPD and recent suicidal behavior, the two treatment arms that included skills training reduced nonsuicidal self-injury and depression more than DBT individual therapy delivered without skills training^[3]. Anxiety improved in both skills arms but not in the arm without skills^[3].

In a 2006 review, the strongest and most consistent evidence for DBT came from women with BPD and repeated self-injurious behavior^[2]. The first randomized trial of DBT enrolled 44 such women and found less self-harm and fewer inpatient days than usual community care^[2]. A later trial of 101 participants compared DBT with treatment by community experts in BPD and found fewer suicide attempts, hospitalizations and emergency room visits with DBT^[2].

The criteria clinicians use to diagnose BPD are covered in Symptoms of Borderline Personality Disorder.

DBT adapted for adolescents (DBT-A) is the second major use, and a 2018 trial of it enrolled 173 youths aged 12 to 18 with a prior suicide attempt at 4 academic medical centers^[4]. The authors concluded that, with two independent trials supporting it, DBT was the first well-established treatment for reducing repeated suicide attempts and self-harm in youths^[4]. Population data for this age group are on the adolescents 12-17 page.

Evidence for other uses is thinner and often older: a 2006 review described promising results for women with BPD and a substance use disorder, for binge-eating disorder and for depressed older adults with personality disorders^[2]. In one binge-eating trial cited there, 86% of women in a 20-week DBT skills group had stopped bingeing by the end of treatment, but that fell to 56% six months later^[2]. The same review cautioned against applying DBT well beyond the patients it was tested on^[2].

Randomized trials show DBT reduces self-harm in high-risk groups, though some advantages fade after treatment ends^[4]. In the 2018 adolescent trial, 90.3% of youths in DBT had no suicide attempt after 6 months of treatment, versus 78.9% in individual and group supportive therapy^[4]. The share with no nonsuicidal self-injury was 56.9% versus 40.0%^[4].

Between months 6 and 12, the difference between the two groups was no longer statistically significant^[4]. Treatment completion was 75.6% in DBT and 55.2% in supportive therapy^[4].

A 2021 meta-analysis pooled 21 studies of DBT-A covering 1,673 adolescents^[8]. Compared with control groups, DBT-A had small to moderate effects on self-harm (g = -0.44) and suicidal ideation (g = -0.31)^[8]. Evidence that it reduced BPD symptoms came only from uncontrolled before-and-after studies^[8].

Not every review is as positive. The 2024 VA/DoD guideline on patients at risk for suicide judged the evidence insufficient to recommend for or against DBT to reduce suicidal ideation and the risk of suicide attempts or suicide^[6][7]. The recommendation addresses suicidal ideation, suicide attempts and suicide; it does not rate DBT's effect on BPD symptoms^[7].

For people with BPD, how DBT compares with mentalization-based treatment, schema therapy and general psychiatric management is covered in this review of BPD psychotherapy trials. Data on suicidal thoughts in the U.S. are on the suicidal ideation page.

DBT is a form of cognitive behavioral therapy (CBT) and uses many standard CBT tools, including exposure, contingency management, problem solving and cognitive restructuring^[2]. NIMH lists both DBT and CBT among the psychotherapies used for BPD^[1].

Four elements set DBT apart: its five treatment functions, the biosocial theory with its focus on emotions, a dialectical philosophy and a heavy emphasis on acceptance and mindfulness^[2]. The five functions are building skills, carrying them into daily life, improving motivation and reducing harmful behavior, supporting the therapist and structuring the environment^[2].

In practice, a DBT therapist pairs acceptance-based options such as radical acceptance and validation with change-based ones such as problem solving^[2]. How CBT performs on its own is covered in Cognitive Behavioral Therapy for Depression, and another acceptance-based approach is profiled in ACT Therapists.

Standard DBT has usually been tested as a 12-month treatment^[5]. The 2015 component trial delivered 1 year of treatment followed by 1 year of follow-up^[3].

Shorter courses are being tested. In a 2022 trial at two Canadian sites, 240 adults with BPD who were suicidal or self-harming received either 6 or 12 months of comprehensive DBT^[5]. Six months was noninferior to 12 months for total self-harm at 6, 12 and 24 months, the 6-month group improved faster on BPD symptoms, and dropout did not differ^[5].

The adolescent model is also shorter: treatment in the 2018 trial lasted 6 months and included parent contact as needed^[4]. Dropout also varies by format: in the 2015 trial, it was 24% in standard DBT and 48% in DBT without skills training^[3].