Dialectical behaviour therapy (DBT)
Explains what DBT is, what problems it can help with and what sessions are like. Includes links to find a therapist.
The aim of DBT is to help you:
- Understand and accept your difficult feelings
- Learn skills to manage them
- Become able to make positive changes in your life
‘Dialectical’ means trying to understand how two things that seem opposite could both be true. For example, accepting yourself and changing your behaviour might feel contradictory. But DBT teaches that it's possible for you to achieve both these goals together.
Before DBT, I felt like the only solution was suicide... through learning various skills from DBT I can ride the waves of my depression rather than letting them swallow me.
Experiences of DBT
Watch Debbie and Lechelle talk about getting a BPD diagnosis, and their experience of DBT as treatment.
After a few months I found that, although how I felt and a lot of my symptoms did not change, I was managing them all so much better. I could actually get through days without a crisis.
Research shows that DBT can be helpful in tackling problems like:
It was originally developed for borderline personality disorder (BPD), so most of the evidence for it so far has been about treating people with this diagnosis. Some NHS services are also starting to offer DBT for:
- Children and adolescents
- Drug and alcohol problems
- Eating problems
- Offending behaviour (committing crimes)
But regardless of your diagnosis or problems, DBT might not be right for you.
DBT is more likely to work for you if:
- You're committed to making positive changes in yourself
- You're ready to work hard at therapy, and do homework assignments
- You're ready to focus mostly on your present and future, rather than your past
- You feel able to do some sessions in a group with others
Some people like group work, but others find it harder. You might ideally prefer to work with a DBT therapist 1-to-1, but unfortunately this is not always offered as an option. Talk to your doctor about what you would find most helpful to see what is available in your area.
It's important to remember that everyone experiences therapy differently.
I was really nervous about the group aspect of DBT. When I started group I wouldn’t speak or make eye contact, but everyone was supportive and by the end I was much more confident and even taught a skill session to the other group members.
Some therapists may offer you an assessment or pre-treatment phase of DBT. This is where the therapist will look at how suitable DBT is for you. They might offer you several sessions where you will learn about the DBT model. Then if you decide it is the right therapy for you, they will ask you to make a commitment to the treatment.
Individual therapy usually involves weekly one-to-one sessions with a DBT therapist. Each session lasts approximately 45–60 minutes.
The individuals sessions have a hierarchy of goals:
- To help keep you safe by reducing suicidal and self-harming behaviours.
- To reduce behaviours that interfere with therapy.
- To help you reach your goals and improve your quality of life by addressing what's getting in the way. This might be other mental health problems like depression or hearing voices. Or it might be things in your personal life like employment or relationship problems.
- To help you learn new skills to replace unhelpful behaviours and help you achieve your goals.
Your DBT therapist is likely to ask you to fill out diary cards as homework, and bring them to sessions. This is for you to track your emotions and actions, and look for patterns and triggers in your life. You then use this information to decide together what you will work on in each session. You can find some sample diary cards on the DBT Self Help website.
I’ve learned that emotions are not the enemy. They are useful and have functions. I still feel emotions intensely, but I can now identify them and know how to manage them without using harmful behaviours.
In these sessions DBT therapists will teach you skills in a group setting. This is not group therapy, but more like a series of teaching sessions.
There are usually two therapists in a group and sessions might be weekly. The room is sometimes arranged like a classroom where your skills trainers will be sat at the front. The aim of these sessions is to teach you skills that you apply to your day-to-day life.
There are typically four skills modules:
- Mindfulness. This is a set of skills that focus your attention on the present, rather than worries about the past or the future. You might have a mindfulness module running between other modules. DBT sessions may often also start with a short mindfulness exercise. See our pages on mindfulness for more information.
- Distress tolerance. This means learning to deal with crises without harmful behaviours, like self-harm.
- Interpersonal effectiveness. This means learning to ask for things and say no to other people, with respect for yourself and others.
- Emotion regulation. This is a set of skills you can use to understand, be more aware, and have more control over your emotions.
In group sessions your therapist might ask you to do group exercises and use role-play. You are also given homework each week to help you practise these skills in your day-to-day life.
DBT often uses telephone crisis coaching to support you in your day-to-day life. This means that you can call your therapist for support between sessions. For example:
- when you need help to deal with an immediate crisis (such as feeling suicidal or wanting to self-harm)
- when you are trying to use DBT skills but want some advice on how to do it
- if you need to repair your relationship with your therapist.
But you can expect your therapist to set some clear boundaries around this. For example:
- calls are usually brief
- calls should only take place between hours you agree with them
- in particular circumstances, they might ask you to wait 24 hours before calling them.
During sessions DBT therapists will use a balance of acceptance and change techniques.
Acceptance techniques focus on:
- Understanding yourself as a person
- Making sense of why you might do things such as self-harm or misuse drugs
For example, a DBT therapist might suggest that this has been your only way of coping with intense emotions. So even though it’s damaging in the long-term, and may alarm other people, your behaviour makes sense.
Finally someone is saying 'yes it makes sense' rather than 'no that's wrong’.
Change techniques focus on replacing behaviours that harm you with behaviours that help you. This may mean your therapist:
- Challenges your unhelpful thoughts
- Encourages you to find new ways of dealing with distress
It’s not a short term thing. You have to work at it every single day. It’s hard to do, and even now, some 2 years after I completed the therapy, I’m still having to work at it.
The main ways to seek DBT are through the NHS with referral from your doctor or mental health team, or through the private sector.
There is currently no official register of DBT therapists in the UK. But some directories may let you filter your search by diagnosis or type of therapy.
Unfortunately, many people find that accessing DBT can be quite difficult. DBT isn't available everywhere, and NHS waiting lists can be very long. And many of us can't afford to go private.
If you're in this situation, our page on facing barriers to seeking help has ideas on how to cope.
I was referred to a Personality Disorder clinic but found out only group DBT is available is this area. And the waiting list was approximately 6 months long. I’m left here with no hope of ever receiving individual DBT therapy.
Unlike CBT, it can be difficult to learn DBT techniques by yourself. It can also be overwhelming when you start doing DBT. So doing it by yourself doesn’t usually work as well as going to sessions run by trained therapists.
Doing a formal course can help you:
- Stay motivated if you feel like giving up
- Find situations where you can practise DBT skills
- Feel supported and less alone, as others in the group are going through the same process
But you may be able to find DBT self-help materials available online. This might include diary cards, exercises and behavioural analysis sheets. You could use these to brush up your DBT training alongside or after finishing a formal course. The DBT Self Help website offers these resources.
At first it was really tough, and I wondered what the point of it was going to be. Some of the DBT skills seemed silly to me, but I had committed myself to the process and as time passed, it started to make more sense.
Best practice and clinical guidance
- Behavioural Tech. What is DBT? [online] Available at: http://behavioraltech.org/resources/whatisdbt.cfm [Accessed 9 November 2020]
- DBT Self-Help. Diary Card Explanations. [online] Available at: https://www.dbtselfhelp.com/html/diary_card_definition.html [Accessed 9 November 2020]
- NHS (2019) Borderline Personality Disorder. [online] Available at: https://www.nhs.uk/conditions/borderline-personality-disorder/treatment/ [Accessed 9 November 2020]
- NICE (2009). Borderline personality disorder: recognition and management. [online] Available at: https://www.nice.org.uk/guidance/cg78/resources/borderline-personality-disorder-recognition-and-management-pdf-975635141317 [Accessed 9 November 2020]
Sources of specific claims
- Access to service: Dialectical Behaviour Therapy Services. [online] Available at: https://slam.nhs.uk/service-detail/service/camhs-dialectical-behaviour-therapy-service-138/ [link updated 4 July 2023]
- Children and adolescents: NHS Tees, Esk and Wear Valley (2017) A Young Person’s Guide to Dialectical Behaviour Therapy - Westwood Centre [online]. Available at: https://www.tewv.nhs.uk/services/a-young-persons-guide-to-dialectical-behaviour-therapy-westwood-centre/ [Accessed 9 November 2020]
- Children and adolescents: CAMHS Dialectical Behaviour Therapy Service [online]. Available at: https://www.slam.nhs.uk/our-services/service-finder-details?CODE=SU0437 [Accessed 9 November 2020]
- Eating disorders: NHS Leicester Adult Eating Disorder Service. About Us [online]. Available at http://www.leicestereatingdisorders.co.uk/about-us/ [Accessed 9 November 2020]
- What happens during a DBT session: Essex behavioural therapy. Dialectical Behaviour Therapy (DBT) Skills for Borderline Personality Disorder (BPD) - individual therapy. [online] Available at: http://essex-behavioural-therapy.co.uk/article.asp?topic=dialectical-behaviour-therapy-dbt-skills&id=39 [Accessed 9 November]
- What happens during a DBT session: Chapman, A. L. (2006) ‘Dialectical behavior therapy: current indications and unique elements,’ In Psychiatry (Edgmont), 3(9), pp. 62 - 68
- Telephone coaching: Behavioural Tech. (2019) Phone Coaching in DBT - part 1 [online] Available at: https://behavioraltech.org/phone-coaching-in-dbt-part-1/ [Accessed 9 November 2020]
- Telephone coaching: Behavioural Tech. (2019) Phone Coaching in DBT - part 2 [online] Available at: https://behavioraltech.org/phone-coaching-in-dbt-part-2/ [Accessed 9 November 2020]
- Little, H., Tickle, A. C. & das Nair, R. (2017) ‘Process and impact of dialectical behaviour therapy: A systematic review of perceptions of clients with a diagnosis of borderline personality disorder,’ In Psychology and Psychotherapy, 91 (3), pp. 278-301
- Panos, P. T., Jackson, J. W., Hasan, O., & Panos, A. (2014) ‘Meta-analysis and systematic review assessing the efficacy of dialectical behavior therapy (DBT),’ In Research on Social Work Practice, 24(2), pp. 213-223
- Rudge, S., Feigenbaum, J., &, Fonagy, P. (2014) Mechanisms of Change in Dialectical Behaviour Therapy and Cognitive Behaviour Therapy for Borderline Personality Disorder: A Critical Review of the Literature. [online] Available at: https://discovery.ucl.ac.uk/id/eprint/1543100/7/Fonagy_Mechanisms%20of%20change%20in%20dialectical%20behaviour%20therapy_combined.pdf [Accessed 9 November 2020]
- Bay Area DBT & Couples Counselling Centre. (2016) What happens in a group DBT session? [online] Available at: https://bayareadbtcc.com/happens-dbt-group/ [Accessed 9 November 2020]
- Chen, E. Y., Matthews, L., Allen, C., Kuo, J. R., & Linehan, M. M. (2008) ‘Dialectical behavior therapy for clients with binge‐eating disorder or bulimia nervosa and borderline personality disorder,’ In International Journal of Eating Disorders, 41(6) pp. 505-512
- Dimeff, L., & Linehan, M. M. (2001) Dialectical behavior therapy in a nutshell. The California Psychologist, 34(3), 10-13
- Linehan, M. (1993) Cognitive-behavioral treatment of borderline personality disorder. Guilford press.
- Linehan, M. M., Dimeff, L. A., Reynolds, S. K., Comtois, K. A., Welch, S. S., Heagerty, P., & Kivlahan, D. R. (2002) ‘Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder,’ In Drug and alcohol dependence, 67(1) pp. 13-26
- Lynch, T. R., Chapman, A. L., Rosenthal, M. Z., Kuo, J. R., & Linehan, M. M. (2006)‘Mechanisms of change in dialectical behavior therapy: Theoretical and empirical observations,’ In Journal of clinical psychology, 62(4), pp. 459-480
- McMain, S. F., Links, P. S., Gnam, W. H., Guimond, T., Cardish, R. J., Korman, L., & Streiner, D. L. (2009) ‘A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder,’ In American Journal of Psychiatry, 166(12), pp. 1365. -1374
- (2020). What a DBT session looks like. [online] Available at: https://www.youtube.com/watch?v=iQEurMdJtds [Accessed 9 November 2020]
- Palmer, R. L. (2002) ‘Dialectical behaviour therapy for borderline personality disorder,’ In Advances in psychiatric treatment, 8(1), pp. 10-16
- Palmer, R. L., Birchall, H., Damani, S., Gatward, N., McGrain, L., & Parker, L. (2003) ‘A dialectical behavior therapy program for people with an eating disorder and borderline personality disorder—description and outcome,’ In International Journal of Eating Disorders, 33(3) pp. 281-286
- Salsman, N., & Linehan, M. M. (2006) ‘Dialectical-behavioral therapy for borderline personality disorder,’ In Primary Psychiatry, 13(5), pp. 51
- Swales, M. A. (2010). ‘Implementing Dialectical Behaviour Therapy: organizational pre-treatment,’ In The Cognitive Behaviour Therapist, 3(04), pp.145 -157