Dialectical behavior therapy (DBT) is a type of psychotherapy (often called “talk therapy”) used to treat people with certain mental health conditions that involve problems in regulating emotions. It aims to help people develop skills they can use in their daily lives to effectively manage emotions, maintain or improve interpersonal relationships, tolerate distress, and avoid behaviors that are harmful or detrimental to their quality of life. The overall goal of DBT is to help people with significant emotional regulation problems change patterns of behavior, emotion, thought, and interpersonal interaction associated with problems in their daily lives.

Originally developed by psychologist Marsha Linehan in the 1970s and 1980s, DBT was initially designed to treat chronic suicidality in people with borderline personality disorder (BPD). However, it has since been adapted to treat various other mental health conditions, such as depression, eating disorders, self-harming behaviors, and substance use disorders. Of note, DBT is not a suicide prevention program. Rather, a core tenet of DBT is helping individuals learn and practice new skills to reduce ineffective, self-destructive behaviors and build a “life worth living.”

DBT is an evidence-based treatment program designed to help people with mental health conditions who have problems regulating emotions. It is most commonly used to treat people with borderline personality disorder, though it is also used as a treatment for several other conditions, including people with substance use disorders, major depressive disorder, bipolar disorder, attention deficit and hyperactivity disorder (ADHD), and eating disorders. In some cases, medication may be used in conjunction with DBT.

People who may benefit from DBT include those struggling with emotional regulation, self-destructive behaviors, and interpersonal difficulties, and those who have not found success with other therapeutic approaches.

In DBT, the term “dialectical” refers to finding a balance between two seemingly opposing concepts: acceptance and change. DBT patients learn to accept themselves and their emotions and thoughts as they are, without judgment, and work toward making positive changes to build a life worth living. DBT treatment involves teaching people skills to learn acceptance and to help them make changes. The term “behavior” is used because DBT aims to help people identify problematic behaviors and replace them with new, more effective ones.

DBT can be provided by a range of mental health professionals including psychologists, psychiatrists, licensed clinical social workers (LCSW), licensed marriage and family therapists (LMFT), and licensed professional counselors (LPC), among others. It is recommended that people seeking treatment find a licensed mental health professional who has completed a specialized DBT training or certificate program.

During DBT, people are taught skills in four areas:

• Mindfulness skills help people focus on and accept the present moment without judgment. Mindfulness in DBT involves three “what” skills (observing, describing, and participating in the present moment) and three “how” skills (nonjudgmental state of mind, paying attention to one thing at a time, and doing what is needed in the present moment).
• Distress tolerance skills help people better tolerate and accept distress and pain. In DBT, people are taught that distress and pain cannot be entirely avoided in life, but by using certain strategies, they can be tolerated.
• Interpersonal effectiveness skills include strategies people can use to assert themselves in social situations, including saying no, asking for what they want, and dealing with conflict in relationships. Additionally, these skills also emphasize building new and maintaining existing relationships, as well as maintaining self-respect in them.
• Emotion regulation skills help people better understand and control their emotions. In DBT, people learn several strategies to improve their emotion regulation, including identifying and labeling their current emotions, identifying obstacles that prevent them from changing their emotions, and engaging in positive events and experiences, among others.

DBT consists of four main components:

• Individual therapy typically involves weekly, 50- to 60-minute sessions during which people work one-on-one with a therapist to practice applying the skills outlined above. The therapist may give homework assignments, tasking people to observe their emotions over the course of a week and practice DBT skills in their everyday lives. Homework often involves recording one’s daily emotions and actions on a “diary card,” which the therapist reviews during each session. Diary cards ask people to document their daily urges and actions to harm themselves, engage in suicidal behavior, or use drugs, and to rate their emotions every day. Additionally, the diary card is used to tailor DBT treatment to each person’s needs by asking individuals to track specific behaviors getting in the way of their individualized “life worth living” goals.
• Group skills training sessions meet weekly for 1.5 to 2.5 hours. The sessions are organized like a class in which a leader and co-leader guide the group through exercises, lessons, and activities. A training session may begin with a mindfulness exercise and then move on to reviewing and discussing homework from the previous session, lessons on DBT skills, assigning new homework, and a concluding exercise.
• Phone coaching aims to help people practice DBT skills in their daily lives. The therapist is available to patients by phone (or other forms of communication) between sessions to help them apply skills to life events and activities as they happen.
• DBT consultation team meetings in which therapists meet with one another to discuss cases, share insights, and ensure that their treatment adheres to DBT principles.

The time it takes for someone to complete a DBT treatment program varies, depending on individual treatment goals and response to the therapy. In general, outpatient DBT requires at least six months of treatment, but it often takes a year or longer to complete.

The four DBT skills (mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation) are taught in separate group skills training modules. The standard DBT training schedule begins with two weeks of mindfulness training followed by five- to seven-week training modules in distress tolerance, interpersonal effectiveness, and emotion regulation. A two-week module of mindfulness training is interspersed between each five- to seven-week module.

In all, it takes around six months to complete the skills training modules following the standard DBT schedule. The modules are often repeated, however, meaning that many people spend a year or longer in a DBT program.

DBT programs may not follow the standard schedule. For instance, inpatient and partial hospitalization day programs may offer shortened skills training schedules.

Research has shown significant improvements in patients who undergo DBT, including reduced self-harm behaviors, decreased suicidal ideation and behavior, lower hospitalization rates, and improved social functioning.

The outlook and prognosis can vary depending on the individual and the severity of their condition. Patients who fully participate in all components of DBT and apply the skills learned in their daily lives often see the most benefit.

It's important to note that progress in DBT can take time and commitment. Some people may begin to see improvement in their symptoms and coping skills within a few months, while for others, significant progress may take a year or more. The key is consistent participation and application of the DBT skills.

However, as with any therapy, individual results may vary, and it's crucial to have these discussions with a mental health professional who can provide guidance based on personal circumstances and needs.

“Yale New Haven Hospital offers specialized DBT treatment for adults and adolescents at intensive outpatient [IOP] and outpatient levels of care,” says Sarah Barnes, PhD, an assistant professor of Psychiatry at Yale School of Medicine and a member of the medical staff at Yale New Haven Hospital. “At the Adult DBT Intensive Outpatient Program, comprehensive DBT is modified for a group format, with patients receiving DBT skills training, reviewing their diary cards, and reviewing DBT skills homework in an IOP setting that meets for 3 hours, 3 times per week, for an 8-week length of stay. Patients also have access to phone coaching outside of IOP hours to help generalize their use of skills to their home context. After graduating from DBT IOP, many patients are eligible to participate in a once-weekly Outpatient DBT Skills Training group to help further solidify their use of DBT skills. Patients complete the Outpatient DBT Skills group for 6 months to 12 months, and then may be eligible for DBT Graduate Group, which is a patient-led group that emphasizes the application of DBT skills and maintaining a life worth living, a central goal for patients completing DBT.”

For adolescents and their families, there is a DBT-informed IOP track at the Adolescent IOP, which also includes DBT skills training and homework review for youth, as well as a group where caregivers and their teens participate together to support adaptive caregiver/teen relationships. As with the DBT services for adults, there is also an outpatient Multifamily DBT Skills training group offered to teens and their caregivers to reinforce the use of DBT skills at home. This group is often a step-down for youth and caregivers completing the Adolescent DBT IOP track, though patients may be admitted to this group directly, depending on needs.

To that end, at both Adult and Adolescent Services, Yale offers high quality DBT treatment across levels of care, allowing patients and their families to be matched to treatments that best fit their needs. Additionally, offering DBT services across levels of care also supports patients in maintaining their treatment gains and meeting individualized goals.