Dialectical Behavior Therapy (DBT)

Presentation

Dialectical Behavior Therapy (DBT) is a third-wave psychotherapeutic approach developed in the 1980s by Marsha M. Linehan, psychology professor at the University of Washington. Initially designed to treat patients with borderline personality disorder (BPD) and chronic suicidal behaviors, DBT is now applied to a wide range of disorders characterized by intense emotional dysregulation.

The term 'dialectical' refers to the synthesis between two seemingly contradictory polarities: unconditional acceptance of the patient as they are AND the necessity for change. This dialectical tension is at the heart of the approach and pervades all treatment levels.

Founder: Marsha M. Linehan (born 1943), psychology professor, University of Washington

Core Principles

DBT is based on the biosocial theory positing that BPD results from the interaction between biological vulnerability to emotional dysregulation and an invalidating childhood environment. Standard treatment comprises four complementary modalities:

1. Weekly individual therapy: hierarchical targeting (life-threatening behaviors, therapy-interfering behaviors, quality of life) and behavioral chain analysis.

2. Skills training group: weekly 2.5-hour sessions teaching four modules — mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness.

3. Phone coaching: brief between-session calls to help generalize skills during crises.

4. Consultation team: weekly therapist meetings to maintain motivation and competence.

Main Indications

• Borderline personality disorder
• Chronic suicidal behaviors and self-harm
• Severe emotional dysregulation
• Eating disorders (bulimia, binge eating)
• Substance addictions and abuse
• Complex PTSD
• Treatment-resistant depression
• Bipolar disorder (emotion regulation component)

Session Overview

Standard DBT treatment lasts a minimum of one year. The individual session (50-60 minutes) follows a hierarchical agenda: first life-threatening behaviors (suicidal ideation, self-harm), then therapy-interfering behaviors (absences, non-compliance), then quality-of-life-impairing behaviors.

The primary tool is chain analysis: therapist and patient deconstruct a problematic episode by identifying the triggering event, pre-existing vulnerabilities, the thought-emotion-behavior chain and consequences. Alternative solutions are then identified and practiced. The skills group follows a structured psychoeducational format with practical exercises and homework review.

Variations and Sub-techniques

• Standard DBT (full one-year program)
• DBT-A (adapted for adolescents, includes family)
• DBT for eating disorders
• DBT for substance use disorders (DBT-SUD)
• Abbreviated DBT (6-month protocols)
• Inpatient and residential DBT

Contraindications

• Untreated acute psychotic episode
• Severe intellectual disability preventing skills learning
• Antisocial personality disorder (limited treatment engagement)
• Housing instability preventing program adherence
• Refusal to engage in therapeutic contract (non-suicide agreement)