Introduction:
DBT, or dialectical behaviour therapy, is a type of talking therapy commonly used within psychotherapy, based upon cognitive behavioural therapy (CBT; Rizvi et al., 2024). DBT is evidence-based, being originally developed by the psychotherapist Dr. Marsha Linehan (Chapman, 2006), in the context of her previous efforts to develop a psychotherapeutic treatment forsuicidal female clients presenting with multiple problems.
Dr. Linehan conducted a literature review, investigating other psychotherapeutic and psychosocial interventions for conditions such as anxiety disorders and depression; these findings were assembled into a package of evidence-based interventions rooted in CBT, which she termed dialectical behaviour therapy (ibid. 2006).
Linehan termed DBT as dialectic in that it is founded upon the concept of life being composed of opposing, or dialectical, forces, which must be acknowledged simultaneously to bring about effective psychological change (Hofmann and Gomez, 2017); in other words, the interaction of conflicting ideas (May et al., 2016). Initially, DBT was developed to treat borderline personality disorder (BPD) but it is also utilised in the treatment of other psychological conditions, such as mood disorders, substance use disorders and post-traumatic stress disorder (PTSD).
The purpose of DBT is to support individuals to develop psychological skills to manage difficult-to-handle emotions, in addition to managing their stress more effectively and improve their interpersonal communication skills (Yale Medicine, 2025).
The overarching goal of DBT, as such, is to facilitate individuals to build a life that they feel is worth living (Minnesota Center for Psychology, 2020) by enhancing client motivation and supporting individual clients to apply these psychological skills learnt to specific challenges and events which arise in their lives.
What is BPD?
The DSM-5 (American Psychological Association, 2013) defines borderline personality disorder (BPD) as a chronic disorder encompassing symptoms such as frantic efforts to avoid real (or imagined) abandonment, identity disturbances, unstable relationships, recurrent suicidal threats/ideation or self-mutilating behaviours, affective instability, difficulties controlling anger and/or stress-related paranoid/dissociative thoughts.
BPD is characterised by pervasive patterns of instability in mood, self-image and interpersonal relationships, in addition to marked impulsivity, fear of abandonment and chronic feelings of emptiness (Chapman et al., 2024). Individuals with BPD can often present with distorted perceptions of themselves and others around them, leading to difficulties in maintaining stable, healthy relationships.
BPD impacts individual interpersonal and occupational functioning, in addition to individuals with BPD statistically utilising healthcare at a higher rate (ibid. 2024) compared to that of other mental health conditions such as depression (Bender et al., 2001)
Core Components of DBT:
The core components of dialectical behavioural therapyare mindfulness, interpersonal effectiveness (or interpersonal communication skills), emotional regulation and distress tolerance(May et al., 2016).
Mindfulness, in the context of DBT, refers to a psychological process (Bishop, 2004) which leads to a mental state characterised by nonjudgemental awareness of present-moment experience, including one’s bodily sensations, consciousness, thoughts and awareness of their surrounding environment while encouraging awareness, curiosity and acceptance(Hofmann and Gomez, 2017; Kabat-Zinn, 2003).
In DBT, many mindfulness techniques have been derived from established traditional meditative practices, being subdivided by Linehan (1993) into “what” and “how” skills; “what” skills facilitate individual clients to observe, describe and participate fully in the present moment, whereas “how” skills teach patients to be present within the moment adopting a nonjudgemental mindset, focusing on one thing at a time and in an effective manner.
Teaching these skills, in the context of BPD, targets specific issues such as a tendency to idealise, or devalue, themselves and/or other individuals, in addition to tendencies for individuals to ruminate about the past or worry about the future instead of living in the present moment (ibid. 1993)
Interpersonal effectiveness, within DBT, focuses on teaching social skills which are effective within relationships (May et al., 2016); this is particularly pertinent in BPD as many individuals with BPD can often present with a history of childhood abuse, neglect or other factors contributing to invalidation, which lead to difficulty in forming secure interpersonal attachments earlier on in life (ibid. 2016).
This leads to individuals with BPD often ending relationships prematurely, due to difficulties in tolerating and/or managing interpersonal conflict. In short, interpersonal training within DBT facilitates individual clients to ask for what they need, say “no” to inappropriate demands and manage interpersonal conflicts better. Linehan (1993) notes that this allows individuals with BPD to maintain meaningful relationships while being able to set personal boundaries within their relationships.
DBT teaches specific emotion regulation skills, in the context of enhancing individual control over emotions (May et al., 2016); intense, labile emotions can often lead to the development of dysfunctional behavioural patterns which aim to avoid negative emotions.
Emotion regulation skill training in the context of DBT focuses thus on identifying and labelling emotions, in order that individuals can understand how emotions can lead to behaviours which hinder overall functioning, in addition to identifying obstacles to changing, or modifying these emotions (e.g. parasuicidal behaviours and other dysfunctional behaviour) which the individual utilises for communication and/or psychological validation of their experience.
Emotion regulation training in addition supports individuals to avoid situations of vulnerability which lead to negative emotions, and increase positive experiences and events in their lives; within emotion regulation, individuals are encouraged to utilise mindfulness to accept and tolerate painful emotions in a nonjudgemental manner (Linehan, 1993).
The final component of DBT, distress tolerance, aims to teach patients that distress and pain are inevitable components of life, and unwillingness to accept this fact often leads to greater suffering; the aim of distress tolerance training, thus, is to teach individuals how to experience their situation nonjudgmentally in lieu of attempting to change it; acceptance must not be confused, however, with approval.
Distress tolerance training includes, in addition, the teaching of crisis survival skills alongside acceptance strategies; crisis survival skills encompass techniques for individuals to distract, self-soothe and adjust their thoughts into the present moment, whereas acceptance skills work on transforming intolerable suffering into tolerable pain.
DBT for BPD:
DBT, as developed by Dr. Marsha Linehan, was intended to address specific challenges that individuals with borderline personality disorder (BPD) who presented to her practice arrived with; in particular, parasuicidal behaviours (May et al., 2016). Linehan defined these behaviours as encompassing any acute, intentional self-injurious behaviours with or without suicidal intent, including both self-mutilative behaviours and (de facto)suicidal attempts.
In the context of BPD, thus, DBT aims to replace maladaptive behaviours with more healthier coping skills, in particular the four underpinning psychological skills or competencies of DBT: mindfulness, interpersonal effectiveness, emotion regulation and distress tolerance. It is important to note that DBT is the only empirically supported treatment for BPD as discussed in the Cochrane (2012) collaborative review.
There have been a number of studies, including randomised controlled trials (RCTs) researching the efficacy of DBT in BPD (May et al., 2016); the Linehan Institute has compiled a summary of studies researching DBT (Linehan et al., 2014). This compilation concluded that DBT was more effective than community-based treatment in several aspects, including reduction in parasuicidal behaviour, increased treatment adherence and reduced number of hospitalisations.
As discussed, DBT targets specific challenges associated with BPD; these include emotional dysregulation (which is addressed in emotion regulation training), fear of abandonment (addressed specifically in interpersonal effectiveness) and impulsive behaviours; DBT has been found particularly effective in reducing self-harm (McCauley et al., 2018) and suicidal ideation (Kothgassner et al., 2021).
Conclusion:
DBT is not only utilised in the treatment of BPD, although initially developed for the treatment of a specific maladaptive behaviour (parasuicidal behaviour) in BPD, but has also been utilised in individuals presenting with primary conditions ranging from attention deficit hyperactivity disorder (ADHD; Ulusoy et al., 2025) and bipolar disorder (van Dijk et al., 2013) to trichotillomania (recurrent hair-pulling; Linehan et al., 2014).
As a psychotherapist, I provide DBT therapy as part of my integrative approach; if you would like to look into DBT therapy, feel free to book an initial consultation, where I can discuss your needs, therapy goals and work towards a plan for the future.
References:
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