Developed in the late 1980s by psychologist Dr. Marsha Linehan, Dialectical Behavior Therapy (DBT) is a comprehensive, evidence-based form of psychotherapy designed to help individuals manage intense, painful emotions and navigate challenging interpersonal relationships. Initially created to treat chronically suicidal individuals diagnosed with borderline personality disorder (BPD), its principles and skills have since been successfully adapted to address a wide range of mental health conditions, including depression, anxiety, eating disorders, and substance use disorders. At its core, DBT empowers individuals by teaching them four concrete skill sets that foster a life experienced as worth living.
The Core Philosophy: A Balance of Acceptance and Change
The term “dialectical” refers to the synthesis of two opposites. In DBT, the central dialectic is between acceptance and change. This means the therapy simultaneously validates an individual’s current emotional state and experiences while also coaching them on how to change their harmful behaviors and build a more effective life.
Many individuals who struggle with overwhelming emotions feel invalidated and misunderstood. DBT starts by acknowledging that their pain is real and their reactions are understandable given their life experiences. From this foundation of acceptance, the therapy then introduces strategies for change, asserting that while their suffering is valid, they must learn new skills to create a different, better future.
Core Skill 1: Mindfulness
Mindfulness is the foundational skill in DBT, woven through all other modules. It is the practice of being fully aware and present in the current moment without judgment. DBT mindfulness helps individuals separate themselves from their thoughts and emotions, allowing them to observe their internal experiences without being controlled by them.
The “What” Skills: Observing, Describing, and Participating
The “What” skills dictate what you do when practicing mindfulness. The first is to Observe, which involves simply noticing your internal and external environment. This could mean paying attention to the sensation of your breath, the sounds in the room, or the thoughts passing through your mind, all without pushing them away or clinging to them.
The second skill is to Describe, putting words to what you observe. You might say to yourself, “I am noticing the thought that I am a failure,” or “I feel a tightness in my chest.” Describing is non-judgmental; it is a factual report of your experience.
Finally, Participate means throwing yourself completely into the current moment’s activity. Whether you are washing dishes, talking to a friend, or walking outside, you engage with your full attention, becoming one with the experience.
The “How” Skills: Non-Judgmentally, One-Mindfully, and Effectively
The “How” skills guide how you practice the “What” skills. The first is to be Non-Judgmental. This involves seeing things as they are, without labeling them as “good” or “bad.” You let go of evaluations and simply witness your experience.
One-Mindfully means focusing on one thing at a time. In a world of multitasking, this skill encourages you to bring your full attention to the present task or moment, letting go of distractions from the past or worries about the future.
Lastly, Effectively means doing what works to achieve your goals. It involves focusing on the practical reality of a situation and acting in a way that moves you closer to your desired outcome, rather than being driven by emotional reactions like anger or pride.
Core Skill 2: Distress Tolerance
While emotion regulation focuses on changing emotions, distress tolerance is about surviving crisis situations without making them worse. These skills are for moments of intense emotional or physical pain when you cannot immediately solve the problem. The goal is to get through the moment without resorting to impulsive or destructive behaviors.
Crisis Survival Skills: TIPP, ACCEPTS, and More
The TIPP skills are designed to rapidly change your body chemistry to reduce extreme emotional arousal. T stands for Temperature, specifically using cold water on your face to trigger the “dive reflex,” which quickly lowers your heart rate. I is for Intense Exercise, like running or jumping jacks, for at least 20 minutes to burn off angry energy. P is for Paced Breathing, slowing your breath down significantly. The final P is for Paired Muscle Relaxation, tensing and then relaxing different muscle groups to release physical tension.
The ACCEPTS acronym provides seven ways to distract yourself from painful emotions. These include engaging in different Activities, Contributing to others, making Comparisons to feel better, using opposite Emotions, Pushing away the situation temporarily, focusing on other Thoughts, and using intense physical Sensations (like holding ice) to ground yourself.
Radical Acceptance
A cornerstone of distress tolerance is Radical Acceptance. This is the skill of accepting reality exactly as it is, without judgment or resistance. It does not mean you approve of the reality, but you stop fighting it. Fighting reality only creates more suffering. By radically accepting what has happened, you free yourself to figure out how to move forward effectively.
Core Skill 3: Emotion Regulation
This module helps individuals better understand and manage their emotions. The goal is not to eliminate emotions but to reduce emotional vulnerability and learn how to modulate intense feelings so they are less overwhelming and destructive. This involves identifying and labeling emotions, understanding what they do for you, and learning how to change unwanted emotional responses.
Understanding and Changing Unwanted Emotions
A key skill is Checking the Facts. Often, our emotional reactions are based on interpretations rather than objective facts. This skill involves examining the evidence for and against our thoughts and beliefs to see if our emotional response fits the actual situation.
Opposite Action is a powerful skill for changing an emotion that is unjustified or unhelpful. If you feel unjustified fear, you approach what you are afraid of. If you feel intense but unhelpful anger, you gently avoid the person and do something kind instead. Acting opposite to the emotional urge rewires the brain’s response over time.
Finally, Problem Solving is used when an emotion is justified and signals that a situation needs to be changed. It involves clearly defining the problem, brainstorming solutions, and creating an action plan to address the root cause of the emotional distress.
Core Skill 4: Interpersonal Effectiveness
This set of skills teaches individuals how to navigate relationships, assert their needs, and manage conflict in a way that maintains self-respect and strengthens connections. It helps people ask for what they want and say no to what they don’t want, all while treating themselves and others with respect.
Asking for What You Want: The DEAR MAN Skill
The DEAR MAN acronym is a script for making a request or saying no effectively. Describe the situation factually. Express your feelings and opinions. Assert your needs clearly. Reinforce the person by explaining the positive outcomes of getting what you want. Stay Mindful and on topic, Appear confident, and be willing to Negotiate.
Maintaining the Relationship: The GIVE Skill
While DEAR MAN focuses on the objective, the GIVE skills focus on preserving the relationship during an interaction. Be Gentle in your approach, act Interested in the other person’s perspective, Validate their feelings, and use an Easy manner with humor or a soft tone.
Maintaining Self-Respect: The FAST Skill
The FAST skills help you maintain your self-respect, regardless of the outcome of the interaction. Be Fair to yourself and others. Make no unnecessary Apologies. Stick to your values. And be Truthful, avoiding lies or exaggeration.
What Does DBT Treatment Involve?
Comprehensive DBT is not just one type of therapy; it is a multi-faceted program. It typically includes weekly individual therapy sessions where the therapist helps the client apply the skills to their specific life challenges. It also involves a weekly group skills training session, which functions like a class where clients learn the four core modules.
A unique feature of DBT is phone coaching, which allows clients to call their therapist for in-the-moment coaching on how to use skills during a crisis. Finally, the therapists themselves participate in a consultation team to support each other and ensure they are providing the best possible treatment. This structure provides a robust support system for both the client and the provider.
In conclusion, Dialectical Behavior Therapy offers a powerful and practical framework for anyone struggling with emotional dysregulation. By teaching concrete skills grounded in the balance of acceptance and change, DBT provides a clear path toward building a life that is not only manageable but also meaningful and fulfilling. It empowers individuals with the tools to tolerate distress, regulate their emotions, and build healthier, more effective relationships, ultimately fostering profound and lasting personal growth.
