DBT: Dialectical Behavioral Therapy


Linnea Butler, LMFT Lisa Prosser-Dodds, PhD Bay Area Mental Health

I walk down the street.
There is a deep hole in the sidewalk.
I fall in.
I am lost... I am helpless.
It isn't my fault.
It takes forever to find a way out.

I walk down the same street.
There is a deep hole in the sidewalk.
I pretend I don't see it.
I fall in again.
I can't believe I am in the same place.
But, it isn't my fault.
It still takes me a long time to get out.

I walk down the same street.
There is a deep hole in the sidewalk.
I see it is there.
I still fall in. It's a habit.
My eyes are open. I know where I am.
It is my fault. I get out immediately.

walk down the same street.
There is a deep hole in the sidewalk.
I walk around it.

I walk down another street.
~ Portia Nelson

It's time for a new street!

What is DBT?
Have you ever been in a situation where everything feels hopeless? Where your emotions feel like they’re in full control and driving your actions? Maybe you don’t really feel in control whenever a life crisis occurs and maybe it feels like the emotions are driving the bus and making the big decisions. 

Naturally, this can cause a lot of mayhem in anyone’s life, intensifying any struggle and simply making any situation feel hopeless. But there is hope. Hope that you can rip your emotions out of the driver’s seat of the bus and assume control once more. Learning a set of life skills through DBT can assist anyone in taking back control.

Dialectical Behavior Therapy (DBT) is an evidence-based therapy (which means it has been tested with real people). It was developed alongside other methods, such as Cognitive Behavioral Therapy (CBT), Rational Emotive Therapy (RET), and Acceptance and Commitment Therapy (ACT), as well as many others dealing with feelings, thoughts and behaviors. DBT was developed by Marsha Linehan in the late 1980s and fully introduced in1999. DBT was originally developed to treat Borderline Personality Disorder, but through ongoing testing, it is successful to treat a multitude of other life struggles people often go through such as Depression, Anxiety, Bipolar Personality Disorder and Trauma. Basically anything where people experience strong emotions that are out of control or “driving the bus”.

When might DBT be a good fit for you?

DBT has a flexible treatment range and is ideal for treating a variety of difficulties and has been effective for many different people facing multiple problems. For example, DBT can be ideal for someone who often feels overwhelmed or even trapped by their emotions, or someone who often lets their anger get the best of them.

DBT is helpful for people who are not getting the results they want in life or relationships because of their emotional expressions. These and more are potentially treatable under a DBT program.
DBT teaches skills that can be helpful throughout life. If you need help learning how to manage and regulate your emotions, or if you’re going through a tough time and need some extra help, DBT might be a good choice for you.

Some of the diagnoses that DBT has been proven in treating include the following:

  • Anxiety Depression
  • Borderline Personality Disorder
  • Post Traumatic Stress Disorder (PTSD)
  • Eating Disorders
  • Substance Abuse
  • Co-occurring Disorders
  • Compassion Fatigue

DBT Treats Emotional Dysregulation

Emotional dysregulation happens when someone does not react to events around them in what is deemed to be a socially acceptable manner. Friends and family might refer to you as “overreacting” or tell you that you’re “too sensitive”. Others might tell you that your anger is bigger than it needs to be, like when someone reacts to a broken glass by screaming at the person who dropped the glass for a prolonged time and then holding onto that anger for longer than what is considered healthy.

What is Emotion Dysregulation?

Emotional dysregulation is composed of these three core traits:
High Sensitivity: emotions seem to come out of nowhere
High Reactivity: they hit like a ton of bricks
Slow Return to Baseline: once you get triggered it takes a long time to come back down

DBT treats this pattern of emotional difficulties by teaching skills to help regulate emotions. These skills can help you better deal with your emotions during seemingly impossible situations. When you connect to the reasonable side of your brain through using the skills, your emotions begin to calm down. Emotion regulation involves taking your thoughts, feelings, and expressions and managing them in a way that flexible enough to get you the results you want.

So what exactly does emotional dysregulation feel like?

When it becomes difficult to control or manage your emotional response during stressful experiences, emotion dysregulation can be a common occurrence. Emotional dysregulation often happens when you are responding to challenging stimulus. It can be characterized as having an extreme emotional reaction to interpersonal and environmental challenges.

These reactions are often considered beyond the expected emotional responses. An example of this, would be reacting to a small inconvenience, like being cut off in traffic, by going into a fit of rage, crying, yelling, and/or making others in the car very uncomfortable.

These reactions can not only be sudden and intense but are also characterized by lasting a long time, longer than most people’s reactions. An emotionally dysregulated person becomes highly sensitive towards anything else that might happen and has a very hard time calming down.

One important factor we now know is that emotional dysregulation is largely influenced by biological factors outside of anyone’s control.

These factors influence increased impulsivity, choosing to engage in behaviors that provide short-term relief, yet have long-term consequences. These factors often make it hard for a person to control their reactions to emotions. DBT skills help manage these emotional reactions. Most people learn these skills through their childhood and adolescence.

Unfortunately, many people lived through an invalidating environment where these skills were not taught during childhood and some people simply do not learn these skills as they grow into adults.
Not knowing these skills can make those invalidating environments even more difficult to navigate. 

Invalidating environments happen as a result of any number of circumstances and it may not be intentional. Some reasons can include:

  • The adults may not be fully aware that their behavior is invalidating
  • The adults may believe validating someone’s emotions will lead to a stronger emotional response
  • They may be under a high degree of stress
  • The environment could simply be a poor fit for you
  • The environment is effected by some form of abuse or trauma

While some of the factors above can be easily resolved, it takes the proper skills to regulate our emotions. It’s possible the environment is influenced by the power of someone without these skills. This can lead to a pattern of conflict and escalated tensions.

But there’s good news! These skills can be learned at any age. It’s not too late to learn how to apply these skills to your day-to-day life. And that’s how DBT can help: by teaching you life skills to help you better adapt to many of the situations that create emotional reactions that are problematic.

What exactly are these skills?

So, at this point you may be wondering what exactly does DBT offer that will help you decide if DBT would be a good fit for you. Well, as we said in the previous section, DBT teaches a variety of skills that help with emotional regulation as well as other basic life skills. 

DBT is taught in 4 modules:

  • Mindfulness 
  • Distress Tolerance
  • Interpersonal Effectiveness
  • Emotion Regulation

Let’s break down the modules and explain how each one can help you regulate your emotions in day to day life.


Mindfulness is choosing to live fully in the moment by experiencing the world around you as it is happening rather than allowing your mind to wander off to other concerns, worries, or regrets.
This can be as simple as deciding to notice the wind rustling through trees while on a walk or feeling how warm the water feels on your back while in the shower. Mindfulness skills can be practiced at any moment, making them easily adaptable to daily life.

Research shows that mindfulness can decrease levels of stress and make life an increasingly joyful experience. It allows you to have better control over your mind rather than allowing your mind to run off on a tangent. This can end up making life much easier to enjoy. You can experience the vibrant world around you and all it has to offer. Mindfulness is used to access one’s inner wisdom, which each person has, to help guide you to become the person you want to be.

Distress Tolerance:

Distress Tolerance skills can help you in those tough moments when everything around you seems to be falling apart. When achieving a goal or completing a difficult task just seems impossible. Remember the example of being cut off in traffic earlier? Practicing distress tolerance can help prevent extreme reactions to situations as simple as getting stuck in traffic when you’re late, or having a knock-down-drag-out fight with a partner or family member. Distress Tolerance can help even when nothing seems to be going right. It helps you survive tough situations that are impossible to change. It also helps you to cope and survive a crisis situation while helping you tolerate heightened emotions.

Distress tolerance skills include the following:

  • Self-soothing using your senses
  • Distracting yourself from overwhelming emotional pain
  • Improving each moment through skills like visualization and meaning making
  • Assessing the pros and cons of a situation so you can make an informed decision

Interpersonal Effectiveness: 

Interpersonal Effectiveness skills will help you communicate your wants and needs to those around you in an effective and practical manner. Have you ever felt that you can’t ask for what you want, or say “NO” to someone? That your needs aren’t being met by your partner or maybe your friends and family? Perhaps you aren’t sure how to ask for what you want, so you just resort to keeping quiet until it just becomes too much and you explode. Interpersonal effectiveness can teach you how to communicate your needs to others in a way that it doesn’t boil over to a breaking point. This all comes together to help you build strong and healthy relationships. This skill helps you manage relationships while also balancing your priorities and demands so that you know what you expect out of every encounter, how you want the other person to feel about themselves, and how you want to feel about yourself afterwards.

Interpersonal Effectiveness also increases the likelihood of positive outcomes in these relationships.
Some key interpersonal effectiveness skills include the following:

  • Objective Effectiveness: figuring out and getting what you want
  • Relationship Effectiveness: strengthening the relationship
  • Self Respect Effectiveness: staying true to yourself

Emotion Regulation:

The main focus of emotion regulation is discovering the function of each emotional response and learning to notice what “action urges” (what you want to do) come with what you feel. You learn to connect to your inner wisdom to decide if engaging in those urges would be the most effective way to respond to what is going on.

Connecting to that wisdom allows you to figure out if your emotional reactions fit the circumstances. If your wisdom decides that reaction does not fit, you can adjust your responses to be more effective. Emotion regulation is also about building your resiliency and reducing your emotional vulnerability to painful, unwanted emotions so that they don’t happen as often, or feel as overwhelming.

Making sure that your baseline emotional needs are met is pivotal to emotion regulation. DBT teaches you how to apply these healthy habits in your everyday life.

Emotion Regulation skills include:

  • Observing and describing emotions
  • Acting the opposite of the “action urge”
  • Reducing vulnerability to emotions
  • Checking the facts of a situation
  • Problem solving to change emotions

What does the “D” stand for again?

The "D" in DBT stands for Dialectics. Dialectics are when two contradictory truths coexist in the world without one overtaking the other. Dialectics happen when simultaneous and opposing truths are existing in your world. They seem mutually exclusive, but both can contribute and be correct in their own separate ways. The practice of recognizing dialectics includes engaging in exercises that help to foster this idea that two opposing truths can coexist. Holding two conflicting truths in the same mental space is tough… but it leads to a place of balance and equanimity.

The main overarching dialectic that exists within DBT is between acceptance and change and balancing those two strategies instead of focusing on one or the other. You can Accept yourself as you are right now, AND you need to Change to live a fuller, happier life.

How a DBT Program Works:

A DBT program is a combination of group sessions and individual therapy. Group sessions meet once a week for 2 hours and are similar to being in a classroom where you learn and practice new skills. Individual sessions are weekly, one hour sessions with your primary therapist to explore the skills more deeply and learn to apply them to the toughest situations in your life.

The first cycle of treatment primarily teaches you what these skills are and how you can practice them. The second cycle of treatment then focuses on guiding you in the application of these skills to your day to day life. Going through two cycles is important! Just learning these skills cognitively in the first cycle might not necessarily prepare you in actively applying them to your life. The second cycle helps you integrate the skills and really apply them!

Group Therapy Cycle:

Full DBT treatment include both group and individual therapy. In each of these environments (group and individual work) DBT aims to teach you the important life skills we discussed above. It has the potential to help you reach a better understanding of yourself and those around you, and can potentially help you live a more mindful and happier life. Always remember it is never too late to live the life you want to live and become the person you want to become!