Dialectical Behavior Therapy (DBT) was developed by Marsha Linehan at the University of Washington in the late 1980s, after her early attempts to use standard CBT with chronically suicidal patients kept failing. Patients experienced the constant push to "change" as invalidating and dropped out. Linehan's response was to build a treatment around an explicit tension: full acceptance of the person as they are, and a clear push toward change.1
That tension is what "dialectical" refers to. The therapist holds both poles at once, and so, eventually, does the patient.
DBT was designed for borderline personality disorder (BPD), and the strongest evidence is still there. A 2006 randomized trial published in Archives of General Psychiatry compared one year of DBT with treatment by community experts in 101 women with BPD and recent suicidal behavior; DBT roughly halved suicide attempts and reduced hospital admissions and dropout.2 A 2019 meta-analysis of 18 trials confirmed a moderate effect on suicidal and self-harm behavior across populations.3 Adapted versions are now used for eating disorders, substance use, and adolescents with severe emotion dysregulation.
The four skill modules
DBT skills are organized into four modules. Most of the "DBT" content people encounter online (apps, journals, worksheets) comes from these.
Mindfulness comes first, drawn loosely from contemplative traditions but stripped to a behavioral skill: noticing thoughts, sensations, and emotions without reacting or judging. The other three modules lean on it because you can't regulate an emotion you haven't noticed. Distress tolerance is the crisis kit (cold water on the face, paced breathing, deliberate distraction) for moments when the emotional load is too high to problem-solve. Emotion regulation works on the longer timescale: reducing vulnerability through sleep, eating, exercise, and building positive experiences, and using "opposite action" when an emotion isn't fitting the situation. Interpersonal effectiveness teaches the conversational scripts — DEAR MAN, GIVE, FAST — for asking for what you need, saying no, and keeping relationships and self-respect intact while doing it.
What "comprehensive" DBT looks like
Standard DBT is more than weekly sessions. The full programme has four components, and the trial evidence is for that combination, not for any single piece on its own:
- Weekly individual therapy, focused on the patient's specific behavioral targets in a fixed hierarchy. Life-threatening behavior comes first, then therapy-interfering, then quality-of-life.
- Group skills training in class format, typically 2–2.5 hours per week, working through the four modules over roughly six months and then repeating.
- Phone coaching: brief, between-session calls so patients can apply skills in the moment, before a crisis escalates.
- A weekly consultation team for the clinicians themselves. DBT treats clinician burnout and drift as a clinical risk in its own right.
Apps and self-help materials based on DBT skills can be a useful adjunct, particularly for tracking emotions and rehearsing skills between sessions. They are not a substitute for comprehensive DBT in someone with active suicidality or BPD.
References
- Linehan, M. M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. Guilford Press.
- Linehan, M. M., Comtois, K. A., Murray, A. M., et al. (2006). Two-Year Randomized Controlled Trial and Follow-up of Dialectical Behavior Therapy vs Therapy by Experts for Suicidal Behaviors and Borderline Personality Disorder. Archives of General Psychiatry, 63(7), 757–766. doi:10.1001/archpsyc.63.7.757
- DeCou, C. R., Comtois, K. A., & Landes, S. J. (2019). Dialectical Behavior Therapy Is Effective for the Treatment of Suicidal Behavior: A Meta-Analysis. Behavior Therapy, 50(1), 60–72. doi:10.1016/j.beth.2018.03.009
- Behavioral Tech (Linehan Institute). DBT training and resources. behavioraltech.org