Dialectical Behaviour Therapy is an evidence-based treatment initially developed for the treatment of borderline personality disorder (BPD) by Professor Marsha M. Linehan. In more recent years, DBT has been recognised as a treatment for suicidal and self-harming behaviours, pervasive emotion dysregulation as well as BPD.
Its popularity began, and grew exponentially, in the USA prior to its recognition and favour in Europe, chiefly due to its success in effectively treating complex presentations and difficult-to-treat client populations. The latest research on DBT indicates:
- DBT is an effective treatment for people with BPD (Storebø et al., 2020)
- DBT is more effective than treatment as usual at reducing BPD symptomatology, inappropriate anger, self-harming behaviour, and improving general functioning (Storebø et al., 2020)
- Emotion regulation skills use is a fundamental facilitator of change for clients participating in DBT (Mehlum, 2021; McMain et al., 2018; Kramer et al., 2016)
- Standalone DBT skills training improves emotion dysregulation, anxiety symptoms, depression and binge eating disorder/ builima (Delaquis et al., 2022)
- Enhanced emotion regulation leads to improvements in mindfulness skills which results in reductions in BPD symptomatology (Hood et al., 2024)
- Dialectical Behaviour Therapy can be effective in other populations such as those with eating disorders, substance misuse, adolescents with self-harming behaviours, and forensic settings (Storebø et al., 2020)
- There are two major adaptations for clients with BPD and PTSD both of which have evidence for their efficacy (Harned et al, 2022; Bohus et al, 2020; Prillinger et al, 2024)
- DBT reduces suicide and self-harming behaviour and general PTSD in inpatient populations with a history of childhood sexual abuse (Bohus et al., 2012)
- Individuals with psychosis may benefit from a DBT-skills based intervention (Lawlor et al., 2022)
- DBT in forensic settings is successful at treating antisocial attitudes and personality traits, substance use, education and family issues (Tomlinson, 2018)
- DBT may be superior at treating substance use compared to alternative treatments (Haktanir & Callender, 2020)
- DBT, with some skills modification, was found to be acceptable by, and may be helpful for, adults with autism spectrum disorder without intellectual disability (Bemmouma et al., 2022; Ritschel et al., 2022; Huntjens et al, 2025)
- DBT is recommended by NICE for treatment of women with a diagnosis of BPD who are suicidal and self-harming (NICE, 2012) as well as adolescents who are suicidal self-harming (NICE, 2022)
- Findings suggest that sexual minority and racial/ethnic minority people may benefit from DBT as much as heterosexual and Non-Hispanic White people, respectively. (Harned et al., 2022)
- DBT trials in the US have been shown to be representative of the ethnic and racial demographics in the US. Sexually minoritised people were slightly overrepresented in those studies. (Harned et al. 2022)
Why DBT?
Research shows that DBT improves symptomatology of BPD and associated transdiagnostic behaviours such as non-suicidal self-injury (NSSI), suicide attempts, depression, dysfunctional eating, and feelings of hopelessness. The latest National Institute and Care Excellence (NICE) guideless propose DBT as the treatment of choice for women with BPD (NICE, 2012) and adolescents with significant emotion regulation difficulties and frequent episodes of self-harm (NICE, 2022).
Helping Clients in Dialectical Behaviour Therapy
Providing a DBT Programme to your clients teaches them the DBT Skills necessary to regulate emotions, control suicidal and self-harming behaviours and improve interpersonal relations and, most importantly, help them develop a life worth living. With an ever-expanding evidence base, the scope of DBT has been widened to include individuals with disorders associated with BPD such as eating disorders, substance misuse, and bipolar disorder. There is also some evidence for the effectiveness of DBT Skills for transdiagnostic symptoms such as depression. Additionally, DBT has been adapted to function in a variety of different settings and populations e.g. working with children and adolescents, people with intellectual disabilities or in prisons.
The Development of Dialectical Behaviour Therapy
Dialectical Behaviour Therapy (Linehan, 1993) was developed in the early 1990s by Marsha Linehan in the University of Washington, Seattle. At the time, the treatment was developed to treat adult women with a history of chronic suicide attempts, suicide ideation, and self-harming behaviours. The treatment first became associated with BPD due to women who met criteria for BPD often exhibiting these behaviours; at the time there was no evidence base treatment for people with these difficulties.
The treatment was developed as Linehan encountered challenges when trying to treat this population with standard Cognitive Behaviour Therapy:
- The unrelenting focus on change was invalidating for the clients and impacted engagement with treatment and increased drop out.
- Client behaviour or reactions to therapists pushing for change would negatively impact the therapist and they would ‘back off’ which inadvertently reinforced the clients’ behaviour. Similarly, therapists would be reinforced for allowing change of topics during challenging conversations by interpersonal warmth from the client.
- The time allocated during an individual CBT session was not sufficient to address the volume and severity of problems presented by clients and to dedicate time to teach and help apply more adaptive skills.
In response to these problems Linehan incorporated validation and dialectics and significantly reformulated the treatment to create the DBT we know today. The treatment relies on three underlying principles: behavioural science, Zen Buddhist philosophy and dialectics. Each of these principles are operationalised into specific strategies and the skills taught to clients. Hence, DBT comprises five functions with five corresponding modes:
a) enhancing and maintaining the client’s motivation to change is done through Individual Therapy (approx. 60mins weekly)
b) enhancing the client’s capabilities is achieved through attending Skills Group (approx. 120 mins weekly)
c) ensuring that the client’s new capabilities are generalized to all relevant environments is reaching via Phone Coaching (ad-hoc, average duration approx. 6 mins per week)
d) enhancing the therapist’s motivation to treat clients while also enhancing the therapist’s capabilities is attained through the Consultation Team (minimum 90 mins weekly)
e) structure the environment so that treatment can take place is completed via consultation to the environment
The treatment itself is structured by stages and targets which refer to the order in which problems are addressed during treatment. Specifically, during Stage 1, DBT first targets life threatening behaviours (which includes suicidal behaviours, NSSI, imminently life-threatening behaviours and homicidal behaviours), followed by behaviours which interfere with the natural progression of therapy and may lead to therapy termination (i.e. therapy interfering behaviours), followed by behaviours which impede the quality of life of the client. The ultimate goal of Stage I is the progression from behavioural dyscontrol to behavioural control. Stage II focuses on assisting the client to move from a state of quiet desperation to one of full emotional experiencing. Stage III centres on problems in living with the goal that the client has a life of typical levels of happiness and unhappiness.
In Linehan and colleagues first RCT in 1991, the data established DBT as an effective treatment for women with a diagnosis of BPD with self-harming and suicidal behaviours. Linehan and her team went on to carry out two more RCTs, the findings were as follows: 1) where those receiving DBT displayed lower scores on anger and higher scores on global functioning compared to TAU (Linehan et al., 1994) 2) DBT participants were less likely to attempt suicide, be hospitalised due to suicide ideation and had lower medical risk across all suicidal and non-suicidal self-injurious behaviours compared to those treated by community treatment experts (Linehan et al., 2006).
Since the initial RCT, the evidence base for DBT has continued to grow with now more than 40 RCTs of comprehensive DBT demonstrating DBT as an effective treatment for BPD across different countries and treatment settings (Storebo et al., 2020). In addition to numerous effectiveness studies establishing DBT for treatment of BPD and associated behaviors in routine practice
References
Bemmouna, D., Coutelle, R., Weibel, S., & Weiner, L. (2022). Feasibility, Acceptability and Preliminary Efficacy of Dialectical Behavior Therapy for Autistic Adults without Intellectual Disability: A Mixed Methods Study. Journal of autism and developmental disorders, 52(10), 4337–4354. https://doi.org/10.1007/s10803-021-05317-w
Bohus, M., Dyer, A. S., Priebe, K., Krüger, A., Kleindienst, N., Schmahl, C., … & Steil, R. (2013). Dialectical behaviour therapy for post-traumatic stress disorder after childhood sexual abuse in patients with and without borderline personality disorder: A randomised controlled trial. Psychotherapy and psychosomatics, 82(4), 221-233.
Bohus, M., Kleindienst, N., Hahn, C., Müller-Engelmann, M., Ludäscher, P., Steil, R., Fydrich, T., Kuehner, C., Resick, P. A., Stiglmayr, C., Schmahl, C., & Priebe, K. (2020).
Dialectical Behavior Therapy for Posttraumatic Stress Disorder (DBT-PTSD) Compared With Cognitive Processing Therapy (CPT) in Complex Presentations of PTSD in Women Survivors of Childhood Abuse: A Randomized Clinical Trial. JAMA psychiatry, 77(12), 1235–1245. https://doi.org/10.1001/jamapsychiatry.2020.2148
Delaquis, C. P., Joyce, K. M., Zalewski, M., Katz, L. Y., Sulymka, J., Agostinho, T., & Roos, L. E. (2022). Dialectical behaviour therapy skills training groups for common mental health disorders: A systematic review and meta-analysis. Journal of affective disorders.
Haktanır, A., & Callender, K. A. (2020). Meta-Analysis of Dialectical Behavior Therapy (DBT) for Treating Substance Use. Research on Education and Psychology, 4(Special Issue), 74-87.
Harned, M. S. (2022). Treating trauma in dialectical behavior therapy: The DBT prolonged exposure protocol (DBT PE). Guilford Publications.
Hood, P., Maraun, M., McMain, S. F., Kuo, J. R., & Chapman, A. L. (2024). The role of mindfulness and emotion regulation in dialectical behavioral therapy for borderline personality disorder. Personality Disorders: Theory, Research, and Treatment, 15(2), 134–145. https://doi.org/10.1037/per0000640
Kramer, U., Pascual-Leone, A., Berthoud, L., de Roten, Y., Marquet, P., Kolly, S., Despland, J. N., & Page, D. (2016). Assertive Anger Mediates Effects of Dialectical Behaviour-informed Skills Training for Borderline Personality Disorder: A Randomized Controlled Trial. Clinical psychology & psychotherapy, 23(3), 189–202. https://doi.org/10.1002/cpp.1956
Lawlor, C., Vitoratou, S., Duffy, J., Cooper, B., De Souza, T., Le Boutillier, C., Carter, B., Hepworth, C., & Jolley, S. (2022). Managing emotions in psychosis: Evaluation of a brief DBT-informed skills group for individuals with psychosis in routine community services. The British journal of clinical psychology, 61(3), 735–756. https://doi.org/10.1111/bjc.12359
Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of general psychiatry, 48(12), 1060–1064. https://doi.org/10.1001/archpsyc.1991.01810360024003
Linehan, M. M., Tutek, D. A., Heard, H. L., & Armstrong, H. E. (1994). Interpersonal outcome of cognitive behavioral treatment for chronically suicidal borderline patients. The American journal of psychiatry, 151(12), 1771–1776. https://doi.org/10.1176/ajp.151.12.1771
McMain, S. F., Fitzpatrick, S., Boritz, T., Barnhart, R., Links, P., & Streiner, D. L. (2018). Outcome trajectories and prognostic factors for suicide and self-harm behaviors in patients with borderline personality disorder following one year of outpatient psychotherapy. Journal of personality disorders, 32(4), 497-512.
Mehlum L. (2021). Mechanisms of change in dialectical behaviour therapy for people with borderline personality disorder. Current opinion in psychology, 37, 89–93. https://doi.org/10.1016/j.copsyc.2020.08.017
Prillinger, K., Goreis, A., Macura, S., Hajek Gross, C., Lozar, A., Fanninger, S., Mayer, A., Oppenauer, C., Plener, P. L., & Kothgassner, O. D. (2024). A systematic review and meta-analysis on the efficacy of dialectical behavior therapy variants for the treatment of post-traumatic stress disorder. European journal of psychotraumatology, 15(1), 2406662. https://doi.org/10.1080/20008066.2024.2406662
Ritschel, L. A., Guy, L., & Maddox, B. B. (2022). A pilot study of dialectical behaviour therapy skills training for autistic adults. Behavioural and cognitive psychotherapy, 50(2), 187–202. https://doi.org/10.1017/S1352465821000370
Tomlinson, M. F. (2018). A theoretical and empirical review of dialectical behavior therapy within forensic psychiatric and correctional settings worldwide. The International Journal of Forensic Mental Health, 17(1), 72–95. https://doi.org/10.1080/14999013.2017.1416003
DBT Articles
The following articles are written by Professor Michaela Swales (Director of the British Isles DBT Training Team) and should provide you with useful information on what to consider when setting up a DBT Programme to ensure it’s continuing success.
Dialectical Behavioural Therapy Informative Articles
Requirements for Intensive Training
Requirements for Foundation Training
Implementing DBT: Selecting, Training and Supervising a Team
Implementing DBT: Organizational Pre-Treatment
This useful document has been created by Dr. Christine Dunkley a Senior Trainer of the British Isles DBT Training Team.
What are the Components of a Comprehensive DBT Programme
Some useful articles when trying to demonstrate the cost-effectiveness of a DBT Programme are below.
Developing the financial case for DBT training
Financial-Cost-Effectiveness-DBT[CH1]
Starting a DBT Programme
DBT programmes provide multiple treatment modalities that address the key skills and motivational deficits presented by clients with a diagnosis of BPD. Thus, DBT Programmes provide skills training for clients, often in a group format; individual DBT psychotherapy, to help clients identify and solve problems in changing their behaviours; and treatment modalities to support generalisation of the new skills beyond the treatment environment, most commonly by telephone coaching. In addition, DBT Programmes enhance the skills of therapists on the team and maintain their motivation to treat effectively by providing a mandatory weekly consultation team meeting where therapists receive supervision and consultation on their clinical work. Therefore each member of the programme will need to have dedicated time of at least 1 1/2 days a week to the DBT Programme.
Implementing DBT selecting, training and supervising a team: Article by Michaela Swales
Dialectical Behaviour Therapy Intensive Training™
This training is intended for teams that are invested in learning DBT to a high standard in order to better implement the treatment in their settings. As DBT is a treatment that requires an ongoing consultation team, the Intensive Training is designed for treatment teams, not individual practitioners intending to practice alone.
A DBT team (minimum of 4, maximum of 8) is a group of mental health professionals who meet at least weekly to assist each other in applying DBT in their practice setting. Training is conducted in two, five-day sessions of instruction divided by six to nine months of home study and requires a high level of dedication so we ask teams to discuss their level of commitment prior to applying.
Training is conducted with teams, as DBT recognises that therapists need a supportive system in order to sustain work with this client group. A team is defined as a group of clinicians who regularly meet and work together. Teams should be formed and meeting regularly prior to commencing training.
Team members must commit to attending both parts of the intensive training and be in a position to undertake development work in the period between the training blocks. This requires each member of the team to commit a minimum of one to one-and-a-half days per week each to the joint development of skills and experience. Management support of this should be arranged prior to commencing training. It is not possible to accept individual applications for training, nor is it possible for teams to attend for a reduced time period.
During Part I of the training, teams will learn more about the practice of DBT, both individual therapy, skills group training, telephone consultations, and case management strategies via didactic presentations, role plays and other clinical exercises, together with viewing and discussing video-taped clinical material. Teams have the opportunity to think about the implementation of DBT within their own settings and to receive guidance on how to adapt DBT to unique aspects of their own services.
Part II of the training requires teams to present their work, developed during the intervening months, for discussion with the trainers and other teams. Teams are required to present a protocol for delivering DBT within their own clinical setting and present a clinical case they have treated over the period of training. There is opportunity for further therapy skills development and the aim is to consolidate the teams’ work and enable it to proceed confidently.
DBT is an integrative therapy based on behavioural and cognitive principles. Clinicians from a range of professional and therapeutic backgrounds have trained and are training in DBT, including former psychodynamic therapists. However it is essential for potential DBT therapists to have and/or be open to learning and applying basic behavioural principles. Each team should have at least one member with a background in psychology and one with a background in CBT. Attached is the team and individual requirements for attending the training.[CH2]