Dialectical Behavior Therapy
Dialectical behavior therapy (DBT) is a comprehensive cognitive behavioral treatment. It aims to treat people who see little or no 
improvement with other therapy models. This treatment focuses on problem solving and acceptance-based strategies. It operates within 
a framework of dialectical methods. The term dialectical refers to the processes that bring opposite concepts together such as change 
and acceptance.

Certified practitioners of DBT offer acceptance and support to people in therapy. Many of the people they work with have conditions 
described as "difficult to treat." They work to develop techniques for achieving goals, improving well-being, and effecting lasting 
positive change.

What Is Dialectical Behavior Therapy?
Currently, DBT is used to treat people with chronic or severe mental health issues. Issues DBT treats include self-harm, eating and 
food issues, addiction, and posttraumatic stress, as well as borderline personality. DBT was originally designed to treat people who 
had chronic suicidal thoughts as a symptom of borderline personality.

DBT can be used in a variety of mental health settings. It incorporates the following five components:

1. Capability enhancement. DBT provides opportunities for the development of existing skills. In treatment, four basic skill sets 
   are taught. These are emotion regulation, mindfulness, interpersonal effectiveness, and distress tolerance.
2. Generalization. DBT therapists use various techniques to encourage the transfer of learned skills across all settings. People in 
   therapy may learn to apply what they have learned at home, at school, at work, and in the community. For example, a therapist might 
   ask the person in treatment to talk with a partner about a conflict. The person may use emotion regulation skills before and after 
   the discussion.
3. Motivational enhancement. DBT uses individualized behavioral treatment plans to reduce problematic behaviors that might negatively 
   affect quality of life. For example, therapists might use self-monitoring tracking sheets so sessions can be adapted to address the 
   most severe issues first.
4. Capability and motivational enhancement of therapists. Because DBT is often provided to people who experience chronic, severe, 
   and intense mental health issues, therapists receive a great deal of supervision and support to prevent things like vicarious 
   traumatization or burnout. For example, treatment-team meetings are held frequently to give therapists a space to provide and 
   receive support, training, and clinical guidance.
5. Structuring of the environment. A goal of therapy is often to ensure positive, adaptive behaviors are reinforced across all 
   environmental settings. For example, if someone participates in multiple treatment programs within one agency, the therapist 
   might make sure each program was set up to reinforce all the positive skills and behaviors learned.

The standard form of DBT consists of individual therapy, skills training group, phone coaching, and a therapist consultation team. 
Those in standard DBT attend therapy and a skills training group weekly. The groups are designed to help those in treatment develop 
behavioral skills through group work and homework assignments. These assignments allow people to practice learned skills in day-to-day 
life. Phone coaching is also an important part of DBT. It helps people in treatment reach out to their therapist for support when a 
challenging situation comes up between sessions.

The issues faced by many who participate in DBT can be complex and severe. Due to this, a consultation team is considered essential 
for DBT providers. The team is made up of group leaders and individual therapists. It can offer support, motivation, and therapy to 
the therapists working with difficult issues.

Development and History
DBT was developed by Marsha Linehan in the 1970s. She developed DBT through her work with two mental health populations: 
People with chronic thoughts of suicide and people diagnosed with borderline personality disorder. Linehan was intrigued by the 
building reputation of cognitive behavioral therapy (CBT). She decided to utilize standard CBT in her practice. Linehan and her 
colleagues experienced difficulties after conducting research relative to the effectiveness of CBT in her chosen population. 
They discovered three major problems with the application of standard CBT:

1. Participants experienced the change-focused interventions as invalidating. These feelings often resulted in withdrawal from 
   therapy, aggression toward therapists, or a fluctuation of both extremes.
2. Participants and therapists recreated a pattern of reinforcement in which good work was stalled and avoidance and redirection was 
   encouraged. When therapists pushed for change, participants reacted in anger. When therapists allowed a subject change, participants 
   reacted with warmth and positive feedback. This loop seemed to trick both therapist and participant into thinking they were on 
   the right track, when in retrospect, they were not.
3. Due to the intensity of crisis-related situations, therapists spent a good deal of time addressing safety concerns, such as 
   suicidal thoughts or gestures, hostility and threats toward the therapist, or self-injurious behavior. Often, little time was left 
   to teach coping skills or address behavioral functioning.

After analyzing these problems, Linehan devised several adaptations to CBT. These directly addressed the needs of the population. 
Acceptance-based techniques were included to ensure participants felt supported and validated before they were asked to focus on change. 
In addition, dialectics were incorporated to allow therapists and participants in treatment to focus on the synthesis of polar opposites, 
such as acceptance and change. This helped them to avoid becoming trapped in patterns of extreme position-taking.

These and other adaptations were added to the practice of CBT. In 1993, Linehan published the first official treatment manual, 
Cognitive Behavioral Treatment of Borderline Personality Disorder. Since then, the practice of DBT has grown in popularity. 
Over the last several decades, a great deal of research has supported the efficacy of DBT. This form of therapy is now practiced 
in dozens of countries around the world. It is also listed in SAMHSA's Registry of Evidence-Based Programs and Practices.