Content warning: Discussion of DBT treatment in this article includes mention of suicidality and self-harm. If you or someone you know may be in danger of self harm or suicide, please get help. Call 911 for emergencies or contact the Canada Suicide Prevention Service hotline at 1-833-456-4566 (24 / 7) or text 45645 (4pm to 12am ET).

Dialectical behaviour therapy (DBT) is a form of psychotherapy or counselling therapy that aims to help us live in the present moment, accept how things are (not how they should be), regulate our emotions, and learn to cope with stress and crisis moments. 

DBT is an iteration of cognitive behavioural therapy (CBT) and usually involves individual and/or group psychotherapy, one-on-one coaching, and skills building to support healthy emotions, thoughts and behaviours. 

The word “dialectical” refers to the existence of two opposing forces. In DBT, we learn to constantly balance both acceptance (what we’re going through is real and hard) and change (we can make positive change for ourselves). 

Knowing this duality helps us navigate and manage our emotional and behavioural responses to life’s challenges. DBT is about moving away from judgements and from all-or-nothing thinking into an understanding that “this is hard, and I can do it.” 

History of dialectical behaviour therapy (DBT)

DBT was first developed by American psychologist Dr. Marsha Linehan in the late 1970s to help treat suicidal behaviours, those with borderline personality disorder and other more complex issues that revolved around extreme emotional responses. 

She initially focused her work with adult women with histories of self-harm or suicidal ideation. At the time, CBT was gaining in credibility and popularity, so she decided to apply that behavioural approach to her patients. However, she found key elements of CBT were not effective for her patients for three reasons:

1. The focus on changing thoughts in CBT was invalidating her patients' experiences and reality.
2. Because these patients tended to be dealing with more extreme emotional dysregulation, therapists were unknowingly changing their approach when the patient became angry or they threatened self-harm.
3. The severity of the patients’ struggles were beyond the scope of the standard CBT model—it did not provide time to help with both deep presenting issues (deep symptoms of anxiety and depression) and to develop new skills.

This prompted Linehan and her team to change the model. They started to ensure their patients knew their behaviours were accepted (validated), so they grew to know they could trust themselves. Acceptance fueled the ability for change. Adding in dialectics helped both the therapist and patient move forward instead of getting stuck in extreme emotions or fixed thinking.

Today, DBT is used to help with a variety of mental disorders and mental health challenges, like substance abuse, depression, eating disorders and post-traumatic stress disorder.

How does dialectical behaviour therapy (DBT) work?

DBT is a program (it could take up to a year) with stages and skills training with a therapist. Throughout a program, you can expect one-on-one therapy or counselling, group therapy, and coaching (e.g. support on the phone to help manage in-the-moment challenges with newly developing coping skills). 

The multi-stage DBT approach typically involves:

• Stage one: This is the starting line when many people feel in emotional distress, including engaging in destructive behaviour like substance abuse or self-harm. The goal in stage one is gaining control of our behaviours. 
• Stage two: While in control of our behaviours, we might still be suffering, sometimes in silence. This is about moving into a more emotionally healthy state, including through emotional regulation and distress tolerance (see more on these below).
• Stage three: This is about learning to live a functioning life, defining some goals, knowing our self-worth and having self respect, and being able to cope with both ups and downs of life.
• Stage four: In stage four, we find deeper meaning in life. This could be spiritual for some people, or other ways to get a sense of connection to the broader world and find joy.

The stages may not be chronological, they may ebb and flow through treatment. That’s not a failure, it’s just a normal part of change and learning new skills. 

Throughout these phases, four categories of skills are taught:

• Mindfulness: Mindfulness therapy techniques teach us to be in the present moment, accepting our thoughts and feelings without judgement of ourselves or anyone else, and without trying to control them. A simple mindfulness technique is focused breathing—inhaling and exhaling and watching your belly rise and fall.
  
  
• Distress tolerance: This is where we learn to cope during challenges without turning to our impulses or harmful habits to lessen distress. We accept when something is impossible to change, and how to move away from thinking about how things “should be.”
  
  
• Interpersonal effectiveness: This is about navigating relationships with others, including through conflict. We learn to ask what others might need, how to say no, and maintain our sense of self in our relationships with others.
  
  
• Emotion regulation: Identifying and naming our emotions can be empowering. This technique helps us acknowledge our emotions, again without judgement. Eventually, we learn our emotions do not need to control our thoughts and behaviours. 

One of the main goals of DBT is to help you become your own “case manager''. By focusing on skills building alongside a trained therapist, we eventually become more automatic in how we respond to challenges. It won’t make hard life moments disappear, but we can learn to trust ourselves and the process of working through challenges while coping in a healthier way.

Dialectical behaviour therapy is an evidence based therapy modality. That means there is a lot of scientific research proving it’s effective, and plenty of training available to teach therapists how to work with people using DBT. For that reason, you’ll likely come across DBT on many of First Session’s partner therapist profiles under their modalities.

You might work through a full year-long program, or you might use some of these tools in a “DBT-informed” way. You might focus more on other behavioural therapies like cognitive behavioural therapy (CBT), mindfulness therapy, or more body-focused approaches (somatic therapy) like eye movement desensitization and reprocessing (EMDR) therapy. There are dozens more tools, methods and techniques out there. Feel free to ask your therapist about their specializations and how they might work for you. 

‍You can easily search for therapists and counsellors in Canada who specialize in DBT on First Session.