Dialectical behaviour therapy

Domain II · Behavioural & cognitive · Marsha Linehan · 1993

What it is

DBT is a comprehensive, team-delivered cognitive-behavioural treatment. Marsha Linehan developed it at the University of Washington for chronically suicidal people, and it was later extended to borderline personality disorder and other problems of emotion dysregulation. Model of change: problem…

Format

• Individual therapy: weekly, about 1 hour. The individual therapist is the primary therapist and works on motivation, applies skills to the client's specific problems, and works through the target hierarchy. The therapist also teaches the client to be their own case manager, stepping in directly…
• Between-session phone coaching: brief, skill-focused calls, typically 5–15 minutes. It is "not therapy on the phone".

Who practises it, and how they are trained or regulated

• Skills training group: weekly, about 2–2.5 hours. Each session runs mindfulness practice, then homework review, then new material. The full curriculum takes 24 weeks, with briefer subsets used for some populations. A standard adult course is commonly one year, so clients go through the modules twice; one residential programme used 1 year for adults and 6 months for adolescents.
• Increasing behavioural skills: mindfulness, distress tolerance, interpersonal effectiveness, emotion regulation, self-management.
• In the skills group the hierarchy is different. Behaviours that would destroy the group come first, then skill acquisition and strengthening, then reducing behaviours that interfere with the group. Suicidal behaviour is handed back to the individual therapist.

Questions to explore with your client

• What drew you to it, and what are you hoping it will change?
• Is there physical contact? Was it explained beforehand, and do you feel free to say no or stop at any point?
• Does it involve any substance, plant preparation, remedy or supplement? Has your doctor or prescriber been told, especially about any medication you take?
• Does it involve intense or unusual breathing? Have you been told about the medical conditions for which that is not advised?
• Does it involve fasting, a special diet or 'detox'? Have you discussed this with your doctor?
• Who runs it, and what training or registration do they hold?
• What actually happens in a session or meeting, and how often?
• What does it cost, and is there pressure to commit to more?
• How do you feel afterwards, in the hours and days that follow?
• Does it fit with, or clash with, the work we do here?

What practitioners of it watch for

• all-or-nothing intensity.
• rumination dressed up as mindfulness.
• pushing cognitive skills in a crisis.
• a forced grin, which defeats the purpose.
• a creeping slide into routine intervention.

Problems the guide addresses

• Low or wavering commitment
• Stuck clients: no change after several weeks
• Resistance, hostility, or a polarised "you're wrong" stance
• Overwhelm, high arousal or dissociation in session
• Non-adherence: diary card or homework not done
• Missed sessions and dropout
• Ruptures in the therapeutic relationship
• Crisis-driven sessions: the "crisis of the week"
• Phone coaching problems
• Group-specific problems

When to involve someone else

• New or worsening physical symptoms, or advice to stop or change prescribed medication: involve the client's doctor or prescriber.
• Signs of coercion, isolation from family and friends, escalating costs or secrecy: discuss openly and consider safeguarding.
• A crisis or thoughts of suicide: follow your crisis protocol. In the US, call or text 988; in the UK and Ireland, Samaritans on 116 123.

Drawn automatically from the guide's own sections. Stay curious: neither endorse nor dismiss what the client values, and check anything that matters against the full guide and its sources. Not medical advice.