What is dialectical behaviour therapy (DBT) and who was it designed for? Read about mindfulness, distress tolerance, emotion regulation and relationship skills.
For some people, emotions are not like a wave that rises slowly but like a storm that strikes all at once. A message answered late turns into hours of panic and anger; a criticism leads to a collapse lasting days. The regret that follows burns at least as much as the original feeling. If this description sounds familiar, you may have thought, "Something in me is broken." Dialectical behaviour therapy is an approach developed precisely so that people living with emotions this intense can cope with them without having to eliminate them. In this article we explain how this method, also known as DBT, came about, what the word "dialectical" means, the four core skill areas, and some skills you can try in everyday life.
What Is Dialectical Behaviour Therapy?
Dialectical behaviour therapy is an approach based on cognitive behavioural therapy, developed in the 1980s and 1990s by the American psychologist Marsha Linehan. Working initially with people who had self-harming behaviours and recurring suicidal thoughts, Linehan observed that standard cognitive behavioural methods fell short with this group. When clients kept hearing that they needed to "change", they felt misunderstood and judged, and dropped out of therapy.
Linehan's solution was to combine change-focused behavioural techniques with acceptance and mindfulness practices inspired by the Zen tradition. This is where the word "dialectical" comes from: accepting that two truths which seem opposed can both be true at the same time. The core dialectic of DBT is this:
You accept yourself as you are, and at the same time you need to change.
These two ideas do not exclude each other. When a person feels that their pain is understood and that their reactions make sense, they become more ready to take the steps change requires. The therapist, too, constantly balances deep understanding and validation with a firm expectation of change.
Who Was Dialectical Behaviour Therapy Developed For?
DBT was first developed for people diagnosed with borderline personality disorder who were experiencing chronic suicidal thoughts. It is worth remembering that this diagnosis can only be made through a thorough professional assessment, and that it is not a label that defines a person. Over time it became clear that DBT, and especially its skills training, could be helpful for a wider group. Today it is used in adapted forms in the following areas:
- People living with intense, rapidly changing emotions
- People with self-harming behaviours
- Emotional eating and binge eating episodes
- Emotion regulation difficulties alongside substance use
- Intense emotional reactions following trauma
- Programmes adapted for adolescents and their families
Why are the emotions so intense? The biosocial view
Linehan explains intense difficulties with emotion regulation through a "biosocial" model. According to this model, some people are emotionally more sensitive from birth: their emotions are triggered more easily, felt more intensely and take longer to settle. When this sensitivity meets an environment in which emotions are not taken seriously, are belittled or are punished, the difficulty grows. Linehan calls this an "invalidating environment".
In Turkey many people will recognise phrases like these: "What is there to cry about?", "Don't exaggerate, nobody else makes such a fuss", "Girls don't shout like that", "A real man doesn't get upset." Most parents who say these things do not mean harm; they behave as they themselves learned. But an emotionally sensitive child in this environment cannot learn to recognise and regulate their feelings. They either suppress their emotions or express them ever more loudly in order to be heard. In adulthood this can turn into emotions experienced in an "all or nothing" way.
The Components of a Standard DBT Programme
A comprehensive DBT programme is not a single session; it is a structured treatment model in which several components run together:
- Individual therapy: Weekly sessions address the person's goals, the situations they struggle with and the crises they go through. The client usually fills in a diary card every day, recording their emotions, urges and the skills they have used.
- Skills training group: In weekly groups, organised rather like a class, the four skill modules are taught systematically and reinforced with homework.
- Skills coaching between sessions: When the person struggles to apply the skills they have learned in a difficult moment, they can receive brief telephone support from their therapist. The limits of this support are clearly set in advance.
- Therapist consultation team: DBT therapists meet regularly as a team and support each other, because working with intense crises is demanding for the therapist too.
Because of this structure, comprehensive DBT is delivered by teams with specific training in this field. Some therapists, however, teach only DBT skills within individual therapy; this may be called "DBT-informed skills work".
The Four Core Skill Modules
The most widely known and most easily transferable part of DBT is its four skill modules.
1. Mindfulness
This is the foundation of all the other skills. It enables a person to notice, without judging, what they are thinking and feeling right now and what is happening in their body. The concept of "wise mind" is important in DBT: an inner wisdom that takes both into account, lying between the "emotion mind", which acts only on feelings, and the "reasonable mind", which acts only on logic. For more on mindfulness practices, see our article on mindfulness.
2. Distress tolerance
These are skills used to get through a moment without making things worse when you cannot change the situation straight away. For example, the STOP skill: Stop, take a step back, observe the situation, then proceed mindfully. Or methods that quickly change the body's chemistry: splashing your face with cold water, a short burst of intense physical activity, breathing out slowly. Another important concept in this module is "radical acceptance": stopping the fight against a reality you cannot change. This does not mean approving of it, but directing your energy towards the things you can change.
3. Emotion regulation
This aims to help people recognise and name their emotions, become less vulnerable to them and reduce the intensity of unwanted emotions. One frequently used skill here is "opposite action": doing the opposite of the behaviour an emotion is pushing you towards. For example, when shame pushes you to hide, if the situation does not really warrant shame, lifting your head and carrying on speaking. Another is reducing emotional vulnerability by attending to basic needs such as regular sleep, nutrition and movement. We discuss this in more detail in our article on emotion regulation skills.
4. Interpersonal effectiveness
This teaches you to express your needs in relationships, set boundaries and say "no", while protecting both the relationship and your self-respect. For example, when making a request, structured communication patterns are used, consisting of steps such as describing the situation objectively, expressing your feeling, saying clearly what you want and pointing out what the other person gains.
Dialectical Behaviour Therapy: How Long Does It Take and What Does the Research Say?
Standard DBT programmes are usually planned for at least six months to a year; completing all four skill modules and embedding the skills into daily life takes time. Programmes adapted for adolescents or for specific problems may be shorter. The length is assessed according to the person's goals and progress.
DBT is one of the psychotherapy approaches with strong research support. Controlled studies show that it can be helpful particularly in reducing self-harming behaviour, suicide attempts and emergency department visits, and in developing emotion regulation skills. At the same time, it should be noted that results vary from person to person and that the intensive participation the programme requires is not easy for everyone. Weekly individual sessions, a skills group and homework are a considerable investment of time and effort.
In Turkey, comprehensive DBT programmes are still available in only a limited number of centres, mostly in the big cities. For this reason many people learn DBT skills within cognitive behavioural therapy or in short-term skills groups.
DBT Skills You Can Try in Everyday Life
The exercises below are inspired by DBT skills. They do not replace therapy; but they can give you a starting point for coping with intense emotions.
- Name your emotion: When an intense emotion arrives, instead of saying "I feel bad", try to find a more precise word: is it hurt, shame, jealousy or fear? Naming an emotion can reduce its intensity somewhat.
- Check the facts: Ask yourself, "Is the intensity of this emotion proportionate to what has actually happened?" Does your friend not replying to your message for two hours mean they have abandoned you, or could there be other explanations?
- Cold water: When you are in the middle of an emotional storm, splash your face with cold water for a few seconds. This can trigger the body's calming response. If you have a health condition affecting your heart rhythm, consult your doctor before trying this method.
- Prepare a crisis card: At a calm moment, write down on a card or in a phone note five things that help in difficult moments: who you can call, which music does you good, which short walking route calms you down.
- Say a validating sentence to yourself: Make a sentence that begins, "It makes sense that I'm struggling this much, because..." Validating yourself does not mean magnifying the emotion but stopping the fight against it.
Imagine a young woman who is shaken by an intense fear of abandonment and anger after her boyfriend cancels their evening plans at the last minute. In the past, at moments like this, she would send message after message and then cry all night, blaming herself. This time she first washes her face with cold water, then names her emotion: "Fear and hurt." She checks the facts: the reason for the cancellation is an emergency at work. She postpones her messages for an hour and, once she has calmed down, expresses her disappointment in a short, clear sentence. The emotion does not disappear; but this time she manages to handle it.
When Should You Seek Professional Support?
Intense emotions are part of being human. However, it is important to seek support from a mental health professional in the following situations:
- Your emotions frequently reach an intensity you cannot control and are damaging your relationships, work or studies
- You harm yourself, or are thinking about it, as a way of coping with emotional pain
- You feel intense regret after behaviours such as sudden outbursts of anger, impulsive spending, or alcohol or substance use
- Your relationships constantly swing between intense closeness and sudden breaks
- You carry a chronic sense of emptiness
- Thoughts of ending your life are crossing your mind
If you are having thoughts of harming yourself or suicidal thoughts, do not carry them alone. Talk to someone you trust and to a mental health professional as soon as possible; in an emergency, call 112 (emergency services). Our article on self-harm may also help you understand self-harming behaviour.
How Are Intense Emotions Addressed in Therapy?
Comprehensive DBT is a programme delivered through individual therapy, a skills group, telephone coaching and a therapist team, and it requires specialist training. Clinical Psychologist Eda Erkan Alapala is a clinical psychologist who has completed four years of Cognitive Behavioural Therapy training to EABCT standards with the Association for Cognitive and Behavioural Therapies (KDTD); she does not run a standard DBT programme. Even so, DBT is part of the cognitive behavioural tradition, and skills such as recognising and naming emotions, tolerating distress and interpersonal communication can be worked on within a cognitive behavioural therapy framework according to the client's needs.
In work in the area of depression and mood, the intensity of the difficulties, the level of risk and the degree of support needed are carefully assessed in the first sessions. If it seems that a comprehensive DBT programme would be more appropriate, this is discussed openly and help is offered with a referral. Where necessary, an assessment by a psychiatrist is also recommended.
Frequently Asked Questions
Is DBT used only for borderline personality disorder?
No. Although it was first developed for this group, adapted forms are now used for many people who experience intense difficulties with emotion regulation. You do not need a particular diagnosis to benefit from DBT skills.
What is the difference between DBT and CBT?
DBT is an offshoot of CBT; however, it places much more weight on acceptance and validation, turns skills training into a systematic programme and includes specific strategies for moments of crisis. CBT, on the other hand, focuses more on changing patterns of thought and behaviour.
Can DBT be used with adolescents?
Yes. In DBT programmes adapted for adolescents, families also take part in the skills groups. In this way both the young person and the parents learn to respond to emotional crises while speaking the same language at home.
Can I learn DBT skills from books?
Skills books and worksheets can be a useful start. But if you are experiencing intense emotions, self-harm or periods of crisis, learning and practising the skills with a professional is both safer and more effective.
Bu yazı genel bilgilendirme amaçlıdır; tanı veya tedavi yerine geçmez. Yaşadığınız güçlükler için bir ruh sağlığı uzmanına başvurmanız önerilir. Acil bir durumda lütfen 112'yi arayın.
Eda Erkan Alapala
Klinik Psikolog. İstanbul Kent Üniversitesi Klinik Psikoloji Tezli Yüksek Lisans mezunu; bilişsel davranışçı terapi, çocuk merkezli oyun terapisi ve çocuk-ergen psikoterapisi alanlarında eğitimlerini tamamlamıştır.
Eğitimler
