Origins & Development
Marsha Linehan, PhD
Late 1980s–1990s
University of Washington, Seattle
The Problem DBT Was Designed to Solve
Target Population
Originally: Women with borderline personality disorder (BPD) and chronic suicidality
Key Challenge: Standard CBT approaches were ineffective and sometimes harmful for this population
Why? Clients experienced therapists' focus on change as invalidating, leading to dropout and crisis escalation
Client Characteristics
- Emotional dysregulation and extreme emotional sensitivity
- Self-harm and suicidal behaviours
- Unstable relationships and fear of abandonment
- Difficulty tolerating distress
- Impulsive, mood-dependent behaviour
- History of invalidating environments (often trauma)
Theoretical Foundation: The Biosocial Theory
Creation of Problems
- Born with heightened emotional sensitivity
- Raised in environment that invalidates emotional experiences
- Never develop effective emotion regulation skills
- Learn maladaptive coping (self-harm, avoidance)
Maintenance of Problems
- Maladaptive behaviours are negatively reinforced (reduce distress temporarily)
- Emotional dysregulation creates more invalidating responses from others
- Vicious cycle: emotions → dysfunctional behaviour → negative consequences → more emotions
Core Philosophy: Dialectics
The Central Dialectic
⚖️ CHANGE (building a life worth living)
Both are necessary. Both are valid. The synthesis creates transformation.
Structure of DBT Treatment
The Multi-Modal Approach
1. Individual Therapy
Weekly, 50-60 minutes
Focus on:
- Reducing life-threatening behaviours
- Decreasing therapy-interfering behaviours
- Reducing quality-of-life-interfering behaviours
- Increasing skilful behaviour
2. Skills Training Group
Weekly, 2-2.5 hours (separate from individual)
Psychoeducational format teaching the four skill modules
This is group therapy, not individual therapy in a group setting
3. Phone Coaching
As needed, between sessions
Brief calls to help clients:
- Use skills in real-time crises
- Generalise skills to daily life
- Repair relationships after conflict
4. Consultation Team
Weekly therapist meeting
Therapists meet to:
- Stay motivated and avoid burnout
- Maintain adherence to DBT principles
- Consult on difficult cases
- This is DBT for the therapists
Key Structural Point
- Skills training is delivered separately from individual therapy
- Different functions: Individual = motivation & application; Group = learning
- Requires team approach – not solo practice
The Four Skills Modules
The Dialectical Structure of Skills
ACCEPTANCE Skills
Surviving the present moment
- ✓ Mindfulness (core for all)
- ✓ Distress Tolerance
CHANGE Skills
Building a life worth living
- ✓ Mindfulness (core for all)
- ✓ Emotion Regulation
- ✓ Interpersonal Effectiveness
CORE SKILL (Foundation for Everything)
Mindfulness
Being present and aware in the current moment
- What skills: Observe, Describe, Participate
- How skills: Non-judgementally, One-mindfully, Effectively
- Awareness without attachment
- Required for both acceptance AND change
ACCEPTANCE SKILLS
When you cannot change the situation or your emotions are too high for change work
Distress Tolerance
Surviving crises without making things worse
- Crisis survival skills: TIPP (Temperature, Intense exercise, Paced breathing), ACCEPTS, Self-Soothe, IMPROVE, STOP
- Reality acceptance skills: Radical Acceptance, Turning the Mind, Willingness, Half-Smiling
- Tolerating pain without impulsive action
- Accepting reality as it is, even when it's painful
CHANGE SKILLS
When you can actively work to change emotions, behaviours, or situations
Emotion Regulation
Understanding and changing emotional responses
- Understanding the function of emotions
- Reducing vulnerability: PLEASE (treat PhysicaL illness, balanced Eating, avoid mood-Altering drugs, balanced Sleep, Exercise)
- Increasing positive emotions: Build Mastery, Pleasant Activities
- Opposite Action: Acting opposite to emotion urge when emotion doesn't fit facts
- Problem Solving: When emotion fits the facts
Interpersonal Effectiveness
Getting what you need from relationships whilst maintaining self-respect
- DEAR MAN: Objective effectiveness (getting what you want, saying no)
- GIVE: Relationship effectiveness (maintaining the relationship)
- FAST: Self-respect effectiveness (keeping your dignity)
- Balancing objectives, relationships, and self-respect
Key Treatment Methods & Strategies
Validation
Six levels of validation, from being present to radical genuineness
Communicates that the person's responses make sense given their history and current situation
Irreverence
Strategic use of humour, confrontation, or "calling BS" to shake clients out of stuck patterns
The dialectical opposite of validation—therapists move fluidly between acceptance and pushing for change
Behavioural Chain Analysis
Detailed analysis of problem behaviours from vulnerability factors through consequences
Identifies where to intervene and which skills to use
Diary Cards
Daily self-monitoring of target behaviours, emotions, and skill use
Reviewed every individual session to track progress and guide treatment
Commitment Strategies
Techniques to strengthen client commitment to change
Includes playing devil's advocate, foot-in-the-door, connecting to values
Key Contrasts with Standard CBT Approaches
What Makes DBT Distinctive?
- Dialectical philosophy: Accepts paradox; holds acceptance and change in tension rather than prioritising change
- Validation is primary: Without validation, change strategies backfire with this population
- Comprehensive system: Not just techniques but a complete treatment framework requiring team delivery
- Biosocial theory: Explains how problems develop through transaction between biology and environment
- Behavioural focus: Targets behaviours (especially life-threatening ones) before cognitions
- Skills training as separate component: Psychoeducation happens in group, not individual therapy
- Between-session coaching: Therapist availability for brief skills coaching
- Therapist consultation team: Required component to prevent burnout and maintain adherence