Dialectical Behaviour Therapy (DBT)
Dialectical Behaviour Therapy (DBT) is an intensive group and individual therapy treatment model that derives from Cognitive Behaviour Therapy (CBT) and is applied in the management of mental health disorders, including Personality Disorder (PD), binge eating and recurrent depression. The DBT approach equips patients with a balance of acceptance and change techniques for the purpose of increasing capacity to self-regulate, improving coping skills, and enhancing emotional regulation. It has been successful in effectively treating people whose emotional problems are particularly difficult to manage within a therapeutic relationship or an institutional setting.
DBT is founded on Linehan’s biopsychosocial model of emotional dysregulation. It is delivered in four treatment modes (i.e. skills group training, individual sessions, telephone consultation, and therapist consultation team meetings), in four non-chronological treatment stages, over a period of 6-18 months. DBT can be delivered to children, adolescents, and adults. Its delivery is associated with significant improvement across several outcomes including PD symptomatology, suicidal ideation, suicide attempts, self-harming, depression, psychosocial functioning, and anger.
DBT is delivered in Scotland and across the UK.
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Usability Rating
5
Supports Rating
5
Evidence Rating
4 - 5
Fit Rating
NYR
Capacity Rating
NYR
Need Rating
NYR
The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
Usability - Rating: 5
5 - Highly Usable
The intervention has operationalised principles and values, core components that are measurable and observable, a fidelity assessment, identified modifiable components
Core Components
Dialectical Behaviour Therapy (DBT) is a defined intensive group and individual therapy, derived from CBT, and used in the management of mental health disorders that include Personality Disorder (PD), eating disorders, self-harm and suicidal behaviours. This psychotherapeutic approach focuses on the acceptance of self and lived experiences. It also focuses on the opposing idea of changing maladaptive thinking patterns and behaviours. Hence, the DBT approach equips patients with a balance of acceptance and change techniques for the purpose of enhancing coping skills, emotional regulation, and interpersonal relationships.
DBT aims to achieve five essential functions: improve patient motivation to change; enhance patient capabilities; generalise new behaviours; structure the environment; and enhance therapist capability and motivation. This is delivered via four treatment modes.
- Skills group training: 1.5-2.5 hour psychoeducational group sessions that focus on helping patients learn and rehearse new skills. Core skills addressed include mindfulness, distress tolerance, interpersonal effectiveness, and emotional regulation.
- Individual DBT sessions: 60-minute weekly sessions of individual therapy that focus on applying skills to achieve patient specific goals and targets. These sessions also identify and address commitment to therapy and motivation to change
- Between session interventions: Telephone consultation: Includes telephone consultations between sessions (if needed) to assist patients with identifying and employing their skills in challenging situations and prompts such as flash cards or cope ahead plans. These help to increase skills generalisation, as they help patients to transition newly acquired in-therapy skills to non-therapy environments
- Therapist consultation team meeting: 1-2 hour therapist meetings that include case discussions to ensure the adoption of dialectic stance as it relates to patient treatment. Meetings also support practitioner adherence to treatment manual, and support therapist’s delivery of DBT.
DBT is divided into four non-chronological treatment stages, each with different treatment targets. These are;
- Stage 1: Focuses on behavioural stabilisation. It aims to equip patients with skills that address immediate and severe life-threatening behaviours, as well as therapy interfering behaviours. Quality of life behaviours can also be addressed in this stage
- Stage 2: Addresses trauma related memories and emotional processing of the experiences
- Stage 3: Focuses on developing areas related to self, including self-respect, self-confidence, and reaching individual goals
- Stage 4: Addresses existential issues to develop greater capacity for joy and fulfilment
DBT is typically delivered to adolescents and adults, over a period of 6-18 months.
Fidelity
Practitioners delivering DBT should receive training and ongoing clinical supervision. Practitioner adherence to the model is a high priority in DBT, and the Team Consult (weekly team meeting) supports this with clear guidelines about how this meeting is used. Practitioner fidelity to treatment can be monitored and evaluated using appropriate measures, such as the widely used Dialectical Behaviour Therapy Adherence Checklist – Individual Therapy (DBT AC-I) (1).
Modifiable Components
Dialectical Behavioural Therapy is also available as Dialectical Behaviour Therapy for Substance Abusers (DBT-S) to address co-occurring substance dependency and BPD. DBT can be delivered face-to-face, online, or via DBT apps (e.g. DBT Coach, DBT Diary Card and Skills Coach, and DBT Trivia & Quiz). DBT continues to build on an evidence base for DBT for adolescents and DBT for PTSD.
The model of ‘Decider Skills’ offers a simplified framework of DBT skills to teach patients about their emotions and thoughts. It uses the four modules in DBT – Distress Tolerance, Emotional Regulation, Mindfulness and Interpersonal Effectiveness.
The model of ‘Emotional Coping Skills’ is a transdiagnostic approach derived from DBT. It is offered as an eight-week intervention for in-patient and out-patients and can be run in a group or individual format.
Supports - Rating: 5
5 - Well Supported
Comprehensive resources are available to support implementation, including resources for building the competency of staff and organisational practice as a standard part of the intervention
Implementation Support
British Isles for DBT (BIDBT) training is the main training organisation to access virtual or in-person training the UK. They are endorsed and supported by Behavioural Tech Institute, which is the founder Marsha Linehan’s body in the USA. Therapists and teams who have trained with them continue to have access to the trainers for implementation support. The training also provides guidance about preparing an organisation for supporting a DBT team.
British Isles DBT training have created a Benchmarking Website Tool. Benchmarking is the basis to programme evaluation and continues quality improvement. The practical tool allows DBT teams to collect outcome data and benchmark their programme, and to map their DBT programme and connect with others.
There are also other training organisations in the UK and BIDBT are closely linked to the Society for DBT (UK). Society for DBT (UK) are a professional membership organisation dedicated to practitioners in DBT, aiming to further develop DBT as an evidence-based therapy. They have a role of regulating accreditation of therapists and supervisors, annual virtual conference to bring latest developments in DBT internationally to their members, as well as the regulation of courses that provide DBT training. Teams also have access to the organisation for implementation support. European DBT Association is an international multidisciplinary association dedicated to promoting the improvement, dissemination and quality control of DBT.
DBT Network Scotland – This is an informal network of the 8 plus DBT Teams in Scotland that get together for a network day bi-annually. The network has a mailing list of 50+ trained DBT therapists in Scotland. At least five teams have been established for over 10 years, and this provides an opportunity from guiding newer teams and supporting implementation in Scotland via the network. Experienced teams/therapists offer implementation and development support within this network to share previous learning from implementation and for cross-fertilisation. This includes sharing of data plan and outcome measurement in DBT teams.
Start-up Costs
The BIDBT training costs include licence requirements – this includes access to the DBT Manual, which is available as a digital resource.
The workbook can be provided for each patient on the programme. Some services may have a budget to purchase a hard copy for each patient on the programme at a cost of £20.
The 10 days DBT training is acquired through ‘Intensive’ training for a whole team (5 days + 5 days 6 months later), or for individuals who join existing teams (Foundation training = 5 days + Upgrade training = 5 days). This is approximately £1850 in total (over two payments, usually approximately within one year).
Building Staff Competency
Qualifications Required
To access DBT training one must have a core profession, i.e. nursing, occupational therapy, social work, psychology, medical registration.
Training Requirements
High quality regulated training is available in the UK, mostly accessed through the British Isles DBT training organisation. It is suggested that a small group (between 4-10 staff members, depending on the size of the board) of experienced mental health staff, each given at least 1.5 days ringfenced time, is the most effective way of planning training and implementation of a new DBT team (2). Team can initially train over a 12-month period via the ‘Intensive Training’ route, where the whole team trains together and receive support for implementation from the training organisation. This involves five days initial training, then a further five days of support with problem solving teething and developing adherence.
Supervision Requirements
It is recommended practice in Scotland that this psychological intervention is conducted under regular supervision with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions (Further information: Supervision of psychological therapies and intervention | NHS Educ. There is additional guidance from DBT training organisations on participation in the weekly DBT team consult, where ongoing coaching continues post-training. There are opportunities to formally be accredited as DBT therapist of supervisor via the Society of DBT.
Evidence - Rating: 4 - 5
4 - Evidence
The intervention has demonstrated effectiveness with one rigorous, external research study with the focus population and a control group.
5 - High Evidence
The intervention has demonstrated evidence of effectiveness based on at least two rigorous, external research studies with the focus population and control groups, and has demonstrated sustained effects at least one year post treatment.
Theory of Change
DBT is founded on Linehan’s biopsychosocial model of PD which suggests that emotional dysregulation is fundamental to the difficulties experienced in PD. It hypothesises that people with PD have heightened emotional response systems arising from biological vulnerabilities or early childhood experiences. It suggests that problematic behaviours with PD are a consequence of high emotional arousal and a means of coping with the painful emotions. DBT therefore focuses primarily on helping patients to recognise, accept, and moderate emotional responses. This is expected to increase patient’s capacity to self-regulate, improve coping skills, enhance emotional regulation, and better interpersonal relationships.
Young People 14+ Outcomes for Personality Disorder
Compared to control groups, the following outcomes were observed;
- Significantly reduced self-harming at post-intervention (13)(14)
- Significantly reduced suicidal ideation and suicide attempts at post-intervention (13)(14)
- Significantly reduced BPD symptoms at post-intervention (13)
Significantly reduced non-suicidal self-injury at end-of-treatment (14)
Adult Outcomes for Chronic Depression
DBT group participants showed significantly greater improvements in depressive symptoms compared with the control condition (12)
Adult Outcomes for binge eating disorder
Compared to treatment as usual or non-dialectical behavioural therapy, the following outcomes were observed;
- Compared to waitlist control, DBT resulted in significantly fewer binge eating episodes and significantly greater rates of abstinence from binge eating at the end of treatment (7)
- Significant reduction in body mass index, decreases in the binge eating scale and decreased difficulties in emotion regulation compared to waiting list control at end of 10 week treatment (9)
- CBT, computerised guided self help and DBT were equally effective in reducing binge eating at 6- and 12-month follow up (8)
- Significant reductions in binge frequency from both DBT guided self help, DBT unguided self help or an unguided self-help self-esteem control at post treatment and 12-week follow up with no differences between groups (10).
Adult Outcomes for Personality Disorder
Compared to treatment as usual or non-dialectical behavioural therapy, the following outcomes were observed;
- Significantly reduced self-harming behaviours at end-of-treatment (3)(4)
- Significantly reduced depression. Effects observed were significantly greater when DBT was delivered for more than 4 months (4)
- Significantly greater reduction in overall BPD symptomatology or symptom severity at end of treatment or at 1-year (6)
- Significantly improved psychosocial functioning at end of treatment (3)(6)
- Significantly reduced anger, impulsivity, dissociation and psychotic-like symptoms at end of treatment (3)(6)
Young People 14+ - Personality Disorder - Rating: 5
Evidence for DBT in CYP on outcomes that include BPD symptoms are one meta-analytic study and one Randomised Controlled Trial (RCT).
The first was a meta-analytic study that evaluated the efficacy of DBT for Adolescents (DBT-A) on self-harm and suicidal ideation (13). In total, 21 studies comprised of 1673 adolescents, aged 12-19 years, were included in the meta-analyses. Included participants had engaged in self-injury at least once.
The second was a randomised study that evaluated the effectiveness of DBT for adolescents (DBT-A) on participants with high suicidal risks (14). The study included 173 adolescents, aged 12-18 years, who had at least 1 lifetime suicide attempt, elevated past-month suicidal ideation, self-injury repetition, or met 3 or more borderline personality disorder criteria. DBT delivered included 4 components: weekly individual psychotherapy, multifamily group skills training, youth and parent telephone coaching, and weekly therapist team consultation. The study was conducted in USA.
Adults - Chronic Depression - Rating: 4
A Cochrane systematic review and meta analysis reviewed the evidence for psychological therapies for treatment-resistant depression in adults and included six trials (n = 698) (11) . One included trial compared 16 week group DBT with usual care and antidepressants with a comparator of usual care with antidepressants (n = 19) (12).
Adult - Eating Disorders - Rating: 5
SIGN (2022) included a systematic review that identified two small RCTs of DBT and further RCTs in the summary of the evidence for DBT for binge eating (7)(8)(9)(10).
Adults - Personality Disorder - Rating: 5
Some of the best available evidence for DBT in the management of PD in adults comes from meta-analytic studies. These are described below.
The first was a meta-analytic study that evaluated the effectiveness of psychological therapies in the management of Borderline Personality Disorder (BPD) (3). It included 31 RCTs-one (n=1870), of which 10 studies evaluated DBT as a standalone treatment. Participants in the included RCTs were adults, majority with a BPD diagnosis.
The second was a meta-analytic study that evaluated the effectiveness of DBT on reducing self-harming behaviours and negative emotions in patients with BPD (4). The meta-analysis included 11 RCTs that enrolled patients who met the diagnostic criteria for BPD. DBT delivery included standard DBT and DBT skills training delivered over a range of 8 weeks to 52 weeks. There were no participant age restrictions for included studies.
The third was a multivariate multilevel meta-analysis that evaluated the effectiveness of psychological treatments for BPD (5). It included 87 studies (N = 5881), of which 33 treatment arms were for DBT (n = 2503) and 10 treatment arms were for reduced DBT (n = 273). DBT treatments were classified as full DBT if they included the four standard DBT components, or reduced DBT if not all four components were present. Included participants were adult patients (aged ≥ 18) with a primary diagnosis of BPD.
The fourth was a Cochrane review that evaluated the effectiveness of psychological therapies for people with borderline personality disorder (6). The study included psychological intervention regardless of theoretical orientation. The review included 24 randomised parallel arm trials that investigated the effect of DBT and DBT-related treatments.
Need
Comparable Population
DBT has been shown to be effective in adolescents and adults with binge eating, recurrent depression, personality disorder, self harm, or have suicidal ideation.
Desired Outcome
DBT delivery is associated with significant improvements across several outcomes including PD symptomatology, suicidal ideation, suicide attempts, self-harming, depression, psychosocial functioning, and anger.
1 - Does Not Meet Need
The intervention has not demonstrated meeting need for the identified population
2 - Minimally Meets Need
The intervention has demonstrated meeting need for the identified population through practice experience; data has not been analysed for specific subpopulations
3 - Somewhat Meets Need
The intervention has demonstrated meeting need for the identified population through less rigorous research design with a comparable population; data has not been analysed for specific subpopulations
4 - Meets Need
The intervention has demonstrated meeting need for the identified population through rigorous research with a comparable population; data has not been analysed for specific subpopulations
5 - Strongly Meets Need
The intervention has demonstrated meeting the need for the identified population through rigorous research with a comparable population; data demonstrates the intervention meets the need of specific subpopulations
Fit
Values
Dialectical Behaviour Therapy (DBT) is used in the management of mental health disorders that include Personality Disorder (PD), self-harm, binge eating and recurrent depression. It focuses on acceptance of self and lived experiences. It also focuses on the opposing idea of changing maladaptive thinking patterns and behaviours for the purpose of increasing capacity to self-regulate, improving coping skills, and enhancing emotional regulation. DBT is founded on Linehan’s biopsychosocial model of BPD.
Priorities
DBT focuses on achieving five essential functions (i.e. improving patient motivation to change; enhancing patient capabilities; generalising new behaviours; structuring the environment; and enhancing therapist capability and motivation). This approach equips patients with a balance of acceptance and change techniques for the purpose of increasing capacity to self-regulate, improving coping skills, and enhancing emotional regulation. DBT can be delivered to children, adolescents and adults, in formats that include in-person, online and app delivery.
Existing Initiatives
1 - Does Not Fit
The intervention does not fit with the priorities of the implementing site or local community values
2 - Minimal Fit
The intervention fits with some of the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
3 - Somewhat Fit
The intervention fits with the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
4 - Fit
The intervention fits with the priorities of the implementing site and local community values; however, the values of culturally and linguistically specific population have not been assessed for fit
5 - Strong Fit
The intervention fits with the priorities of the implementing site; local community values, including the values of culturally and linguistically specific populations; and other existing initiatives
Capacity
Technology Support
DBT treatment modes includes telephone consultation. Other delivery modes (i.e. skills group training, individual sessions, and therapist consultation team meetings) can be delivered without access to technology. Access to video platforms for remote delivery can be useful as is access to methods of recording sessions for supervision
Administrative Support
DBT is delivered in four treatment modes that include skills group training, individual sessions, telephone consultation, and therapist consultation team meetings. DBT can be delivered for up to 12 months or longer. Administrative support is needed to manage appointments, collate and input outcome measures, and process written reports.
Financial Support
1 - No Capacity
The implementing site adopting this intervention does not have the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
2 - Minimal Capacity
The implementing site adopting this intervention has minimal capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
3 - Some Capacity
The implementing site adopting this intervention has some of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
4 - Adequate Capacity
The implementing site adopting this intervention has most of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
5 - Strong Capacity
Implementing site adopting this intervention has a qualified workforce and all of the financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
