Dialectical behavioral therapy: is it effective?

DBT is a combination of psychotherapy and the idea of mindfulness, meaning you focus attention on what you're sensing and feeling in the moment. DBT was initially developed to treat people diagnosed with borderline personality disorder (BPD). It's also sometimes used to treat substance use disorders, post-traumatic stress disorder (PTSD), depression, and eating disorders. However, unlike some other forms of psychotherapy, research on DBT is thin and not resoundingly conclusive.

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DBT is an offshoot of cognitive-behavioral therapy (CBT) developed to treat particularly severe, chronically suicidal cases of borderline personality disorder in women (Chapman, 2006).  

People with borderline personality disorder struggle to regulate their emotions. Their intense feelings can fuel impulsivity and stormy relationships. Among the symptoms (National Institute of Mental Health, 2017):

• Self-harm behavior, including threats of suicide or actual attempts

• Unstable relationships that flip between expressions of love and hate

• Frantic efforts to avoid abandonment by friends and family

• Uncontrollable anger followed by guilt

• Periods of intense depression

Some 79% of people with borderline personality disorder say they’ve attempted suicide, and about 10% of all people with BPD die from suicide—a rate thought to be 50 times higher than the general population (Substance Abuse and Mental Health Services Administration, 2014).

Researchers think that BPD affects about 1.4% of the U.S. population, with women making up 75% of people who receive a diagnosis. Experts believe that the causes include genetics, life experiences, and how an individual's emotional regulation system functions in the brain (National Institute of Mental Health, 2017).

Dialectical behavioral therapy has gained wider acceptance to treat women and men with other mental health problems that can lead to self-harm or suicide attempts, including substance abuse and eating disorders (Chapman, 2020). It has also been used to treat severe cases of depression and post-traumatic stress disorder (University of Washington, n.d.).

DBT teaches "skills for enhancing emotion regulation, distress tolerance, and building a life worth living" in order to reduce the risk of self-harm or suicide attempts (McCauley, 2018). It emphasizes helping a person regulate and tolerate their emotions (American Psychological Association, n.d.).

The therapy involves three components that are carried out in the same time frame (University of Washington, n.d.): 

• Skills training: Group classes that meet weekly for up to six months to learn behavioral skills, including how to tolerate distress rather than changing the situation and how to ask for what you want or say "no" without offending others.

• Individual therapy: Weekly one-on-one sessions to help you apply the skills you're learning.

• Phone coaching: Help when needed in the midst of a difficult situation.

DBT is designed to proceed in stages, as a person moves from being miserable with out-of-control behavior to a life of quiet desperation to a final stage marked by ordinary happiness and unhappiness and the ability to define goals, build self-respect and find peace (University of Washington, n.d.).

In a small study, 78 people diagnosed with borderline personality disorder participated in dialectical behavioral therapy for up to a year, at which time 77 percent of them no longer met the criteria for the disorder. On average, the participants "significantly improved regarding self-injurious behaviors, number of inpatient hospital stays, severity of borderline symptoms and psychopathology."

However, there was no control group, so the researchers can't conclude that the positive outcomes were the result of DBT (Stiglmayr 2014).

A small clinical trial, involving 173 adolescents who had previously attempted suicide, found evidence for "a significant advantage for dialectical behavioral therapy compared with individual and group supportive therapy for reducing repeat suicide attempts, nonsuicidal self-injury, and total self-harm after treatment" (McCauley, 2018).

Another clinical trial with 101 women with BPD compared DBT to community treatment over a two-year period and found that fewer women treated with DBT attempted suicide (23 versus 46 percent) or required psychiatric hospitalization (20 versus 49 percent) (Linehan, 2006).

Perhaps most useful is a broad review, called a meta-analysis, of 18 existing controlled dialectical behavioral therapy trials that concluded it might reduce self-directed violence and the frequency of psychiatric crisis services (DeCou, 2018). As meta-analyses go, this was a lukewarm conclusion. 

For someone with a severe mental condition that puts them at great risk of suicide, including borderline personality disorder, some therapists may recommend dialectical behavioral therapy. 

If you or a loved one fits this description, it's vital to immediately seek help from a primary doctor, psychologists, or other healthcare provider, as an immediate emergency intervention is in order, and there are many therapies and medications that an expert can consider in prescribing treatment.

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Current version

June 04, 2021

Written by

Robert Roy Britt

Fact checked by

Felix Gussone, MD

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About the medical reviewer

Felix Gussone, MD, Ro

Felix Gussone is a physician, health journalist and a Manager, Medical Content & Education at Ro.