Dialectical Behavior Therapy (DBT) was developed by Marsha Linehan in the 1980s as a response to the shortcomings that she saw in traditional cognitive behavioral therapy (CBT). DBT emphasizes both acceptance (“I am trying as hard as I can”) and change (“I need to try harder”) in a dialectical approach to mental health. 

In its 40+ years of existence, DBT has become one of the most studied forms of therapy on the planet. That being said, while the qualities of DBT make it effective at treating a wide variety of behavioral problems, there are instances where using DBT may be less effective. This article discusses the pros and cons of DBT, as well as a few alternatives for readers still weighing their options. 

The Pros & Cons of DBT

The Pros of DBT Therapy

Effective for Complex Conditions

DBT was initially created to treat borderline personality disorder (BPD); however, its use expanded greatly over four decards of research. DBT is now used to treat a host of behavioral disorders, including:

• Bipolar I and II
• Depression
• Anxiety
• Eating Disorders
• OCD

In addition, DBT is adaptable enough that it can be combined with other forms of therapy to make it even more effective. For example, Exposure and Response Prevention (ERP) is typically considered the gold standard for treating OCD. ERP can be included in a structured DBT treatment plan in which patients learn the skills necessary to overcome triggering situations while having the opportunity to test those skills in a controlled environment.

Skills Training

DBT focuses on four core skills:

DBT provides several exercises to build these skills, providing patients with an actionable pathway towards dealing with their problems. Giving patients something to work on prevents the often frustrating feeling of stagnation that other “talk-therapy” models heavily utilize.

Emphasis on Acceptance AND Change

DBT, as the name suggests, focuses on the dialectic; a philosophic word that means embracing the shared truth in opposite statements. We’ve already demonstrated the most popular example in DBT, which are the joint statements:

The balance between these two forces – acceptance and change – is the central path of DBT. It allows patients to strive for change without feelings of judgment, which are more common in traditional forms of CBT. In fact, most other forms of therapy focus on one side of this dynamic, as shown in the table below:

DBT teaches patients how to accept who they are and what limitations they have while at the same time still pushing those limitations and working towards “building a life worth living” – the ultimate goal of DBT.

Supportive Structure

Whereas other forms of therapy often focus entirely on the individual and their relationship with their feelings, emotions, and behaviors, DBT emphasizes a group approach in which patients and residents participate in group therapy sessions along with individual coaching. This allows patients to:

• Feel Validated: One of the most helpful things in therapy is knowing you aren’t alone. Hearing that others experience the same struggles you do can make it easier to accept and regulate big emotions.

• Learn: Group therapy allows patients to practice learned skills in a controlled environment. This makes therapy more actionable than a simple 1:1 provides.

• Get Feedback: Learning how group therapy members handle their problems can give patients new perspectives that make it easier to approach their own challenges.

In addition, DBT clinicians always operate as a part of a team. If there is not a team involved, it is NOT DBT. These professional teams allow clinicians to maintain objectivity in their designated treatment plans and ensure that treatment is carried out effectively and according to the patient’s needs.

Typical Composition of a DBT Team

Evidence-Based

DBT is one of the most studied and tested forms of therapy in the world. To date, DBT has been tested in:

• 33 independent studies
• 12 independent testing sites
• 5 countries
• 12 patient populations

Nearly every aspect of DBT has been tested in a clinical setting. For example:

• DBT has been correlated with improving cognitive function (attention, memory, fluency, response inhibition, planning, set shifting, tolerance for delayed rewards, time perception)

• DBT has been shown to reduce instances of self-harming behaviors and depression

• DBT can function as part of a coordinated implementation with other forms of therapy with measurable success

• DBT can even change subconscious reactions to emotions and feelings rather than just behavioral patterns

• Despite the often non-linear nature of recovery, most patients who stick with a DBT program ultimately lead better lives

The effects of DBT are so well-measured that some professionals are calling for it to be provided as a publicly funded service.

The Cons of DBT Therapy

Time-Intensive

On average, outpatient DBT treatment takes between 6-12 months and usually consists of 1-3 individual sessions per week and 1-3 group sessions per week, depending on if the patient’s treatment includes family therapy as well as standard group therapy. As a result, even outpatient treatment can average between 8-15 hours per week, with more intensive outpatient (IOP) treatment taking even more time. The final option is residential treatment, where the patient lives at an onsite facility for constant supervision and training.

These extensive commitments stem from the underlying belief that therapy is an intensive process requiring much work and dedication. Marsha Linehan describes it this way:

“The path out of hell is through misery. By refusing to accept the misery that is part of climbing out of hell, you fall back into hell.”

 

― Marsha Linehan, DBT Skills Training: Manual

May Not Address Underlying Issues

As a skill-based form of therapy, DBT’s primary focus is on developing the relationship between a patient and their feelings, emotions, and behaviors. While DBT does contain some psychoeducational elements, even these elements are intended to let the patient learn about their condition in a medical sense rather than the personal cause of their distress or disorder.

It is important to keep a few considerations in mind:

• Treatment varies by facility, specialist, and patient: As previously mentioned, DBT is a remarkably adaptable form of treatment. Different facilities may include deeper explorations, and it’s certainly possible to find DBT clinicians with a background in other modalities of therapy.
• Behavioral therapy can lay the groundwork for more intensive exploratory work: For many patients, therapy is a lifelong pursuit. Just like an emergency surgeon first addresses the primary concerns before moving on to addressing the underlying cause, DBT allows patients to manage their initial feelings before moving on to other, more exploratory therapy options.

Requires Specialized Training

Training for DBT is highly specialized and requires a great degree of work to become fully licensed. As such, finding a DBT-Linehan-certified provider is difficult. It is even more difficult because many well-meaning providers represent themselves as providing DBT therapy when they do not. For example, many “DBT providers” work without the input of a team. This, by definition, is not DBT treatment, despite the fact that they might utilize DBT skills.

Fundamentally, this means that DBT may not be available in all areas. For patients who know that they want DBT but do not have a provider in their area, this typically means having to travel, which can be especially challenging since treatment typically lasts 6-12 months.

Cost

Because of the number of professionals on a DBT team, the inclusion of group therapy, and the duration of treatment, DBT can be more expensive than other forms of therapy. In addition, many DBT clinics do not work with insurance due to the high degree of specialization. This means that patients typically need to do a bit more legwork to find offices that either:

• Provide insurance verification
• Provide share-of-cost information
• Provide direct billing

Similarly, research-based institutions will often provide discounted services since treating the patient means being able to further the medical understanding surrounding their treatment.

Considering the Alternatives

For those still weighing the pros and cons of DBT therapy, we would be remiss if we didn’t point out that there are other evidence-based therapies that may be worth looking into. The table below provides a very brief set of pros and cons for a few of the most popular, as well as why you might want to consider them instead of DBT.

Other Therapy Options Besides DBT

As the table indicates, each of these options has a more or less specific use-case targeted at a specific trigger. By comparison, DBT is more focused on providing patients with a more healthy overall understanding of their feelings, emotions, and behaviors.

DBT Therapy with Compass Behavioral Health

In short, DBT treatment comes with a few important considerations, however, the advantages that it provides – its ability to treat complex conditions, its evidence-based use of practical skills, and the supportive structure to help patients embrace conflicting truths in their lives – far outweigh them. Here at Compass Behavioral Health, we’ve seen patients come in struggling with a wide range of disorders who have all benefited from DBT treatment.

Nicole Zaha, Psy.D.

Associate Director Of Post Doctoral Training, Clinical Supervisor. Licensed Clinical Psychologist (Lic. PSY29916)
DBT-Linehan Board of Certification, Certified Clinician™

Dr. Zaha mentors post-doctoral psychologists through Compass’ Comprehensive DBT Fellowship training program. She has also provided individual, group, skills coaching, and family therapies at residential, partial hospitalization, intensive outpatient and outpatient levels of care and supervision to residential staff at Compass Behavioral Health since 2017. Dr. Zaha was intensively trained in DBT, CBT, ACT, and CBASP during her practicum at Harbor-UCLA in 2008-2009, under the direction of Lynn McFarr, Ph.D. Dr. Zaha’s internship was completed at Metropolitan State Hospital (APA Accredited), in Norwalk, California, in which she helped to train and develop an inpatient DBT team, and provided DBT services to patients on a specialized unit. Her graduate studies focused on Family Psychology and Adolescent Identity Formation and emphasized multicultural and spiritual integration. She graduated from Azusa Pacific University (APA Accredited) with her Doctorate in Clinical Psychology in 2010. She worked as a Psychological Assistant at Clearview Residential DBT Program in Los Angeles, California for six years during which she aided in transitioning the residential program from a psychodynamic model to DBT. She trained staff members in DBT interventions, including skills coaching, and crisis intervention along with serving as an individual and group therapist. She has been directly supervised and intensively trained in DBT-Prolonged Exposure by developer Melanie Harned, Ph.D. and has a special interest and experience in assessing and treating trauma. In addition, she has received advanced training in DBT for specific populations, including for substance use, eating disorders, adolescents, and emotionally dysregulated families. She has been formally trained in Behavior Activation, as well as Mindful Self-Compassion by developers Kristin Neff, Ph.D. and Chris Germer, Ph.D. and in Exposure and Response Prevention by developer Jonathan Abramowitz, Ph.D. Dr. Zaha also currently works as a Qualified Medical Evaluator and provides psychological evaluations for adults with industrial injuries.