Dialectical behaviour therapy (DBT)

Dialectical behaviour therapy is almost always called DBT. It’s a structured therapy for people whose emotions come on hard and fast, and who find it hard to settle again once that happens.

It teaches practical skills, in a set order, for four things: staying present, getting through a crisis without making it worse, managing strong emotions, and handling other people.

“Dialectical” points at the idea the whole therapy is built on. Two opposite things can be true at once. You’re doing the best you can with what you’ve got, and some things still need to change. DBT holds both. That’s why it feels different from a therapy that pushes only for change, or one that offers only acceptance.

DBT was developed in the United States in the 1980s and 1990s by Marsha Linehan. She built it for people other treatments were struggling to help.

The four sets of skills

Mindfulness Paying attention to what's happening right now, including what you feel, without being pulled into the past or the future, and without acting on it straight away. Several therapies teach it, including ACT and DBT. More in the jargon decoder — noticing what’s happening right now, including what you feel, without acting on it straight away.
Distress tolerance — getting through a bad few hours without doing something that costs you later. This is the part people tend to use first.
Emotion regulation — working out what an emotion is doing, and changing the things that make it stronger, like poor sleep, skipped meals and avoidance.
Interpersonal effectiveness — asking for things, saying no, and keeping your self-respect and the relationship intact while you do.

The skills get taught, practised, and used between sessions. It’s closer to a course than to a conversation.

A full program, and DBT-informed therapy

One distinction matters more than any other when you’re looking, and it’s rarely explained.

A full program has four parts running at once:

a weekly individual session
a weekly skills group of about two hours
phone coaching between sessions, for when you need to use a skill in real time
a consultation team that supports the therapists

A full program usually runs six to twelve months, often longer.

DBT-informed therapy is a therapist using DBT ideas and teaching DBT skills in ordinary individual sessions. No group, no phone coaching, no team.

Most of what’s offered privately in Australia is DBT-informed. That isn’t a bad thing, and it also isn’t the thing tested in the research. If a service calls itself DBT, it’s fair to ask which parts you’d actually be getting.

What it’s like

Individual sessions are structured. Many programs ask you to keep a diary card, a short daily record of emotions, urges and skills used, and the session works from it. There’s an order to what gets dealt with first: anything that puts you at risk, then anything that gets in the way of the therapy itself, then quality of life.

The skills group feels like a class. A leader teaches the skill, the group practises it, and there’s Between-session tasks (homework) Things some therapists give you to practise between sessions, such as tracking when a mood shifts or trying a different response to a situation. You go through how they went at the next session. More in the jargon decoder . People often find the group the hardest part to commit to and the most useful part in the end.

Phone coaching is short and specific. It’s for using a skill in the moment, not for a session by phone, and therapists set out when and how it works.

Who it tends to suit

DBT suits people whose difficulty is less about one particular problem and more about the intensity of their emotions. Feelings arrive fast, take a long time to come down, and lead to things that are hard to undo.

It also suits people who’ve found that understanding a pattern hasn’t been enough to change it, because DBT spends most of its time on what to do differently.

DBT was developed for, and has its strongest evidence in, people with a diagnosis of borderline personality disorder, and people who repeatedly harm themselves. It’s also used for eating difficulties, substance use, and long-standing difficulties with anger.

The therapy asks a lot: the group, the homework, the diary card, often for the better part of a year. That commitment is the main reason people don’t start, or don’t finish.

If things are difficult right now, you don’t have to wait for a program to begin. Lifeline is on 13 11 14, the Suicide Call Back Service on 1300 659 467, and Kids Helpline on 1800 55 1800 for people aged 5 to 25. In an emergency, call 000. Crisis and emergency support has more.

What the evidence says

DBT has been tested more thoroughly than most therapies. Most of that research is with people who have a diagnosis of borderline personality disorder. Trials find fewer episodes of self-harm, fewer trips to hospital, and more people staying in treatment than in the groups they were compared with.

The national guideline for that diagnosis came out in 2012 and has since been withdrawn, so Australia has no current one. The main guidance here now comes from the Project Air Strategy at the University of Wollongong. It recommends several structured therapies, and DBT is one of them.

Two honest qualifications. Most of the research tests the full program, not the DBT-informed version most people are offered. And when full DBT is compared with other structured treatments built for the same problems, rather than with usual care, the gap gets much smaller.

Getting it in Australia

Full programs are much harder to find than DBT-informed therapy, and the waits are longer.

Public and specialist services. Some public mental health services run full programs. Victoria has Spectrum, a statewide service for people with borderline personality disorder, and New South Wales has the Project Air Strategy. Availability varies a lot by state and by area, and eligibility is usually tied to a Referral A letter from a GP, psychiatrist or paediatrician that you need for the Medicare rebate. You can see a psychologist without one if you pay the full fee. More in the jargon decoder from a mental health service or a GP (general practitioner) For most people, where getting help starts. A GP can write a Mental Health Treatment Plan, prescribe medication and refer you on, and some are trained to deliver a small number of structured therapy sessions themselves. More in the jargon decoder .

Private programs exist in most capital cities, run by Psychologist Someone trained to assess mental health problems and treat them with therapy. It takes at least six years of study and supervised practice, and they're registered with Ahpra, the national regulator. Psychologists can't prescribe medication. More in the jargon decoder and Psychotherapist Someone trained in therapy, often for longer-standing patterns. Like counsellor, the title isn't protected in Australia, and Medicare doesn't give a rebate for psychotherapists. More in the jargon decoder . They cost, and the cost is the sum of the parts: the individual session plus the group.

What Medicare Australia's public health insurance scheme. For mental health, it gives rebates on sessions with psychologists and some other professionals, usually through a Mental Health Treatment Plan. More in the jargon decoder Rebate The amount Medicare pays back towards a session. It comes back to you after you've paid, so what you pay yourself is the fee minus the rebate. More in the jargon decoder . A Mental Health Treatment Plan A document your GP writes with you. It makes you eligible for a Medicare rebate on up to ten individual sessions a calendar year: six, then a review with your GP, then the remaining four. The plan itself isn't therapy. More in the jargon decoder gives you a Medicare rebate on up to ten individual sessions a calendar year. Up to ten group sessions a year are rebated separately, on top of those. The group needs four to ten people, and each session has to run for at least an hour. The group rebate can make a skills group affordable for some people, and group therapy has the detail.

One catch worth knowing before you plan around it: rebated group sessions by video are only for people in smaller country towns and remote areas, and you have to be at least 15 kilometres by road from the therapist. In a city, a regional centre or a larger country town, a rebated group has to be attended in person.

Ten individual sessions and ten group sessions won’t cover a full program year. Ask up front what the whole thing costs and what happens when the rebates run out.

Getting a place. Programs usually take intakes in cohorts rather than continuously, so there may be a wait for the next group start as well as a waiting list.

If DBT isn’t available, or isn’t right

Skills groups on their own are easier to find than full programs, and some services run short skills-only courses.

Some long-standing patterns are more about relationships and how you see yourself than about intensity. Schema therapy works that ground in a different way.

As with any structured therapy, fit with the therapist matters as much as the method. Why who you see matters more than what they do explains why. And if you’re still working out whether you want therapy at all, what therapy actually is covers the basics, and would I benefit from therapy? helps you work out whether it’s worth a try.