Dialectical Behavior Therapy in San Francisco
Dialectical behavior therapy (DBT) is a structured, skills-based form of cognitive-behavioral therapy developed by psychologist Marsha Linehan. It balances strategies for accepting difficult experiences with strategies for changing unhelpful patterns, and it teaches four core skill sets: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. DBT was originally created for chronic suicidality and borderline personality disorder, and its skills have since been adapted to help people manage emotion dysregulation that can accompany conditions such as anxiety and depression.
At a Glance
- Dialectical behavior therapy was developed by psychologist Marsha Linehan and integrates behavior therapy, cognitive-behavioral principles, and mindfulness[2]
- The term 'dialectical' reflects a balance between accepting experiences as they are and working to change unhelpful patterns[2]
- DBT teaches four skill sets: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness[1]
- Randomized controlled trials indicate DBT can reduce self-harm and psychiatric hospitalizations in people with borderline personality disorder, and adaptations have been studied for mood, anxiety, substance use, and other conditions marked by emotion dysregulation[2]
Overview
Dialectical behavior therapy is a comprehensive, evidence-informed approach within the cognitive-behavioral family of treatments. It was developed by Marsha Linehan in the early 1990s, initially to help people experiencing chronic suicidal thoughts and self-harm in the context of borderline personality disorder. Its central idea is to hold two things at once: validating a person's experience as understandable while also building concrete skills to change patterns that cause distress.
Full-model DBT is typically delivered across four coordinated components: weekly individual therapy, a group skills-training class, telephone or between-session coaching to apply skills in real time, and a consultation team that supports the clinicians providing care. This structure is designed so that skills learned in the group are practiced and reinforced in daily life and in individual sessions.
The skills themselves are organized into four modules. Mindfulness centers on paying attention to the present moment without judgment. Distress tolerance offers ways to get through crises without making them worse. Emotion regulation helps people understand and moderate intense feelings. Interpersonal effectiveness focuses on communicating needs and maintaining relationships while respecting personal limits.
In many outpatient practices, DBT is offered in an adapted or "DBT-informed" format that draws on the skills curriculum without necessarily including every element of the full model. These skills-focused adaptations are increasingly used to help people manage the emotion dysregulation that can accompany anxiety and depression, though the evidence base for these uses is still developing relative to the well-established evidence for borderline personality disorder.
What to Expect
- Initial assessment and orientation, in which the clinician reviews the person's history and goals and explains how DBT works, including its structure and expectations.
- Collaborative commitment to treatment, where the person and clinician agree on target goals such as reducing self-harm, managing intense emotions, or improving relationships.
- Enrollment in skills training, delivered either in a group class or, in some adaptations, individually, covering the four skill modules in sequence.
- Regular individual therapy sessions that apply the skills to the person's specific situations and track progress toward the agreed-upon goals.
- Practice of skills between sessions through structured homework, and, in the full model, access to phone or between-session coaching to use skills in the moment.
- Ongoing monitoring, often using diary cards or similar tools, to observe emotions, urges, and skill use over time and to guide the focus of sessions.
- Periodic review of goals and progress, adjusting the treatment plan and considering whether to continue, taper, or transition to a maintenance phase.
How does Dialectical Behavior Therapy work?
- DBT is built on the idea of dialectics, meaning the deliberate balancing of two seemingly opposite strategies: acceptance and change. Therapists work to validate a person's experience as real and understandable while also helping them build skills to change behaviors that create suffering. This balance is thought to reduce the sense of invalidation that can intensify emotional reactions.
- The mindfulness module teaches skills for observing thoughts and feelings without being overwhelmed by them, which may create space between an emotion and a reaction. Distress tolerance skills provide concrete techniques for surviving intense moments, such as urges to self-harm, without acting on them.
- Emotion regulation skills help people identify, name, and reduce the intensity of difficult emotions, and to build experiences that support more stable mood over time. Interpersonal effectiveness skills focus on asking for what one needs, setting limits, and preserving relationships, which can reduce a common source of emotional stress.
- Because the skills are practiced repeatedly and applied to real-life situations through coaching and homework, DBT is generally understood to work by helping people replace automatic, distressing responses with learned, more adaptive ones. Research suggests that increased skills use is associated with reductions in emotion dysregulation.
When It's Recommended
- Borderline personality disorder, where DBT has the strongest evidence base
- Chronic suicidal thoughts and recurrent self-harm behaviors
- Difficulty regulating intense emotions across a range of mental health conditions
- Anxiety symptoms accompanied by emotion-dysregulation features, as a skills-based adaptation
- Depression accompanied by emotion-dysregulation features, as a skills-based adaptation
- Post-traumatic stress disorder, studied as an adaptation
- Eating disorders such as binge-eating and bulimia, studied as an adaptation
- Substance use disorders, studied as an adaptation
Is a dialectical behavior therapy right for you?
Reach out to learn more from Mario A. Benitez-Lopez.
Recovery & Aftercare
- DBT is generally a longer-term, structured process rather than a brief course of treatment, and comprehensive programs commonly run for several months to a year or more
- Skills are intended to be practiced and reinforced over time, and many people continue to use them well beyond the formal treatment period
- Progress often unfolds gradually, and the early phase focused on safety and crisis skills may precede work on longer-term goals
- When treatment is winding down, clinicians and clients typically plan a transition or maintenance phase to support continued use of skills
- Ongoing follow-up may be recommended to sustain gains and address new challenges as they arise
Alternative Treatments
- Cognitive behavioral therapy (CBT)
- Other evidence-based psychotherapies such as acceptance and commitment therapy or mentalization-based treatment
- Medication management, when appropriate, often used alongside psychotherapy
- Higher levels of care such as intensive outpatient or partial hospitalization programs for higher-risk presentations
Frequently Asked Questions
- Dialectical behavior therapy, or DBT, is a structured, skills-based form of cognitive-behavioral therapy developed by Marsha Linehan. It teaches four core skill sets: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness, while balancing acceptance of difficult experiences with strategies for change.
- DBT does not involve any physical procedures, so it does not hurt in a physical sense. However, talking about distressing thoughts, memories, or emotions can bring temporary emotional discomfort, especially early in treatment. Many people find that the skills gradually make difficult moments more manageable over time.
- DBT is widely regarded as a safe, evidence-informed psychotherapy when delivered by a trained clinician. It was originally designed to help people at high risk of self-harm, and it includes structure intended to support safety. As with any therapy, it works best when the level of care matches a person's needs, which is something to discuss with a clinician.
- Comprehensive DBT programs commonly run for several months to a year or more, typically with weekly individual sessions and a weekly skills group. Adapted or skills-only formats used in some outpatient settings may be shorter, and the right length depends on a person's goals and situation.
- In full-model DBT, a person usually attends weekly individual therapy and a skills-training group, practices skills through homework between sessions, and may have access to between-session coaching. Sessions focus on applying mindfulness, distress tolerance, emotion regulation, and interpersonal skills to real-life situations and tracking progress toward agreed goals.
- Some situations, such as acute psychosis, a manic episode, or severe untreated substance withdrawal, may need to be stabilized before starting skills-based DBT. Skills-only formats can also be insufficient on their own for high-risk presentations. A thorough evaluation helps determine whether DBT, and which form of it, is a good fit.
What are the risks of Dialectical Behavior Therapy?
Who should avoid this
- Conditions that generally require a different primary treatment first, such as acute psychosis or a manic episode, may need to be stabilized before engaging in skills-based DBT work
- Severe, untreated substance withdrawal typically warrants medical stabilization before beginning structured therapy
- Skills-only or DBT-informed formats may be insufficient on their own for high-risk presentations, such as active suicidality, that are usually addressed within the full DBT model or a higher level of care
- Significant cognitive impairment may limit a person's ability to engage with the skills curriculum and may call for an alternative or modified approach
- Circumstances that prevent consistent participation in individual sessions, skills group, and between-session practice can reduce the suitability of the full model
Possible risks
- Discussing distressing thoughts, memories, or emotions during therapy can bring temporary emotional discomfort
- DBT, especially the full model, involves a substantial time commitment and adherence demands, including group attendance, individual sessions, and between-session practice
- Symptoms may fluctuate or feel more intense early in treatment as a person begins confronting difficult experiences and changing established patterns
- Skills-only or DBT-informed adaptations may not provide enough structure or support for someone with a high-risk presentation, which is an important reason to discuss the right level of care with a clinician
- As with any psychotherapy, benefit is not guaranteed, and individual responses vary
Your practitioner
Mario A. Benitez-Lopez, MD
I am a board-certified adult psychiatrist and the founder of San Francisco Concierge Psychiatry. I completed my psychiatry residency at the University of Washington and hold a master's in clinical research from Stanford. I offer bilingual (English and Spanish) care in a concierge model built around small panels and longer sessions, spanning medication management, deprescribing, and evidence-based individual and couples therapy.
Sources & references
This article draws on 5 sources, including government health agencies, peer-reviewed research, leading medical institutions.
Government & research
Medical institutions
Medically reviewed by Mario A. Benitez-Lopez, MD · Last reviewed: 2026-07-26