Dialectical Behavior Therapy (DBT) is a type of psychotherapy/talk therapy. It is based on Cognitive Behavior Therapy (CBT), a type of talk therapy that focuses on helping understand how thoughts affect emotions and behaviors. DBT is a more specific form of CBT for people with heightened emotional sensitivity. CBT is a therapy that focuses on helping patients change their negative thoughts and behaviors. In contrast, DBT focuses on helping patients accept their thoughts and behaviors while teaching them how to manage the things they can control.

"Dialectical" means two opposing things being true at once. In DBT, the dialectics are Acceptance and Change. DBT focuses on helping people accept the reality of their lives and behaviors AND helping them learn to change their lives and their unhealthy behaviors. The goal is to move from "either/or" to "both/and."

DBT teaches four skill modules:

1. Mindfulness: This set of skills teaches clients to live ‘here and now’ and not stay in the past or worry about the future.
2. Emotion Regulation: This set of skills teaches clients how to detect and reflect a person’s emotions without judgment and determine what role those emotions play in our bodies and minds.
3. Interpersonal Effectiveness: This set of skills teaches clients to ask for what they need from themselves and others while keeping calm if things don’t go as desired.
4. Distress Tolerance: This set of skills teaches clients how to tolerate strong emotions that usually send the person into a whirlwind of emotions and thoughts often leading to destructive behaviors.

Comprehensive DBT has 4 components:

1. Individual therapy: supports the learning of skills, provides time to troubleshoot learning, provides much-needed validation, and models a healthy relationship.
2. DBT skills group: once a week (90 minutes). This group teaches the four skills modules (Mindfulness, Emotion Regulation, Distress Tolerance and Interpersonal Effectiveness) within a 24-week period. Typically, clients need to be in the group for 2 rounds of skills group, totaling 1 year.
3. Phone coaching: is used to support use of skills in the moment.
4. Therapist consultation: provides a space for therapists to discuss cases to ensure they are providing the best therapy possible.

*If the treatment has 1-3 components, it is considered DBT-informed.

Dialectical behavior therapy (DBT) was developed in the 1980s by Marsha Linehan, a Behaviorist, and Psychologist. Her early experiences and treatments were the driving force behind her becoming the creator of DBT. Linehan described her struggles with mental illness as "Hell" and vowed that once she got out, she would return to get others out as well. Thus, her journey was to develop a treatment specifically for people who were chronically suicidal.

In the 1970s, Linehan began researching chronically suicidal patients. She initially tried solely behavior therapy to treat these patients and learned quickly that many patients found behavior therapy to be strongly aversive, leading to them getting angry and quitting treatment. The patients would often report feeling "invalidated" by the treatment. Linehan decided to shift gears and try a Humanistic approach, which could be described as the opposite of behaviorism. Humanistic psychologists believe that behaviorists are too concerned with the scientific study and analysis of the actions of people as organisms and pay little attention to aspects of people as feeling, thinking individuals.

Linehan discovered the Humanistic approach did not work with these patients either. She decided to combine the two approaches. So instead of doing just behaviorism or just humanism, they were moving back and forth between acceptance (Humanism) and change (Behaviorism). Dialects helped to balance those two seemingly opposite theories. Over the years, the therapy has been proven effective for many other mental health and behavioral conditions, including:

• Borderline personality disorder (BPD).
• Self-harm.
• Suicidal behavior.
• Post-traumatic stress disorder (PTSD).
• Substance use disorder.
• Eating disorders, specifically binge eating disorder and bulimia
• Depression.
• Anxiety.

Dialectical behavior therapy (DBT) is especially effective for people who have difficulty managing and regulating their emotions.

DBT has proven to be effective for treating and managing a wide range of mental health conditions, including:

• Borderline personality disorder (BPD).
• Self-harm.
• Suicidal behavior.
• Post-traumatic stress disorder (PTSD).
• Substance use disorder.
• Eating disorders, specifically binge eating disorder and bulimia
• Depression.
• Anxiety.

It’s important to note that the reason DBT has proved effective for treating these conditions is that each of these conditions is thought to be associated with issues that result from unhealthy or problematic efforts to control intense, negative emotions. Rather than depending on efforts that cause problems for the person, DBT helps people learn healthier ways to cope.

There are nine symptoms associated with borderline personality disorder (BPD), according to the DSM-5. You need to meet five or more of the following symptoms to be diagnosed with borderline personality disorder:

DBT was created to treat borderline personality disorder. Studies have shown that there is some overlap in BPD and Autism presentations. It is also not uncommon for the two diagnoses to co-occur. Given the similarities, DBT can be an effective treatment for both diagnoses. 

Overlaps in “High-Masking” Autism and BPD presentations:

• Shame
• Mood dysregulation
• A diffuse sense of self
• interpersonal difficulties
• suicidality and self-harm
• Emotion dysregulation
• Increased rates of eating disorders & substance abuse
• Black and white thinking/splitting
• Difficulty with impulse control
• Rejection sensitivity
• Feelings of emptiness
• Paranoia
• May struggle with maintaining friendships or have one intense friendship at a time ("favorite person")
• Mentalization deficits (difficulty understanding the mental state of oneself or others)
• Theory of Mind deficits (inability to accurately explain and predict other people’s behavior)

How DBT is applied to Autistic individuals

During its development, DBT was shaped to avoid making people feel criticized or invalidated, which can cause great suffering in people with BPD and Autism. DBT uses a validating environment to encourage self-driven change to improve individual quality of life. It teaches skills to help regulate emotions, navigate social situations, and effectively self-advocate. Focusing on learning how to navigate social situations reduces the vulnerability Autistic individuals struggle with in social settings. The breakdown on boundary setting is beneficial, showing the person how to recognize red flag behaviors and protect themselves. The skills can also help navigate conflicts and prevent alienating people.

Though this therapy aims to change behaviors, it is important to clarify that DBT is NOT about building compliance or changing the person to benefit others. It is NOT a therapy to "treat Autism". Instead, DBT balances acceptance and change to grow a sense of self, where authenticity and imperfection work together. The changes this treatment encourages are largely driven by the individual and are focused on skill acquisition and empowerment, not eliminating Autistic traits. Autism is a neurotype and DBT therapists do not seek to make a client "less Autistic". 

While developed with BPD in mind, the theories transfer to autism-specific struggles. Therapists focus on helping individuals resolve the stigma around Autism, thus understanding and accepting their personality. The treatment plan focuses on their individual goals. For example, a treatment plan might focus on environmental accommodations, such as providing a quiet area or "safe space" to retreat when feeling overwhelmed to reduce or prevent meltdowns specific to Autism. Acceptance and emotion regulation practices help develop tools to implement when emotions overwhelm. This focus on balance, awareness, non-judgment, and targeted change can provide a structured and approachable way for autistic individuals to unmask.