Dialectical Behaviour Therapy

What is Dialectical Behaviour Therapy (DBT)?

DBT is a model of therapy that has been developed to help individuals who struggle on a day to day basis with managing their emotional states.  When having these difficulties, individuals may utilise strategies that are less then helpful to them and others. These may include self harming behaviour, suicidal intentions and actions, lashing out and/or rejecting others, and other impulsive behaviours such as over-spending, over-eating, drinking, taking drugs, gambling and promiscuous  activity, to name but a few.

Due to having difficulties in controlling emotions & behaviours, relationships can be difficult to maintain, and those seeking to help can be rejected.  Individuals who experience these difficulties  spanning across their early adult & adult years often attract the psychiatric diagnostic label of “Borderline Personality Disorder, or Emotionally Unstable Personality Disorder’. This can often be an unhelpful diagnosis, as it can lead to ‘professionals’ judging behaviours, and not fully understanding the overwhelming struggles of the individual underneath.

Dr Marsha Lineman, an American psychologist, developed DBT. Her perspective on those with a diagnosis of ‘borderline or emotionally unstable personality disorder’ is  that individuals are actually suffering from ‘emotional regulation disorder’, and this inability to regulate emotions often lies in traumatic early experiences, particularly in relation to inattentive, neglectful, and/or abusive primary care-givers. That, as children, these individuals have not been taught, or experienced how to regulate the primary emotions of anger, disgust, fear, happiness, sadness and surprise (shock). An inability to regulate these primary emotions leads to them becoming overwhelming and then an unhelpful action will be performed (eg self harm, lashing out, etc) to get rid of the emotion, which unfortunately leads to unwanted secondary emotions, such as guilt and shame, and of course the consequences of the unhelpful action that has been taken.

DBT recognises that whilst individuals engage in behaviours that are unhelpful to themselves and others (eg self harming, suicidal, impulsive and risky behaviours are called “Life Threatening Behaviours”), that the individual is doing the best they can, with the resources that they have got. DBT encourages individuals to consider their life goals in terms of having “A Life Worth Living”.

DBT identifies four areas that individuals who struggle to manage their emotions, have not had any help with:

 – Distress Tolerance
 – Emotion Regulation
 – Interpersonal Effectiveness
 – Core Mindfulness, being able to make ‘wise mind’ decisions, rather than take impulsive actions

DBT proposes that having a therapist who respects the individual, and can teach them the core skills that have been missing in their early years, will encourage the individual to value their own life by reducing their “Life Threatening Behaviours’” and work towards “A Life Worth Living”.

What does Dialectical mean?

The word “dialectical” describes the notion that two opposing ideas can be true at the same time. In DBT, there is always more than one way to think about a situation, and all people have something unique and different to offer. Dialectics allows for a balance between acceptance and change, both of which are necessary for establishing a fulfilling life.

What this means is that a DBT therapist accepts clients as they are by understanding that engaging in unhelpful behaviours is the client’s way of solving a problem (emotional distress) while also acknowledging that they need to change in order to reach their life goals, and have “A Life Worth Living”.

The Behavioural element of DBT means that your therapist will primarily offer strategies with the deliberate intention of rewarding your learning and use of helpful behaviours, and reducing  your Life Threatening Behaviours.

What does DBT involve?

The absolute primary target of DBT is to keep the client alive – as described earlier, many individuals experience repeated and intensive urges to harm themselves or end their lives, as an unhelpful strategy to manage their distress.  Therefore, if you are engaging in DBT, the first thing your therapist will ask of you is to commit to the first treatment goal of reducing “Life Threatening Behaviours”. You will also be expected to complete diary cards on a weekly basis.

You initially enter the “Pre-Treatment’ Phase, which typically involves:

 – 4-6 sessions
 – Orientation to the DBT model
 – Use of diary cards
 – Introduction to the core skills
  – Strengthening your commitment to reducing “Life Threatening Behaviours”
 – Therapist & Client working together on producing a written agreement. (This is re-visited at 6 months, or if commitment wanes).

Once you have made this commitment, and developed a crisis plan with your therapist, your therapist will then begin to teach you the core skills of: emotion regulation, distress tolerance, interpersonal effectiveness and core mindfulness.  This is very much a teaching approach, and you will have ‘homework’ activities and things to practice between sessions, which includes the completion of diary cards which are reviewed at the beginning of each session.

If you are receiving DBT in a residential or specialist NHS setting, you may be offered a “full DBT programme”. This will involve weekly sessions with an individual therapist, and also weekly group meetings.

If you are engaging with DBT with a private therapist, it is likely that you will receive DBT-informed therapy, as you may not have access to the weekly group meetings.

DBT is considered a long-term therapy, and you will be asked to commit to a year long DBT programme. This will involve weekly sessions of therapy, with a review at 6 months.

How will I work on early trauma, if it is identified?

One of the sad and unfortunate consequences of using life threatening behaviours to manage emotional distress that has been caused  by early traumatic experience is that it can make accessing trauma therapy difficult. This is because it is necessary in trauma-focused therapy for you to process the trauma by being exposed to thinking about it and describing it, in the comforting presence of your therapist. Understandably, for those who find it difficult to manage difficult emotions and distress, engagement in trauma therapy can lead to an escalation in self harming and suicidal behaviours, thus making trauma therapy too risky. Sometimes, what is called ‘chronic’ or ‘complex’ PTSD can develop. (please see trauma pages for more information)

One of the benefits of engaging with  DBT is that you will learn to tolerate and manage your distress, reduce your life threatening behaviours, and improve your quality of life. Once you have achieved this, the third (and I believe) essential target of DBT is the resolution of early trauma.  This will involve you engaging in a form of trauma focused therapy in order to work through early traumas. Upon completion of this stage, you should be well on your journey to A Life Worth Living.

Why choose Nicola @ Nine Wellbeing as my DBT therapist

Nicola is a fully qualified DBT therapist, having undertaken the intensive DBT programme in 2012.  Nicola has previously spent many years working in specialist NHS Eating Disorder and Personality Disorder settings delivering full DBT programmes, and is highly experienced in working with these presentations.  Nicola is a warm and sensitive therapist who values the unique person behind their experience, and as a qualified trauma therapist is passionately committed to working with you to reduce the impact of relational trauma.

Please note that if you engage in individual DBT therapy with Nicola, you will be receiving DBT-informed therapy, as there will be no group component to your DBT treatment.

I want to find out more about DBT therapy with Nicola @ Nine Wellbeing.
What do I do?

Contact Nicola to book an initial consultation

How much does DBT therapy cost?

DBT sessions cost £60 per session.  Sessions usually last between 50 minutes and 1 hour.
Trauma focused sessions can cost up to £120 per session (1.5 hours).


Nicola Forshaw holds a Masters Degree in Counselling (with distinction), a diploma in Cognitive Behavioural Therapy, and a certificate in Dialectical Behaviour Therapy.  Nicola is a highly experienced trauma/PTSD therapist and is fully qualified in EMDR (Eye Movement Desensitisation and Reprocessing). She is accredited by BACP (British Association of Counselling & Psychotherapy), and is also a registered member.