Pros and Cons of DBT Therapy

Dialectical behavior therapy is an evidence-based treatment with a strong body of research to support it. Will it work for you personally? Read on to discover a list of four pros and cons of DBT therapy, to help you decide for yourself if it would be effective for you to try.

Let me acknowledge my personal bias up front: I am the opposite of objective about this. This is the first style of therapy that worked for me personally to reduce my own anxiety and to accept the parts of my life that I did not know how to sit with. I pursued advanced training in this type of therapy and then dedicated my career to delivering DBT because it worked for me personally, and because watching it work for other people is immensely rewarding.

That does not mean I cannot see its flaws. No therapy style is perfect, and none of them work for everyone. So let's get into that nitty gritty today, in the hopes that looking at some of the benefits and some of the risks can help you determine if DBT could fit your life. Each of these elements can be viewed as a con or as a pro, depending on what you are looking for.

Cons of DBT therapy

In the interest of giving a full picture of both the benefits and the risks of doing DBT work, I will start with what I view as some of the more difficult parts of the treatment. Here are some of the cons to know about beforehand.

Heavily structured framework

As a DBT therapist I start every session constructing an agenda with my clients based on a hierarchy of what is most important to them and to me to explore that day. I often have people fill out information about their week ahead of time on an app or a piece of paper, and we start the session going over that together. For clients who are used to talk therapy, where the container of therapy is more loose, and there is no set order of what to focus on when, this can be jarring. If you are part of a comprehensive DBT program, you go through DBT therapy groups concurrently with your individual sessions. As you progress through DBT groups there is a set order of the four modules and a set order for which skills to teach when. That means that you do not have control over which skills you learn in therapy group that day.

Time investment

DBT was originally designed to take one year to progress through. The four modules worth of material take six months to get through total, with the expectation that it will take at least two passes through the material to actually absorb enough of it. This is because it was initially developed for people in crisis, people who have been diagnosed with borderline personality disorder, and people who have tried other treatments before only to find that they do not work for them. For these groups of people, crises can come up and make it difficult to mindfully absorb six months of material. For people who are looking for faster changes in their life, six months to a year can seem like a lifetime. DBT is designed to progress over phases, where the first phase you focus on emergency skills for dealing with crisis, and then you move on to longer term work, like addressing traumatic events from the past or exploring how to live fully in line with your values. None of this can be accomplished over a short period. DBT requires a serious time investment.

Designed with Christian, white, heterosexual clients in mind

DBT was originally intended to serve one very specific group of people who did really need support. This is a therapy that got its start in 1991 and was developed by a white woman, Marsha Linehan. Placing DBT within the context of the biographical details of its founder, we can start to see how and why DBT deals with race or systems of oppression or polyamorous relationships in a specific way. Minority stressors, microaggressions, or powerful systems put in place to do harm: none of these get a lot of airtime in DBT. It is often left up to the client to raise these issues, instead of being addressed thoughtfully at the outset. You can bend DBT to serve the cause of advancing social justice, but I would argue that that’s not what it was originally intended to do. That’s what I’m trying to do with Full Focus Therapy: take the usefulness of the guiding philosophy of DBT, and the specific helpful skills from DBT, and make them work for LGBTQ+ people. 

Acronyms gone wild

This facet of doing DBT feels inescapable: you cannot talk about DBT for more than five minutes without having to explain an acronym and why it’s called that. We use memory aides so that in the moment of crisis you can pull up the skill you need. Sometimes, the way those acronyms come together is a little questionable. I have to call out one in particular: the PLEASE skill, or the skill for taking care of your physical body in order to take care of your mental health. Tell me why this acronym reads:

• Treat Physical iLlness: take care of your body when it feels sick, with things like going to the doctor for preventative visits

• Balance your Eating: eat the amount of food and the kinds of food that work for you and your body

• Avoid mind-altering substances: be careful about what substances you put in your body and be mindful about the impact those substances have on you

• Get enough Sleep: consistently get the amount of sleep that leaves you well-rested

• Get regular Exercise: aim for exercising for 30 minutes a day, again based on what limits your body sets.

Many DBT programs take this skill into their own hands and scramble it around to form something a little more intuitive. I’ve often heard the PLEASE skill remixed as the SEEDS skill, which I feel suits the metaphor of nurturing your long-term physical health better. SEEDS stands for:

• Symptoms: same as “treating physical illness”

• Eating

• Exercise

• Drugs

• Sleep

Pros of DBT therapy

Time to dive into what works about DBT! Below you will find my personal top four parts of doing DBT work.

DBT gives tangible advice and honesty

Many therapists I talk to share their hesitancy around “telling clients what to do,” or giving their clients honest feedback about what it is like to spend an hour with them. I love that DBT makes room for both of these things, because I honor the privilege we get as therapists to be one of the people in our client's’ lives they can trust to be real with them. As a DBT therapist I will say to my clients “hey, I’m nervous to bring this up with you out of the fear that it will be hard for you to hear, and I do think it would be something you’d want to know. Can I share that with you now?” Because DBT is more directive, and my clients are used to me making tangible suggestions for what to try next, this question does not come out of left field. I have never once had a client tell me they did not want to know what I was going to say- most of us are innately curious about ourselves as people, and part of being a dedicated therapist means creating a space where your clients can trust you to be honest with them. A DBT therapist might look you straight on and say “dump his a**!” or “you are doing this to yourself!” when it’s appropriate and helpful to say, and I think that builds up the real relationship we share, rather than detracting from it. 

Using skills leads to building mastery leads to self-esteem

Sometimes a client will say to me “there’s no guidebook for how to do this” or “I wish I had like a step-by-step for how to make this choice,” and it makes me feel so satisfied when I can tell them, “actually, there is!” Sometimes I have the exact right skill that somebody needs right then, and it is electrifying! I love it! Now that is of course not always the case. Not every problem has a solution, and not every situation needs a particular tool from the DBT toolbox. What I find in those situations, where there is no quick fix and there is no skill I can teach them that’s going to make a heartache less unbearable, is that many clients are left to rely on their own internal sense of capability. They have to try and draw from their own inner power. And I think that having used other skills in other situations in their lives can provide some backbone. It shows them that they are capable, and they can survive unsurvivable things, and they have the power within themselves to turn cruelty or horror into fertilizer for a life worth living. 

Proven results in making change, and in finding acceptance

Most of the people I work with who come looking for DBT want to make a serious change in their lives. I love that there is room for designing specific steps together and there is time dedicated to following through on those changes. DBT gets results in a way no other form of therapy I have practiced does. We see it again and again in the research, and I saw it again and again in the people I work with doing DBT. Here’s one example of the kind of results I’m talking about: the participants in one research study conducted by the VA who received DBT “reported significantly greater decreases in suicidal ideation, hopelessness, depression, and anger expression. In addition, only patients in DBT demonstrated significant decreases in number of parasuicidal acts, anger experienced but not expressed, and dissociation and a strong trend on number of hospitalizations, although treatment group differences were not statistically significant on these variables.”

We change what we can; what do we do with the rest? What I did not expect to enjoy was the other half of DBT skills, the acceptance side. DBT grounds acceptance work in legitimizing how difficult, how impossible it is to accept some parts of our lives. And then amidst that difficulty: Here is how to sit with this pain. Here is how you can crack open the door to acceptance even one millimeter further. Here is how to exist with the unthinkable. 

Physicality of therapy sessions

DBT is a creative, physical kind of therapy. I’m right beside my clients as we dunk our heads in bowls of ice water. I’m on the ground sweating through a  “broken toe” pose from yoga to practice tolerating distress. DBT is not something I teach to another person out of a manual, although there is often a manual there; DBT is something I use in my life every day, and we practice the different parts of it together to find what works for each person. There is room for experimentation and creativity, because DBT has the solid ground of researched techniques to stand on.

If looking at the risks of benefits of doing DBT has you feeling curious to learn more, read about how DBT therapy works at Full Focus Therapy here. Or more generally, you can read about what LGBTQ+ friendly therapy can look like here.