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 at the University of Washington. 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. I trained in DBT at the University of Washington, in a year-long course of training and supervision, and I see both people who want the skills for themselves and people already in a DBT program.
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
Marsha Linehan developed dialectical behavior therapy in the early 1990s for people experiencing chronic suicidal thoughts and self-harm in the context of borderline personality disorder. DBT is a comprehensive, evidence-informed treatment within the cognitive-behavioral family. Its central position is that both acceptance and change are necessary: a person’s experience can be understandable, and patterns that cause distress can still need to change.
Full-model DBT coordinates four components: weekly individual therapy, a group skills-training class, telephone or other between-session coaching, and consultation among the clinicians providing care. This structure is designed to move skills from the group into daily life, with continued practice and reinforcement during individual sessions.
The curriculum has four modules. Mindfulness teaches attention to the present moment without judgment. Distress tolerance addresses how to get through a crisis without making it worse. Emotion regulation focuses on understanding and moderating intense feelings. Interpersonal effectiveness covers asking for what you need, maintaining relationships, and respecting your own limits.
Many outpatient settings offer an adapted or DBT-informed format rather than the full model. These formats use the DBT skills curriculum without necessarily providing all four components. Skills-focused adaptations are increasingly used for emotion dysregulation that accompanies anxiety or depression, although the evidence for these uses is still developing compared with the established evidence for borderline personality disorder.
What to Expect
- Initial assessment and orientation, in which the clinician reviews your history and goals and explains how DBT works, including its structure and expectations.
- Collaborative commitment to treatment, in which you and the 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 your own 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 your 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?
- The word dialectical refers to holding two apparently opposite strategies at once: acceptance and change. A DBT therapist validates the person’s experience as real and understandable while helping that person change behaviors that create suffering. This balance is thought to reduce the sense of invalidation that can intensify emotional reactions.
- Mindfulness skills build the habit of observing thoughts and feelings without being overwhelmed by them. This may create space between an emotion and the reaction that follows it. Distress tolerance provides concrete ways to survive an intense moment, including an urge to self-harm, without acting on that urge.
- Emotion regulation skills help you identify and name difficult emotions, reduce their intensity, and build experiences that support a more stable mood over time. Interpersonal effectiveness focuses on asking for what you need, setting limits, and preserving relationships. These skills can reduce a common source of emotional stress.
- DBT skills are practiced repeatedly through homework, coaching, and application to situations that occur outside the session. The aim is to replace automatic responses that create distress with learned, more adaptive responses. Research suggests that increased use of DBT skills is associated with reduced emotion dysregulation.
- The four modules include named skills that are rehearsed until they are available under pressure. Wise mind sits between pure emotion and pure logic. Radical acceptance applies to circumstances that cannot change. Opposite action means doing the reverse of what an emotion urges when that emotion misreads the facts. I teach these skills one to one, weekly, over months.
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
Have questions about this treatment?
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 balances acceptance of difficult experiences with efforts to change unhelpful patterns. Its four core skill sets are mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.
- DBT does not involve a physical procedure, so it does not hurt physically. Talking about distressing thoughts, memories, or emotions can cause temporary emotional discomfort, particularly early in treatment. Many people find that difficult moments become more manageable as they learn and practice the skills.
- DBT is widely regarded as a safe, evidence-informed psychotherapy when a trained clinician delivers it. It was originally designed for people at high risk of self-harm and includes structure intended to support safety. The level of care still needs to match the person’s needs, particularly when there is ongoing self-harm or suicidality.
- Comprehensive DBT commonly lasts several months to a year or more, with weekly individual sessions and a weekly skills group. Adapted or skills-only outpatient treatment may be shorter. The appropriate length depends on your situation and treatment goals.
- In full-model DBT, you usually attend weekly individual therapy and a skills-training group, complete homework between sessions, and may use between-session coaching. Treatment applies mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness skills to situations in your life while tracking progress toward agreed goals.
- Acute psychosis, a manic episode, or severe untreated substance withdrawal may need to be stabilized before skills-based DBT begins. A skills-only format may also be insufficient for a high-risk presentation. A thorough evaluation helps determine whether DBT is appropriate and whether the full model, an adapted format, or another level of care fits the situation.
- No, and the difference matters before you choose. A full DBT program provides individual sessions, a weekly skills class with other patients, phone coaching between sessions, and consultation among the clinicians treating participants. I am one physician, so I provide the adapted individual form: the four skills modules taught one to one and applied to what happened during your week. For a high-risk presentation, particularly ongoing self-harm or suicidality, a comprehensive program is the appropriate level of care. I would tell you that and help you find one.
- Here, yes. In most DBT settings, one clinician handles the skills work and another handles prescribing. That is a reasonable division of labor, but it also means that no single person sees the full week. I handle both, so if distress tolerance skills are failing on days when a dose is wearing off, the person noticing that connection can address both the medication and the skills work.
- Yes. Your DBT program remains your primary treatment, while I manage medication using the same skills vocabulary that the program teaches. The same arrangement can work when you are doing DBT with an individual therapist.
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
- Circumstances that prevent consistent participation in individual sessions, skills group, and between-session practice can reduce the suitability of the full model
Who needs extra 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
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: 2026-08-31