Psychiatry: treatments
Dialectical behaviour therapy (DBT)
Dialectical behaviour therapy (DBT) is a structured therapy that teaches skills to manage intense emotions, self-harm and relationship crises. It was developed for borderline personality disorder and is now used for many people with severe emotional dysregulation.
Depth by stage, Pre-U → Consultant (details)
What is it?
DBT was developed by psychologist Marsha Linehan for people who repeatedly self-harmed or felt suicidal and had not been helped by other therapies. It blends CBT with acceptance and mindfulness ideas. The 'dialectic' is the balance between accepting yourself as you are and working hard to change.
Standard DBT has four parts running together: weekly individual therapy, a weekly skills-training group, phone coaching between sessions for crises, and a consultation team that supports the therapists. The skills taught are mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness.
Full DBT programmes are resource-heavy and still limited in Malaysia, but DBT-informed skills groups and adapted versions are increasingly offered, including for adolescents.
Why does a psychiatrist need it?
Patients with emotional dysregulation and repeated self-harm are among the most challenging and high-risk in psychiatry. Psychiatrists must understand DBT to refer appropriately, use its validation and skills language, avoid harmful reactions such as rejection after self-harm, and support DBT-trained colleagues.
What level is expected at each stage?
Scale: 1. Aware → 2. Understands → 3. Applies → 4. Masters / Teaches. What the levels mean.
- Pre-UNot expected
- Pre-clinicalNot expected
- ClinicalAwareAware of DBT as a treatment for borderline personality disorder.
- HousemanshipNot expected
- Medical officerAwareRecognises patients who may benefit and uses basic validation in emergencies.
- Psych traineeUnderstandsUnderstands the model and skills modules; may co-facilitate a skills group.
- Specialist / consultantAppliesIntegrates DBT principles into service design for self-harm and personality disorder care.
What are the key topics?
Model
- Biosocial theory: emotional vulnerability plus an invalidating environment
- Dialectics: acceptance and change
- Treatment hierarchy: life-threatening behaviours, therapy-interfering behaviours, quality-of-life issues
- Diary cards and chain analysis of problem behaviours
Skills modules
- Mindfulness: observe, describe, participate non-judgementally
- Distress tolerance: TIP skills, distraction, radical acceptance
- Emotion regulation: naming emotions, opposite action, reducing vulnerability
- Interpersonal effectiveness: asking for needs, saying no, keeping self-respect
Programme structure
- Individual therapy
- Skills-training group
- Between-session coaching
- Therapist consultation team
- Adaptations: DBT for adolescents (DBT-A), substance use, eating disorders
Evidence and context
- Reductions in self-harm and hospital use in borderline personality disorder
- Comparison with mentalization-based treatment and other structured approaches
- Cultural adaptation in Malaysia, including family and religious considerations
- Using DBT-informed approaches when full DBT is unavailable
How is it learned and assessed?
- Introduced in teaching on personality disorders and self-harm
- Seminars and possible co-facilitation of skills groups during specialist training
- Examined in MMed (Psychiatry) and MRCPsych papers under psychotherapies and personality disorders
- Formal DBT training is a separate, intensive course for clinicians who wish to deliver it
Typical textbooks and resources
- Cognitive-Behavioral Treatment of Borderline Personality Disorder — Marsha M. Linehan
- DBT Skills Training Manual — Marsha M. Linehan
- NICE guidance on borderline personality disorder and self-harm (UK)
Titles are widely used examples; editions change. Use university libraries or legitimate purchases.
Common questions
Who is DBT for?
Mainly people with intense, rapidly changing emotions who self-harm or feel suicidal, especially those with borderline personality disorder. Adapted versions help adolescents and people with substance use or eating problems.
How long does DBT last?
A standard programme often runs for around six months to a year, combining weekly individual sessions and a weekly skills group.