When it comes to therapy options for mental health, two of the most widely known and effective approaches are Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT). For most individuals who did not go to school to learn about therapy, CBT and DBT sound like two random acronyms.
In this blog, I will describe each of these modalities and break down the differences between them so that you can better determine what approach is best for you.
Cognitive Behavioral Therapy (CBT) is one of the most commonly used and researched forms of therapy. This is why insurance companies love CBT - they know it helps (most) people! Developed by an American psychiatrist and professor, Aaron Beck, in the 1960s, CBT was groundbreaking because it encouraged clients to focus on current thought patterns and behaviors (rather than unconscious, past experiences).
CBT teaches us that thoughts, feelings, and behaviors are interconnected. In other words, what we think affects how we feel and behave. According to CBT, if we change how we act or how we think, then we can change the way we feel.
One of the primary goals of CBT is to help clients identify and challenge negative thought patterns and replace them with more balanced and constructive ones. For example, imagine that you possess the core belief: “I’m a failure.” In CBT sessions, you would CBT sessions you and your therapist would work to challenge (or provide evidence against) this thought. Over time, you will integrate more adaptive beliefs, such as “I didn’t succeed this time, but I can learn from it.”
At the beginning of CBT treatment, you and your therapist work collaboratively to identify specific problems you want to address. Sessions might include exercises like thought records (journaling negative thoughts and challenging them) or behavioral experiments (testing new behaviors to see if they result in different outcomes). Often, you will be assigned “homework” to complete between sessions.
CBT is incredibly effective for a range of mental health issues. Beth Fordham and her colleagues (2021) conducted a comprehensive review of the wide range of research on CBT and found it to be highly effective for various mental health conditions, including anxiety disorders (such as generalized anxiety disorder, panic disorder, and social anxiety), depression (particularly mild to moderate cases), post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), chronic pain, substance use disorders, eating disorders, and sleep disorders like insomnia. CBT is one of the most widely endorsed therapies by insurance companies because of the extensive research base that supports the efficacy of this modality.
While CBT is excellent for many, there are some clients who struggle with participating in this modality. In my experience as a psychologist, I have found that some clients find that CBT is frustrating because they feel they are consistently trying to “fix” themselves by changing their thoughts. You may find that sometimes, no matter how much you try to shift your thinking, certain thoughts continue to pop up. This can be quite disheartening when you are putting a great deal of time and energy into trying to change unhelpful core beliefs. Additionally, CBT is focused on problem-solving, leaving less space to sit with and accept current thoughts and emotions.
This is where third-wave behavioral cognitive therapies, such as Dialectical Behavior Therapy (DBT), come in.
Dr. Marsha Linehan, the creator of Dialectical Behavior Therapy (DBT), started developing this treatment in the late 1970s when she was providing CBT to clients diagnosed with Borderline Personality Disorder (BPD) who struggled with self-harm and suicidal thoughts. Linehan found that her clients were frequently dropping out of the CBT treatment that she was providing, and she wanted to find a better way to support her clients. While reviewing tapes of her sessions, Linehan noticed that there were moments of rupture in her relationship with clients when she used certain CBT interventions. It appeared that clients felt invalidated by her - she consistently asked her clients to change their thoughts and behaviors; however, these clients wanted to be met with compassion and acceptance for where they were at. This realization fueled Linehan (1993) to create another approach to support her clients, which we now know as Dialectical Behavior Therapy (DBT).
While DBT shares many similarities with CBT in that it focuses on changing ineffective emotions and behaviors, DBT introduces a critical component that sets it apart: acceptance. Where CBT focuses on change, DBT aims to strike a balance between accepting things as they are and working to change them. This is a foundational “dialectical” principle of DBT: everyone is doing the best they can at every given moment with the resources they have (acceptance) AND everyone needs to do better (change).
While DBT was initially developed by Linehan for the treatment of BPD, over time, this modality has expanded and is considered a transdiagnostic approach. In other words, it is an effective treatment for a wide variety of populations: post-traumatic stress disorder (PTSD), anxiety, eating disorders, substance use challenges, mood disorders (including depression and bipolar disorder), adolescents at risk for suicide and self-harm, dependent personality disorder (DPD), forensic populations, and chronic pain and somatic disorders.
It is worth noting that while DBT helps many people, it is particularly beneficial for individuals who identify as emotionally sensitive. DBT teaches us that if you possess the trait of emotional sensitivity, you feel more frequently, intensely, and for longer durations. This term was coined by Linehan, who developed Dialectical Behavior therapy (DBT) to help emotionally sensitive people who have a history of invalidation. The theoretical foundation of DBT is called biosocial theory, which states that when an emotionally sensitive person is met with an invalidating environment, it can lead to malapative coping skills and low self-esteem.
If you frequently feel overwhelmed by emotions and have a history of being told you are “too much,” you will likely benefit from DBT. One of the reasons DBT helps people who feel intensely is that it emphasizes compassion and self-validation. If you are in DBT treatment, you will learn that your feelings are important, even if you do not like experiencing them or if other people tell you that they are “wrong.” One of the greatest strengths of DBT is that it helps clients radically accept their emotions and meet those feelings with compassion.
An additional component of DBT that sets it apart from CBT is that is focuses heavily on skill development. During DBT sessions, therapists teach clients skills from four modules: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. If you undergo DBT treatment, you will learn skills that will help you observe and participate in the present moment, tolerate distress and overwhelm, better manage emotions, and improve your relationships.
It is important to note that not all DBT is created equal. While some therapists provide comprehensive DBT, other therapists provide DBT-informed treatment. If you are struggling with self-harm or life-interfering behaviors, you may benefit most from comprehensive DBT treatment. This treatment would include weekly individual therapy, groups where you learn DBT skills (DBT skills training), and as-needed phone coaching between sessions with your primary therapist.
Most therapists who provide DBT therapy will provide DBT-informed treatment - if you are interested in comprehensive, adherent treatment, make sure you check with the treatment center or provider to ensure that you are receiving the treatment you are seeking.
While there are some significant similarities in these modalities, DBT is considered a third wave of cognitive behavioral therapy because it includes the foundations of CBT with an added focus on mindfulness, acceptance, and self-compassion.
Picking a therapeutic modality is a personal choice. Here are some things to keep in mind when making the decision:
When we are in the overwhelming process of choosing a therapist, we oftentimes feel like we have to pick the perfect treatment for us. The reality is that many therapists combine techniques from both CBT and DBT. This means you do not necessarily have to “choose” one. There is significant overlap between these modalities - modern CBT often incorporates mindfulness, and many DBT therapists use cognitive restructuring techniques from CBT.
Choosing the right therapy may take time, and that is okay. I encourage you to take a page from the DBT handbook and practice some self-compassion as you embark on the journey of finding the help that you deserve.
Fordham B et al (2021). The evidence for cognitive behavioural therapy in any condition, population or context: a meta- review of systematic reviews and panoramic meta-analysis. Psychological Medicine 51, 21–29. https://doi.org/10.1017/ S0033291720005292
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.
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