Do You Have to Be in Crisis to Do DBT?
Written by Jessica Oliver, MSW, LCSW, with clinical contributions from Samantha White, MS, LPC
A lot of people read about DBT, recognize themselves in about half of it, and then talk themselves out of it.
The reasoning usually goes one of two directions. Either "I'm not bad enough for that," or "that's for people with borderline personality disorder and that's not me."
Both of those are worth a closer look, because I've watched a lot of people wait years longer than they needed to.
Who is DBT actually for?
I asked Sam White, one of our therapists, to describe it in plain language. Here's what she said:
"DBT is meant for individuals who experience things like a rollercoaster of emotions, difficulty in their personal relationships, feel like stressors are piling up, and have trouble staying in the here and now."
Read that again, because there's nothing in it about hospitals or diagnoses.
A rollercoaster of emotions. Relationships that keep going sideways. The sense that everything is stacking up faster than you can handle it. Difficulty staying in the present moment.
That's a much wider door than most people assume.
Sam spent much of her career at Ozark Center in Joplin, where she served on both the DBT team and the RO-DBT team and was DBT Team Lead from 2020 to 2022. She's DBTmo certified, certified in RO-DBT Level 1, and certified in Prolonged Exposure. I've been doing DBT since 2005, in a state forensic hospital, in a school for kids with significant emotion regulation challenges, and in private practice. Between the two of us, we've seen who actually shows up for this treatment, and it's a broader group than the research summaries suggest.
Was DBT created for borderline personality disorder?
Yes, originally. Absolutely.
Marsha Linehan developed DBT while working with people who were chronically suicidal and repeatedly self-harming, many of whom met criteria for borderline personality disorder. She has spoken publicly about her own history with that kind of suffering, which is part of why the treatment is built the way it is. It was designed by someone who understood the problem from the inside.
One thing I’ve always found interesting is that Linehan has said she was never interested in borderline personality disorder as a disorder in itself. What she was trying to treat was suicidal behavior. BPD was the diagnostic category the research world had for those patients, so that's the category the studies got built around.
That origin gave DBT the strongest evidence base of any treatment for BPD. It also gave it a reputation that has since stopped being accurate.
Because here's what happened next. Researchers kept studying DBT in other populations, and it kept working. Today it's used for eating disorders, substance use, treatment-resistant depression, PTSD alongside other diagnoses, and emotion dysregulation generally, whether or not anyone has ever put a personality disorder label on it.
While we're here, one thing about that diagnosis. Borderline personality disorder is one of the most stigmatized labels in mental health, and a lot of that stigma comes from clinicians rather than the public. It is not a character flaw and it is not a life sentence. It describes a pattern of intense emotions, unstable relationships, and difficulty with identity that usually developed in an environment that consistently invalidated what someone felt. We've written about what that kind of environment does to a person here: the impact of invalidation.
BPD also happens to be one of the most treatable things we work with. That is not what most people have been told.
Do you need a BPD diagnosis to do DBT?
No. Absolutely not. You don't need any particular diagnosis.
We aren't screening for a label. We're looking at how your emotional system works and what it's costing you.
If your emotions come on faster and bigger than other people's and take longer to settle, if you've found ways to survive those feelings that help in the moment and cost you later, if your relationships keep ending in ways that leave you wrecked, DBT was built for that pattern. The diagnosis is beside the point.
The same is true in reverse. Plenty of people carry a BPD diagnosis and don't need comprehensive DBT right now. What matters is the pattern and the level of intensity, not the paperwork.
What if you've tried therapy for depression and nothing has worked?
This is the group I most wish knew about DBT. This is the group I’ve personally seen benefit so much from a treatment that is literally designed to help you create and live a life worth living.
Here's Sam again:
"DBT is also recommended for treatment-resistant depression. If you have tried everything and nothing seems to be helping with a depressed mood, DBT may be the answer."
If you've done years of talk therapy, tried several medications, and you're still depressed, the usual conclusion people reach is that they're the problem. That something about them is broken in a way that doesn't respond to treatment.
I'd offer a different explanation. Sometimes the treatment wasn't built for what you're actually carrying.
Depression that doesn't move often isn't just depression. It's frequently sitting on top of emotion dysregulation, or a history of being invalidated, or a set of coping strategies that made sense once and are now keeping things stuck. Insight alone doesn't shift that. Skills, practiced weekly, in your real life, with a therapist watching the patterns with you, sometimes does.
We've written more about that here:
What if you think your emotions are too much for a therapist?
This one comes up more than you'd guess, and it stops people from calling at all.
If you've had the experience of a therapist looking overwhelmed, or changing the subject, or gently suggesting you find someone else, you learn something from that. You learn to manage the room. You show up to therapy and give the tolerable version.
I want to name something about DBT specifically. It's one of the few treatments explicitly designed for high intensity, which is why it includes a weekly consultation team for the therapists. Your clinician isn't carrying your care alone, and they aren't supposed to. That structure exists so nobody has to flinch.
We wrote a whole post about this fear: what if my emotions are too much for a therapist.
What about teenagers?
A lot of families find DBT after something frightening happens. A discovery about self-harm. A comment about not wanting to be here. A child who has tried to run away several times. A teen engaging in risky sexual or substance abuse behavior. A call from a school counselor about problems in school..
If that's where you are, you're not alone in it and there are real things to do. We've written for parents in that position:
But teens don't have to be in crisis for DBT to be the right call either. A teenager whose emotions run hot, who fights constantly with everyone in the house, who can't seem to let anything go, is a good candidate long before anything scary happens.
One of my favorite things about DBT with teenagers is that we teach the whole family. In a multifamily skills group, parents learn the same skills their kid is learning, and we ask them to use them too. It changes the temperature of a house faster than individual therapy alone does. If you want a starting point on that, we wrote about validating your teenager, which is a skill most of us were never taught.
You can also read more about our teen counseling services.
Who is DBT not a good fit for?
There are three groups that immediately come to mind when I think about who I would not recommend for DBT:
People who are actively experiencing psychosis. Sam put it directly: DBT is not meant for individuals who are actively experiencing psychosis. That needs different treatment first. Usually here I recommend having a psychiatrist and therapist who can work together until the symptoms of psychosis are stable.
People who need a higher level of care right now. Comprehensive DBT is an outpatient treatment. If someone needs daily support, medical monitoring, or a safer setting than once a week, that comes first. We'd help you find it.
People whose situation is genuinely smaller than this. If what you're carrying is mostly stress, or a specific problem you're working through, or you want a few coping tools, comprehensive DBT would be a much larger commitment than your situation calls for. There are approaches that would serve you better and cost you far less. We'd tell you that, and we'd help you find the right person.
That last one matters to me. DBT is a life changing treatment for people who need their life to change. It is an expensive, demanding, six month answer to a question you may not be asking. I LOVE DBT. I believe it is an incredible vehicle to change lives. But if you don’t need it, then it’s not worth the investment of time, money and energy.
Not sure if any of these are you? Reach out and one of our DBT therapists can meet with you and help you figure out if it’s the right fit. We’ll be honest about our opinion and point you in another direction if DBT isn’t the best match for you at this time.
So how do you know which one you are?
You don't have to figure this out by yourself before you call. That's the part I most want people to hear.
Comprehensive DBT doesn't start the way a regular first therapy appointment does. It starts with an orientation and commitment process that takes several weeks. You meet with an individual DBT therapist, you go through exactly what the program involves, what we're asking of you, and what you can ask of us. You talk about what you want your life to look like and what's getting in the way.
Then you decide, on purpose, whether to commit.
That process exists partly because people do better when they've genuinely chosen a treatment rather than agreed to it in a first appointment while overwhelmed. But it also exists so that both of you can find out whether this is the right treatment before anyone is six months in.
If you're not sure whether you're "bad enough," that's exactly the conversation orientation is designed to have.
If you want the background on how comprehensive DBT differs from what most practices offer, we covered that here: comprehensive DBT vs. DBT-informed therapy. And if you want to know what the skills themselves are, we walked through all four sets here: what are DBT skills.
One skill worth knowing about while you decide, because it applies directly to being stuck in a situation you can't fix today: radical acceptance.
Begin DBT in Columbia or Lee's Summit
You don't have to be at your worst to deserve good treatment. And you don't have to have a specific diagnosis to benefit from learning how your emotions work and what to do when they get loud.
If you've been reading this thinking "some of that is me, but probably not enough of it," that's worth a conversation rather than another year of waiting.
Call us at 816-287-1116 in Lee's Summit or 573-328-2288 in Columbia, or contact us here. You can also read more on our DBT page.
We have offices in Columbia and Lee's Summit and see clients throughout Missouri by telehealth. Skills groups and consultation team meet online, so wherever you are in the state, you can be part of the full program.
Whenever you're ready for effective care and lasting change, we're here.
About the Author
Jessica is the founder and clinical director of Aspire Counseling. She started learning DBT in 2005 as a BSW student at Fulton State Hospital and has practiced it in three settings since: a state forensic hospital, a school for students with significant emotion regulation challenges, and private practice, where she sat on a consultation team that included Ronda Oswalt Reitz, PhD. She's also trained in EMDR, Cognitive Processing Therapy, and Prolonged Exposure, which she originally learned in order to be a better DBT clinician. She sees adults in Columbia and online throughout Missouri.
Sam White sees clients at Aspire Counseling in Columbia and online throughout Missouri. She spent much of her career at Ozark Center in Joplin, where she served on both the DBT team and the RO-DBT team and was DBT Team Lead from 2020 to 2022. She's DBTmo certified, certified in RO-DBT Level 1, and fully trained in Prolonged Exposure. She also spent three years as a professor and program director supervising provisionally licensed counselors. Sam specializes in eating disorders and disordered eating, trauma, anxiety, and working with first responders.
If you're having thoughts of suicide or you're worried about your safety right now, please call or text 988 to reach the Suicide and Crisis Lifeline, or go to your nearest emergency room. You can reach the Crisis Text Line by texting HOME to 741741.
