Dialectical behaviour therapy (DBT) skills, online across NZ

What is DBT?

Dialectical Behaviour Therapy (DBT) is a structured cognitive behavioural therapy developed by Marsha Linehan for people whose emotions are intense and fast-changing. It balances acceptance with change and teaches four sets of skills: mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness. Research supports full DBT programmes for borderline personality disorder, and DBT skills for emotional dysregulation more broadly.

What "dialectical" means, and why it matters

A dialectic is two things that seem to contradict each other being true at the same time. DBT is built on one in particular: you are doing the best you can, and you need to do better. Most people who arrive at DBT have been told one half of that for years. Either everyone has been telling them to try harder, or everyone has been making allowances. Holding both is what makes the therapy work.

In practice this shows up as a balance between acceptance and change. Your psychologist will take your emotional reactions seriously as understandable responses to your history and your wiring, and will also expect you to learn and use skills that change what happens next. Validation without change leaves you stuck. Change without validation feels like being told you are the problem.

DBT grew out of Marsha Linehan's work in the 1980s and 1990s with people whose suicidal behaviour and emotional pain had not responded to standard CBT. It has since been adapted far beyond that original group.

The four skills modules

DBT skills are taught explicitly, practised between sessions and tracked. They fall into four groups. The names can sound clinical; the content is practical.

• Mindfulness. The foundation for everything else: noticing what is happening in your mind and body without immediately reacting to it or judging it. DBT teaches this through specific skills (observe, describe, participate) rather than long meditation, and introduces the idea of "wise mind", the place where emotion and reason inform each other instead of fighting.
• Distress tolerance. Getting through a crisis without making it worse. This includes fast physical tools for bringing down a surge of emotion (cold water on the face, paced breathing, intense brief exercise), a structured pause before acting on an urge, and radical acceptance, which means stopping the fight with a reality you cannot change right now. These are the skills for the 11pm moment when the urge is to send the message, pour the drink or walk out.
• Emotion regulation. Understanding what emotions are for, naming them accurately, checking whether the intensity fits the facts, and acting opposite to an emotion's urge when the emotion is not justified (approaching rather than avoiding when afraid, gently engaging rather than attacking when angry). This module also covers the basics that make everyone more reactive when neglected: sleep, eating, exercise, illness and substances.
• Interpersonal effectiveness. Asking for what you need and saying no, in ways that keep both the relationship and your self-respect intact. Scripts for difficult conversations, how to balance your priorities against someone else's, and how to stop oscillating between people-pleasing and blowing up.

In a full programme the modules are taught in a weekly skills group over about six months. In individual DBT-informed therapy the same skills are taught one-to-one, selected and sequenced around what you need most.

Who DBT skills suit

DBT skills were developed for people with extreme emotional sensitivity, and they remain the clearest treatment for emotional dysregulation: emotions that are quick to fire, intense and slow to settle. You do not need a diagnosis to benefit, and many people who learn DBT skills do not have one. Common reasons people come:

• Anger that arrives faster than thought, followed by shame and repair. See also our anger page.
• Harsh self-criticism and a sense of being fundamentally too much or not enough.
• Impulsive actions under emotional pressure: spending, drinking, texting an ex, quitting a job by email, self-harm.
• Relationships that run hot and cold, with intense closeness followed by conflict or withdrawal, and a fear of being left.
• Emotional intensity linked to trauma, ADHD or long-standing patterns from childhood.
• A diagnosis of borderline personality disorder (BPD) or BPD traits, where DBT has the most direct evidence.

Research on DBT skills training delivered on its own, without the rest of a full programme, suggests it helps with emotional dysregulation across a range of problems, including anxiety and depression, not just BPD.

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Full DBT programmes versus DBT-informed individual therapy

This distinction matters, and we want to be clear about it. A full DBT programme, the version tested in most of the research on borderline personality disorder, has four parts: weekly individual therapy, a weekly skills group, between-session phone coaching, and a consultation team for the therapists. It usually runs for about a year and is designed for people at high risk, often with recurrent self-harm or suicidal behaviour.

Mindwell does not offer a full DBT programme. What we offer is individual DBT-informed therapy by video: one-to-one sessions with a psychologist who teaches the DBT skills, uses DBT's methods (such as chain analysis of a difficult event and diary cards to track emotions and skills use) and holds the dialectical stance throughout. There is no group and no between-session phone coaching.

For many adults with emotional dysregulation, that is an appropriate level of care. For some it is not. If you are self-harming regularly, have had recent suicide attempts, or are in frequent crisis, a full programme through Health NZ community mental health services or a specialist DBT provider is the right pathway, and your GP can refer you. The NICE guideline on borderline personality disorder recommends comprehensive DBT for women for whom reducing recurrent self-harm is a priority. Your Mindwell psychologist will tell you honestly in the first session if they think you need more than we can provide.

What the evidence says

A 2020 Cochrane review of 75 randomised trials involving 4,507 people found that psychotherapy in general, and DBT specifically, reduced the severity of borderline personality disorder, reduced self-harm and improved day-to-day functioning compared with usual treatment. The reviewers rated the quality of the evidence as low, which means the size of the effects is uncertain, but the direction was consistent. DBT is the most studied of the therapies for BPD and is recommended in clinical guidelines.

For DBT skills on their own, a 2015 systematic review of studies using skills training as a stand-alone treatment found benefits across a range of populations, and a randomised pilot trial of DBT skills for people with anxiety and depression and high emotional dysregulation found greater improvements in emotion regulation than an active comparison group. This is the evidence that supports using DBT skills outside a full programme, which is what Mindwell does. It is encouraging rather than definitive, and your psychologist will track whether it is helping you.

Doing DBT-informed therapy online

DBT skills are meant to be used where life happens, and video therapy puts the teaching there from the start. The breathing technique is practised in your lounge. The cold-water skill is tried at your own kitchen sink. The script for a hard conversation is rehearsed where you will have it. A chain analysis of last Thursday's blow-up can be done with the actual text thread in front of you.

Between sessions you will usually keep a brief diary card, noting emotions, urges and which skills you used, and you may be asked to practise one or two skills deliberately each week. Research on live video psychotherapy across conditions finds outcomes comparable to in-person treatment, and the structured, skills-based nature of DBT translates well to the format.

What online delivery at Mindwell does not include is phone coaching between sessions. If you are likely to need real-time support in a crisis, that is one of the signs a full programme would serve you better.

Safety, and when more help is needed

Mindwell is not a crisis or emergency service, and that matters more for this kind of work than most. If you are in immediate danger, call 111. If you need to talk to someone now, 1737 is free to call or text at any time, and Lifeline is on 0800 543 354 from 7am to midnight.

In the first session your psychologist will ask directly about self-harm, suicidal thoughts and risk. This is not to screen you out; it is to make sure the plan fits. Some people with a history of self-harm do well in individual DBT-informed therapy with a clear safety plan. Others need the structure and intensity of a full programme, and your psychologist can talk with you about options. If you are already with a community mental health team, talk with them about whether private sessions fit alongside what they are providing.

What to expect at Mindwell

All sessions are 50-minute video appointments through Carepatron, running in your browser. You book online, choose a psychologist or take the first available, and first sessions are typically within 7 days. No referral is needed. You will receive a confirmation email with your video link and a short intake form.

The first one or two sessions are for history, understanding how emotional dysregulation shows up for you, assessing risk and agreeing a plan. DBT-informed work is usually weekly, at least to begin with, because skills need repetition to stick. Sessions cost $199 + GST ($228.85 including GST), paid at booking, with receipts for health insurance.

Sandy Laurenson, Katherine Lee, Jeremy Mason, Jake Meads and Candice van der Merwe all list DBT among their approaches and offer individual DBT-informed therapy. Mindwell works with adults 18 and over in New Zealand and is not an ACC provider.

Related support: Emotional dysregulation · Anger management · Relationships and attachment · Trauma therapy