The DBT Target Hierarchy: What It Is and How It Works
If you've ever wondered how a DBT therapist decides what to focus on in any given session, the answer is the target hierarchy. It's one of the most important organizing tools in DBT, and understanding it can help clients, families, and even other clinicians make sense of why treatment looks the way it does.
What Is the Target Hierarchy?
In DBT, not all problems get equal attention at the same time. The target hierarchy is a prioritized framework that tells the therapist — and the client — what to work on first, second, and third. Think of it as a structured to-do list organized by urgency and risk, not by what feels most pressing in the moment.
This matters more than it might seem. When someone is in significant emotional pain, it's easy for a session to get pulled toward whatever feels most overwhelming that week. The target hierarchy keeps treatment grounded and ensures the most dangerous issues never get buried beneath the loudest ones.
The top three levels are:
Life-threatening behaviors — suicidal thoughts, urges to self-harm, suicide attempts, or anything that puts the client's life at risk
Therapy-interfering behaviors — anything that gets in the way of treatment itself, such as missing sessions, arriving late, or becoming so dysregulated in session that meaningful work can't happen
Quality-of-life problems — painful circumstances that make daily life harder, like a troubled relationship, financial instability, substance use, or a major life transition
Here's an example of why the order matters:
Imagine someone comes into session devastated about her divorce. It's real, it's painful, and it's absolutely worth addressing. But she also mentions she's been having thoughts of ending her life. The divorce doesn't move to the top of the list — the suicidal thoughts do.
Why? Because if she's not safe, nothing else can be worked on. The divorce may be what's driving the pain, but the suicidal thinking is the most dangerous response to it. Once she's stable and safe, the therapist can turn full attention to the grief, the identity shift, and everything a divorce brings. The hierarchy isn't about saying the divorce doesn't matter — it's about making sure she's alive to get through it.
This structure, outlined by Marsha Linehan in her foundational 1993 text, helps therapists stay focused and ensures that even when life feels like everything is on fire at once, treatment has a clear and principled direction.
It's worth noting that the target hierarchy is most active in the first stage of DBT, when stabilization is the primary goal.
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