Dialectical behavior therapy (DBT) is a skills-based talk therapy for people who feel emotions very intensely. Its skills are taught in four modules: mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness. This guide explains what each module is for, walks through some of the most widely taught DBT skills with everyday examples, and describes how DBT is usually delivered. If you or someone you love is in crisis, call 911, the nearest ER, or call or text 988.
Key Takeaways
- DBT is based on cognitive behavioral therapy (CBT) but adds a strong focus on acceptance alongside change.
- Its skills fall into four modules: mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness.
- Mindfulness and distress tolerance are acceptance-focused; emotion regulation and interpersonal effectiveness are change-focused.
- Skills are easier to use in hard moments when they have been practiced in calmer ones.
- Many people learn DBT skills in a structured program with a trained provider rather than on their own.
What Is Dialectical Behavior Therapy (DBT)?
Cleveland Clinic describes DBT as a type of talk therapy based on CBT but specially adapted for people who experience emotions very intensely. It was developed by psychologist Marsha Linehan and was first used for borderline personality disorder (BPD). Providers now offer it for other concerns as well, including PTSD, substance use, some eating disorders, depression and anxiety. DBT skills are also adapted for teens.
“Dialectical” means holding two ideas that seem opposite at the same time. In DBT, the central pair is acceptance and change: accepting yourself and your situation as they are right now, while also working to change patterns that are not helping. As Mind puts it, CBT focuses on changing unhelpful ways of thinking and behaving, while DBT does this too but also focuses on accepting who you are.
How DBT Is Usually Delivered
A full DBT program usually combines several parts:
- Individual therapy: regular one-to-one sessions focused on your goals and on what gets in the way of them.
- Skills training: often in a group that works more like a class than traditional group therapy, with weekly practice assignments.
- Coaching between sessions: brief, agreed-upon contact for help using a skill in a real situation.
- Diary cards: a simple daily log of emotions, urges and skills used, reviewed in sessions to spot patterns.
Programs vary. Some people take part in comprehensive DBT, while others learn DBT skills alongside another type of therapy, and some groups in clinician-led group therapy draw on DBT skills. For a closer look at how comprehensive DBT fits into care for personality disorders, see evidence-based treatment for personality disorders.
The Four DBT Skills Modules at a Glance
| Module | What it helps with | Example skills |
|---|---|---|
| Mindfulness | Noticing what is happening, inside and around you, without judging it | Wise mind; “what” and “how” skills |
| Distress tolerance | Getting through intense moments without making them worse | TIPP, ACCEPTS, self-soothing, radical acceptance |
| Emotion regulation | Understanding emotions and lowering vulnerability to intense ones | Check the facts, opposite action, PLEASE |
| Interpersonal effectiveness | Asking for what you need, saying no and keeping self-respect | DEAR MAN, GIVE, FAST |
Mindfulness runs through all four modules, because every other skill depends on first noticing what you feel and what is actually happening.
1. Mindfulness: Wise Mind and the “What” and “How” Skills
DBT describes three states of mind. Emotion mind is when feelings are driving decisions. Reasonable mind is when logic is in charge and feelings are pushed aside. Wise mind is the overlap, where you can take your emotions seriously and still think clearly about what will help. Many DBT skills are ways of getting back to wise mind.
The mindfulness module breaks this into two sets of skills:
- “What” skills: observe (notice sensations, thoughts and feelings without reacting), describe (put words to them, such as “my jaw is tight and I’m thinking I’ll be blamed”) and participate (throw yourself fully into the present activity).
- “How” skills: do it nonjudgmentally (stick to facts, not labels like “stupid” or “awful”), one-mindfully (one thing at a time) and effectively (focus on what works in this situation, not on being right).
A simple daily practice is to pick one routine activity, such as washing dishes, and spend two minutes only observing and describing it. For more on attention-based practices and how they relate to the stress response, see clinical mindfulness and nervous system regulation.
2. Distress Tolerance: Getting Through Intense Moments
Distress tolerance skills are for moments when an emotion is so strong that it is hard to think, and the immediate goal is to get through without making things worse. They are short-term tools. They are not meant to solve the underlying problem, and they work alongside the rest of a care plan.
TIPP: Changing Your Body’s Response
TIPP skills target the physical side of intense emotion:
- Temperature: cool your face with cold water or a cold pack for about 30 seconds.
- Intense exercise: a short burst of vigorous movement, such as fast walking or jumping jacks, to use up the energy an emotion creates.
- Paced breathing: slow your breathing and make each out-breath longer than the in-breath.
- Paired muscle relaxation: tense a muscle group while breathing in, then release it as you breathe out.
The DBT skills handout on TIP skills includes an important caution: very cold water lowers heart rate quickly, and intense exercise raises it. If you have a heart or other medical condition, take a medication that lowers your heart rate (such as a beta-blocker), are allergic to cold or have an eating disorder, check with your health care provider before using the temperature or exercise skills. Paced breathing and muscle relaxation are gentler places to start.
ACCEPTS and Self-Soothing: Intentional Distraction
ACCEPTS is a reminder of ways to shift attention until an emotion eases: Activities, Contributing (doing something kind for someone else), Comparisons (with a time you coped before), opposite Emotions (a funny show, uplifting music), Pushing away (setting the problem aside for now), other Thoughts (counting, puzzles) and Sensations (holding something cold or textured). Self-soothing uses the five senses: a familiar scent, a warm drink, a cozy blanket, calming music or a pleasant view. The aim is a planned break, not long-term avoidance.
Radical Acceptance
Radical acceptance means fully acknowledging a reality you cannot change right now, such as a loss, a decision someone else made or something that already happened. It is not approval and it is not giving up. Fighting a fact you cannot change tends to add suffering on top of pain; accepting it frees up energy for the next useful step. People often practice it by noticing the thought “this shouldn’t be happening” and gently replacing it with “this is what is happening.”
3. Emotion Regulation: Understanding and Shifting Emotions
Emotion regulation skills help you understand what you are feeling, why, and what you can do about it. The goal is not to stop having emotions. Emotions carry information. The goal is to have more say in how intense they get and how you respond.
- Name the emotion: notice the trigger, body sensations, thoughts and urges, then give the feeling a specific name, such as disappointed, ashamed or irritated, rather than “bad.”
- Check the facts: ask whether the emotion and its intensity fit the situation. If you feel anxious about a friend’s short text, what else could explain it?
- Opposite action: when an emotion does not fit the facts, or acting on it would not help, do the opposite of what it urges. If sadness urges you to stay in bed and cancel plans, opposite action might be getting dressed and keeping one small plan. If the emotion does fit the facts, problem-solving the situation is usually the better route.
PLEASE: Lowering Emotional Vulnerability
Emotions are harder to manage when your body is run down. PLEASE is a checklist for the basics:
- PL – treat PhysicaL illness: see a health care provider when you are unwell, and take prescribed medications as directed.
- E – balanced Eating: regular meals without long gaps.
- A – Avoid mood-altering substances: alcohol and non-prescribed drugs can make emotions harder to manage.
- S – balanced Sleep: a steady sleep schedule where possible.
- E – Exercise: some regular movement that fits your health and ability.
Alongside PLEASE, DBT encourages building positive experiences into daily life and practicing small tasks that build a sense of competence. If sleep is a major problem, CBT for insomnia is a structured approach worth asking about.
4. Interpersonal Effectiveness: DEAR MAN, GIVE and FAST
Interpersonal effectiveness skills help you ask for what you need, say no and handle conflict while protecting both the relationship and your self-respect. Three acronyms cover different goals.
DEAR MAN is for getting what you want or need:
- Describe the situation using facts.
- Express how you feel about it, using “I” statements.
- Assert what you want or clearly say no.
- Reinforce: explain how the request helps the other person or the relationship.
- Stay Mindful of your goal instead of getting pulled into side arguments.
- Appear confident in your tone and posture.
- Negotiate: be willing to give a little to get a little.
For example: “The last three weekends I’ve done the grocery run (Describe). I’m feeling worn out (Express). Could you take this Saturday (Assert)? I’d really appreciate it, and I’ll cook dinner that night (Reinforce).”
GIVE is for keeping the relationship strong: be Gentle, act Interested, Validate the other person’s feelings and use an Easy manner. FAST is for keeping self-respect: be Fair to yourself and others, skip unneeded Apologies, Stick to your values and be Truthful. For more on boundaries in close relationships, see self-care, boundaries and self-compassion.
What the Research Shows, and Its Limits
DBT is one of the most studied therapies for people with intense emotions, and it has strong research support for BPD in particular. Cleveland Clinic notes that it is also provided for several other conditions. Research does not mean it fits everyone, though. Mind notes that DBT is more likely to work for people who feel able to do practice between sessions, who are ready to focus mostly on the present and future rather than the past, and who feel able to take part in some group sessions. A full program is also a real commitment: Cleveland Clinic notes that DBT usually takes at least six months to a year, and that progress tends to be gradual rather than complete.
How to Start Practicing DBT Skills
- Practice when calm. A skill you have rehearsed is far easier to reach for when emotions are high.
- Start with one or two skills. Paced breathing and “check the facts” are common starting points.
- Write it down. A simple diary card, noting the emotion, its intensity from 0 to 10 and the skill you tried, shows what helps over time.
- Expect it to feel awkward. New skills often feel artificial at first. That usually fades with repetition.
- Get support. Mind notes that DBT can be hard to learn on your own, and that self-help materials tend to be most useful alongside, or after, sessions with a trained therapist.
Getting Started With DBT in Maryland
If DBT sounds like a fit, it can help to ask a provider about their DBT training and whether they offer a full program or DBT skills within another therapy. Blue Sails Counseling Providers offer DBT. You can read how it fits into care on the personality disorders and BPD guide and the outpatient therapy page, or start with client intake.
For more guides on therapy approaches and medication, see the therapy and medication guide.
Frequently Asked Questions
What is the difference between DBT and CBT?
DBT is based on CBT. Both work on unhelpful patterns of thinking and behavior, but DBT adds a strong focus on acceptance and teaches specific skills for intense emotions, distress and relationships, often in a skills group.
Do I need a borderline personality disorder diagnosis to use DBT skills?
No. DBT was first developed for BPD, but providers now use it and its skills for other concerns that involve intense emotions, such as depression, anxiety, PTSD and substance use. A provider can help you decide whether it fits.
Can I learn DBT skills on my own?
You can practice skills from books or worksheets, but DBT can be hard to learn alone. Self-help materials tend to be most useful alongside, or after, working with a trained provider who can help you choose and adapt skills.
How long does DBT take?
It varies with the program and your goals. Cleveland Clinic notes that a full DBT program usually takes at least six months to a year. Learning a few skills alongside another therapy can be shorter.
Can DBT be combined with medication or other therapy?
Yes. Some people learn DBT skills alongside another therapy, and DBT can be used alongside medication. Decisions about medication are made with your prescriber.
Sources
Sources: Cleveland Clinic — Dialectical Behavior Therapy (DBT), Mind — Dialectical behaviour therapy (DBT), Linehan, DBT Skills Training Handouts — TIP Skills: Changing Your Body Chemistry.