Dialectical behavior therapy (DBT)

Dialectical behavior therapy, also spelled dialectical behaviour therapy, is a structured therapy built on cognitive behavioral therapy (CBT). It was developed to help people who experience emotions very intensely and who struggle with self-harm, suicidal thoughts or impulsive behaviors.

"Dialectical" refers to balancing two ideas that seem opposite: acceptance and change. In DBT, people learn to accept themselves and their experiences as they are, while also working to change behaviors that cause harm. This balance helps people who may have felt either judged or stuck in previous treatment.

DBT is skills-based. Rather than focusing only on talking about problems, it teaches practical tools that people practice in daily life. The approach is collaborative, validating and focused on building a "life worth living," a phrase often used in DBT.

DBT has strong research support, particularly for borderline personality disorder and for reducing self-harm. It's also been adapted for teenagers, eating disorders, substance use and other conditions involving emotional dysregulation.

Comprehensive DBT usually includes several components:

• Individual therapy: weekly sessions focusing on personal goals, problem behaviors and applying skills
• Skills training group: weekly classes that teach DBT skills in a structured way, similar to a course
• Phone or between-session coaching: brief support to help apply skills in real-life moments, in many programs
• Therapist consultation team: therapists meet regularly to support each other and maintain the quality of treatment

Treatment often follows a hierarchy of targets. Life-threatening behaviors, such as self-harm or suicidal behavior, come first. Next are behaviors that interfere with therapy, then issues that affect quality of life, and then building skills and goals.

People often use diary cards to track emotions, urges and skills used each day, which helps identify patterns.

A standard comprehensive DBT program commonly lasts around six months to a year, but some services offer shorter programs or DBT-informed therapy that uses the skills without every component.

DBT skills are usually taught in four modules:

• Mindfulness: the foundation of DBT. Learning to observe thoughts, emotions and sensations in the present moment without judgment, which helps create space between feelings and reactions.
• Distress tolerance: skills for getting through crises without making things worse. These include distraction, self-soothing and radical acceptance of situations that can't be changed right now.
• Emotion regulation: understanding emotions, reducing vulnerability to intense moods through sleep, nutrition and exercise, and changing emotions when they're unhelpful, for example by acting opposite to an urge.
• Interpersonal effectiveness: asking for what you need, saying no, setting boundaries and maintaining relationships and self-respect.

Each module includes specific, memorable skills, often with acronyms that make them easier to recall in difficult moments.

DBT skills are practical and can be used by anyone, not just people in formal treatment. Many people find that learning to name and regulate emotions improves relationships, work and overall wellbeing.

TIPP skills are one of the best-known distress tolerance tools in DBT. They're designed to quickly reduce extreme emotional arousal, when emotions are so intense that thinking clearly feels impossible. TIPP stands for:

• Temperature: changing body temperature, such as splashing cold water on your face, to calm the body's stress response
• Intense exercise: short bursts of vigorous activity to release built-up energy
• Paced breathing: slowing your breathing, with exhales longer than inhales
• Paired muscle relaxation: tensing and releasing muscles while breathing out

These techniques work on the body, which can then help the mind settle. Anyone with heart conditions or other health concerns should check with a doctor before using cold water or intense exercise techniques.

Other distress tolerance skills include distraction with activities, self-soothing through the senses, weighing pros and cons of acting on urges, and radical acceptance.

These skills don't solve underlying problems, but they help people get through crises safely so they can address problems later.

DBT for BPD is the original and most researched use of the therapy. People with borderline personality disorder often experience intense emotions, fear of abandonment, unstable relationships and self-harm, and DBT helps reduce these difficulties.

DBT and DBT-informed approaches are also used for:

• Self-harm and suicidal behavior
• Emotional dysregulation from various causes
• Eating disorders, especially binge eating and bulimia
• Substance use problems
• Depression that hasn't responded to other treatments
• PTSD, combined with trauma-focused treatment
• Teenagers with intense emotions or self-harm, often with family involvement
• ADHD-related emotional difficulties

DBT may not be the best fit for everyone. For conditions like specific phobias or OCD, other approaches such as exposure-based CBT are often more targeted. A clinician can help you decide whether DBT suits your needs.

DBT is also helpful for families, who can learn skills to support a loved one and reduce conflict.

Look for a clinical psychologist, psychologist or psychotherapist with specific training in DBT. It's reasonable to ask whether they offer comprehensive DBT or DBT-informed therapy, and whether they work as part of a consultation team.

At the start, there's usually an assessment and a "commitment" phase, where you and the therapist agree on goals and discuss what treatment will involve. DBT asks for active participation: attending sessions, completing diary cards and practicing skills between sessions.

DBT can be challenging, but many people describe it as life-changing because it gives them tools they can use for the rest of their lives.

If you're currently experiencing thoughts of suicide or self-harm, seek help right away: call 911 or your local emergency number, or call or text 988 in the US (Samaritans 116 123 in the UK and Ireland). A therapist can then help you start working on longer-term strategies, including DBT.