DBT Skills Explained: Distress Tolerance, Mindfulness and Emotion Regulation

A woman sits in her parked car outside her workplace, gripping the steering wheel. Ten minutes earlier, a colleague made an offhand remark about her presentation, and something inside her has detonated. Her chest is tight, her face is hot, and a stream of thoughts has taken over: she is a failure, everyone sees it, she should quit, she should say something cruel in reply, she should disappear. The urge to act is overwhelming. She could send a furious email, drive away, or abandon the day entirely. Instead, she does something she practiced for months in a skills group. She names what is happening, “This is shame, and this is anger, and the urge is to run.” She slows her breathing, lets out a long exhale, and checks the facts: one comment, one meeting, no evidence that her career is over. She does not feel calm, but she feels steady enough to choose. She walks into the building.

That sequence of steps, small and almost invisible from the outside, is the practical heart of dialectical behavior therapy, usually called DBT. Developed in the late 1980s by the American psychologist Marsha Linehan, DBT began as a treatment for people with chronic suicidal thoughts and borderline personality disorder, and it has since become one of the most widely used and best-studied psychological therapies in the world. Its distinctive contribution is not a single insight but a toolbox: a set of concrete, teachable skills for the moments when emotions run higher than a person’s ability to manage them. Those skills are organized into four groups, mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness, and the first three are the subject of this article.

The skills matter for a simple reason. Most people were never taught how to handle intense emotion. They were told to calm down, to think positive, to toughen up, or to stop overreacting, none of which counts as instruction. Emotional regulation is a skill set like any other, and, like reading or swimming, it can be learned in a systematic way by people who struggle with it. A growing body of research indicates that DBT skills help not only people with borderline personality disorder but also those with depression, anxiety, eating disorders, substance use problems, attention-deficit hyperactivity disorder, trauma-related conditions, and the ordinary emotional difficulties that affect many people at some point in their lives.

This article offers a detailed, evidence-based explanation of the DBT skills of mindfulness, distress tolerance, and emotion regulation. It explains where the skills come from and the theory behind them, describes the main skills in each module in plain language and with examples, discusses how they are combined in real life, covers the common obstacles that make them hard to use, and reviews the evidence for their effectiveness in different groups. It also offers guidance on getting started, on finding treatment, and on supporting someone who is learning them. It is an educational overview and not a substitute for treatment. Skills learned from reading are most useful when practiced and, for people with serious difficulties, when taught by a trained therapist. The central message is that emotions that feel unmanageable can become manageable through practice, and that the ability to tolerate, understand, and change emotional experience is learned and not innate.

What DBT Is and Where the Skills Come From

Dialectical behavior therapy is a structured form of cognitive behavioral therapy that combines change-focused strategies with acceptance-based strategies drawn from mindfulness and Zen practice. Its name reflects its philosophical foundation, dialectics, the idea that opposites can be held together and that progress comes from the synthesis of apparently conflicting positions. In DBT, the central dialectic is between acceptance and change: a person is accepted exactly as they are, and, at the same time, encouraged to change in ways that will build a better life.

The Origins of the Treatment

Marsha Linehan began her career studying suicidal behavior and, in the 1970s and 1980s, set out to adapt standard cognitive behavioral therapy for chronically suicidal women at the University of Washington. She found that when therapists focused relentlessly on change, urging clients to alter their thoughts and behavior, many experienced it as invalidating, as though their pain was being dismissed, and became more distressed, angry, or likely to drop out. When therapists focused only on acceptance and support, clients felt understood but did not change. The solution she developed was to build both into every session, a combination that she described as dialectical. She also incorporated mindfulness practices after studying contemplative traditions, including Zen, which she has said helped her to find a way to accept difficult reality. The first randomized controlled trial of the therapy, published in 1991, found that it reduced suicide attempts and self-harm and decreased hospital admissions compared with usual treatment. Linehan later disclosed publicly that she had herself struggled with severe emotional distress as a young woman, and her memoir describes how the therapy emerged from her own search for a way out.

The Biosocial Theory

The skills are grounded in a theory of how emotional difficulties develop. According to Linehan’s biosocial theory, problems with emotion regulation arise from the interaction of two factors. The first is biological vulnerability: a person born with, or who develops, high emotional sensitivity, strong reactivity, and a slow return to emotional baseline. Such a person feels emotions quickly, intensely, and for a long time. The second is an invalidating environment, one in which a child’s emotional experiences are repeatedly dismissed, punished, or treated as wrong or exaggerated, and in which the child is not taught how to label, understand, and regulate emotions. The combination leaves the person without the skills that most people absorb in childhood, and without confidence in their own emotional experience. From this perspective, many behaviors that look destructive, such as self-harm, substance use, explosive anger, or withdrawal, are attempts to cope with unbearable feelings in the absence of better tools. Treatment therefore focuses on building the missing skills.

The Dialectical Philosophy

Dialectics in DBT rests on three ideas. First, reality is made of opposing forces that exist together: a person can be doing the best they can and still need to do better, feel safe and feel afraid, love someone and be angry with them. Second, everything is interconnected, so that changes in one part of a system affect the others. Third, change is constant, and nothing remains fixed. Practically, the stance encourages flexibility and avoids the black-and-white thinking that characterizes emotional crises. It also gives therapists and clients a way of resolving stuck positions: instead of arguing over who is right, both perspectives are held and a synthesis is sought. A frequently used example is the statement “I am doing the best I can, and I need to try harder,” in which neither half cancels the other.

The Evidence Base

DBT is among the most thoroughly tested psychotherapies for emotional dysregulation. Multiple randomized controlled trials and meta-analyses show that comprehensive DBT reduces self-harm, suicidal behavior, hospitalizations, depression, anger, and impulsivity in people with borderline personality disorder, with effects that tend to persist at follow-up. Trials by Linehan and colleagues, and by independent groups in the Netherlands, Germany, the United Kingdom, and elsewhere, have found similar patterns. Adaptations of the therapy for adolescents, for eating disorders, for substance use, for post-traumatic stress, and for other conditions have also shown benefit. A notable finding is that skills training alone, without the other components, can be effective for several groups. A trial by Linehan and colleagues published in 2015 found that a skills-only version of DBT was more effective than a standard group therapy for reducing suicidal behavior and also than the full therapy in some respects, and a 2021 trial reported that DBT skills training in a group format was a viable and effective stand-alone treatment. Overall, the evidence supports the view that the skills themselves are an active ingredient.

Beyond Borderline Personality Disorder

Because the skills address general processes of emotion regulation, they have been used in many settings. They are taught in schools, hospitals, prisons, community programs, and workplaces. They are used with people who have bipolar disorder, depression, anxiety, binge eating disorder, bulimia, post-traumatic stress, attention-deficit hyperactivity disorder, autism, and substance use disorders, and with people with no diagnosis who wish to improve their emotional coping. The research is strongest for borderline personality disorder and self-harm, good for eating disorders and some forms of depression, and growing for other conditions. In each case, the level of evidence varies, and treatment decisions should be made with a clinician.

How the Skills Are Organized

In standard DBT, skills are taught in a weekly group that resembles a class, typically lasting about two to two and a half hours, with homework assigned and reviewed each week. A full cycle of the four modules takes about six months, and many programs run the cycle twice, for a year in total. The group format emphasizes learning and practice, not therapy in the sense of discussing personal histories, which is dealt with in individual sessions.

The Four Modules

Mindfulness skills help a person to be aware of the present moment without judgment, and they are taught first and revisited throughout. Distress tolerance skills help a person to survive crises without making things worse and to accept reality when it cannot be changed. Emotion regulation skills help a person to understand emotions, reduce vulnerability to painful ones, and change them when helpful. Interpersonal effectiveness skills help a person to ask for what they need, say no, and maintain relationships and self-respect. The modules complement each other. Mindfulness provides the awareness on which the other skills depend, distress tolerance is used when emotion is too intense for change, emotion regulation is used when change is possible, and interpersonal effectiveness applies these skills in relationships.

Acceptance and Change Skills

The modules can also be divided by their basic stance. Mindfulness and distress tolerance are acceptance skills, which teach a person to tolerate and accept reality as it is. Emotion regulation and interpersonal effectiveness are change skills, which teach a person to alter emotions, situations, and relationships. A skilled practitioner learns to judge which is needed: when a situation can be changed, change it, and when it cannot, accept it. This distinction is one of the most useful ideas in the whole therapy.

The Diary Card and Practice

An important tool is the diary card, a daily self-monitoring sheet, filled in by the person, that records emotions, urges, target behaviors, and the skills used. It allows the person and therapist to see patterns and to track progress. Skills are learned by practice, much as an athlete trains before a match. People are encouraged to practice when calm, so that the skills are available in a crisis, since it is almost impossible to learn a new skill while flooded with emotion.

The Skills Mindset: Rating Distress and Choosing Skills

A central practical habit is rating the intensity of emotion or distress on a scale from zero to one hundred. This simple step builds awareness and helps in choosing skills. As a rough guide, when distress is moderate, a person has access to their thinking and can use regulation and problem-solving skills, while at very high levels, thinking is impaired, and crisis survival skills are more appropriate. This is sometimes described as the principle that one cannot use a skill that requires thinking when the thinking brain has gone offline.

Mindfulness: The Foundation of All the Skills

Mindfulness is the practice of paying attention, on purpose, to the present moment, without judgment. In DBT, it is called the core skill because every other skill depends on it: a person cannot regulate an emotion that they have not noticed, cannot tolerate a crisis that they are not aware of, and cannot communicate effectively if they are not present in the conversation. DBT uses a secular, practical version of mindfulness, drawn from Zen and other contemplative traditions and adapted by Linehan to be teachable to people in acute distress.

Wise Mind

The central concept is wise mind. Linehan describes three states of mind. Emotion mind is the state in which feelings control thinking and behavior, so that a person acts on mood and urge, and facts seem to bend to fit the feeling. Reasonable mind is the state in which logic, planning, and facts predominate, and emotions are disregarded. Neither is wrong, and each is useful in its place, but each alone is incomplete. Wise mind is the integration of the two, adding intuition and a deep inner knowing. It is the part of every person that knows what is right for them, which they can reach when they are calm and attentive. It is described as a place of inner wisdom, available to everyone, though not always accessible. Many people describe the experience of wise mind as a quiet sense of knowing, a moment of calm clarity, or the voice that is present when they consider a decision with their whole selves.

A simple way to find wise mind is to take a slow breath and to ask oneself a question, such as “Is this wise?” and to wait quietly for an answer, without forcing it. Another practice is to imagine a stone dropping slowly into a clear lake, settling at the center, and to rest attention there. The aim is not to produce a particular feeling but to build familiarity with a state of balanced awareness.

The What Skills: Observe, Describe, Participate

Mindfulness skills are divided into what to do and how to do it. The three what skills describe the activities of mindfulness. Observing means noticing experience without trying to change it or label it: attending to sensations, sights, sounds, smells, thoughts, and feelings as they arise and pass. Observing is like watching clouds float across the sky. The goal is to notice, and to step back from experience, so that thoughts and feelings are seen as events and not as commands.

Describing means putting words to what is observed, in a factual way. Instead of saying “I am worthless,” a person might say “I am having the thought that I am worthless,” or “I feel a tightness in my chest and a sense of dread.” This simple shift creates distance between the person and the experience and discriminates between facts and interpretations. Research on affect labeling by Matthew Lieberman and colleagues suggests that putting feelings into words reduces activity in the amygdala and increases activity in prefrontal regions, which may explain why naming an emotion can reduce its intensity.

Participating means entering fully into an activity, without self-consciousness, becoming one with the moment, as a skilled dancer or a person absorbed in a conversation does. It is the opposite of standing outside experience and monitoring it. For many people who have spent years watching themselves from outside, full participation is a relief and a skill to be built.

The How Skills: Nonjudgmentally, One-Mindfully, Effectively

The how skills describe the manner of practice. Nonjudgmentally means observing and describing without evaluating as good or bad, right or wrong, and replacing judgments with facts and with descriptions of consequences. It does not mean approving of everything. A person can recognize that a situation is harmful and still describe it without condemning themselves or others. Many people with emotional difficulties judge themselves harshly, and the shift to nonjudgmental awareness is among the hardest and most helpful changes. A practical technique is to notice the word should, and the words good, bad, terrible, and awful, and to substitute a description.

One-mindfully means doing one thing at a time with full attention, and, when the mind wanders, as it will, gently bringing it back. In a world of multitasking, this is countercultural, but it reduces distraction and stress. Examples include eating a meal without screens, listening to a person without planning a reply, or washing dishes while attending to the water and the sounds.

Effectively means focusing on what works, doing what is needed in a situation, and letting go of being right, of vengeance, and of useless anger. A person who is effective asks “What is my goal here? What will help me to reach it?” and acts accordingly, even when they do not like it. The skill is sometimes summed up as playing the cards that one is dealt, and not wasting energy on wishing the hand were different.

Mindfulness Practices in DBT

DBT teaches a wide range of practices, from formal meditation to everyday exercises. Mindful breathing involves attending to the breath, noticing its rhythm and the sensations in the body, and returning to it when the mind wanders. Mindful eating, such as slowly attending to the appearance, smell, texture, and taste of a piece of fruit, shows how attention transforms an everyday act. Mindful walking attends to the sensations in the feet and legs. Other practices include observing thoughts as clouds, leaves floating down a stream, or trains passing through a station, and noticing emotions as waves. A practice named mindfulness of current emotion involves observing a feeling without trying to push it away or to hold onto it, noticing where it is felt in the body, and allowing it to rise and fall. Each of these aims to train the attention muscle.

Some practices are suited to people who find sitting meditation difficult, including trauma survivors for whom stillness may be frightening. Movement-based practices, such as mindful walking or gentle stretching, and external-focus practices, such as attending to sounds or objects in the room, may be more comfortable. Practice should be adapted, and people with trauma are encouraged to work with a therapist who can tailor it. Brief exercises, repeated throughout the day, tend to be more effective than rare long sessions, particularly in the beginning.

Common Obstacles in Mindfulness Practice

Beginners commonly report that they cannot stop their thoughts, that they become bored or restless, that they fall asleep, or that mindfulness makes them feel worse. These are normal. The aim of mindfulness is not to stop thoughts but to notice them and return attention, and each return is a repetition that builds the skill. Sleepiness can be addressed by sitting upright, opening the eyes, or practicing at a different time of day. Boredom and restlessness can be observed as experiences. If practice triggers strong distress, or flashbacks, a person should stop, use grounding, and seek guidance, since some people need a modified approach.

The Evidence for Mindfulness

Mindfulness-based interventions have been studied extensively, and meta-analyses find moderate benefits for anxiety, depression, and stress, comparable to other established treatments in some studies, though the quality of research varies and effects tend to be smaller when compared with active controls. Within DBT, mindfulness skills are regarded as foundational, and studies of the therapy suggest that increases in mindfulness and in the capacity to describe and not judge experience are associated with reductions in self-harm and emotional distress. Neuroimaging studies of mindfulness practice report changes in regions involved in attention and emotion regulation, including the prefrontal cortex and the amygdala, though the findings are preliminary and the practical relevance is still being established. It is also important to note that mindfulness is not a panacea, and that a small proportion of people report adverse effects, including increased anxiety or dissociation, particularly with intensive practice, which is why guidance is advisable.

A Mindfulness Practice to Begin With

A simple way to begin is a three-minute exercise. Sit comfortably and allow the eyes to close or rest on a point in front of you. For the first minute, notice whatever is present: thoughts, feelings, and sensations, describing them silently. For the second minute, gather attention onto the breath and follow each inhalation and exhalation. For the third minute, widen attention to the whole body and the surroundings. When the mind wanders, notice where it went and bring it back without criticism. Practicing this once or twice a day provides a foundation for the other skills.

Distress Tolerance: Surviving the Crisis Without Making It Worse

Distress tolerance skills are designed for the situations in which emotional pain is intense and cannot be reduced immediately, and in which acting on impulse would make matters worse. Linehan observed that people who lack these skills often turn to behaviors that bring quick relief but create long-term damage: self-harm, substance use, binge eating, rage, reckless behavior, or running away from commitments. The aim of distress tolerance is not to feel better, though that often follows, but to get through the moment without causing harm and to accept reality when it cannot be changed. The module has two parts, crisis survival skills and reality acceptance skills.

Why Tolerating Distress Matters

Pain is part of life, and avoiding all of it is neither possible nor desirable. Linehan has expressed the idea in a formula: pain plus nonacceptance equals suffering. The pain is the unavoidable hurt of a loss, a failure, or a threat. The suffering is added by fighting reality, by judging oneself for feeling pain, and by trying to escape it in ways that cause further harm. Distress tolerance aims to reduce the suffering component by teaching acceptance of the pain and by providing safe ways of coping. A further reason is that emotions pass. Research on the time course of emotional experience suggests that the acute peak of an emotion typically lasts minutes, though it can be renewed by thoughts and events, and that the urge to act weakens if it is not acted on. Learning that distress can be survived builds confidence and reduces the fear of emotion itself.

When to Use Crisis Survival Skills

These skills are for crises in which emotion is very high, usually above seventy or eighty on the zero-to-one-hundred scale, a problem cannot be solved immediately, and the person is at risk of acting impulsively. They are not intended for everyday sadness or for avoiding all uncomfortable feelings, and they should not be used as a permanent way of avoiding problems. A person who relies on distraction and never deals with the underlying situation is not using them as intended. They are bridges to get across a bad moment.

The STOP Skill

STOP is a brief sequence for pausing before acting. The letters stand for stop, take a step back, observe, and proceed mindfully. First, stop: freeze, do not react, and do not move a muscle if necessary. Second, take a step back, literally or metaphorically, from the situation, take a breath, and do not let the emotion control action. Third, observe what is happening inside and outside: what are the thoughts, the feelings, the sensations, and the facts of the situation, who is involved, and what are the options. Fourth, proceed mindfully: act with awareness of the goals, the likely consequences, and what will help. The skill is simple and powerful because it introduces a gap between the impulse and the action, and it is useful in moments such as an argument, an urge to send an angry message, or the urge to use a substance.

Pros and Cons

The pros and cons skill helps to resist harmful urges by clearly weighing the short-term and long-term consequences of acting on the urge and of tolerating the distress. A person lists four things: the pros of acting on the urge, the cons of acting on the urge, the pros of not acting, and the cons of not acting. The list is written down, ideally in advance, when calm, and consulted when the urge is strong. Because intense emotion tends to narrow thinking to the short-term benefits of an action, the list brings the long-term costs back into view. A person who feels the urge to send a furious message to a partner might remember that the pros are the relief of expression, and the cons are damaged trust and regret, and that the pros of waiting are the chance of a calmer conversation.

Physiological Skills for Lowering Arousal

Intense emotion is a bodily state, and some skills work directly on the body. One set of skills is described by the acronym TIPP, which stands for changing body temperature, intense exercise, paced breathing, and paired muscle relaxation. Some of these skills involve strong physical sensations, and in this article the emphasis is on the gentler and safer elements. Paced breathing, in which the person slows the breath to about five or six breaths per minute with the exhalation longer than the inhalation, activates the parasympathetic nervous system and lowers heart rate. Paired muscle relaxation involves tensing a muscle group while breathing in, and releasing it while breathing out and saying a calming word, a technique that can be practiced in advance so that it quickly produces relaxation. Intense exercise, such as running, fast walking, or any vigorous activity for a short time, uses up the energy of arousal and can lower emotional intensity. The temperature element, which uses physical sensation to alter physiological arousal, is best learned from a trained DBT therapist who can advise on safe use. Skills that rely on pain, shock, or intense physical discomfort should never be used as a substitute for self-harm, and anyone who experiences urges to hurt themselves should work with a therapist to find safe alternatives and should contact a crisis service if they are in danger.

Distracting With ACCEPTS

When emotion is overwhelming, temporary distraction can bring it down to a level at which other skills can be used. The acronym ACCEPTS lists seven strategies. Activities means engaging in absorbing tasks, such as a hobby, cleaning, a puzzle, a game, or a walk. Contributing means doing something for someone else, such as helping a friend, volunteering, or doing a small kindness, which shifts attention outward and builds self-worth. Comparisons means comparing oneself with people who are coping less well, or with one’s own past, to gain perspective, used with care and without self-criticism. Emotions means generating a different emotion by watching a funny film, listening to music that evokes another mood, or reading something uplifting. Pushing away means temporarily setting the situation aside, for example by imagining placing it in a box on a shelf, with the intention to return to it later. Thoughts means occupying the mind with other thinking, such as counting, doing puzzles, reciting a list, or doing mental arithmetic. Sensations means using intense but safe sensory experiences, such as listening to loud music, a warm shower, or squeezing a stress ball or sucking a strong mint. The goal is a short-term break, not permanent avoidance.

Self-Soothing Through the Five Senses

Self-soothing involves comforting oneself with kindness through each of the senses. For vision, a person might look at a beautiful picture, a view of nature, or a favorite photograph. For hearing, they might listen to calming music, the sounds of nature, or a familiar voice. For smell, they might use a favorite scent, fresh coffee, flowers, or a candle. For taste, they might slowly savor a favorite food or a warm drink, with full attention. For touch, they might take a warm bath, wrap in a soft blanket, stroke a pet, or put on comfortable clothes. The principle is to treat oneself as one would treat a distressed friend. People who grew up without much comfort may find self-soothing awkward at first, and it improves with practice. A person can build a self-soothing kit in advance, containing items that are calming for each of the senses.

Improving the Moment With IMPROVE

The IMPROVE skill offers ways of making the moment more bearable. The letters stand for imagery, meaning, prayer, relaxation, one thing in the moment, vacation, and encouragement. Imagery means picturing a safe, peaceful place, or imagining coping well in a difficult situation. Meaning means finding purpose or value in the suffering, which many people find helps, such as seeing a hard time as a step toward a goal or as a test of strength. Prayer means connecting with a higher power, with the universe, or with one’s deepest values, whatever it means to the person, with an attitude of openness and willingness. Relaxation uses calming techniques such as breathing and muscle relaxation. One thing in the moment means focusing on the single task at hand and bringing the attention back each time it drifts. Vacation means taking a brief break from the problem, such as a short rest, turning off the phone for an hour, or going for a short walk. Encouragement means speaking to oneself kindly, as a supportive coach would: “I can get through this. I have done hard things before.”

Reality Acceptance Skills

While crisis survival skills help a person to get through acute moments, reality acceptance skills address the longer-term suffering that arises when a person cannot accept things that cannot be changed. Reality acceptance includes radical acceptance, turning the mind, willingness, and mindfulness of current thoughts.

Radical Acceptance

Radical acceptance means completely and totally accepting reality as it is in the present moment, with the whole self, mind, and body. It does not mean approving of what has happened, condoning harm, giving up, or liking it. It means ceasing to fight against the facts. Typical statements are “This is what happened,” “There are reasons why it happened,” and “I cannot change it now.” The skill is relevant to losses, injustices, illnesses, and mistakes, and to the many circumstances beyond a person’s control. Linehan points out that rejecting reality does not change it. Refusing to accept a painful fact prolongs the pain, and acceptance, though hard, opens the way to coping and to changing what can be changed.

People often resist because they fear that acceptance will mean that they approve of what happened or that they will be defeated by it. It helps to separate acceptance from approval and to practice in stages: noticing when one is fighting reality, reminding oneself that the facts are real, considering the causes that led to them, practicing acceptance with the body through relaxed posture and a half smile, listing what one would do if one did accept, and acting as if one has accepted. Acceptance is often a process that must be renewed many times, and grief may arise as it is practiced, which is natural.

Turning the Mind and Willingness

Turning the mind is the practice of choosing to accept, again and again, like turning at a fork in the road. Because the mind tends to drift back to resistance, each return is another turn. Willingness is the readiness to do what is needed in each situation, in a way that is effective, as opposed to willfulness, which is refusing to tolerate the situation or to do what is needed, and sitting on the hands, giving up, or insisting that things be different. Willfulness may look like stubbornness, saying “I can’t,” or refusing to act. The shift to willingness is often made through a small action, such as extending a hand to a half smile, or saying “I am willing.”

The Half-Smile and Willing Hands

Two body-based practices help acceptance. In the half smile, a person relaxes the face and allows the corners of the lips to lift slightly, with a serene expression, which sends a signal of openness to the brain. In willing hands, the person relaxes the hands, with palms open, as a way of expressing acceptance through the body. Research on facial feedback suggests that facial expressions can influence emotion modestly, though the effects are debated. The practice is not used to force happiness but to align the body with a willing attitude.

Allowing Emotions and Urge Surfing

Urge surfing, borrowed from relapse prevention work by Alan Marlatt, is a skill for riding out urges without acting. The person observes an urge as a wave that rises, reaches a peak, and falls, noticing where it is felt in the body, and imagining riding the wave like a surfer. The skill rests on the observation that urges are temporary, usually peaking within twenty to thirty minutes if not acted on. Each urge that passes weakens the pattern. It is helpful for urges to self-harm, to use substances, to binge, to send angry messages, or to engage in other impulsive acts, and it is often paired with distraction and the pros and cons skill.

Mindfulness of Current Thoughts

This skill teaches a person to observe thoughts as mental events and not as truths or commands. Thoughts can be seen as clouds, as leaves floating on a stream, or as a train of cars passing, and a person can say “I notice that I am having the thought that…” The skill reduces the power of distressing thoughts and prevents the exhaustion of arguing with them. It belongs to the family of acceptance-based approaches and overlaps with cognitive defusion in acceptance and commitment therapy.

Using Distress Tolerance Wisely

Distress tolerance skills are tools for particular moments. They can be misused if a person applies them as a way of avoiding problems that need to be solved, or as a way of suppressing all feelings. They also do not replace help in a true emergency. A useful rule is to ask whether the situation can be changed. If it can, move toward problem solving and emotion regulation, and if it cannot, use acceptance. Another useful practice is to create a distress tolerance plan in advance, writing down the skills that work, the contacts to call, and the steps to take when emotion reaches a certain level.

A Crisis Plan and Emergency Resources

A written crisis plan, prepared with a therapist when calm, can be a lifesaver. It typically lists warning signs, the skills that have helped, people and places that provide distraction and support, professional and crisis numbers, and ways of making the environment safer, such as removing means of self-harm. Anyone who is thinking of ending their life, or who feels that they cannot keep themselves safe, should contact local emergency services or a crisis line immediately, or go to the nearest emergency department, and tell a trusted person. Skills are important, but they are not a substitute for emergency help.

Emotion Regulation: Understanding and Changing Emotions

Emotion regulation skills address the problem from the other direction. Instead of surviving emotion, a person learns to understand it, to reduce vulnerability to painful emotions, to increase positive experiences, and to change emotions when changing is helpful. The module rests on the principle that emotions are not enemies. They are useful signals that organize behavior, communicate to others, and give information, and the aim is not to eliminate them but to have a say in how they affect life.

The Goals of Emotion Regulation

Linehan sets out several goals. They are to understand and name emotions, to reduce the frequency of unwanted emotions, to reduce vulnerability to emotion mind, and to decrease emotional suffering. Understanding emotion is the first step, because a person who cannot identify what they feel cannot regulate it. Research supports this: difficulties in identifying and describing emotions, called alexithymia, are linked to many mental health problems.

What Emotions Do

Emotions serve three functions. They motivate action, preparing the body to respond, as fear prepares for flight and anger for defense. They communicate to others through facial expressions, posture, and voice, which shape how others respond. And they give the person information about the situation, signaling that something matters. Because emotions are useful, trying to get rid of them altogether is neither possible nor wise. The challenge is that emotions can also be out of proportion, can be based on inaccurate interpretations, and can push a person toward actions that do not help, and the skills address these.

The Model of Emotion

DBT describes emotion as a chain. A prompting event, which may be external, such as something someone says, or internal, such as a thought or a memory, triggers an interpretation, which gives rise to a vulnerability factor, a physical sensation, an urge, a facial and bodily expression, and an aftereffect, which includes how the person acts and how they feel afterward. Understanding this chain allows a person to see points at which they can intervene: changing the prompting event, adjusting the interpretation, altering the body’s state, resisting the urge, changing the expression, or managing the aftereffects. The idea is sometimes demonstrated with a written exercise in which a person describes an emotional episode step by step.

Observing and Describing Emotions

The skill of observing and describing emotions, an extension of mindfulness, involves noticing the emotion without judging it or acting on it, stepping back, and experiencing it as a wave. A person identifies the prompting event, the interpretation, the bodily sensations, the urge, the action, and the aftereffects, and gives the emotion a name. The vocabulary of emotion matters. Instead of saying simply that they feel bad, a person learns to distinguish between sadness, disappointment, loneliness, shame, guilt, jealousy, anxiety, fear, irritation, and anger. Research suggests that people with a richer emotional vocabulary, a quality called emotional granularity, regulate emotion better, and that learning to differentiate emotions can reduce overwhelm. A person might keep a list of emotion words and practice choosing the most precise one.

Primary and Secondary Emotions

Distinguishing primary from secondary emotions is a core skill. A primary emotion is the immediate reaction to an event, such as fear on hearing bad news. A secondary emotion is a reaction to the primary emotion or to the thought, such as shame about being afraid, or anger at oneself for crying. Secondary emotions often obscure the primary one and increase suffering. Many people with emotional difficulties have been taught that their feelings are unacceptable and feel shame, anger, or anxiety about feeling, so that the secondary emotion is prominent. Identifying the primary emotion beneath, such as hurt beneath anger, can help a person to respond to what is happening and to be more accurately understood by others.

Myths About Emotions

DBT identifies several unhelpful beliefs about emotion that increase suffering. Examples include the beliefs that there is a right way to feel in every situation, that letting others know that I feel bad is a weakness, that negative feelings are bad and destructive, that being emotional means being out of control, that all painful emotions are the result of a bad attitude, that emotions should be hidden at all times, that other people are the best judges of how I feel, that extreme emotions are a sign of being unstable, and that emotions are not worth paying attention to. Questioning these myths, by looking at the evidence and at their effects, is part of the training, and many people find that they have absorbed these beliefs from childhood.

Checking the Facts

Emotions are influenced by interpretations, and interpretations can be inaccurate. The check-the-facts skill involves asking a series of questions. What emotion do I want to change? What event prompted it? What are my interpretations, thoughts, and assumptions about it? Am I assuming a threat? What is the worst that could happen, and how likely is it? Do my emotions and their intensity fit the facts? The person separates facts from interpretations, considers other possible explanations, and examines whether the emotion’s intensity is proportionate. If the emotion fits the facts, then the person moves to problem solving. If it does not, they might use opposite action. In the example at the start of this article, checking the facts reduced the woman’s certainty that her career was ruined. The skill echoes cognitive restructuring and rests on well-established principles from cognitive behavioral therapy.

Opposite Action

Opposite action is one of the most distinctive and effective emotion regulation skills. The principle is that every emotion has an action urge, and that acting on the urge strengthens the emotion, while acting opposite weakens it. The skill applies when the emotion does not fit the facts or when acting on it would not be effective. The person identifies the action urge, asks whether it is justified, and, if not, does the opposite, completely, with the whole body and mind, including facial expression and posture, tone of voice, and thoughts.

For fear that does not fit the facts, the urge is to avoid, and the opposite action is to approach: do the thing that one fears, repeatedly, in graded steps. For sadness and depression, the urge is to withdraw and become inactive, and the opposite action is to become active and engaged, doing things that provide a sense of connection and mastery. For anger that is not justified or effective, the urge is to attack, and the opposite action is to gently avoid the person, be kind, or take a break, and to imagine empathy for the other person. For shame that does not fit the facts, the urge is to hide, and the opposite action is to share the experience with someone who will understand, and to stop hiding. For guilt that does not fit the facts, the opposite action is to stop apologizing and to carry on. For jealousy and envy, and for love for someone who is not available or good for the person, there are corresponding opposite actions. The skill is the behavioral core of exposure therapy and behavioral activation, and its effectiveness is supported by the research behind those treatments.

It is important to note when not to use opposite action. If the emotion fits the facts, for example, if there really is danger, then fear is useful, and the right action is to protect oneself. Similarly, anger at a real injustice may motivate useful change. The skill is applied after checking the facts.

Problem Solving

When an emotion fits the facts, and the situation can be changed, the skill is problem solving. The person describes the problem factually, checks that it is a problem to be solved and not an emotion to be accepted, sets a goal, brainstorms solutions without judging them, chooses a solution that fits the goal and the situation, puts it into action, and evaluates the results. This may sound simple, but many people under stress skip steps, for example, by acting before defining the problem or by getting stuck on the first idea. Learning the sequence builds a habit. Problem solving is also paired with acceptance, since problems that cannot be solved require distress tolerance and radical acceptance.

Reducing Vulnerability: ABC PLEASE

A major theme is that people are more likely to be overtaken by emotion when they are physically and psychologically depleted. The ABC PLEASE skills aim to reduce this vulnerability. The A stands for accumulating positive emotions in the short term by doing pleasant things each day, and in the long term by building a life that fits one’s values. The B stands for build mastery, doing things that give a sense of competence and achievement, at a level that is challenging but possible. The C stands for cope ahead with emotional situations, rehearsing in imagination how to use skills in situations that are likely to be difficult. PLEASE stands for treat physical illness, balance eating, avoid mood-altering substances, balance sleep, and get exercise. Together these steps provide the foundation for emotional resilience.

Accumulating Positive Emotions

A person who is depressed or overwhelmed often finds that pleasant activities have dropped away, which deepens the low mood. The skill encourages people to schedule at least one pleasant event each day, even if it is small, such as a walk, a call to a friend, or a favorite meal, and to attend to it mindfully, bringing attention back when thoughts about worries intrude. Over the longer term, people identify values, such as relationships, creativity, health, or service, and set goals that reflect them, taking small steps toward them each day. This is related to behavioral activation, which is one of the best-supported treatments for depression. Another element is to avoid worrying about when the positive experience will end, which can spoil it.

Building Mastery and Coping Ahead

Building mastery involves planning at least one activity each day that gives a feeling of accomplishment, such as finishing a task, learning a skill, or doing something difficult, thereby increasing self-efficacy and self-respect. Coping ahead means imagining, in detail and with the senses, a situation that is likely to trigger difficult emotions, deciding on the skills that will be used, and rehearsing in imagination coping effectively. It prepares the mind and reduces the shock of the actual event. For example, a person who fears an upcoming family gathering imagines the setting, the triggering comments, and their own use of breathing, opposite action, and assertive communication, and visualizes a good outcome. The skill draws on research showing that mental rehearsal improves performance.

Taking Care of the Body: PLEASE in Detail

Treating physical illness means attending to medical problems and taking medications as prescribed, since untreated pain and illness raise emotional vulnerability. Balancing eating means eating regular meals with enough nutrition, avoiding both overeating and undereating, and noticing how food affects mood. Avoiding mood-altering substances means staying away from drugs and alcohol, which disrupt emotion regulation, and limiting caffeine if it increases anxiety. Balancing sleep means keeping to a regular sleep schedule and aiming for the amount of sleep that is right for the person, since sleep loss increases emotional reactivity, as studies of sleep deprivation consistently show. Getting exercise means doing moderate physical activity most days, which reduces anxiety and depression. These steps may appear ordinary, but many people find that they are among the most powerful ways to reduce emotional crises.

Mindfulness of Current Emotions

When an emotion is present and nothing can or should be done at that moment, the skill is to let it be. The person observes the emotion, notes where it is felt in the body, experiences it like a wave, remembers that they are not the emotion and that they do not have to act on it, practices loving the emotion, in the sense of accepting it without judgment, and avoids trying to block or suppress it. Research on emotional suppression indicates that it tends to increase physiological arousal and does not reduce the subjective experience, while acceptance of emotion is associated with better outcomes. This skill connects the mindfulness and emotion regulation modules.

Emotions and Their Fit With the Facts: A Reference

DBT teaches that each emotion has typical situations that justify it. Fear fits situations in which there is a threat to life, health, or well-being, or a threat to something valued. Anger fits situations in which a person is being blocked from a goal, is being attacked, or an important thing is being threatened. Sadness fits situations of loss or of things not being as hoped. Shame fits situations in which a person has violated their own or their group’s values and might be rejected. Guilt fits situations in which a person has violated their own values and has caused harm. Jealousy fits situations in which a valued relationship is threatened. Love fits situations in which someone is good for the person. Checking whether an emotion fits the facts, and whether its intensity matches the situation, helps to decide between acting on the emotion and using opposite action.

An Example of the Skills Working Together

Consider a man who is waiting for a message from a friend, and who, after several hours, begins to feel a growing wave of anxiety and anger. He uses mindfulness to observe: his heart is racing, his jaw is tight, and he is thinking that his friend does not care. He describes the emotion: anxiety, sadness, and anger, with the urge to send a sharp message. He checks the facts: the friend is often busy and has replied late before, and there is no evidence of rejection. He recognizes that the emotion is more intense than the facts warrant, and uses opposite action by not sending the angry message and by doing something absorbing. He uses paced breathing to lower arousal, and schedules a pleasant activity for the evening. Later, when calm, he writes a friendly message. Each step uses a different skill, and together they change the course of the episode.

Interpersonal Effectiveness: The Fourth Module in Brief

Although this article focuses on three modules, a brief word about the fourth shows how they connect. Interpersonal effectiveness skills help a person to get what they want from others, to keep and strengthen relationships, and to preserve self-respect. The skills are organized into acronyms. DEAR MAN is a sequence for asking for something or saying no: describe the situation, express feelings, assert the request, reinforce by explaining the benefits, stay mindful, appear confident, and negotiate. GIVE is a set of skills for maintaining relationships, standing for being gentle, acting interested, validating, and using an easy manner. FAST is a set of skills for maintaining self-respect, standing for being fair, not apologizing unnecessarily, sticking to values, and being truthful. Mindfulness helps a person to stay present in a conversation, distress tolerance helps when the other person says no, and emotion regulation reduces the intensity of emotion that gets in the way of speaking effectively. Many emotional crises are interpersonal, so this module often determines whether the other skills have an effect in real life.

Putting the Skills Together

Skills are most useful when used flexibly, in combination, and at the right time. Understanding how they fit together helps learners to avoid the common mistake of trying to use every skill at once, or of using one skill in every situation.

Choosing a Skill

A simple decision pathway can help. First, notice the emotion and rate its intensity, using mindfulness. If the intensity is very high and there is an urge to do something harmful, use crisis survival skills: STOP, breathing, distraction, self-soothing, and, if needed, call the crisis plan. If the intensity is moderate and the situation can be changed, use emotion regulation and problem solving, and check the facts. If the emotion does not fit the facts, use opposite action. If the situation cannot be changed, use radical acceptance and willingness. If the issue involves another person, add interpersonal effectiveness. If vulnerability is high because of poor sleep, hunger, or other factors, address them, since they affect everything else. This is not a rigid formula but a map.

Skills Across the Day

People who use skills most effectively do so before crises develop, in the form of daily habits. A morning routine might include a few minutes of mindfulness, a plan for a pleasant activity and a mastery activity, a review of the day’s likely triggers with coping ahead, and attention to sleep and food. Through the day, brief check-ins, such as pausing to name the current emotion and rate it, build awareness. In the evening, a review of the diary card and of what worked reinforces learning. The aim is to make skills part of life and not something saved for emergencies.

The Skills Hierarchy of Practice

Skills are learned in stages. At first, a person recognizes the skill when it is explained, then uses it when calm, then uses it when mildly upset, and finally uses it when highly emotional. Progress from one stage to the next takes repetition. Many people become discouraged when they cannot use a skill in a crisis, and it helps to know that this is normal and that the answer is more practice at lower levels of distress. Therapists often assign small, specific practice tasks, and people who practice regularly make faster progress.

A Composite Example

The following account is a composite and does not describe a real person. A man in his late twenties, whom we shall call Tom, began DBT skills training after a period in which he drank heavily, ended a relationship in a rage, and was hospitalized after an overdose of tablets. Early on, he found the skills awkward and sometimes felt silly rating his feelings. His therapist encouraged him to practice with minor irritations. He learned to catch the early signs of anger: heat in his chest and a clenched jaw. When he felt an urge to storm out of the house or open a bottle, he used STOP and paced breathing, and phoned a friend from his crisis plan. He used pros and cons to remind himself of what drinking had cost. He learned that much of his anger was actually shame, and that when he checked the facts, his interpretations were often harsher than the situation warranted. Over several months, he reduced his alcohol use, stopped the pattern of explosive arguments, and started attending a weekly climbing group, which gave him mastery and connection. He still has hard days, but he says that for the first time he feels that he has a toolkit and not just a feeling of being swept away.

Common Obstacles and How to Work With Them

Learning DBT skills is not always easy. Many people who could benefit from them struggle to use them, and understanding the typical obstacles helps to prevent discouragement.

Not Using Skills in the Moment

The most common obstacle is forgetting or being unable to use skills when emotion is high, because the parts of the brain involved in planning and learning are less accessible at high arousal. Solutions include practicing when calm, writing skills on cards or on a phone, keeping a short list of go-to skills, setting reminders, and asking a coach or trusted person to prompt. Starting with the easiest skills, such as breathing or distraction, helps.

Believing That Skills Do Not Work

Some people try a skill once, find that it does not remove the pain, and conclude that it is useless. Skills are not designed to eliminate emotion immediately. Their aim is to reduce intensity, to prevent harmful action, and to build capacity over time. It can help to track the change in the rating of distress before and after a skill, which often shows a modest but real reduction, and to remember that skills are cumulative.

Invalidation and Self-Criticism

Many people respond to difficulty with harsh self-judgment, saying that they are failing at skills, which makes things worse. DBT stresses self-validation, acknowledging that one is doing the best one can with the resources one has, while working to improve. Treating oneself as one would a friend, and noticing small successes, builds momentum.

Skills Feel Fake or Mechanical

Some people feel that using skills is artificial, like pretending to be calm. It is natural for new behavior to feel awkward, just as learning an instrument feels awkward at first. With practice, skills become automatic. It may also help to find the skills that suit one’s own style and preferences, as no one needs to use all of them.

Emotional Avoidance Disguised as Skills

Distraction and self-soothing can be misused as ways of avoiding emotion altogether. A sign of this is when a person never returns to the problem or never allows themselves to feel. The balance of acceptance and change means that emotions are sometimes to be felt fully, and that problems are to be solved when possible. A therapist can help to maintain this balance.

Trauma and Mindfulness

For people with a history of trauma, mindfulness and relaxation practices can sometimes trigger distress, flashbacks, or dissociation. This does not mean that the skills are unsuitable, but that they may need to be modified, with eyes open, shorter durations, an external focus, and grounding. Therapists with experience of trauma can adapt the practice. Where the trauma is severe, specific trauma treatment may be needed alongside the skills.

Lack of Support and Invalidating Surroundings

People trying to use skills in an environment that is critical, chaotic, or dismissive may find it hard. Where possible, involving family members, using family skills programs, and building a supportive network can help. In some situations, the environment is not safe, and safety planning comes first.

Practical Barriers

Time, cost, access to trained therapists, and the demands of work and family can all get in the way. Self-help workbooks, online programs, and skills groups that are offered in a flexible way can help to reduce these barriers, though they do not replace comprehensive treatment for severe difficulties.

DBT Skills for Different Groups and Conditions

Although DBT was originally developed for borderline personality disorder, its skills are used with many groups. The evidence varies, but a few applications are particularly well developed.

Adolescents and Families

DBT for adolescents, developed by Alec Miller and Jill Rathus, adapts the treatment for teenagers with emotional and behavioral difficulties, including self-harm and suicidal thoughts. A distinctive feature is multifamily skills training, in which parents and teenagers learn the skills together, and a module on walking the middle path, which teaches dialectical thinking and ways of resolving conflicts between parents and teenagers. Trials, including one by Mehlum and colleagues in Norway and another by McCauley and colleagues in the United States, found that DBT for adolescents reduced self-harm and suicidal ideation compared with enhanced usual care. Skills are also taught in schools, as part of programs to build emotional resilience in young people.

Eating Disorders

Emotional dysregulation is a central factor in bulimia and binge eating, and DBT has been adapted to teach emotion regulation as an alternative to bingeing and purging. Trials by Debra Safer and colleagues found that DBT for binge eating disorder and bulimia reduced binge episodes, and that skills of mindfulness and distress tolerance, such as urge surfing, were helpful. In anorexia nervosa, adaptations such as radically open DBT have been developed for people with overcontrol.

Substance Use

DBT has been adapted for people with substance use disorders, including those with borderline personality disorder. It includes skills for managing cravings, such as urge surfing and distress tolerance, along with dialectical abstinence, a stance that combines a commitment to abstinence with a plan for returning to treatment after a lapse. Trials by Linehan and colleagues found that DBT reduced drug use in women with borderline personality disorder and substance use disorders.

Depression and Anxiety

Emotion regulation skills help with depression and anxiety by providing tools for behavioral activation, opposite action, and acceptance. Studies of DBT for treatment-resistant depression in older adults, by Thomas Lynch and colleagues, found benefits, and radically open DBT has been developed for people with chronic overcontrol, such as those with chronic depression, anxiety, and obsessive-compulsive personality traits. Skills are used to reduce avoidance and to allow people to engage in valued activities despite emotional discomfort.

Trauma and Post-Traumatic Stress

DBT skills are used to stabilize people before and during trauma-focused treatment. DBT with a prolonged exposure protocol for post-traumatic stress disorder, developed by Melanie Harned, combines skills training with exposure therapy for people with borderline personality disorder and trauma, and trials have found that it is effective. Skills of grounding, distress tolerance, and emotion regulation help to reduce dissociation and self-harm and increase readiness for trauma processing.

Attention-Deficit Hyperactivity Disorder

Emotional dysregulation is common in attention-deficit hyperactivity disorder, and DBT skills have been adapted for adults with the condition, including mindfulness to improve attention and emotion regulation and distress tolerance for impulsive reactions. Studies indicate benefits, such as reduced symptoms and improved functioning.

Autism and Neurodiversity

Adaptations for autistic people are being developed, using clearer language, concrete examples, visual supports, and attention to sensory needs, since emotion dysregulation is common and DBT’s skills-based structure is a good fit for many. Evidence is still limited, and treatment should respect the person’s neurodivergent experience and not aim to suppress it.

Bipolar Disorder and Other Conditions

DBT skills have been used as an adjunct for bipolar disorder, to reduce emotional reactivity and to support medication, and for conditions such as chronic pain, anger problems, and gambling. The wide range of applications reflects the generality of emotion regulation difficulties, but the quality of evidence differs among conditions.

Workplaces, Schools, and the General Public

Skills are taught in schools through programs such as DBT Steps-A, in which mindfulness, distress tolerance, and emotion regulation skills are given to entire classes, with the aim of promoting resilience. They are also used in the workplace to reduce stress and conflict. These applications are promising, though evidence is preliminary.

Learning DBT Skills: Getting Started

People who want to learn the skills have several options, and the right one depends on the severity of their difficulties, their resources, and their preferences.

Comprehensive DBT

For people with severe emotional dysregulation, self-harm, suicidal thoughts, or borderline personality disorder, comprehensive DBT, which includes individual therapy, skills group, phone coaching, and therapist consultation, is recommended. It is usually delivered over six months to a year or more. Programs vary in availability, and many countries have certified programs. People can ask a general practitioner or mental health service for a referral and can ask whether a program follows the evidence-based model.

Skills Training Groups

Skills groups are widely available and may be a good option for people with less severe difficulties or those who are also in other therapy. They teach the four modules over several months, with homework. Many people find the group format helpful because they learn from others and see that they are not alone.

Self-Help and Online Resources

Workbooks, such as the manual by Marsha Linehan, and others written for the general public, provide a clear introduction to the skills, with exercises and worksheets. Online courses and applications offer guided practice, reminders, and diary cards. Self-help is effective for some people with milder difficulties, but for those with serious problems, working with a trained therapist is advisable. Using a workbook alongside therapy is often useful.

Choosing a Therapist

When choosing a therapist, it is reasonable to ask whether they have training in DBT, whether they are part of a consultation team, whether they use the full model or only the skills, and how they handle crises. A therapist who emphasizes both validation and change, who is collaborative, and who respects the person’s pace is a good sign. In many countries, organizations maintain lists of clinicians who have undergone intensive training and certification.

Starting Small

Whatever route is chosen, it is helpful to start small. Choose one or two skills, such as mindful breathing and the STOP skill, and practice them daily for a few weeks. Keep a simple record. Add further skills gradually. Ask for help if the skills are not working or if distress is high. The point is not to master all the skills but to build a personal set that works.

Supporting Someone Who Is Learning DBT Skills

Family members, partners, and friends can play a valuable part in a person’s learning of skills, and their own understanding of the approach helps.

What Helps

Learning about the skills, or attending a family skills program, helps a supporter to understand what the person is trying to do and to use the same language. Validation is among the most useful responses: acknowledging that the person’s feelings make sense, without necessarily agreeing with every interpretation or approving of every behavior. Encouraging the use of skills, in a gentle and non-controlling way, can help, for example, by asking “Would it help to take a few breaths?” or “What skill might be useful?” at a calm moment, not in the middle of an argument. Celebrating progress, however small, builds motivation, and being patient with setbacks supports persistence.

What to Avoid

Avoid using skills as a weapon, such as telling someone in a crisis to use their skills or accusing them of failing to practice. Avoid dismissing their emotions or telling them to calm down. Do not take over their problems, since building competence requires them to practice. Do not make agreements to provide constant reassurance that may prevent them from using their own skills. If the person is in danger, do not hesitate to contact emergency services.

Using the Skills Yourself

Supporters can benefit from the skills themselves. Mindfulness helps to stay present, distress tolerance helps to get through painful moments, emotion regulation helps in dealing with the stress of supporting someone, and interpersonal effectiveness helps to set boundaries kindly. Modeling skills is one of the best ways to help, and looking after one’s own wellbeing is not selfish.

Parents and Teenagers

Parents of teenagers can benefit from learning the skills alongside their children, and from the dialectical principle that they can accept their teenager and also expect change, that they can set limits and also show understanding. Family programs adapted for parents, such as the Family Connections program and multifamily skills groups, offer education and support, and they reduce the burden on caregivers.

Common Myths About DBT Skills

Several misconceptions prevent people from trying DBT skills or from using them well. The first is that DBT is only for borderline personality disorder. Although it was developed for that condition, its skills are used for many conditions and by people without any diagnosis. The second is that skills are about suppressing emotion. They are about understanding, accepting, and, where useful, changing emotion, not about hiding it. The third is that mindfulness is about emptying the mind or feeling calm. It is about noticing what is present, including a busy mind, without judgment.

A fourth myth is that distress tolerance means putting up with abuse or giving in to unacceptable situations. Radical acceptance concerns accepting facts that cannot be changed, and it does not mean approving of harm or giving up efforts to change what can be changed. A fifth is that skills should work immediately. They build over time. A sixth is that if a person needs skills, they are weak. Skills are learned abilities, and many people who are highly sensitive find that they develop great emotional strength. A seventh is that reading about skills is the same as having therapy. Reading is a good start, but for serious difficulties, trained guidance matters. An eighth is that DBT is a quick fix. Comprehensive DBT typically takes six months to a year or more, and benefits grow with practice.

A Realistic and Hopeful Outlook

The outlook for people who learn and practice DBT skills is encouraging. Studies show that skills training helps people to reduce self-harm, decrease hospital admissions, lower depression and anger, and improve relationships and quality of life, and that the benefits are maintained in follow-up studies. Many people report that the most valuable change is a new relationship with their emotions: they become less frightening, more understandable, and more manageable, and the person feels that they have a choice in how to respond.

Progress is not linear. Skills are used imperfectly at first, setbacks occur, particularly at times of stress, and practice has to be renewed. But the skills remain available, and those who continue to use them tend to find that they work more quickly and naturally over time. Recovery does not mean the absence of painful emotion. It means that painful emotion no longer drives destructive behavior or dominates life, and that joy, connection, and meaning have room to grow. Linehan’s phrase for the goal of treatment is building a life worth living, and the skills are the means by which people build it, step by step.

When to Seek Help

It is time to seek professional help when emotions feel unmanageable, when they lead to self-harm, suicidal thoughts, substance misuse, binge eating, rage, or other behaviors that cause harm, when relationships are repeatedly damaged by emotional reactions, or when you feel hopeless. A good first step is to see a general practitioner or a mental health professional, and to ask about DBT or DBT-informed treatment. If you are having thoughts of suicide or feel that you may harm yourself, contact local emergency services or a crisis line immediately, or go to the nearest emergency department. Skills are valuable, but they are not a substitute for emergency help or for treatment of serious conditions.

Conclusion

DBT skills offer a practical answer to a very common human problem: how to live with emotions that are stronger than the tools one has to manage them. Mindfulness provides the foundation, teaching a person to observe, describe, and participate in experience without judgment, and to reach the wise mind that integrates emotion and reason. Distress tolerance provides the means of surviving crises without making them worse, through pausing, weighing consequences, calming the body, distracting, self-soothing, improving the moment, and, above all, radically accepting what cannot be changed. Emotion regulation provides the means of understanding emotions, checking whether they fit the facts, acting opposite to unhelpful urges, solving problems, reducing vulnerability through sleep, food, exercise, and balance, and building a life with positive experience and mastery.

The skills rest on a compassionate theory, that people who struggle with emotion are not defective or manipulative but are doing their best with a sensitive nervous system and often an invalidating history, and that they can learn what they were never taught. The evidence from decades of research supports this view, showing that DBT and skills training reduce suffering and save lives. Anyone who recognizes themselves in these descriptions is encouraged to begin small, to practice regularly and without self-criticism, to seek a trained therapist if difficulties are serious, and to contact emergency services or a crisis line in a crisis. Emotions will always be part of being human, and their intensity may never vanish, but the ability to meet them with awareness, tolerance, and skill can be learned, and with it the capacity to build a life that feels worth living.

FAQ About DBT Skills

What are DBT skills, and who are they for?

DBT skills are a set of practical, teachable strategies for managing emotions, behavior, and relationships, developed by Marsha Linehan as part of dialectical behavior therapy. They are organized into four modules: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. They were originally designed for people with borderline personality disorder and chronic suicidal thoughts, but they are now used for many conditions, including depression, anxiety, eating disorders, substance use, post-traumatic stress, and attention-deficit hyperactivity disorder, and by people who simply want to improve their emotional coping. They are taught in groups, in individual therapy, through workbooks, and online, and can be useful whenever emotions feel overwhelming.

What is the difference between distress tolerance and emotion regulation?

Distress tolerance skills are for getting through painful moments without making things worse, especially when emotion is very intense and the situation cannot be changed immediately. They include pausing, distracting, self-soothing, calming the body, weighing pros and cons, and radical acceptance. Emotion regulation skills are for understanding emotions, reducing vulnerability to painful ones, and changing them when change is helpful. They include naming emotions, checking the facts, opposite action, problem solving, and caring for sleep, food, and exercise. In short, distress tolerance is about acceptance and survival, while emotion regulation is about change and prevention, and a skilled person learns when to use each.

What is wise mind?

Wise mind is the DBT concept of the integration of emotion mind, in which feelings dominate, and reasonable mind, in which logic and facts dominate. It adds a sense of intuitive knowing, and it is the part of every person that can see what is right in a situation when they are calm and attentive. People often describe it as a feeling of inner calm and clarity when making a decision. It can be accessed through mindful breathing and by asking oneself a question and waiting for an answer, without forcing it. Wise mind is not always available in moments of intense emotion, which is why regular practice is helpful.

What does radical acceptance mean, and does it mean I have to approve of what happened?

Radical acceptance means fully acknowledging reality as it is, without fighting it, in the case of facts that cannot be changed. It does not mean approving of what happened, forgetting it, giving up on change, or liking it. It means ceasing to waste energy in resisting the facts, since refusing to accept a painful reality does not change it and tends to add suffering to the pain. A person can radically accept that a loss has occurred and still grieve, still seek justice, and still work to change what can be changed in the future. It is a skill that is practiced repeatedly, and often involves grief.

How does opposite action work?

Opposite action is a skill for emotions that do not fit the facts or that are not helpful to act on. Every emotion has an urge to act, and acting on the urge strengthens the emotion, while acting in the opposite way weakens it. For example, when fear does not fit the facts, the urge is to avoid, and the opposite action is to approach the feared situation in manageable steps. When sadness leads to withdrawal, the opposite action is to become active and connected. When shame is not justified, the opposite action is to stop hiding and to share the experience with a trusted person. The person acts completely, including posture, facial expression, and thoughts. It should be used only after checking that the emotion does not fit the facts.

Do DBT skills really work, and what does the research say?

Yes, the research is encouraging. Randomized trials and meta-analyses show that comprehensive DBT reduces self-harm, suicidal behavior, hospital admissions, depression, and anger in people with borderline personality disorder, with benefits lasting at follow-up. Adaptations for adolescents, eating disorders, substance use, and trauma also show benefit. Trials of skills training alone, including a trial by Linehan and colleagues published in 2015, found that group skills training can be an effective stand-alone treatment for some people. The evidence is strongest for borderline personality disorder and self-harm, and growing for other conditions. Skills work best when practiced regularly, and results vary between individuals.

Can I learn DBT skills on my own?

Many people can learn and benefit from the skills using workbooks, online courses, and applications, particularly if their difficulties are mild to moderate. Self-guided learning works best with regular practice, a diary card, and patience. For people with severe emotion dysregulation, self-harm, suicidal thoughts, or trauma, working with a trained therapist is strongly advisable, since comprehensive DBT includes individual therapy, coaching, and support in crises. Using a workbook alongside therapy is often helpful. If at any point you feel unsafe or hopeless, contact a doctor, a crisis line, or emergency services.

How long does it take to learn DBT skills?

A standard skills group covers the four modules in about six months, and many programs repeat the cycle for a year. Comprehensive DBT typically lasts six months to a year or more. Some people notice benefits within weeks, such as a better ability to pause before reacting, while deeper changes take months of practice. Skills are learned in stages, from understanding them, to using them when calm, to using them when upset. Progress is not linear, and regular practice is the main factor. Many people continue to use and refine the skills for years.

What if I cannot use the skills when I am really upset?

This is very common and does not mean that the skills are failing. When emotion is at its highest, the parts of the brain involved in thinking and planning are less available. The solution is to practice skills when calm and when mildly upset, so that they become automatic, and to keep a short list of simple, go-to skills, such as paced breathing, the STOP skill, and distraction, available on a card or phone. A written crisis plan, prepared in advance, can guide you. Over time, with repetition, the skills become more accessible at higher levels of distress.

Are DBT skills useful for people without a mental health diagnosis?

Yes. The skills address general processes of attention, emotion, and relationships that affect everyone. Many people use mindfulness to reduce stress, distress tolerance to cope with difficult events, emotion regulation to understand and manage moods, and interpersonal effectiveness to communicate better. They are taught in schools, workplaces, and community programs. Anyone can benefit, although people with significant difficulties should seek professional help, since the skills are not a substitute for treatment.

How can I support a family member who is learning DBT skills?

Learn about the skills and, if possible, attend a family skills program. Validate their feelings, acknowledging that their emotions make sense, without necessarily agreeing with everything. Encourage them gently to use skills, at calm moments, and avoid using skills as a weapon in an argument. Celebrate progress and be patient with setbacks. Do not take over their problems, since they need to practice. Use the skills yourself, particularly mindfulness and interpersonal effectiveness, and look after your own wellbeing. If the person is in danger or speaks of suicide, contact emergency services or a crisis line immediately.

Recommended Books on DBT Skills

• DBT Skills Training Manual by Marsha M. Linehan
• DBT Skills Training Handouts and Worksheets by Marsha M. Linehan
• Cognitive-Behavioral Treatment of Borderline Personality Disorder by Marsha M. Linehan
• Building a Life Worth Living: A Memoir by Marsha M. Linehan
• The Dialectical Behavior Therapy Skills Workbook by Matthew McKay, Jeffrey C. Wood, and Jeffrey Brantley
• The Dialectical Behavior Therapy Skills Workbook for Anxiety by Alexander L. Chapman, Kim L. Gratz, and Matthew T. Tull
• Dialectical Behavior Therapy with Suicidal Adolescents by Alec L. Miller, Jill H. Rathus, and Marsha M. Linehan
• The Borderline Personality Disorder Survival Guide: Everything You Need to Know About Living with BPD by Alexander L. Chapman and Kim L. Gratz
• Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life by Jon Kabat-Zinn
• Radical Acceptance: Embracing Your Life with the Heart of a Buddha by Tara Brach