Dialectical behavior therapy (DBT), developed by Marsha Linehan in the late 1980s, was originally designed for chronically suicidal women with borderline personality disorder. Over the next thirty years it became one of the most rigorously studied psychotherapies in mental health. More recently, researchers have begun adapting DBT skills for schizophrenia and other psychotic disorders — not because the diagnoses are similar, but because the underlying problems DBT addresses (intense emotions, impulsivity, self-harm, interpersonal storms) overlap with what many people with schizophrenia struggle with day to day.
DBT teaches concrete skills in four areas — mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness — and adapted versions are increasingly used in schizophrenia for self-harm risk, emotion dysregulation, and crisis management.
What "dialectical" means
DBT is built on the dialectic between acceptance (this is where I am right now, and that is real) and change (and I can move toward something different). Linehan saw that pure change-focused therapies (like classical CBT) felt invalidating to her patients, while pure acceptance-focused work didn't address the harm. DBT holds both.
The four skills modules
Mindfulness
Awareness of the present moment without judgement. Skills include "observe, describe, participate" and "wise mind." For people with psychosis, mindfulness can be adapted to include noticing voices or unusual perceptions without immediately reacting to them.
Distress tolerance
Skills for getting through a crisis without making it worse — TIPP (Temperature, Intense exercise, Paced breathing, Paired muscle relaxation), distraction techniques, and "radical acceptance" of unchangeable facts. These map naturally onto coping with overwhelming voices, paranoia spikes, and panic.
Emotion regulation
Identifying and naming emotions, reducing vulnerability to emotion mind through sleep and structure, and acting opposite to the emotional urge when it doesn't fit the facts.
Interpersonal effectiveness
Skills like DEAR MAN (Describe, Express, Assert, Reinforce, stay Mindful, Appear confident, Negotiate) for asking for what you need, and FAST (Fair, Apologies less, Stick to values, Truthful) for keeping self-respect.
The case for DBT in schizophrenia
People with schizophrenia have elevated rates of self-harm and suicide — roughly 5–10% die by suicide. Many also experience significant emotion dysregulation, especially when paranoia or voices are active. Standard antipsychotic treatment does not target emotion regulation skills directly, and CBT for psychosis (CBTp) focuses primarily on appraisal of psychotic experiences. DBT skills offer a complementary toolkit.
What the evidence shows
Research on DBT specifically for schizophrenia is less mature than the borderline literature, but a growing number of studies and adapted protocols have shown benefit. Notable examples include:
- Adapted DBT skills groups for psychosis (DBT-P) developed by Andrew Chapman and colleagues, with case-series evidence of reduced self-harm and crisis service use.
- DBT in early psychosis programmes, with feasibility data published in Schizophrenia Research and related journals.
- DBT skills training in community mental health settings for people with serious mental illness more broadly, with evidence of improved coping and reduced hospitalisation.
The evidence base is not yet as robust as for CBTp or family psychoeducation, but it is growing, and DBT is now widely offered in early intervention and assertive community treatment programmes.
Where DBT fits well
- People with schizophrenia or schizoaffective disorder who self-harm or have repeated suicidal crises
- People with co-occurring borderline traits or trauma history
- People who struggle with emotion regulation between psychotic episodes
- People who are on the right medication but still cycling in and out of crisis
What adapted DBT for psychosis looks like
Standard DBT involves weekly individual therapy, a weekly skills group, between-session phone coaching, and a therapist consultation team. Adapted versions for psychosis often:
- Use shorter sessions or shorter group cycles
- Slow the pace of skills teaching
- Spend more time normalising and validating psychotic experiences
- Integrate explicit work with voices and paranoia using DBT-style mindfulness
- Work closely with the prescriber and family
What it asks of patients
DBT is structured and skills-focused. Homework — practising skills between sessions — is a core part of the model. People who do well in DBT tend to be those who are willing to engage with the structure, even while being explicitly allowed to find parts of it frustrating.
DBT is hard to use during acute, severely disorganised psychosis. It also is not a substitute for antipsychotic medication when medication is clinically indicated. Talk to your prescriber about how DBT might complement, not replace, your existing treatment.
Finding DBT
Behavioral Tech (the organisation founded by Linehan) maintains a clinician directory. Many academic medical centres and community mental health programmes now offer DBT. When asking about fit, useful questions include: "Have you adapted DBT for psychosis?" and "How will you coordinate with my prescriber?"
The bigger picture
DBT for psychosis is part of a wider movement to bring third-wave behavioural therapies (DBT, ACT, compassion-focused therapy, mindfulness-based approaches) into schizophrenia care. None of these is a replacement for CBTp or medication. They are tools that, used well, can address parts of the experience that the standard toolkit doesn't reach. For more on related approaches, see our guides on ACT for psychosis and compassion-focused therapy.
This article is for educational purposes only and is not medical advice, diagnosis, or treatment. Always consult a qualified mental health professional. If you or someone you know is in crisis, call or text 988 in the US, or your local emergency number.