Why DBT for Psychosis?

For decades, Dialectical Behavior Therapy (DBT) has been recognized as one of the most effective, evidence-based treatments for chronic emotion dysregulation and high-risk behavioral patterns. Yet one group continues to be left out of access to DBT across many clinics, hospitals, and community programs: people experiencing psychosis.

People living with psychotic spectrum disorders (PSD) face profound challenges related to emotion regulation, distress tolerance, and interpersonal effectiveness. These are the very domains DBT was built to target. And increasingly, research and clinical experience show that DBT is a powerful, compassionate, and appropriate treatment for this population.

So why should DBT be offered to people experiencing psychosis?

1) Psychosis is deeply intertwined with emotion dysregulation.

While psychosis is often narrowly conceptualized as a problem of hallucinations and distorted thinking (formerly called “delusions”), clinicians and people with lived experience consistently emphasize the central role of intense emotions. People with PSD struggle with significant emotion dysregulation, including intense emotional reactions to stress, prolonged difficulty returning to baseline, and heightened subjective emotional intensity (Lawlor et al., 2020; Myin-Germeys et al., 2007; Vaessen et al., 2019; Kimhy et al., 2014). DBT directly treats these issues using mindfulness, emotion regulation, and distress tolerance tools, and offers long-term pathways toward stability and resilience that are part of building a life worth living.

2. People with psychosis want practical, skills-based tools.

When you ask people with PSD what they find most helpful in recovery, they often name skills: recognizing triggers, staying regulated, strengthening relationships, and navigating overwhelming moments. Yet traditional services frequently prioritize medication management or insight-oriented therapy while under-delivering practical tools. DBT fills this gap. It gives people clear, actionable strategies they can use immediately—tools that support autonomy, safety, and agency.

3. DBT reduces high-risk behaviors common in PSD.

Suicidality, self-harm, substance use, and impulsive behaviors are significantly elevated among people with psychotic disorders. These behaviors are often driven by emotional pain, trauma histories, stigma, psychotic experiences, and systemic barriers. DBT is an evidence-based treatment for reducing these life-threatening behaviors. When used with people experiencing psychosis, it offers a structured, compassionate framework for staying alive and building a life worth living, even when psychotic experiences are present.

4. The DBT validation model is uniquely suited for psychosis.

Invalidation is a profound part of many people’s experiences of psychosis—being told they’re “crazy,” “making it up,” “too much,” or “dangerous.” Systems often respond with coercion instead of collaboration. DBT’s emphasis on deep, authentic validation can be life-changing. It helps clients feel understood rather than pathologized, builds trust, and reduces shame. Validation also helps people make sense of psychotic experiences, including hallucinations or distorted thinking, by focusing on the emotions they elicit rather than the content of the experiences themselves.

5. Excluding people from DBT is inequitable.

Too often, people with psychosis are told they “don’t fit” DBT programs—messages that reinforce stigma and reproduce systems of exclusion. But the truth is:

• People with PSD are already using DBT skills in their daily lives.

• Many thrive in DBT groups with minimal adaptation.

• Those with the highest stress and risk often need DBT the most.

Equity in mental health means removing unnecessary barriers and offering evidence-based care to all who can benefit—not making assumptions about abilities simply based on diagnosis.

6. DBT supports recovery, not just symptom reduction.

At its heart, DBT is about building a life worth living. For people experiencing psychosis, this often includes:

• finding purpose

• building relationships

• engaging in the community

• reducing shame and self-stigma

• developing agency

Although antipsychotic medications can be life-saving, they are only one piece of the recovery puzzle. DBT helps people shape meaningful, connected lives even when psychotic experiences persist.

A Call to Action:

People experiencing psychosis deserve the same access to evidence-based, compassionate, skills-focused care that others receive. As the field increasingly recognizes emotion dysregulation as a core mechanism underlying psychosis, the rationale for offering DBT becomes not just compelling, but ethical.

Clinicians, program directors, and health systems have the opportunity—and responsibility—to expand DBT access. With thoughtful adaptation and a commitment to equity, DBT can be a transformative resource for individuals navigating psychosis.

It’s time to move beyond outdated assumptions.

It’s time to offer DBT to people experiencing psychosis.