Mental Health

How Dialectical Behavior Therapy Treats Self Harm


Getting oneself to stop self-harm behaviors can take more than just willpower! Emotions preceding self-harm episodes can be very strong and the life-problems leading to these emotions are real. Dialectical Behavior Therapy (DBT) is a psychotherapy aimed at helping people with extreme and chronic emotion dysregulation – having emotions that are very strong, quick to start, and slow to end – learn to build new skills into their life while at the same time reducing the behaviors and patterns that cause them problems. 

Often, DBT therapists find themselves helping people learn to stop engaging in intentional self-harm*. To start, DBT therapy helps someone understand what might be leading to self-harm behaviors (in behaviorist terms, we want to know the antecedents). We also want to know what might be contributing to the behavior happening repeatedly by understanding what happens next (in behaviorist terms, we want to know the consequences). Once we have a handle on understanding this, people begin to use skills they are learning (in DBT Skills Training group) at the times they need it most.

Behavior chain analysis: The tool for understanding why a behavior is happening

A behavior chain analysis (BCA) is a procedure used to understand the causes of a behavior. BCAs are done regularly, often every session for some time. 

Here’s how it tends to go… 

  1. First the behavior is described, including some details such as when this happened and where someone was. The event playing a significant role in prompting the behavior is noted, as well as factors making the person more vulnerable to having the high emotions that lead to the behavior. 
  2. Next are the links in the chain. To outline this, we remember the acronym ABCEF (yes, you’re correct in noting there’s no D). This stands for: actions, body sensations, cognitions – meaning thoughts, events in the environment, and feelings. These links are listed in the order that they occurred, second by second. 
  3. Then, one thinks about what immediately happened next, both inside of them, such as did emotional pain go down, and outside of them, such as someone else showed warmth and concern. Sometimes, it’s what happens after a behavior that keeps the behavior happening again and again. 
  4. Finally, the therapist then helps the person go back and think of important places to use skills. This part is very important; it’s easy for a therapist – myself included some of the time – to want to help someone and have the tendency to make suggestions for strategies to make things better. But, if we don’t yet understand why the behavior is happening, it’s not likely the strategies are going to be the best fit.

Distress tolerance skills: Strategies for not making things worse 

Think about what it feels like to be very anxious, guilty, or angry, for example. What do you feel in your chest? With your breathing? In your stomach? Do you get hot or cold? What types of thoughts are spinning around in your head? What seems unacceptable? Do you want the distress to end? Is it hard to get your mind off a situation you are faced with?

When emotions seem unbearable and physical distress is really high leading to urges for self-harm, one of the first go-to skills is the TIPP skill. TIPP stands for temperature, intense exercise, paced breathing, and paired muscle relaxation. Temperature is about getting something cold (but not too cold, it’s recommended to be over 50 degrees) on your face right under your eyes and on the sides of your nose. Doing this activates something called the mammalian diver reflex (you might want to go look this one up!). When mammals dive into cold waters, upside down, while holding their breath, the body has a reflex that is intended to protect them. And this has an effect of slowing heart rate, making breathing slower and deeper. If you want to try this all-the-way, you can get a bowl of water and ice, hold your breath, lower your face into it, and stay there for about 30 seconds. This skill works fast! The important catch to note is that while it works, the effect doesn’t last for long – so it will need to be followed by other skills.

When urges for self-harm are strong or a person can’t stop focusing on something upsetting, distraction can be useful. I want to say right away that distraction is a skill to be used for a period of time that has an end-point. Distraction can’t be a way of life if someone wants to build a life that is worth living! 

Here are a few distraction techniques to try:

  • Engaging in an activity mindfully. Things like gardening or cooking can take the focus away from problems. So can watching an engaging movie.
  • Replacing thoughts with others. Counting things around oneself, such as ceiling tiles or books on a shelf occupy the mind. Try going through the ‘animal ABCs.’ Alligator, Bumble Bee, Cat, Deer, and so on. Or, count backwards from 1,000 by 7.
  • Comparing yourself to yourself. Remind yourself of other moments that felt this hard or times you got through the same thing and that it ended. 

Someone who engages in self-harm might also experience little hope for change. The emotions are strong, the pain seems unbearable, it’s hard to think differently, and people around might not understand why this is happening. DBT is backed by research showing that it helps people who experience this exact thing. Through understanding the problem, learning new strategies, and using these skills in every-day life people do get better!


*Note: Self-harm refers to a large category of behaviors aimed to hurt oneself. Nonsuicidal self-injury specifically refers to hurting oneself on purpose without the intent to die.