GUIDE · DBT

Pros and cons in DBT: four boxes to fill in before the urge hits

It's 11:48 p.m., your manager has just picked apart your report in a two-line email, and you've typed a reply that ends with "Consider this my resignation." Pros and cons is a crisis survival skill from dialectical behavior therapy (DBT) for moments like this, when an urge is strong and acting on it would make things worse later. You weigh acting on the urge against resisting it in four boxes, and you fill them in on a calm day, long before the urge shows up.

What the DBT pros and cons skill is, and when it fits

Pros and cons comes from DBT, the treatment Marsha Linehan developed. It's one of six crisis survival skills in distress tolerance, the DBT skills for bearing pain you can't fix right away, next to STOP, TIPP, ACCEPTS, self-soothing and IMPROVE the moment. Linehan's teaching notes call it a decision-making strategy: you think through what happens if you act on an urge and if you don't.

Her handout treats an urge as a crisis when it's very strong and acting on it would make things worse in the long run. That covers harmful acts, like drinking, bingeing or hurting yourself, and quieter urges to give up or avoid something you need to do, like skipping a hard appointment.

In Linehan's notes, the aim is for you to see that bearing the distress turns out better than refusing to. This skill isn't a safety plan, though. If you're thinking about suicide or about hurting yourself, reach out now, using the crisis contacts at the bottom of this page.

How to fill in the four boxes

Draw a grid with two rows and two columns. The top row is acting on the urge, the bottom row is resisting it, and the columns are pros and cons. Linehan's notes stress filling in all four boxes:

• Pros of acting on the urge: what you'd get, usually fast, like relief or the thrill of saying what you think.
• Cons of acting on the urge: what it would cost you, tonight and months from now.
• Pros of resisting: what you'd keep or gain, like the job or a week without drinking.
• Cons of resisting: what riding it out costs, like a rough night or anger you don't get to vent.

Fill in both rows, even when they seem to overlap, because each one can turn up something the other misses. List what happens with each choice rather than what doesn't, so "I keep my paycheck and my health insurance" beats "I don't get fired."

Split each box into short term and long term. In Linehan's example, the relief from drinking or yelling comes right away, while the hangover or the damaged relationship comes later. By her definition, a crisis urge makes things worse in the long run, so expect the long-term column to carry most of the weight.

Give each urge its own sheet. Drinking after a fight, sending an angry text and quitting a job each get four boxes of their own, since the consequences differ.

A pros and cons example: the midnight resignation email

Theo is a made-up example. His sheet shows what the boxes might look like, not how the skill will work for you.

Theo has nearly quit his job by email twice, both times late at night after a sharp note from his manager. On a quiet Sunday he fills in a sheet for that one urge.

• Pros of sending the email: instant relief and the feeling of standing up for himself.
• Cons of sending it: no paycheck or health insurance next month, a burned reference and the panic he felt the last time he almost hit Send.
• Pros of not sending it: he keeps his income while he looks around and decides about leaving on his own schedule.
• Cons of not sending it: a bad night and still facing his manager on Monday.

He pins a photo of the sheet in his notes app. Three weeks later, a little after midnight, the urge comes back. He says "No" out loud, moves the email to drafts and reads the sheet twice, then walks around the block with a podcast on. In the morning he deletes the draft and books a call with a recruiter. He may still leave that job, but on a day he picks.

Make your pros and cons sheet

Build the sheet on a calm day, for one urge you know will come back. Linehan's handout says to write it out, carry it with you and rehearse it before an overwhelming urge hits.

1. Pick one urge to work on. Choose the one that's cost you the most lately, like drinking after a fight or sending a furious text.
2. Draw the four boxes. Label the rows acting and resisting, the columns pros and cons, and split each box into short term and long term.
3. Be honest about the urge's pros. Write down the relief and the satisfaction too, so the sheet matches what the urge will tell you later.
4. Fill the long-term boxes with real consequences. List results you can picture, like a missed shift, and what happened the last times you acted on the urge.
5. Keep it where your hand goes first. Pin a photo in your notes app or put a card in your wallet, since it's hard to remember why not to act once you're in emotion mind.
6. Rehearse it before you need it. Read the pros of resisting and the cons of acting several times on ordinary days, so they come to mind when the urge is strong.
7. When the urge hits, say no and read. Say "No" out loud, read the sheet slowly, then turn to ACCEPTS or a walk to get through the next hour. If you're too worked up to read, use TIPP first.
8. Revise it after the urge passes. Add anything you missed, like a cost of acting you noticed only later.

Add one last line to the sheet: the name of someone you can call, and a note that the crisis contacts are at the bottom of this page.

How pros and cons differs from an ordinary list, STOP, TIPP and ACCEPTS

An ordinary decision list weighs options for a choice like which apartment to rent, and Linehan's notes point out that everyone does this. The crisis version looks at one urge, and you write it before you need it. For big life decisions, like whether to file for divorce, her notes tell skills leaders not to favor either side and to trust the person's wise mind. That's a slower job than getting through a midnight urge.

STOP is the pause: stop, take a step back, observe, then proceed mindfully. The sheet is what you read during that pause. TIPP fits when you're too worked up to read anything. Linehan's notes say very high arousal can make most skills impossible to use, and TIPP is built to bring it down fast.

Once you've decided not to act, ACCEPTS and IMPROVE the moment help the next few hours pass, the order her notes suggest: say no to the urge, then distract yourself. Urge surfing takes another tack, watching the urge rise and fall without arguing with it.

Snags: when the urge's side of the sheet looks bigger

The pros of the urge look huge in the moment. Often they're real, at least in the short run. In a 2021 interview study, 9 of 24 people in DBT said they still eased tension with self-harm or impulsive behavior, and some said it worked better and faster than their skills. Linehan's notes make a related point: an immediate reward pulls harder than a delayed one, and rehearsing the sheet is meant to strengthen the delayed side. A 2011 meta-analysis of 46 studies found that people with addictive behaviors tend to discount delayed rewards more steeply, so a later payoff counts for less. Write the urge's pros down honestly, then read the long-term column out loud.

A sheet written in the heat of a crisis. Linehan's notes say you can write one when the urge hits if you don't have one yet, but that it's very hard to do in emotion mind, so ask someone to help you with it. If you're too wound up to hold a pen, start with TIPP and write later.

Using the sheet to argue yourself into the urge. Her notes say people often resist doing pros and cons at all, because part of them knows it makes the urge less likely to win. Inside the sheet, watch for a crowded box of pros for acting, an empty long-term column or a sheet you keep rewriting until it says yes. In a 2015 summary of outcome research, Miller and Rose concluded that when people feel torn, an even-handed pros and cons exercise tends to lower their commitment to change. The crisis version leans one way on purpose: you build it on a calm day, for an urge you've already decided not to follow.

Self-harm and suicidal urges. Linehan's notes treat pros and cons of suicide as work a DBT skills leader guides, and they say a person leaning toward suicide needs a risk assessment and crisis care right away. Don't weigh these urges alone on a worksheet. Get professional help now, using the crisis contacts at the bottom of this page.

How strong the evidence is

The evidence for this one skill is thin. A PubMed search turned up no study that tested pros and cons on its own. In the 2021 interview study, only 2 of the 24 people described using it, against 23 for ACCEPTS, a hint that people in that clinic didn't reach for it first.

Most trials test DBT as a whole package. A 2015 trial of 99 women with borderline personality disorder and a recent suicide attempt found that versions with skills training reduced self-injury and depression more than DBT without it. A 2010 analysis of 108 women linked rising skills use to fewer suicide attempts and less depression, but it looked at skills use overall, not at any single skill. A 2015 review of 17 trials called the evidence for skills training on its own preliminary. Pros and cons is reasonable to try for an urge you know will come back, and it doesn't replace therapy.

Fill in your four boxes with Helpy

The chat below runs with Helpy, the site's AI assistant. Name an urge that keeps coming back, like drinking after an argument or quitting in a rage. It can help you fill in all four boxes, sort short-term from long-term consequences and spot a box you've left thin.

Evidence and sources

• Distress Tolerance chapter (teaching notes), Linehan, DBT Skills Training Manual, Second Edition (Guilford, 2015): the six crisis survival skills, how to do pros and cons in four quadrants with short- and long-term consequences, why to rehearse the sheet and keep a copy, the pull of immediate rewards, the notes on life decisions and on suicidal urges, and when TIPP fits. Teaching notes from a sample chapter the publisher posts, not a study.
• Wesleyan University Counseling and Psychological Services, Crisis Survival Skills handouts: a university's copy of Linehan's 2015 handouts, including the list of crisis survival skills, when to use them and the Pros and Cons handout with its grid and what to do before and when an urge hits. Not research.
• Schaich et al., PLoS One, 2021 (PubMed): interviews with 24 people with borderline personality disorder in DBT at a German university clinic; 2 described using pros and cons, against 23 for ACCEPTS, and 9 described still easing tension with self-harm or impulsive behavior, which some found faster and more effective than skills. A qualitative study that can't show whether skills work, one author sorted the skills people named into groups, and some authors give DBT trainings; we read the full text.
• Linehan et al., JAMA Psychiatry, 2015 (PubMed): 99 women with borderline personality disorder and a suicide attempt in the past year; versions with skills training reduced self-injury and depression more than DBT without it. It lists DBT's parts: individual therapy, skills training, phone coaching and a therapist consultation team. No single skills were tested, and we read only the abstract.
• Neacsiu, Rizvi and Linehan, Behaviour Research and Therapy, 2010 (PubMed): in 108 women from three trials, rising skills use accounted for drops in suicide attempts and depression. Self-reported skills use overall, not any single skill; we read only the abstract.
• Valentine et al., Journal of Clinical Psychology, 2015 (PubMed): a review of 17 trials of DBT skills training without the rest of DBT found preliminary evidence. Study limits rule out strong conclusions; we read only the abstract.
• MacKillop et al., Psychopharmacology, 2011 (PubMed): a meta-analysis of 46 studies found that people with addictive behaviors discounted delayed rewards more steeply than comparison groups, a small effect overall and a medium one after large studies with brief self-report items were set aside. About addiction, not DBT or crisis urges in general; we read the abstract and introduction.
• Miller and Rose, Behavioural and Cognitive Psychotherapy, 2015 (PubMed): a summary of clinical outcome research concluding that with ambivalent people, a neutral decisional balance exercise tends to lower commitment to change, while it may strengthen commitment in people who've already decided. Counseling research, not a test of DBT or crisis urges; we read only the abstract.

Read next

STOP Skill in DBT: 4 Steps to Pause Before You ReactPause before you actACCEPTS (DBT): Distraction Skills for a Crisis MomentDistraction on purposeIMPROVE the Moment (DBT): The 7 Skills, With ExamplesMake a hard moment easier to bear

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