Dialectical Behavior Therapy is an interestingly named treatment.
If you’re as lost as I was when I first heard the term, then you’ve come to the right place. In this piece, you will learn what DBT is, how it works, and some of the most useful and applicable components of treatment.
Whether you are someone who is thinking about participating in Dialectical Behavior Therapy, a therapist who is looking for DBT worksheets to use with clients, or just a curious individual, read on to learn more about it.
Dialectical Behavior Therapy (DBT) is a type of cognitive-behavioral therapy that focuses on the psychosocial aspects of therapy, emphasizing the importance of a collaborative relationship, support for the client, and the development of skills for dealing with highly emotional situations (Psych Central, 2016).
DBT was created for the treatment of individuals struggling with suicidal thoughts but has matured into a treatment for a range of other conditions that involve dysfunctional emotional regulation. It is currently considered the “gold standard” for borderline personality disorder and has even been applied to the treatment of substance abuse and eating disorders (Linehan Institute, n.d.).
DBT is generally characterized by its two main components:
These individual sessions are an opportunity for the therapist and client to address the issues and solutions that came up over the last week, with special attention paid to self-destructive or potentially self-harmful behaviors. These behaviors are targeted not only because they are inherently worrisome, but also because they can seriously disrupt the treatment process and undermine treatment goals.
Clients and therapists work as a team in these individual sessions, with the focus on learning and improving social and coping skills. They may also discuss more general issues relevant to improving the client’s quality of life, or more specific issues like post-traumatic stress disorder.
The weekly sessions are also intended to foster skill-building, but clients learn together with the guidance of a therapist rather than working one-on-one.
These sessions are usually scheduled for two and a half hours and generally focus on developing skills from one of four skill areas:
These four skill modules cover a wide range of useful skills that can be applied in daily life:
1. Interpersonal Effectiveness Module
The skills in this module are related to interacting with others, especially in difficult or potentially damaging situations.
These skills are intended to help clients function effectively when trying to change something (e.g., making a request) or in trying to resist changes (e.g., refusing a request). The intention is to aid the client in meeting their goals in each situation while avoiding any damage to the relationship or to the client’s self-respect (Psych Central, 2016).
2. Distress Tolerance Module
This module includes skills that are extremely important yet often overlooked: skills relating to accepting, tolerating, and learning from suffering.
Many other mental health treatment regimens focus on avoiding pain, changing difficult situations, or walking away from circumstances that cause suffering, but the distress tolerance skills taught through Dialectical Behavior Therapy focus on dealing with the pain and suffering that is inevitable to the human condition.
The distress tolerance module is split into four crisis survival strategies:
In addition, there are many skills that relate to accepting and tolerating the current situation, like radical acceptance and willingness vs. willfulness.
3. Emotion Regulation Module
Many clients who participate in DBT are struggling with personality or mood disorders and can benefit immensely from emotion regulation skills.
Some of these skills that can help clients deal with their emotions include:
4. Mindfulness Module
Readers of this blog are likely already aware of the numerous mindfulness-related skills that can benefit them in their daily life.
These skills include “what” skills or skills that answer the question “What do I do to practice core mindfulness skills?” like observing, describing, and participating. There are also “how” skills or skills that answer the question “How do I practice core mindfulness skills?”, like non-judgment and practicing “One-mindfully” effectively.
Many of these mindfulness skills feed into skills from the other modules; for example, the nonjudgment encouraged in mindfulness is also encouraged in distress tolerance, and the observing and describing skills can be helpful in identifying and labeling emotions.
Dialectical Behavior Therapy was developed by Dr. Marsha Linehan.
She is a Professor of Psychology and adjunct Professor of Psychiatry and Behavioral Sciences at the University of Washington and Director of the Behavioral Research and Therapy Clinics, a research consortium that explores treatments for severely disordered and suicidal individuals (The Linehan Institute, n.d.).
Dr. Linehan is dedicated to promoting effective and accessible resources for the treatment of individuals who are struggling.
Dr. Linehan founded Behavioral Tech LLC, an institute focused on developing and sharing treatment tools for DBT training, consultation, and treatment. Behavioral Tech Research, Inc., was also established by Dr. Linehan in an effort to incorporate online and mobile technology into the successful practice of DBT.
Dr. Linehan approaches her scientific research and development from a perspective that is relatively uncommon in the sciences: one based in spirituality. She has trained with a number of spiritual leaders and influential thinkers, including a Zen master.
This may help explain her affinity for mindfulness, which grew to prominence through a collaboration of traditional Buddhist philosophy and the modern scientific paradigm (The Linehan Institute, n.d.).
You may be thinking that Dialectical Behavior Therapy sounds a lot like cognitive behavioral therapy (CBT) in general.
Of course, DBT is a type of CBT, so similarities are understandable. But DBT also has distinct features that set it apart from most CBT approaches.
DBT, like CBT, focuses on helping people address their dysfunctional thinking and behavior through modification of their thought patterns and, through changing their thoughts, their behavior as well. However, CBT is usually confined to a limited period of time and is often applied with one or two specific goals in mind.
On the other hand, DBT narrows the focus to psychosocial aspects of daily life. Many people have trouble with their thought and behavior patterns, but these issues are often at their most disruptive in the context of relationships with others. DBT was created to approach treatment from this angle, one that is often incorporated in general CBT but is not typically the main focus (Grohol, 2016).
This emphasis on relating to others is what explains the DBT-specific treatment component of group therapy sessions. The benefits of additional therapy to the treatment of severe emotion regulation dysfunction are clear, but it’s the group aspect that really helps explain its importance.
Adding group dynamics to the learning setting offers clients an opportunity to practice relational skills in a safe and supportive environment, a practice that has been shown to be extremely effective.
DBT also differs from general CBT in the use of clients’ history. Both incorporate the past in striving for a healthier future, but this discussion is not a focus of the therapy in DBT as it often is in CBT (Grohol, 2016). The perspective of DBT is that one can learn from their past, but that problems are inevitably rooted in current thoughts and behaviors, and the present is where these will be addressed.
The essential Dialectical Behavior Therapy skills are categorized into the four skill modules as outlined below.
We won’t go into all of them in detail, but these are the main skills and techniques applied in DBT.
As you can see, acronyms are front and center in DBT treatment, in part because it makes remembering these skills in important moments easier.
You may also notice that many of these skills are generally considered effective skills, rather than specific skills for specific problems. While Dialectical Behavior Therapy focuses on the treatment of severely distressed individuals, the means of working towards these goals are not mystical or mysterious. The methods of furthering treatment are grounded in common sense and the straightforward practice of skills.
In fact, these skills are so generally applicable that many of them have practical applications for everyone.
Mindfulness is such a simple and beneficial practice that it’s hard to sum up the potential positive impacts in one section, let alone one article (but we gave it a shot anyway – see our piece on the benefits of mindfulness).
“Mindfulness can be described as simply living your life in the present instead of being stuck in the past or the future. Practicing mindfulness helps us become more aware of our thought patterns, our emotions, and how our thoughts and feelings affect our reactions to events” (Tartakovsky, 2015A).
If your mind has you jumping on the thought train (i.e., one thought leads to another, which often leads to a “should” thought, which can lead to judgment), try to detach yourself from the thought by telling yourself about the thought you are having (e.g., “There’s a thought about the errand I need to run after work”).
This can help you refocus on your current practice and remind yourself that you have thoughts, but you are not your thoughts (Tartakovsky, 2015A).
If you’re interested in learning more about how to practice mindfulness, check out our post on mindfulness exercises and techniques.
This is an important skill that provides obvious benefits for those struggling with emotional dis-regulation, but can also benefit the average person.
Accepting reality is an effective antidote for a common problem in our society: struggling against the pain and suffering that is inherent to life as a human. DBT and Acceptance and Commitment Therapy (ACT) have this in common – both teach that accepting our reality, including the unpleasant aspects of it, is the only way to thrive.
This skill can be harder to practice and build than it seems since there are all sorts of sneaky ways we find to deny the reality of our situation.
These examples from Psych Central can shed some light on when we fight reality and how we can stop this tendency:
The part-humorous, part-helpful Tumblr blog “Shit Borderlines Do” provides some steps towards practicing this skill in the moment:
These steps are by no means exhaustive or required to accept reality, but they can be helpful in the moment.
Dialectical Behavior Therapy’s radical acceptance technique can help in these situations.
Radical acceptance is simply acknowledging the reality of your circumstances instead of fighting it by thinking “This shouldn’t be happening” or “This isn’t fair.”
It can be difficult to accept pain, but fighting the reality of your pain only creates more pain, and this pain is optional. Instead of fighting pain, radical acceptance offers a way to accept it and address it.
In the words of psychotherapist Sheri Van Dijk:
“If you don’t like something, you first have to accept that it is the way it is before you can try to [change] it. If you’re not accepting something, you’ll be so busy fighting that reality that you don’t have the energy to put towards trying to change it” (Tartakovsky, 2015).
This explanation shows us that not only can radical acceptance help us accept the reality of things that we cannot change, it can also help us to realize what can be changed.
The art of being non-judgmental is one that takes practice, but the payoffs can be immense.
Being non-judgmental means that you avoid assigning value to events and feelings.
Instead of facing a difficult situation and thinking “This is awful,” practicing non-judgment allows us to take a step back and realize that the value judgments we make are based on facts (the facts of what is happening) and the emotions we are feeling in reaction (Tartakovsky, 2015B).
For example, you may be stuck in accident-related traffic and thinking “People are such idiots.” If you make an effort to be nonjudgmental, this may translate to “I’m stuck at a standstill in traffic because of an accident up ahead. This makes me frustrated and upset.”
When you break a judgment down into a fact and your emotional reaction, you not only reduce the emotion(s) you are feeling, you can also be empowered to think about ways to solve the problem and make healthy decisions.
Say you are thinking about how selfish your significant other is being right now. Instead of stopping at “My partner is so selfish,” practicing non-judgment may lead to articulating the issue (“My partner is not helping me with this problem, and that makes me angry and disappointed”) and finding a way to solve it (“This is not a wise use of my time and energy. I will talk to my partner about how his/her unwillingness to help me with this problem makes me feel, and try to negotiate a solution with him/her”).
Handling emotional situations in this manner can not only help you reduce your emotional reaction and find smart solutions to problems, it can also improve your self-esteem and self-respect when you handle the issue in a way that makes you proud of yourself (Tartakovsky, 2015B).
You’re probably thinking that these skills sound really helpful and effective, but you may not be sure how to begin learning about and practicing them.
This is where Dialectical Behavior Therapy worksheets, handouts, and manuals can prove to be extremely effective tools in building your skills and improving your ability to accept your situation, deal with difficulty, and solve problems.
We’ll go over some of the most popular and effective ones below.
This handout lists and describes the interpersonal effectiveness skills we outlined earlier, and also provides useful tips to put these skills into practice.
For example, the section on objective effectiveness (the DEAR MAN skills) lists the following tips:
This worksheet describes the concept of the “wise mind” as the intersection between the emotional mind and the reasonable mind. It is a balance between the two minds and is characterized by the ability to recognize and respect your feelings, but also respond to them in a rational manner.
The worksheet offers space to describe an experience that you have had with each of these three “minds” to further your understanding of the minds and how they have come into play in your life.
While this webpage is not laid out as a worksheet, it could easily be adapted into a worksheet, and the lesson it teaches is a valuable one.
It starts with a mini flow chart on identifying the emotion you are feeling and deciding how you can respond.
First, you ask yourself, “Does the emotion fit the facts and is it appropriate in its level of intensity?”
If the answer is yes, it is a primary emotion and your potential solutions are to:
If you answer “no,” it is a secondary emotion with the following potential solutions:
The “opposite action” from above is based on the emotion you are feeling. The next section of the webpage dives into the emotion when it “fits the facts,” and what the opposite action is.
For example, if you are feeling fear, the emotion fits the facts when:
If the emotion does not fit the facts, the opposite actions for fear are:
This flowchart and the “check the facts/opposite action” section could make an excellent worksheet for therapists and other mental health professionals!
This worksheet helps you to identify and understand a situation you are struggling to accept.
First, you answer the question, “What is the problem or situation?”
Next, you describe the part of this situation that is difficult for you to accept.
Then you describe the reality of that situation.
After describing the reality, think about the causes that led up that reality (hint: many of them you will find to be outside of your control).
Next, you practice acceptance with the whole self (mind, body, and spirit) and describe how you did this. The worksheet encourages you to try the following:
“Breathe deeply, put your body into an open, accepting posture, and notice and let go of thoughts and feelings that fight the reality. Practice skills for acceptance such as half-smile, awareness exercises, or prayer. Focus on a statement of acceptance, such as ‘it is what it is’ or ‘everything is as it should be.'”
Finally, you rate your distress tolerance about this difficult situation both before and after practicing radical acceptance, on a scale from 0 (you just can’t take it) to 100 (total acceptance of reality).
The Function of Emotion worksheet helps you to identify the function of an emotional reaction you have had over the last week.
The worksheet moves through the following questions and steps:
Use the following to identify the function(s) of the emotion:
These questions aid the individual in making the connections between a galvanizing event and the reaction s/he had to the event, as well as understanding how the emotional reaction impacts the self and others.
For more useful worksheets and handouts, visit the two websites listed above or this website.
For a resource that can help you apply general DBT treatment, check out this manual from Dr. Linehan herself. It’s not free, but it is an extremely valuable resource for applying DBT with your clients.
This manual is separated into two parts: the first describes DBT and provides instructions on how to set up a treatment program and manage the problems that can arise, while the second gives detailed notes on teaching each DBT skill.
Check out the manual, buying options, and reviews from some very satisfied readers here.
This manual by Eric J. Dykstra and Margaret Charlton outlines how to apply DBT for clients with intellectual or developmental disabilities.
This is an important manual for an often overlooked population in the realm of psychological treatment. Unfortunately, we all are vulnerable to emotional dysfunction and distress, even (and perhaps especially) those with the added difficulty of intellectual or developmental disabilities.
It includes an overview of DBT in general and DBT for general populations, the Standard DBT Model and the adapted model for clients with disabilities, tips on how to format sessions and content to include, and a number of worksheets, handouts, and other resources to improve the effectiveness of DBT with clients who are intellectually or developmentally disabled.
Follow this link to download the manual.
The diary card is an important component of Dialectical Behavior Therapy and an effective way for clients to learn about themselves.
According to dbtselfhelp.com:
“You use the card to track your urges, moods, how you did or did not use DBT Skills, your feelings, and whatever else is helpful to you. You bring these cards with you to your DBT therapist every week to help you look for behavior patterns and triggers that occur in your life. Such information is invaluable to help you to help yourself live a life worth living.”
The diary card may also include space for a general rating for the day and any medications or substances used (legal or illegal).
The client is encouraged to fill out this card regularly and faithfully. While it is important that the client does so, they should know that no one is going to score them or judge them based on their diary card. It is not an assignment to be completed and graded, but a way for them to track their experience and evaluate their progression through DBT treatment and, hopefully, self-improvement.
As with most problems or issues, technology is making an impact on how people keep diary cards.
If you hate to waste paper, don’t like getting ink on your hands, or just get tired of writing, there’s a diary card app that you can use instead.
Check out the app created by a licensed clinical psychologist here.
If you’re interested in learning more about Dialectical Behavior Therapy, as a client, therapist, or just a curious person, there are several books available.
Listed below are some of the most popular and highly reviewed books on DBT out there, and they’re all available for purchase on Amazon.com:
This book has an impressive 4.5-star rating based on almost 650 reviews on Amazon.
It walks the reader through descriptions of DBT and how it can help, introductory exercises, and more advanced skill chapters. This can be an excellent resource for any individual considering DBT or for therapists to recommend to their clients.
Available on Amazon.
There are three main goals of treatments based on DBT and emotion regulation:
There are several ways to work toward these goals.
One of the websites we mentioned earlier, dbtselfhelp.com, offers an outline of how to build emotion regulation skills:
We all have emotions, but there is a theory that there are only a few basic emotions while the rest is interpretation and evaluation.
You can work on your skills related to interpreting emotions by completing a writing challenge described here.
Emotions involve action urges, prompts to perform certain behaviors. These urges are not part of the emotion but can feel like they are. There is often a prompting event, followed by interpretation, body changes in response to the emotions, and action urges.
This can lead to an effective or dysfunctional expression of emotions, which can have a wide range of consequences. To work on describing emotions, try to describe the qualities of your emotions and pay attention to things that may interfere, like secondary emotions that spring from the original emotion.
Follow this link for more information on describing emotions.
Emotions have three major functions in DBT:
You can learn about the function of emotions by answering questions like “What are some examples of situations where your expressions of emotion were misread?” and “Can you think of some times when you misread the emotions of someone else?”
See this page for more information.
We are all vulnerable to negative emotions, but we can build our skills related to reducing vulnerability. You can keep track of the factors that affect your physical and mental well-being, like your diet, any mood-altering drugs, sleep, and exercise.
Refer to these skills in the emotion regulation module for more information.
Increasing positive emotions can be an effective method for dealing with difficult emotions. To build this skill, focus on the positive experiences you have throughout the day (short-term experiences) and the bigger, more impactful ones (long-term experiences).
Focus on building and maintaining positive relationships, and give mindfulness a try to savor positive experiences.
On the flipside of savoring the positive, letting go of the negative also has a place in emotion regulation. While accepting that pain happens is healthy, dwelling on negative emotions is dysfunctional.
Practice observing your emotions, describing and accepting them but not allowing yourself to be overwhelmed by them.
See this page for more information on letting go.
This technique is used to change painful emotions that are harmful rather than helpful. It is not about suppressing our emotions, but accepting the emotion and using it to take a different action.
To practice this technique, list some examples of when you have acted opposite to your current emotion. Describe a situation in which it is not appropriate to act opposite to your emotion to help you learn about the difference between each situation.
Check out this handout for more information.
Dialectical Behavior Therapy is a recognized treatment that is well supported by the evidence. There are many ways to learn about applying DBT, but getting certified is a great option. There are courses and trainings for both individuals interested in practicing DBT and for therapists and other mental health professionals who wish to apply DBT in their work.
Dr. Linehan’s Behavioral Tech Research Institute provides information on Dialectical Behavior Therapy certification for therapists. The certification is available through the DBT-Linehan Board of Certification and requires the following:
You can also become certified through the Dialectical Behavior Therapy National Certification and Accreditation Association (DBTNCAA). This allows you to list a specialized certification in DBT when you apply to Health Care Providers and HMO networks.
Mindfulness can be practiced whether you are participating in Dialectical Behavior Therapy treatment or not, and DBT skills involve mindfulness among many others.
While DBT and mindfulness are not synonymous, they are certainly linked.
DBT is a therapy based on identifying, describing, and modifying thoughts and feelings. Mindfulness has clear applicability in this therapy, through its ability to help practitioners to become more aware of their feelings, thoughts, impulses, and behaviors (Bray, 2013A).
One description of the benefit of mindfulness in Dialectical Behavior Therapy is that it provides the individual with the ability to take control of the mind instead of having the mind control the individual.
Practicing mindfulness helps the individual in DBT to direct their attention to observing, describing, and participating in a nonjudgmental way, which enhances the individual’s skills and leads to improved ability to focus on the positive, let go of the negative, and regulate emotions.
As we’ve said before, mindfulness is an extremely useful skill for individuals dealing with difficult emotions or situations, but it can be an even more effective tool for people struggling with a diagnosis.
The intention of this piece was to provide an overview of Dialectical Behavior Therapy and outline the skills and tools that can help you or your clients to address emotion regulation issues. I hope it has met this goal, and that you know much more about Dialectical Behavior Therapy than you did when you started!
I hope you also keep in mind that the skills involved in DBT are applicable for those that are not suffering from a diagnosed mental health issue as well. Skills like mindfulness, focusing on the positive, letting go of the negative, and accepting the reality of your situation have clear benefits for everyone, not just those who are in the midst of suffering.
Have you tried DBT? Have you applied DBT with your clients? As always, please let us know about your experiences in the comments.
Thanks for reading!
If you wish to learn more, Mindfulness X©is our 8-module mindfulness training package for practitioners which contains all the materials you’ll need to not only enhance your mindfulness skills but also learn how to deliver a science-based mindfulness training to your clients, students or employees.