Introduction
Dialectical Behavior Therapy (DBT) is an evidence-based psychotherapy developed by Dr. Marsha Linehan that combines cognitive-behavioral techniques with mindfulness practices. Originally designed for individuals with borderline personality disorder, DBT has proven effective for various mental health conditions including depression, anxiety, PTSD, eating disorders, and substance abuse.
Why DBT Skills Matter:
- Provides practical tools for emotional regulation
- Improves interpersonal relationships and communication
- Builds distress tolerance and crisis survival skills
- Enhances mindfulness and present-moment awareness
- Reduces self-destructive behaviors and improves quality of life
Core Concepts & Principles
The Four Modules of DBT
| Module | Focus | Primary Goal |
|---|---|---|
| Mindfulness | Present-moment awareness | Observe and describe without judgment |
| Distress Tolerance | Crisis survival | Accept reality and cope without making things worse |
| Emotion Regulation | Managing emotions | Understand, experience, and modify emotions effectively |
| Interpersonal Effectiveness | Relationships | Maintain relationships while getting needs met |
Fundamental DBT Concepts
Dialectical Thinking:
- Both/and rather than either/or thinking
- Finding synthesis between opposing viewpoints
- Balancing acceptance and change
Wise Mind:
- Integration of rational mind and emotion mind
- Intuitive knowing that considers both thoughts and feelings
- Access through mindfulness and self-awareness
Biosocial Theory:
- Emotional vulnerability + invalidating environment = emotional dysregulation
- Biology and environment interact to create difficulties
- Both acceptance and change strategies needed
Step-by-Step Skill Application Process
1. Recognize the Situation
- Identify the trigger – What happened that caused distress?
- Notice physical sensations – Body tension, breathing changes, energy shifts
- Acknowledge emotions – What am I feeling right now?
- Assess intensity – Rate emotions 1-10 to gauge severity
2. Choose Your Skills
- High distress (7-10) – Prioritize distress tolerance skills
- Moderate distress (4-6) – Use emotion regulation or interpersonal skills
- Low distress (1-3) – Practice mindfulness and prevention skills
- Interpersonal conflict – Apply interpersonal effectiveness skills
3. Implement the Skill
- Start simple – Choose one skill rather than combining multiple
- Practice fully – Engage completely rather than half-heartedly
- Be patient – Skills take time to feel natural and effective
- Stay committed – Continue even if initial results are minimal
4. Evaluate Effectiveness
- Rate distress again – Has intensity decreased?
- Assess consequences – Did the skill help or harm the situation?
- Learn from experience – What worked? What didn’t?
- Plan for next time – How can you apply this learning forward?
Mindfulness Skills
The “What” Skills – What You Do
| Skill | Definition | Practice Example |
|---|---|---|
| Observe | Notice without adding words | Watch thoughts come and go like clouds |
| Describe | Put words to experience | “I notice anxiety in my chest” |
| Participate | Throw yourself into activity | Dance, sing, or work without self-consciousness |
The “How” Skills – How You Do It
| Skill | Definition | Application |
|---|---|---|
| Non-judgmentally | See but don’t evaluate | Replace “This is terrible” with “This is painful” |
| One-mindfully | Focus on one thing at a time | Single-task instead of multitasking |
| Effectively | Do what works | Focus on goals rather than being “right” |
Mindfulness Practices
Breathing Exercises:
- 4-7-8 breathing: Inhale 4, hold 7, exhale 8
- Box breathing: 4 counts in, hold 4, out 4, hold 4
- Natural breath observation without changing rhythm
Grounding Techniques:
- 5-4-3-2-1: 5 things you see, 4 hear, 3 touch, 2 smell, 1 taste
- Body scan from head to toe
- Mindful walking with attention to each step
Distress Tolerance Skills
TIPP for Crisis Situations
| Technique | Method | When to Use |
|---|---|---|
| Temperature | Cold water on face/hands, ice cubes | Panic attacks, overwhelming urges |
| Intense Exercise | Running, jumping jacks, push-ups | High emotional intensity |
| Paced Breathing | Exhale longer than inhale | Anxiety, anger, agitation |
| Progressive Muscle Relaxation | Tense and release muscle groups | Physical tension, sleep difficulties |
Distract with ACCEPTS
| Letter | Technique | Examples |
|---|---|---|
| A | Activities | Puzzles, reading, cleaning, hobbies |
| C | Contributing | Volunteering, helping others, acts of kindness |
| C | Comparisons | Others’ situations, your past struggles |
| E | Emotions | Watch comedy, listen to upbeat music |
| P | Push Away | Visualize putting problems in a box |
| T | Thoughts | Counting, puzzles, mental games |
| S | Sensations | Strong flavors, textures, scents |
Self-Soothe with Five Senses
Vision: Beautiful images, nature, art, candles, colors Hearing: Calming music, nature sounds, singing, instruments
Smell: Essential oils, flowers, baking, perfume, fresh air Taste: Tea, gum, mints, favorite foods, sour candies Touch: Soft blankets, warm baths, massage, stress balls, pets
IMPROVE the Moment
| Letter | Technique | Application |
|---|---|---|
| I | Imagery | Visualize peaceful scenes or successful outcomes |
| M | Meaning | Find purpose or lesson in the struggle |
| P | Prayer/Meditation | Connect with higher power or inner wisdom |
| R | Relaxation | Progressive muscle relaxation, yoga, stretching |
| O | One Thing | Focus completely on single activity |
| V | Vacation | Mental break or brief physical change of scenery |
| E | Encouragement | Self-compassionate self-talk |
Radical Acceptance
Steps to Radical Acceptance:
- Notice you’re fighting reality
- Remind yourself that reality is what it is
- Consider the causes of the situation
- Practice accepting with your whole self (mind, body, spirit)
- Notice if you’re fighting acceptance and start again
Acceptance Statements:
- “This is the reality right now”
- “I can’t change what has already happened”
- “Fighting this situation only adds to my suffering”
- “I can handle this, even if I don’t like it”
Emotion Regulation Skills
Understanding Emotions
| Component | Description | Example |
|---|---|---|
| Prompting Event | What triggered the emotion | Receiving criticism at work |
| Interpretation | Thoughts about the event | “My boss thinks I’m incompetent” |
| Body Changes | Physical sensations | Tight chest, clenched jaw |
| Action Urges | What you want to do | Hide, defend, argue |
| Expression | How emotion shows | Facial expression, tone of voice |
PLEASE Skills for Emotional Vulnerability
| Letter | Skill | Practice |
|---|---|---|
| P | Treat PhysicaL illness | Take medications, see doctors when needed |
| L | Balance Eating | Regular meals, avoid mood-altering substances |
| E | Avoid mood-Altering substances | Limit alcohol, drugs, excessive caffeine |
| A | Balance Sleep | 7-9 hours, consistent sleep schedule |
| S | Get Exercise | Regular physical activity appropriate for your fitness level |
| E | Build mastery | Engage in activities that create sense of accomplishment |
Opposite Action
When emotions don’t fit the facts or are too intense:
| Emotion | Opposite Action |
|---|---|
| Fear | Approach what you’re afraid of (if safe) |
| Anger | Be kind, avoid attacking, take time out |
| Sadness | Get active, engage with others, accomplish tasks |
| Shame | Make eye contact, speak up, engage socially |
| Guilt | Continue the behavior (if it aligns with values) |
Mastering Emotions
ABC Skills:
- Accumulate positive experiences – Build pleasant activities into your day
- Build mastery – Do things that make you feel competent and accomplished
- Cope ahead – Rehearse plans for difficult situations
Emotion Surfing:
- Emotions are temporary waves that rise and fall
- Ride the wave without being overwhelmed by it
- Remember: “This too shall pass”
Interpersonal Effectiveness Skills
DEAR MAN for Getting What You Want
| Letter | Skill | Application |
|---|---|---|
| D | Describe | State facts without opinions or judgments |
| E | Express | Share your feelings and opinions |
| A | Assert | Ask clearly for what you want |
| R | Reinforce | Explain benefits of getting what you want |
| M | Mindful | Stay focused on your goal |
| A | Appear confident | Eye contact, clear voice, good posture |
| N | Negotiate | Be willing to compromise |
GIVE for Maintaining Relationships
| Letter | Skill | Method |
|---|---|---|
| G | Gentle | No attacks, threats, or harsh judgments |
| I | Interested | Listen to others’ points of view |
| V | Validate | Acknowledge others’ feelings and perspectives |
| E | Easy manner | Smile, use humor appropriately, be lighthearted |
FAST for Maintaining Self-Respect
| Letter | Skill | Practice |
|---|---|---|
| F | Fair | Be fair to yourself and others |
| A | No Apologies | Don’t apologize for having needs or opinions |
| S | Stick to values | Don’t compromise your integrity |
| T | Truthful | Don’t lie or exaggerate |
Interpersonal Effectiveness Factors
Priority Assessment:
- How important is the objective?
- How important is the relationship?
- How important is self-respect?
- Use this to determine which skills to emphasize
Capability Factors:
- Do you know what you want?
- Do you have the skills to get it?
- Is this the right time?
- Is the other person able to give you what you want?
Comparison of Skill Applications
When to Use Each Module
| Situation | Primary Module | Secondary Support |
|---|---|---|
| Panic attack | Distress Tolerance (TIPP) | Mindfulness (breathing) |
| Relationship conflict | Interpersonal Effectiveness | Emotion Regulation |
| Overwhelming sadness | Emotion Regulation | Distress Tolerance |
| Daily stress | Mindfulness | All modules as prevention |
| Crisis/urges | Distress Tolerance | Mindfulness |
| Chronic emotional instability | Emotion Regulation | PLEASE skills |
Skill Intensity Levels
| Distress Level | Recommended Skills | Focus |
|---|---|---|
| 1-3 (Low) | Mindfulness, PLEASE | Prevention and maintenance |
| 4-6 (Moderate) | Emotion Regulation, GIVE/FAST | Skill building and relationship maintenance |
| 7-8 (High) | Distress Tolerance, DEAR MAN | Crisis management and goal achievement |
| 9-10 (Crisis) | TIPP, ACCEPTS, Radical Acceptance | Immediate safety and crisis survival |
Common Challenges & Solutions
Skill Implementation Difficulties
Challenge: “The skills don’t work for me”
- Causes: Inconsistent practice, unrealistic expectations, wrong skill for situation
- Solutions:
- Practice skills when calm, not just in crisis
- Start with easier skills and build up
- Match skill intensity to distress level
- Be patient – skills improve with repetition
Challenge: “I forget to use skills when I need them”
- Solutions:
- Create skill reminder cards or phone notes
- Practice skills daily, not just during crises
- Use environmental cues (phone alarms, sticky notes)
- Develop automatic skill chains through repetition
Emotional Challenges
Challenge: Feeling overwhelmed by emotions
- Solutions:
- Use TIPP first to reduce intensity
- Practice emotion surfing – ride the wave
- Remember emotions are temporary
- Use opposite action when emotions don’t fit facts
Challenge: Difficulty with radical acceptance
- Solutions:
- Start with small acceptances and build up
- Focus on accepting the situation, not liking it
- Use half-smiling and willing hands posture
- Practice with past events before current situations
Interpersonal Challenges
Challenge: Others react negatively to skill use
- Solutions:
- Explain DBT concepts to close family/friends
- Model skills consistently over time
- Focus on effectiveness rather than being “right”
- Be patient as relationships adjust to changes
Best Practices & Practical Tips
Daily Practice Strategies
Morning Routine:
- 5-minute mindfulness practice
- Review PLEASE skills checklist
- Set intention for skill use during the day
- Identify potential challenges and skill responses
Evening Review:
- Reflect on skill use during the day
- Identify what worked and what didn’t
- Plan skill practice for tomorrow
- Practice gratitude or self-compassion
Skill Building Progression
Week 1-2: Foundation
- Focus on mindfulness basics (observe, describe)
- Learn basic breathing techniques
- Practice TIPP skills
Week 3-4: Expansion
- Add emotion regulation concepts
- Practice opposite action with minor emotions
- Introduce DEAR MAN for simple requests
Week 5-8: Integration
- Combine skills from different modules
- Practice skills in increasingly challenging situations
- Develop personal skill chains for common triggers
Environmental Setup
Create Skill-Supportive Environment:
- Keep skill cards or reminders visible
- Set up distress tolerance kit (ice, music, scents)
- Remove or modify triggers when possible
- Surround yourself with supportive people
Technology Support:
- DBT skill apps for quick reference
- Meditation apps for mindfulness practice
- Mood tracking apps to identify patterns
- Calendar reminders for skill practice
Crisis Planning
Develop Personal Crisis Plan:
- List warning signs of crisis
- Identify specific skills for your common crises
- Create contact list of support people
- Prepare distress tolerance kit in advance
- Practice skills before you need them
Advanced Applications
Combining Skills Effectively
Skill Chains for Common Situations:
Anxiety/Panic:
- TIPP (temperature or paced breathing)
- Mindful breathing
- Self-soothe with senses
- Radical acceptance of physical sensations
Interpersonal Conflict:
- Mindfulness to stay present
- GIVE skills to maintain relationship
- DEAR MAN to express needs
- Opposite action if anger is too intense
Depression/Low Mood:
- Opposite action (get active)
- Build mastery activities
- Accumulate positive experiences
- Self-soothe and self-compassion
Adapting Skills for Specific Conditions
PTSD Applications:
- Grounding techniques for flashbacks
- Window of tolerance awareness
- Modified exposure through opposite action
- Safety-focused interpersonal skills
Eating Disorders:
- Distress tolerance for urges
- Opposite action for restriction/binging urges
- Mindful eating practices
- Self-compassion and radical acceptance
Substance Use:
- Urge surfing techniques
- ACCEPTS for cravings
- Building alternative activities
- PLEASE skills for physical health
Troubleshooting Guide
When Skills Aren’t Working
| Problem | Possible Causes | Solutions |
|---|---|---|
| Skills feel fake/forced | New to practice, self-consciousness | Continue practicing, start with easier skills |
| No immediate relief | Unrealistic expectations | Focus on small improvements, not elimination |
| Can’t remember skills | Insufficient practice | Daily practice, environmental reminders |
| Others don’t respond well | Inconsistent application | Model skills consistently over time |
| Feel worse after using skills | Wrong skill for situation | Reassess situation and skill match |
Warning Signs to Seek Professional Help
- Persistent suicidal thoughts or plans
- Inability to function in daily life despite skill use
- Worsening symptoms over several weeks
- Substance abuse as primary coping method
- Severe relationship or work problems continuing
- Self-harm behaviors increasing
Resources for Further Learning
Professional Resources
Finding DBT Therapy:
- Psychology Today DBT Therapist Directory
- Behavioral Tech DBT Provider Search
- Contact local mental health centers for DBT programs
Training for Professionals:
- Behavioral Tech DBT Training
- DBT-Linehan Board of Certification
- Local university psychology programs
Books & Workbooks
Core DBT Resources:
- “Skills Training Manual for Treating Borderline Personality Disorder” – Marsha Linehan
- “The Dialectical Behavior Therapy Skills Workbook” – Matthew McKay
- “Don’t Let Your Emotions Run Your Life” – Scott Spradlin
- “DBT Skills in Schools” – James Mazza (for educators)
Specialized Applications:
- “The DBT Skills Cookbook” – Julie Fleming and Kiera Van Gelder
- “Mind Over Mood” – Dennis Greenberger and Christine Padesky
- “The Mindful Way Through Depression” – Williams, Teasdale, Segal, Kabat-Zinn
Digital Resources
Apps:
- DBT Coach – Comprehensive skill reminders and tracking
- Mindfulness apps (Headspace, Calm, Insight Timer)
- Mood tracking apps (Daylio, eMoods)
- Crisis text lines (Text HOME to 741741)
Online Resources:
- DBT Self Help – Free skill sheets and resources
- Centre for Clinical Interventions – Free therapy modules
- DBT Path – Online DBT skills groups
Support Communities
Online Communities:
- Reddit r/dbtselfhelp
- Facebook DBT support groups
- NAMI (National Alliance on Mental Illness) support groups
- 7 Cups online emotional support
Crisis Resources:
- National Suicide Prevention Lifeline: 988
- Crisis Text Line: Text HOME to 741741
- International Association for Suicide Prevention: https://www.iasp.info/resources/Crisis_Centres/
Continuing Education
Workshops and Seminars:
- Local mental health organizations
- University continuing education programs
- Online DBT skill workshops
- Mindfulness-based stress reduction (MBSR) programs
Remember: DBT skills are most effective when learned systematically and practiced consistently. Consider working with a qualified DBT therapist or joining a DBT skills group for the most comprehensive learning experience.