Dialectical Behavior Therapy (DBT) is not your average therapy session; it’s like a toolbox filled with colorful tools to tame the unruliest of emotions and turn stress into confetti.
With your clients, you’ll explore the art of mindfulness, allowing them to surf the waves of thoughts without wiping out. Learn the secret dance of distress tolerance and shimmy your way through tough situations without breaking a sweat.
But wait, there’s more! Emotion regulation is a secret superpower. Say goodbye to emotional chaos and hello to emotional peace. And with the skill of interpersonal effectiveness, your clients will learn to navigate through sticky conversations and build connections that would make a social butterfly jealous!
In this article, we’ll journey through the transformative world of DBT interventions, where thoughts become allies and your clients become empowered to make positive changes in their lives.
Before you continue, we thought you might like to download our three Mindfulness Exercises for free. These science-based, comprehensive exercises will help you cultivate a sense of inner peace throughout your daily life and give you the tools to enhance the mindfulness of your clients, students, or employees.
Dialectical Behavior Therapy (DBT) is a type of psychotherapy that psychologist Marsha M. Linehan originally developed in the 1980s (Linehan, 1993). It was initially designed to treat individuals with borderline personality disorder (BPD), but it has since been found effective in treating a range of other mental health conditions, including depression, anxiety, eating disorders, substance abuse, and post-traumatic stress disorder (Chapman, 2006; Bohus et al., 2020).
Linehan noticed an important key to these hard-to-reach clients. She found they engaged in what she called dichotomous thinking. Also known as “splitting,” this is the tendency to see the world in black-and-white terms; things are either all good or all bad (Dimeff & Linehan, 2001).
The crucial problem with this type of thinking is that it gives rise to powerful emotions, which then can lead to impulsive and maladaptive behaviors. For example, a person might not agree with something their boss decided, but rather than taking the time to think through potential solutions, a person with this thinking style may decide their boss is evil and quit on the spot.
The opposite of this type of thinking is dialectical, or seeing things from multiple perspectives. Linehan discovered that this was a valuable tool for clients to learn and understand. Psychological flexibility is critical for overcoming depression and anxiety.
Linehan also stated that the clinician also needed to embrace a dialectic. In DBT, this involves finding a balance between accepting and validating the client as they are, while also encouraging and supporting the need for change and personal growth (Dimeff & Linehan, 2001).
Useful DBT Interventions
Although DBT was created for and is primarily used with clients that have borderline personality disorder, suicidal ideation, or self-harm, it has been shown to be very beneficial for other illnesses as well.
This section will detail some of the best DBT tools for depression and anxiety.
For depression
Dialectical Behavior Therapy (DBT) can effectively treat depression, particularly when combined with other evidence-based therapies (Webb et al., 2016). While DBT as a complete protocol is beneficial, there are certain tools that help with symptoms of depression specifically.
Mindfulness practices are a cornerstone of DBT and have been shown to be beneficial in reducing symptoms of depression (Hofmann & Gómez, 2017). Mindfulness exercises can help individuals become more aware of their emotions and thoughts, reducing rumination and negative thinking patterns associated with depression.
DBT practitioners often use behavioral activation techniques to help individuals with depression engage in activities that bring pleasure and a sense of accomplishment. Encouraging clients to take part in positive experiences can counteract the withdrawal and inactivity often associated with depression (Webb et al., 2016).
Encouraging clients to practice radical acceptance of their current circumstances and emotions can be helpful, particularly in managing depressive symptoms. Acceptance can foster a more compassionate approach toward oneself and reduce self-criticism, which is common in depression.
For borderline personality disorder
DBT was originally created to treat borderline personality disorder. People with BPD often show signs of dichotomous thinking, self-harm, and difficulty maintaining healthy relationships (Kliem et al. 2010).
The DBT tools designed to treat these patterns include mindfulness, distress tolerance, and emotion regulation (Lenz et al., 2016). Each of these includes a set of tools that provide the client with specific practices designed to reduce harmful thoughts and impulsive and destructive actions, and improve closeness and intimacy in relationships (Chapman, 2006).
For anxiety
DBT has also proven to be useful in reducing anxiety. Tools that individuals might find especially beneficial for anxious symptoms are distress tolerance, emotion regulation, and coping ahead (Hofmann & Gómez, 2017).
Using distress tolerance skills, such as splashing cold water on your face or engaging in intense exercise, can provide quick relief from intense anxiety and often relief from panic attacks.
DBT also encourages engaging in comforting activities, like taking a warm bath or using relaxation techniques, that can calm your nervous system during moments of distress.
Checking the facts is one powerful tool for emotion regulation. Evaluating the validity of anxious thoughts and challenging cognitive distortions can help you gain a more balanced perspective.
DBT therapists teach clients how to “cope ahead.” Planning and practicing coping strategies for future anxiety-provoking situations can increase feelings of preparedness and decrease anxiety levels. The PLEASE skill teaches clients to take care of their physical health through healthy mindful eating, regular exercise, and sufficient sleep, all of which can contribute to reduced anxiety levels.
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Creative DBT Group Activities
A critical component of DBT is group therapy. Working in a group helps to enhance engagement, encourages skill practice, and provides a unique way to explore emotions and coping strategies.
Here are 10 creative DBT group activities:
Emotion collage
Ask group members to create collages using images, colors, and words that represent their emotions or feelings. They can share their collages with the group and discuss the emotions depicted and potential coping skills.
Emotion theater
In small groups, have participants act out various emotions and practice using opposite actions to handle the feelings effectively.
Coping skill charades:
Play charades using coping skills as the actions to be guessed. This activity reinforces coping techniques in a fun and interactive way.
Emotion bingo
Play a modified version of bingo using emotions instead of numbers. Participants can share personal experiences related to the emotions called out.
Gratitude journaling
Have participants decorate and maintain gratitude journals, where they regularly write down things they are thankful for.
Skill demonstration
Encourage group members to demonstrate a specific DBT skill of their choice and discuss its effectiveness in managing emotions.
Emotion artifacts
Bring in various objects or artifacts that represent different emotions. Participants can select an object and share how it relates to their emotional experiences.
Coping skill sculpture
Provide craft supplies like modeling clay and ask participants to create sculptures that represent their favorite coping skills.
Role-play scenarios
Divide participants into pairs and assign different scenarios that require the use of DBT skills. They can role-play and then discuss the outcomes.
Inspirational posters
Create posters with DBT quotes, mindfulness quotes, or affirmations to display in the group room, serving as a source of inspiration.
Remember to tailor the activities to the needs and preferences of the group members and encourage open discussion and sharing throughout each activity. The goal is to make learning and practicing DBT tools engaging, enjoyable, and meaningful.
4 Other DBT Tools
Other DBT tools not yet mentioned include the STOP skill, the IMPROVE skill, and opposite action. There are also interpersonal awareness techniques that help with improving communication.
Read on for clarification of each and worksheets to help with implementation.
The STOP skill is an emotion regulation technique that is designed to help with impulse control. The skill comprises the following sequence: stop, take a step back, observe, and proceed mindfully.
The IMPROVE skill is a distress tolerance technique. It is an acronym that stands for “imagery, meaning, prayer, relaxation, one thing at a time, vacation, and encouragement.” The IMPROVE skill is designed to help individuals cope with intense emotions and distressing situations in a healthier and more constructive way.
Opposite action is also an emotion regulation technique that teaches the client to try doing the opposite of what their emotion is urging them to do. For example, shame may be an emotion that causes us to hide. The opposite action would be to stick around, make eye contact, and show confidence.
DBT has many useful techniques to help with interpersonal effectiveness. One such tool is DEAR MAN. This tool helps when someone is struggling to have a difficult conversation. Using the tool to outline exactly what you would like to say is helpful. The acronym stands for:
Describe the problem.
Express your feelings.
Assert what you’d like.
Reinforce how it would benefit the other person.
Mindfully be aware of your impact on the other person.
Appear confident.
Negotiate and be willing to compromise.
5 Recommended DBT Workbooks
Workbooks are a common tool used in DBT. As clients are learning many new skills, it can be helpful to have them available to practice outside of sessions. Listed below are some of the best workbooks currently available.
1. The Dialectical Behavior Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance – Matthew McKay, Jeffrey C. Wood, and Jeffrey Brantley
This is a DBT workbook with a high recommendation and that is very commonly used by therapists.
This thorough workbook introduces the four key skills of DBT: distress tolerance, mindfulness, emotion regulation, and interpersonal effectiveness.
The workbook introduces these concepts in an introductory way, giving step-by-step instructions and practice, and works the reader up to more advanced practices.
While DBT was originally created for borderline personality disorder, it has been shown to be effective in treating many other mental health challenges.
2. DBT Workbook for Adult ADHD and Anxiety: A Practical Guide With Dialectical Behavior Techniques and Coping Skills to Overcome a Scattered Brain, Improve Focus, and Achieve Optimal Mental Performance – Janet Willow
For individuals with attention deficit hyperactivity disorder (ADHD), DBT can offer some support.
While DBT is not a cure for ADHD, it can provide individuals with skills that can reduce anxiety, increase positive coping skills, and help change maladaptive thoughts and behaviors.
This workbook applies DBT skills to the unique challenges experienced by adults with ADHD.
4. Depressed & Anxious: The Dialectical Behavior Therapy Workbook for Overcoming Depression & Anxiety – Thomas Marra
For those who experience depression and anxiety, learning DBT techniques can offer some relief.
The workbook Depressed & Anxious teaches individuals how to identify the thoughts that underlie depression and anxiety.
The workbook offers mindfulness techniques that help provide support for those who feel their emotions are overwhelming and have lost motivation or meaning in their lives.
5. The Neurodivergent Friendly Workbook of DBT Skills – Sonny Jane Wise
Individuals with neurodivergent brains, such as those with autism, ADHD, or high sensitivity to environmental stimuli, may find that DBT skills do not feel accessible.
This book, written by Sonny Jane Wise, is a workbook created specifically for those who experience autistic characteristics such as stimming, meltdowns, and sensory sensitivities.
The author has personal experience and has created a workbook that addresses the unique needs of this population.
DBT Coach is a comprehensive and popular app for learning DBT techniques and maintaining practice.
This app provides video lessons and animations to help users remember their skills. There are over 100 exercises, and the app allows users to track their progress.
This app also can connect clinicians and clients. Clinicians can sign up to track their client’s progress and respond in real time. Clients can share their diary cards where they list what skills they are learning and practicing.
DBT Travel Guide is an app created for folks with BPD. The user interface is simple and easy to use.
This app offers hundreds of skill practices and an option for a diary card. The behavioral chain analysis is one component that is well liked by subscribers.
Marsha Linehan, creator of DBT, has a series of 27 short videos (two to three minutes each) that break down the process of DBT and review each of the skills in detail. In the excerpt below, she discusses how she came to develop DBT.
Distress tolerance is a crucial part of DBT skills training. Our What Are Distress Tolerance Skills? article focuses on this important aspect and also provides great tools.
Want to become trained as a DBT practitioner? Then we have the answer for you in this How to Train in DBT article, which includes everything you need.
Useful tools
Radical acceptance is an important distress tolerance skill that is taught in DBT. This skill helps individuals learn to accept reality as it is, rather than how they wish it could be. This tool provides a client with step-by-step instructions to arrive at acceptance.
Emotional intelligence is the ability to understand the emotions that you are feeling and how they might be affecting behavior. This tool helps clients begin the process by naming and describing emotions.
Becoming skilled at interpersonal effectiveness requires practicing communication skills. This communication tool will help clients practice introducing themselves and a partner or friend to a group and reflect on how it felt and what they could improve.
Mindfulness is also a very important component of DBT. If you’re looking for more science-based ways to help others enjoy the benefits of mindfulness, check out this collection of 17 validated mindfulness tools for practitioners. Use them to help others reduce stress and create positive shifts in their mental, physical, and emotional health.
A Take-Home Message
DBT offers a treasure trove of evidence-based coping skills to empower individuals on their journey to emotional wellbeing.
The magic of DBT lies in its ability to transform distress into growth, emotional chaos into harmony, and turbulent relationships into meaningful connections. As clinicians and clients delve into this therapeutic adventure, they discover the power of self-awareness, the art of effective communication, and the strength to embrace emotions without judgment.
With DBT as their compass, individuals chart a course toward a life filled with authentic empowerment, balance, and the joy of writing their own narrative.
A DBT treatment plan is a comprehensive and individualized roadmap that outlines the goals, objectives, and interventions to be used in the therapy process. The client and their therapist collaboratively develop it, and it serves as a guide to address the client’s specific challenges and promote their emotional wellbeing.
What are the essential DBT coping skills?
Although there is a vast array of DBT coping skills, some have stronger evidence of their effectiveness. The following skills have been proven to show significant outcomes.
Mindfulness skills, such as mindful breathing and body scan meditation, have been shown to have strong therapeutic benefits across many different modalities.
The skill of radical acceptance has been linked to improved emotional regulation and reduced distress in various studies (Robins et al., 2004).
What is the first step in DBT?
The crucial first step of DBT is client stabilization. Before any of the other skills can be learned, a client must commit to decreasing self-harm, suicidal behaviors, and therapy-interfering behaviors, like lateness, skipping sessions, and canceling.
This is achieved by creating a strong therapeutic alliance. DBT-skilled clinicians use validation and radical acceptance to show clients that they are working together (Dimeff & Linehan, 2001).
How intense is the emotion on a scale from 1 to 10?
Can you tolerate this distress without taking impulsive actions?
What are some short-term strategies you can use to manage this intense emotion?
How can you effectively communicate your needs and boundaries in this situation?
What are some ways to maintain self-respect while navigating this relationship?
What are some obstacles you might face in applying these skills, and how can you overcome them?
How can you practice and reinforce these skills outside of therapy?
References
Bohus, M., Kleindienst, N., Hahn, C., Müller-Engelmann, M., Ludäscher, P., Steil, R., & Priebe, K. (2020). Dialectical behavior therapy for posttraumatic stress disorder (DBT-PTSD) compared with cognitive processing therapy (CPT) in complex presentations of PTSD in women survivors of childhood abuse: a randomized clinical trial. JAMA Psychiatry, 77(12), 1235–1245.
Chapman, A. L. (2006). Dialectical behavior therapy: Current indications and unique elements. Psychiatry, 3(9), 62–68.
Dimeff, L., & Linehan, M. M. (2001). Dialectical behavior therapy in a nutshell. The California Psychologist, 34(3), 10–13.
Hofmann, S. G., & Gómez, A. F. (2017). Mindfulness-based interventions for anxiety and depression. PsychiatricClinics, 40(4), 739–749.
Kliem, S., Kröger, C., & Kosfelder, J. (2010). Dialectical behavior therapy for borderline personality disorder: A meta-analysis using mixed-effects modeling. Journal of Consulting and Clinical Psychology, 78(6), 936–951.
Lenz, A. S., Del Conte, G., Hollenbaugh, K. M., & Callendar, K. (2016). Emotional regulation and interpersonal effectiveness as mechanisms of change for treatment outcomes within a DBT program for adolescents. Counseling Outcome Research and Evaluation, 7(2), 73–85.
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.
Robins, C. J., Schmidt. H., & Linehan, M. M. (2004). Dialectical behavior therapy: Synthesizing radical acceptance with skillful means. In S. C. Hayes, V. M. Follette, & M. M. Linehan (Eds.), Mindfulness and acceptance: Expanding the cognitive-behavioral tradition (pp. 30–44). Guilford.
Webb, C. A., Beard, C., Kertz, S. J., Hsu, K. J., & Björgvinsson, T. (2016). Differential role of CBT skills, DBT skills and psychological flexibility in predicting depressive versus anxiety symptom improvement. Behaviour Research and Therapy, 81, 12–20.
About the author
Dr. Amanda O'Bryan is a certified wellness coach and specializes in using evidence-based practices to empower her clients to shift the ways that stress and anxiety impact their lives. She also works as a freelance writer, creating psychoeducational content. Her goal with writing is to help people understand themselves better by presenting cognitive science in a fun and interesting way.
Dialectical Behavior Therapy (DBT) is not your average therapy session; it’s like a toolbox filled with colorful tools to tame the unruliest of emotions and turn stress into confetti.
Although DBT was created for and is primarily used with clients that have borderline personality disorder, suicidal ideation, or self-harm, it has been shown to be very beneficial for other illnesses as well.
Other DBT tools not yet mentioned include the STOP skill, the IMPROVE skill, and opposite action. There are also interpersonal awareness techniques that help with improving communication.
