Dialectical Behavioral Therapy

How-To Therapy Handbook

Part 3: Eleven Therapeutic Traditions

Dialectical Behavioral Therapy (DBT)

What is DBT?

Dialectical Behavior Therapy (DBT) is a therapy approach designed to help people handle intense emotions, reduce impulsive or harmful reactions, improve relationships, and build a life that feels more manageable and meaningful.

DBT combines two ideas that can seem opposite but can both be true:

  • Acceptance: “This is what I am experiencing right now.”
  • Change: “There may be something I can do differently.”

This is the dialectical part of DBT.

For example:

“My feelings make sense given what I have been through, and I am responsible for what I do next.”

DBT is less about deciding whether emotions are “good” or “bad” and more about learning to notice what is happening, understand it, and choose an effective response.

The Four Main DBT Skill Areas

DBT skills are usually organized into four areas:

  1. Mindfulness — noticing what is happening without immediately reacting.
  2. Distress Tolerance — getting through difficult moments without making them worse.
  3. Emotion Regulation — understanding emotions and changing emotional patterns when useful.
  4. Interpersonal Effectiveness — asking for what you need, setting boundaries, and maintaining relationships and self-respect.

A simple way to remember them:

Notice → Survive → Regulate → Communicate

1. MINDFULNESS

Mindfulness is the foundation of DBT.

The goal is not to empty your mind or feel peaceful all the time. The goal is to notice what is happening clearly enough that you have a choice about what to do next.

DBT describes three states of mind:

Emotion Mind

Emotions are driving the situation.

Examples:

  • “They haven’t answered me. They obviously don’t care.”

  • “I’m furious. I need to confront them right now.”

  • “I feel ashamed, so I must have done something wrong.”

Reasonable Mind

Logic and facts dominate while emotions may be ignored.

Examples:

  • “Technically, nothing happened.”

  • “There is no logical reason to be upset.”

  • “Feelings aren’t relevant.”

Wise Mind

Wise Mind tries to include both emotion and reason.

It asks:

“Given my feelings, the facts, my values, and the situation, what seems most effective?”

The Mindfulness “What” Skills

Observe

Notice what is happening.

Notice:

  • thoughts
  • emotions
  • body sensations
  • urges
  • sounds
  • other people’s behavior

Try noticing before interpreting.

Observation: “My partner became quiet.”

Interpretation: “My partner doesn’t care about me.”

Those are not the same thing.

Describe

Put words to what you notice.

Instead of:

“Everything is terrible.”

Try:

“I notice tightness in my chest, sadness, and the thought that I am being rejected.”

Accurate description often reduces confusion.

Participate

Allow yourself to be involved in the present activity instead of constantly watching or judging yourself.

The Mindfulness “How” Skills

Nonjudgmentally

Describe rather than label.

Instead of:

“I’m pathetic for feeling jealous.”

Try:

“I’m noticing jealousy and an urge to seek reassurance.”

One-Mindfully

Do one thing at a time as much as possible.

When listening, listen.

When eating, eat.

When having a difficult conversation, try not to simultaneously rehearse your defense.

Effectively

Ask:

“What actually works here?”

Effective does not necessarily mean proving that you are right.

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Handbook Navigation & References

Part One:Clinical Approach
Part Two: Clinical Pragmatism (you are here).
Part Three: Therapeutic Orientation Deep-Dives
  • Section 1: Foundational Theory –  Contemporary Psychodynamic Theory
  • Section 2: Interpersonal
  • Section3: Relational Psychodynamic
  • Section 4: Emotion-Focused (EFT)
  • Section 5: Dialectical Behavioral Therapy (DBT)
  • Section 6: Acceptance and Commitment Therapy (ACT)
  • Section 7: Cognitive Behavioral Therapy (CBT)
  • Section 8: Existential Therapy
  • Section 9: Family Systems Therapy (FST)
  • Section 10: Multicultural and Culturally Responsive
  • Section 11: Trauma-Informed

Primary Sources

  1. Linehan, M. M. (2015). DBT Skills Training Manual (2nd ed.). Guilford Press.
  2. Linehan, M. M. (2015). DBT Skills Training Handouts and Worksheets (2nd ed.). Guilford Press.
    These are the main sources for the four modules and named skills.

Foundational treatment texts:

  • Linehan, M. M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. Guilford Press.
  • Rizvi, S. L., & Linehan, M. M. (2005). “The treatment of maladaptive shame in borderline personality disorder: A pilot study of ‘opposite action.’” Cognitive and Behavioral Practice, 12, 437–447.

 

Medical References

Alcohol and Alcoholism
Glynis Read May 2015
DOI: 10.1093/alcalc/agv004
URL: https://doi.org/10.1093/alcalc/agv004

Cognitive and behavioral practice
Yoel Everett, et al. 2024
DOI: 10.1016/j.cbpra.2024.04.002
URL: https://doi.org/10.1016/j.cbpra.2024.04.002

Frontiers in Psychology
Eva Fassbinder, et al. 2016
DOI: 10.3389/fpsyg.2016.01373
URL: https://doi.org/10.3389/fpsyg.2016.01373

Psychiatry (Edgmont)
Alexander L Chapman 2006
URL: https://pmc.ncbi.nlm.nih.gov/articles/PMC2963469/

ncbi.nlm.nih.gov
Apr 2026
URL: https://www.ncbi.nlm.nih.gov/books/n/sbu200507/pdf/

Journal of Clinical Medicine
Tanya Saraiya & Teresa Lopez-Castro 2016
DOI: 10.3390/jcm5110094
URL: https://doi.org/10.3390/jcm5110094

Addictive behaviors
Ronda L Dearing, et al. 2005
DOI: 10.1016/j.addbeh.2005.02.002
URL: https://doi.org/10.1016/j.addbeh.2005.02.002

Journal of family psychology : JFP : journal of the Division of Family Psychology of the American Psychological Association (Division 43)
Danielle M Mitnick, et al. 2009
DOI: 10.1037/a0015982
URL: https://doi.org/10.1037/a0015982

Journal of interpersonal violence
Heidi Adams Rueda, et al. 2018
DOI: 10.1177/0886260518814267
URL: https://doi.org/10.1177/0886260518814267

PLoS ONE
Jeongwoon Yang & Sungjae Kim 2022
DOI: 10.1371/journal.pone.0268016
URL: https://doi.org/10.1371/journal.pone.0268016

Trials
Martiño Rodríguez‐González, et al. 2022
DOI: 10.1186/s13063-022-06831-7
URL: https://doi.org/10.1186/s13063-022-06831-7

PLoS ONE
Susan M. Johnson, et al. 2013
DOI: 10.1371/journal.pone.0079314
URL: https://doi.org/10.1371/journal.pone.0079314

BMC Psychology
Zahra Mirzazade, et al. 2025
DOI: 10.1186/s40359-025-03415-3
URL: https://doi.org/10.1186/s40359-025-03415-3

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