Dialectical Behavior Therapy (DBT): Definition, Application, Technique and Worksheets

Dialectical Behavior Therapy (DBT) helps individuals manage intense emotions and improve relationships by teaching skills like mindfulness, emotional regulation, and distress tolerance. The meta-analysis “Meta-Analysis of Dialectical Behavior Therapy (DBT) for Treating Substance Use” (Haktanır & Callender, 2020) reviewed six studies. DBT was more effective than alternative treatments in reducing substance use symptoms at post-treatment. Huge differences were observed in U.S. samples, highlighting DBT’s effectiveness in substance-related treatments.

DBT is commonly used to treat conditions like borderline personality disorder, substance use disorders, depression, and anxiety. The study “Effectiveness of Dialectical Behavior Therapy in Routine Outpatient Care: The Berlin Borderline Study” by Stiglmayr et al. 2014 examined the impact of dialectical behavior therapy (DBT) on borderline personality disorder (BPD) in routine outpatient care. The findings showed major declines in self-injurious behavior, inpatient stays, and BPD symptoms, with 77% no longer meeting the criteria for BPD diagnosis. 

DBT incorporates several core techniques, including mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness, to help individuals cope with stress and improve emotional control. According to Stiglmayr et al. 2014, between 35.5% and 38.5% of participants who undergo Dialectical Behavior Therapy (DBT) show recovery or major improvement in borderline symptoms and overall psychopathology, depending on the specific outcome measure used. This highlights the therapy’s effectiveness in treating borderline personality disorder, with a substantial portion of individuals achieving measurable progress.

Worksheets in DBT guide participants through exercises that reinforce skill-building and reflection, promoting long-term emotional and behavioral change. These worksheets target areas like emotional regulation, distress tolerance, and interpersonal effectiveness, helping individuals apply DBT techniques in real-life situations. As mentioned in the journal article “DBT Skills Training Manual DBT Skills Training Handouts and Worksheets,” by Linehan, Marsha M. 2015, the worksheets promote long-term emotional and behavioral change, making them an essential tool for maintaining progress both during and after therapy by encouraging consistent practice and self-monitoring.

What Is Dialectical Behavior Therapy (DBT)?

Dialectical Behavior Therapy (DBT) is an evidence-based therapy rooted in cognitive-behavioral therapy and designed to address mental health conditions involving emotional dysregulation. It teaches skills in four key areas: mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness, helping individuals manage intense emotions and improve behaviors.

DBT was developed by Dr. Marsha M. Linehan in the late 1980s to initially treat borderline personality disorder but its application has expanded to conditions like depression, anxiety, and substance use disorders. DBT differs from other forms of talk therapy by balancing acceptance with change, which sets it apart from therapies that focus primarily on altering negative thoughts.

The study “Two-Year Randomized Controlled Trial and Follow-up of Dialectical Behavior Therapy vs Therapy by Experts for Suicidal Behaviors and Borderline Personality Disorder” by Linehan et al. 2006 compared DBT with expert psychotherapy in 101 women with Borderline Personality Disorder (BPD). Over two years, those receiving DBT were 50% less likely to attempt suicide. The findings confirm DBT’s unique effectiveness in reducing suicide attempts and improving psychological outcomes.

What Is Dialectical Behavior Therapy (DBT) Used for?

Dialectical Behavior Therapy (DBT) is primarily used to treat a variety of mental disorders by aiding individuals to regulate emotions, cope with stress, and improve relationships. Initially developed to address suicidal behavior and borderline personality disorder (BPD), DBT has since been expanded to treat conditions like post-traumatic stress disorder (PTSD), anxiety, depression, eating disorders, personality disorders, and substance use disorders. The main uses for DBT is to treat the following mental maladies discussed below:

• Borderline personality disorder (BPD): DBT was originally designed to reduce self-harming behaviors and emotional instability by teaching emotional regulation and distress tolerance skills. The research article “Effectiveness of Dialectic Behavioral Therapy in Routine Outpatient Care: the Berlin Borderline Study, found that DBT reduced BPD symptoms by 77% compared to treatment as usual.
• Post-traumatic stress disorder (PTSD): DBT supports individuals to manage trauma-related emotions by providing tools for coping with intrusive memories, flashbacks, and emotional regulation. The study “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” by Bohus, Martin et al. 2020 compared Dialectical Behavior Therapy for PTSD (DBT-PTSD) with Cognitive Processing Therapy (CPT) in women with childhood abuse histories. Both therapies substantially improved PTSD severity, but DBT-PTSD was superior, achieving 58% symptomatic remission compared to 41% for CPT, indicating its enhanced effectiveness for complex PTSD.
• Depression and Anxiety: DBT addresses negative thinking and maladaptive behaviors, assisting patients to manage symptoms of depression and anxiety through emotion regulation and cognitive restructuring. According to a meta-analysis of 11 studies, “The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses,” DBT has an overall success rate of 50-60% in treating various mental health disorders, including depression and anxiety. This aligns with findings for Borderline Personality Disorder (BPD) as well.
• Eating disorders: DBT assists in minimizing binge eating and other disordered behaviors by promoting mindfulness and emotional awareness, and ameliorating self-control. 

The research article “Dialectical Behavior Therapy Adapted for Binge Eating Compared to Cognitive Behavior Therapy in Obese Adults with Binge Eating Disorder: A Controlled Study” by Lammers et al. 2020 evaluated the effectiveness of Dialectical Behavior Therapy for Binge Eating Disorder (DBT-BED) against a more intensive form of Cognitive Behavior Therapy (CBT+) in 74 obese patients with binge eating disorder (BED). Clinically relevant changes were similar between DBT-BED (69.9% at treatment end, 65.0% at follow-up) and CBT+ (52.9% at treatment end, 45.8% at follow-up). The study concludes that while CBT+ outperformed DBT-BED, both treatments achieved comparable levels of meaningful change, suggesting the need for more rigorous randomized controlled trials to explore treatment mediators and moderators.

• Substance use disorder: Dialectical Behavior Therapy (DBT) pivots individuals with substance use disorders (SUDs) by teaching them skills to manage cravings, cope with urges, and prevent relapse. DBT emphasizes acceptance and change, enabling people to balance the desire for sobriety with the challenges of withdrawal or relapse prevention.

As mentioned by Dimeff and Linehan (2008), studies from 1986 to 1997 showed a wide range of borderline personality disorder (BPD) rates among patients with substance use disorders (SUDs), varying from 5% to 65%. They note a 42% prevalence of BPD among 615 heroin users in Sydney, Australia. In contrast, they reported that the prevalence of current SUDs among patients treated for BPD ranged from about 26% to 84%.

How Does Dialectical Behavior Therapy (DBT) Work?

Dialectical Behavior Therapy (DBT) works by guiding individuals through structured phases to build emotional regulation, distress tolerance, and interpersonal effectiveness. As explored by Rizvi et al. 2024 in the research paper “The State of the Science: Dialectical Behavior Therapy,” DBT combines talk therapy with evidence-based therapy methods to address negative thoughts, emotions, and behaviors, helping individuals bolster their mental health. The 4 main components of how DBT works are as follows:

• DBT Pre-assessment: In this initial phase, clients and therapists assess the individual’s needs, set treatment goals, and establish expectations for therapy.
• Individual Therapy: Weekly one-on-one sessions where clients work on understanding their emotions and behaviors, and develop personalized strategies to handle life challenges.
• Group Training: Clients participate in group sessions to practice and reinforce skills such as mindfulness and emotional regulation in a supportive environment.
• Phone Crisis Coaching: Therapists provide on-call support to help clients manage crises in real time, offering guidance to avoid self-destructive behaviors.

What Are the Techniques Used in Dialectical Behavior Therapy?

The techniques used in dialectical behavior therapy are mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. These techniques focus on reinforcing an individual’s ability to manage emotions, tolerate distressing situations, and streamline relationships through structured skill-building practices. The 4 main techniques used in DBT are discussed below:

Mindfulness

Mindfulness in DBT involves developing awareness of the present moment without judgment. This technique helps individuals manage emotions and reduce reactivity. Mindfulness skills taught in DBT include observing thoughts and feelings, describing experiences, and participating fully in the present moment.

The study “The Effect of DBT-Informed Mindfulness Skills (What and How Skills) and Mindfulness-Based Stress Reduction Practices on Test Anxiety in College Students” by Lothes et al. 2021 examined the impact of an 8-week mindfulness program on college students’ test and general anxiety. A total of 43 students were randomly assigned to either a mindfulness group, an online mindfulness group, or a control group. Results showed that participants in the mindfulness groups experienced cuts in test and general anxiety, along with refined mindfulness, while the control group showed no notable changes.

Distress Tolerance

Distress tolerance skills help individuals cope with difficult situations without resorting to harmful behaviors. These techniques include distraction, self-soothing, improving the moment, and evaluating pros and cons.

The study “The Self-Efficacy in Distress Tolerance Scale (SE-DT): A Psychometric Evaluation” by Alfonsson et al. 2022 developed a Swedish adaptation of the General Self-Efficacy scale for distress tolerance skills. The SE-DT showed strong psychometric properties, including high internal consistency (α = .92) and good test-retest reliability. It was sensitive to change and had strong validity, supporting its use in assessing distress tolerance within DBT. Further research is recommended to confirm its effectiveness across broader populations.

Emotion Regulation

Emotion regulation techniques in DBT focus on identifying and labeling emotions, reducing vulnerability to intense emotions, and increasing positive emotional experiences. These skills help individuals build relationships and improve overall emotional well-being.

The study “The Contribution of Skills to the Effectiveness of Dialectical Behavioral Therapy” by Lee et al. 2022 assessed how improvements in DBT skills influence clinical outcomes in 57 adults with borderline personality disorder (BPD) or BPD traits. Participants underwent either comprehensive DBT (DBT-C) or DBT skills training (DBT-S). Over 6 months, enhancements were found in psychological distress, quality of life, mindfulness, and interpersonal effectiveness, but not in borderline symptoms. Emotion regulation was uniquely linked to better clinical outcomes, highlighting its key role in DBT’s effectiveness. Delivery mode did not affect outcomes.

Interpersonal Effectiveness

Interpersonal effectiveness skills in DBT aim to improve communication and assertiveness in relationships. These techniques help individuals express needs, set boundaries, and maintain self-respect while interacting with others.

In the study “The Efficacy of Applying the Interpersonal Effectiveness Skills of Dialectical Behavior Therapy into Communication Skills Workshop for Clinical Nurses,” Wu et al. 2023 explored the impact of incorporating DBT’s Interpersonal Effectiveness (DBT-IE) skills into a 3-hour communication workshop for nurses. Among 164 participants, 72 completed pre- and post-workshop assessments, showing considerable advancements in professional fulfillment, interpersonal coping skills, and reduced dysfunctional coping. A subgroup also demonstrated enhanced performance in Objective Structured Teaching Examinations (OSTE). The workshop received high satisfaction scores, confirming its effectiveness and feasibility.

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What Are the Common Worksheets Used in Dialectical Behavior Therapy?

The common worksheets used in dialectical behavior therapy are chain analysis, diary cards, and emotion regulation. These worksheets assist people to track their progress, identify patterns, and apply DBT skills in everyday life. The common worksheets used in dialectical behavior therapy include:

• Chain Analysis: This worksheet helps individuals break down problematic behaviors step-by-step to understand the triggers, emotions, and events that lead to undesirable actions. It is used to identify patterns and develop healthier coping strategies.

As outlined by Rizvi, Shireen (2019) in the book “Chain Analysis in Dialectical Behavior Therapy,” the five key components of chain analysis are vulnerability factors, prompting event, links (which are thoughts, emotions, behaviors, and other related events involving self and others), target behavior, and consequences (both short-term and long-term).

• Diary Cards: These worksheets are used to track emotions, urges, and behaviors daily. Participants document their use of DBT skills, helping them monitor progress and identify areas for improvement.

In the study “Mobile Diary App Versus Paper-Based Diary Cards for Patients With Borderline Personality Disorder,” Laursen et al. 2021 compared the cost-effectiveness of a mobile diary app with paper-based diary cards in dialectical behavior therapy (DBT) among 78 patients. Over 12 months, both groups showed improvements in quality-adjusted life years (QALYs), depression severity, and borderline severity; however, the paper group had slightly better QALY gains and depression reductions. The app group recorded more skills and had more treatment days. Patients found the app user-friendly, while therapists expressed concerns about its impact on patient interactions. Further research is needed to assess its cost-effectiveness.

• Emotion Regulation: This worksheet focuses on identifying emotional triggers, labeling emotions, and applying emotion regulation skills. It helps individuals learn to manage their emotions more effectively and reduce emotional vulnerability.

In the pilot study “A Preliminary Pilot Study Comparing Dialectical Behavior Therapy Emotion Regulation Skills with Interpersonal Effectiveness Skills and a Control Group Treatment,” Dixon-Gordon et al. 2015 investigated the effects of Dialectical Behavior Therapy (DBT) emotion regulation (ER) skills in 19 women with borderline personality disorder (BPD). Within 6 weeks, participants received DBT-ER, DBT interpersonal effectiveness (DBT-IE), or control treatment. Results indicated large effect sizes for emotional reactivity, problem-solving, distress tolerance, and BPD symptoms in the DBT-ER group. Notably, improvements in non-suicidal self-injury and mindfulness were unique to DBT-ER, suggesting the need for further research.

What Are the Benefits of Dialectical Behavior Therapy?

The benefits of dialectical behavior therapy are improved emotional regulation, better interpersonal skills, reduced suicidal thoughts, enhanced problem-solving skills, and improved quality of life. DBT guides individuals to address overwhelming emotions, navigate relationships more effectively, and derive coping mechanisms to handle life’s challenges, especially among persons struggling with addiction. The most common benefits of dialectical behavior therapy include:

• Improved Emotional Regulation: DBT teaches individuals to better manage their emotions and responses. This leads to fewer emotional outbursts and improved emotional stability.
• Better Interpersonal Skills: Participants learn techniques to build stronger, healthier relationships. These skills help reduce conflicts and enhance communication.
• Reduced Suicidal Thoughts: DBT has been shown to lower instances of suicidal ideation. It provides tools to manage overwhelming feelings that contribute to these thoughts.
• Enhanced Problem-Solving Skills: Individuals are taught how to effectively tackle life challenges. This fosters independence and resilience in difficult situations.
• Improved Quality of Life: As emotional and interpersonal skills improve, overall life satisfaction increases. It helps individuals maintain a more balanced and fulfilling life.

How Effective Is Dialectical Behavior Therapy?

Dialectical Behavior Therapy (DBT) is 30-40% effective in treating borderline personality disorder (BPD), substance use disorders, and suicidal behavior.

Panos et al. 2013 conducted a meta-analysis of five RCTs to evaluate Dialectical Behavior Therapy (DBT) for Borderline Personality Disorder. DBT significantly reduced self-destructive behaviors (30-40%) but only slightly improved treatment retention (16.8%) and had no significant impact on depression (approx. 50%). Overall, DBT effectively stabilizes self-destructive behaviors and improves patient compliance.

How Long Does a Session of DBT Therapy Last?

A DBT therapy session lasts 40 to 60 minutes for individual therapy and 90 to 120 minutes for group skills training. As spotlighted by Yale Medicine, patients in the DBT skills training Intensive Outpatient Program (IOP) attend sessions for 3 hours, 3 times a week, over 8 weeks. Patients review their diary cards during these sessions, complete DBT skills homework, and engage in skills training. They also have access to phone coaching outside of IOP hours to help apply these skills in real-life settings. After completing the IOP, many patients join a once-weekly Outpatient DBT Skills Training group, which lasts 6 to 12 months, to further solidify their DBT skills. The total duration of DBT treatment typically ranges from 6 months to 1 year.

Can DBT Be Used in Group Therapy?

Yes, DBT can be effectively used in group therapy settings. Group skills training is a core component of comprehensive DBT treatment. In the study “Dialectical Behavioral Therapy-Based Group Treatment Versus Treatment as Usual for Adults with ADHD” by Halmøy et al. 2022, researchers compared the effects of DBT-based group therapy (DBT-bGT) with regular treatment for 121 adults with ADHD. After 14 weeks, those who received DBT-bGT had much better improvement in managing ADHD-related issues, including focus and organization, and their symptoms improved significantly more than those in regular treatment. These benefits lasted even after 6 months, showing that DBT-bGT is a useful non-drug treatment option for ADHD in clinical settings. The study supports DBT-bGT as an effective non-pharmacological treatment for ADHD in clinical settings.

Is DBT Only Suitable for Severe Mental Health Conditions Like BPD?

No, DBT is not only suitable for severe mental health conditions like BPD. As discussed by Corliss, Julie (2024), Executive Editor, Harvard Heart Letter for Harvard Health Publishing, in the article “Dialectical Behavior Therapy: What is it and Who Can it Help?”, DBT is now used to treat depression, post-traumatic stress disorder, eating disorders, and substance use disorders.

Is DBT Effective for Treating Substance Abuse?

Yes, DBT is effective for treating substance abuse. In “Dialectical Behavior Therapy for Individuals with Substance Use Problems,” Salsman (2020) reviews 8 randomized controlled trials (RCTs) and 12 uncontrolled and quasiexperimental trials on the efficacy of DBT for substance use disorders (DBT-SUD). Five well-controlled studies across the U.S., Netherlands, and Canada confirm DBT-SUD’s effectiveness. Three RCTs highlight successful DBT modifications for substance use. Additional trials show DBT’s effectiveness in diverse populations, including adolescents and non-Western cultures. This chapter in “The Handbook of Dialectical Behavior Therapy” illustrates that DBT-SUD soon qualifies as an empirically supported treatment by the American Psychological Association.