Dialectical Behavior Therapy
Structured Notes — Skills, Concepts & Children's Adaptations
DBT
What is DBT?
Dialectical Behavior Therapy (DBT) is a type of talk therapy developed by Marsha Linehan in the late 1970s.
Originally created to help people with Borderline Personality Disorder (BPD) who were at serious risk of
suicide, it has since expanded to many other conditions. The word dialectical means finding balance —
specifically between accepting yourself as you are AND making changes to improve your life. It blends
Cognitive Behavioral Therapy (CBT) with mindfulness and acceptance practices.
Definition Origin
A therapy grounded in the idea that the world is Created by Marsha Linehan in the late 1970s to
in continuous change and individuals are treat BPD in persistently suicidal clients — the
constantly in transition. first empirically proven BPD treatment.
Who Does DBT Help?
Originally for BPD Expanded applications
Borderline Personality Disorder, self-harm Depression, Bipolar Disorder, PTSD, Anxiety,
(cutting), suicidal thoughts, gestures and Eating Disorders, Alcohol and Drug Problems.
attempts. Adapted for various ages and settings.
What DBT Targets
DBT targets the root cause of destructive behavior — intense, overwhelming emotions. When emotions
become too much to handle, people act out in harmful ways. DBT addresses both:
Psychological harm Physical harm
Suicidal ideation, self-harm, and emotional Self-injurious acts, substance misuse, and
crises. reckless behavior.
Biosocial Theory — Why BPD Develops
BPD is thought to develop when two factors combine:
Biological vulnerability Invalidating environment
Born with a highly sensitive nervous system — Grew up in a setting that dismissed or punished
emotions hit harder, last longer, and take more emotions, so the person never learned healthy
time to return to normal. Can be genetic or coping skills. May involve abuse, neglect, or
developmental. mismatched parenting.
Result: emotional dysregulation — explosive emotions, impulsive actions, unstable relationships, fear
of abandonment, chronic emptiness, and self-harm.
The Cycle of Dysregulation
2. Emotional 4. Problem 5. Temporary
1. Trigger dysregulation 3. Avoidance behavior relief → Repeats
Each episode reinforces the next. DBT breaks this cycle by teaching new skills and building the ability to sit with distress.
4 Core Skill Modules
1. Mindfulness
Paying attention to the present moment without judging it. It is the foundation of all other DBT skills.
Involves observation, explanation and participation. Helps identify unhelpful thoughts and tolerate difficult
emotions during change. Rooted in Buddhist practice but used here with no religious element.
2. Distress Tolerance
Learning to tolerate pain skillfully — not avoid or suppress it. Includes radical acceptance (fully
accepting reality as it is), turning the mind toward acceptance, and willingness vs. willfulness. Four crisis
survival skills: (1) Distracting yourself, (2) Self-soothing, (3) Improving the moment, (4) Weighing pros and
cons.
3. Emotion Regulation
People with BPD often feel emotions very intensely — angry, frustrated, depressed, or anxious. This
module teaches: naming your emotions accurately, identifying what blocks change, reducing emotional
sensitivity through self-care and lifestyle, and actively creating more positive experiences.
4. Interpersonal Effectiveness
Building healthy relationships while maintaining self-respect. The challenge: people with BPD may know
appropriate responses in theory but struggle to apply them. Teaches how to ask for what you need
clearly, say no without guilt, and handle conflict without letting emotions take over.
Techniques Used in DBT
Problem solving Exposure training
Identify what triggers bad behavior, then work Gradually face feared emotions or situations
out practical solutions with the therapist. instead of avoiding them, reducing reactivity.
Contingency management Behavior modification
Reinforce helpful behaviors; reduce attention Directly replace self-destructive habits with
given to harmful ones. better ones through structured skill practice.
Dialectical Strategies (Therapist Tools)
Devil's advocate Metaphors Paradox Humor
Irreverence Silent intensity Confrontation Consultation to client
Example — Devil's Advocate: The therapist questions whether the client is really committed to change. The client then
argues IN FAVOR of participating — which builds their own motivation.
Three Modes of Delivery
Group skills training
Individual counseling Structured group sessions
One-on-one sessions focused teaching all 4 skill modules: Telephone coaching
on the person's specific triggers, mindfulness, emotion Between-session phone support
goals, and behavioral regulation, distress tolerance, so clients can apply DBT skills
challenges. and interpersonal effectiveness. to real-life crises as they arise.
Goals of Counseling (in order)
1 Stay alive
Eliminate suicidal behavior and self-harm first. Nothing else is addressed until the person is safe.
2 Stay in therapy
Remove anything that gets in the way of treatment — skipping sessions, not doing homework,
resistance.
3 Build a better life
Reduce other damaging behaviors and build new skills for lasting personal change.
4 Stages of Treatment
Stage 1 — Behavior control
Move from out of control to in control. Stop Stage 2 — Emotional processing
life-threatening and therapy-interfering Move from quiet desperation to full emotional
behaviors. experience. Address trauma and PTSD.
Stage 3 — Ordinary happiness Stage 4 — Completeness
Work on relationships, career, and self-respect. For those who still feel empty after Stage 3.
Build an everyday satisfying life. Find spiritual meaning and deeper connection.
DBT Target Hierarchy
Behaviors are addressed in this descending order of priority:
1 Reduce high-risk suicidal behaviors
2 Reduce behaviors interfering with therapy
3 Reduce behaviors that lower quality of life
4 Address post-traumatic stress responses
5 Enhance self-respect
6 Learn all 4 skill modules
7 Additional client-set goals
Process of Change — 5 Functions
1 Preserve motivation
The therapist keeps the client's will to change alive — considered the most significant person in the
client's life.
2 Boost capabilities
Skills are built through groups, phone coaching, and homework assignments.
3 Generalize new skills
Skills must transfer to real life, not just work inside therapy sessions.
4 Support the counselor
Therapists meet weekly for supervision to stay skilled and avoid burnout.
5 Structure the environment
Family may be involved to ensure new behaviors are supported — not punished — at home.
DBT Techniques Adapted for Children
Children need the same core skills but delivered through play, simple language, visuals, and fun
activities. Below is how each DBT module and technique can be applied with children.
Mindfulness: "Notice and breathe" activities
Teach children to pause and notice what they are feeling in their body. Use breathing exercises with
props like blowing a pinwheel, blowing bubbles, or belly-breathing with a stuffed animal on the tummy. "5
senses check-in" works well: what can you see, hear, smell, touch, taste right now?
Activity: Mindful jar — shake a glitter bottle and watch the glitter settle while breathing slowly. When the glitter
settles, the mind settles too.
Distress Tolerance: "Calm-down toolkit"
Instead of acting out when upset, children learn to use a personal toolkit. Items might include a stress
ball, a favourite smell, a comfort object, or a drawing of their "calm place." Teach them to distract using
games, movement, or music. Self-soothing uses the 5 senses — a soft blanket, a favourite song, a cold
drink.
Activity: Make a "calm-down corner" or "feelings box" stocked with items the child chooses. Role-play using it
when pretend-angry.
Emotion Regulation: "Feelings vocabulary and thermometer"
Many children cannot name their emotions, which makes regulation impossible. Use an emotion wheel or
feelings-faces chart. Teach them to rate feeling intensity on a "feelings thermometer" (1-10). Connect
feelings to body sensations — "when I am angry my chest feels tight." Also help children plan positive
events: schedule something fun to look forward to each day.
Activity: Draw a body outline and colour in where different feelings "live." Use a traffic-light system: red = very
upset, yellow = getting worried, green = calm.
Interpersonal Effectiveness: "Use your words" and role-play
Teach children to ask for what they need using simple, clear phrases. Practice saying no kindly. Use
puppets or role-play to act out conflict situations and try different responses. Teach "I statements" — "I
feel sad when you take my toy" instead of hitting or crying. Reinforce that it is always okay to ask a
trusted adult for help.
Activity: Puppet play where one puppet does something upsetting. The child practises what the other puppet
should say and do. Celebrate every kind response.
Behavioral chain analysis: "What happened story"
After a big emotional episode, gently walk the child through what happened step by step in simple
language: What were you doing? What happened next? How did that make you feel? What did you do?
Was that helpful? What could we try next time? Use pictures or a comic-strip format for younger children.
Activity: Draw a story strip of the event with 4-6 boxes. In the last box, draw what a different choice could look
like.
Contingency management: Praise, reward charts, and consistency
When children use a DBT skill — like breathing instead of hitting — immediately notice and praise it. Use
sticker charts where using calm strategies earns points. Avoid accidentally reinforcing meltdowns by
giving in to demands when the child is dysregulated; this teaches them that tantrums work.
Activity: A "skills star chart" — every time the child uses a feeling word, takes 3 calm breaths, or asks for help
instead of acting out, they earn a star.
Exposure training: Gradual "brave ladders"
For children with anxiety or fear, build a "brave ladder" — a list of feared situations from easiest to
hardest. Slowly face each step while using calm-down tools. Celebrate every step taken. Never force —
work collaboratively. For emotion fears, gradually practise sitting with mild discomfort (e.g. a slightly
frustrating puzzle) while using breathing.
Activity: Draw a ladder on paper. Put the scariest thing at the top. Put something easy at the bottom. Work up
one rung at a time with lots of encouragement.