Dialectical behaviour therapy

1. Introduction

Version followed: standard comprehensive outpatient DBT for adults as set out in Linehan's 1993 treatment manual (Cognitive-Behavioral Treatment of Borderline Personality Disorder) and the second-edition DBT Skills Training Manual (2015 skill set). A revised edition of the skills manual came out in 2025; any changes it makes are not covered here [uncertain]. Adolescent DBT (Miller, Rathus & Linehan) is noted where it differs.

DBT is a comprehensive, team-delivered cognitive-behavioural treatment. Marsha Linehan developed it at the University of Washington for chronically suicidal people, and it was later extended to borderline personality disorder and other problems of emotion dysregulation [source: Behavioral Tech, What is DBT; Sidhu IHS slides]. Model of change: problem behaviours (suicidal acts, self-harm, substance use, outbursts) are understood as learned attempts to solve unbearable emotional pain. They arise from a biosocial transaction: a biologically emotionally vulnerable person grows up in an invalidating environment and never learns to regulate emotion [source: Linehan 2015 TOC, ch. 6 'Biosocial Theory of Emotion Dysregulation'; Linehan 1993 TOC, ch. 2]. Change comes from four things working together. The client learns new skills. Motivation and generalisation are built up. Behaviour is analysed and its contingencies changed. All of this sits inside a relationship that keeps balancing acceptance (validation, mindfulness) against change (problem solving, behavioural procedures), and works through the tension between the two by dialectical synthesis rather than compromise. Behavioral Tech defines a dialectic as "a synthesis or integration of opposites" [source: Behavioral Tech, What is DBT]. The overarching goal is a life the client experiences as worth living, not merely the absence of suicidal behaviour [source: Pattie 2022, Part 1; Mishne slides].

2. Framework

Modes and functions (standard outpatient DBT)

Individual therapy: weekly, about 1 hour [source: Sidhu IHS slides; Sprich MGH slides]. The individual therapist is the primary therapist and works on motivation, applies skills to the client's specific problems, and works through the target hierarchy. The therapist also teaches the client to be their own case manager, stepping in directly only when absolutely necessary [source: Behavioral Tech, What is DBT].
Skills training group: weekly, about 2–2.5 hours [source: Sidhu]. Each session runs mindfulness practice, then homework review, then new material [source: Sprich]. The full curriculum takes 24 weeks, with briefer subsets used for some populations [source: Behavioral Tech, What is DBT]. A standard adult course is commonly one year, so clients go through the modules twice; one residential programme used 1 year for adults and 6 months for adolescents [source: Mishne slides; one-year norm otherwise from Linehan 1993: uncertain].
Between-session phone coaching: brief, skill-focused calls, typically 5–15 minutes. It is "not therapy on the phone" [source: Chapman 2019/2025, Behavioral Tech].
Therapist consultation team: weekly, about 1.5–2 hours [source: Sidhu]. The team monitors fidelity, builds skill and keeps therapists motivated with high-risk clients [source: Behavioral Tech, What is DBT].
The slides state that no single component has been shown to work on its own [source: Sidhu]. Behavioral Tech contrasts the four-mode model with individual-only therapy [source: Behavioral Tech].
Five functions: the modes serve five functions: enhancing capabilities (skills group), improving motivation (individual), ensuring generalisation (coaching), structuring the environment (case management), and enhancing therapist capability and motivation (team). This five-part list comes from Linehan's manuals, not drawn on in full; the Behavioral Tech page confirms the motivation and environment-structuring functions [uncertain].
Adolescent DBT: adds a multifamily skills group, coaching for parents as well as teens, family sessions as needed, and a fifth module, Walking the Middle Path [source: Sprich].

Stages

Stage	Client's state	Goal
Pretreatment	Deciding whether to enter DBT	Orientation, agreement on goals, commitment [source: Mishne]
Stage 1	Severe behavioural dyscontrol	Gain behavioural control [source: UNC overview]
Stage 2	"Quiet desperation": controlled behaviour, emotional suffering (e.g. PTSD)	Emotional experiencing; trauma processing, e.g. DBT Prolonged Exposure protocol (Harned, Korslund, Foa & Linehan 2012) [source: UNC overview; UW BRTC publications list]
Stage 3	Ordinary problems in living	Ordinary happiness and unhappiness, self-respect [source: UNC]
Stage 4	Incompleteness	Capacity for sustained joy [source: UNC]

Stage 1 primary target hierarchy (order of priority in every individual session)

Life-threatening behaviours: suicidal acts, suicidal ideation and communications, non-suicidal self-injury.
Therapy-interfering behaviours, by client or therapist.
Quality-of-life-interfering behaviours: e.g. substance use, eating problems, housing, work, serious Axis I problems.
Increasing behavioural skills: mindfulness, distress tolerance, interpersonal effectiveness, emotion regulation, self-management. [source: UNC overview; Sprich; Mishne]

In the skills group the hierarchy is different. Behaviours that would destroy the group come first, then skill acquisition and strengthening, then reducing behaviours that interfere with the group. Suicidal behaviour is handed back to the individual therapist [source: Linehan 2015 TOC, ch. 4 'Skills Training Treatment Targets and Procedures': ordering from standard published accounts: uncertain].

Secondary targets (dialectical dilemmas): emotional vulnerability vs self-invalidation; active passivity vs apparent competence; unrelenting crises vs inhibited grieving (also called inhibited experiencing). Treat these as patterns that feed primary targets, and aim for the synthesis between each pair [source: Sprich; UNC]. Adolescent dilemmas: excessive leniency vs authoritarian control; normalising pathological behaviour vs pathologising normative behaviour; forcing autonomy vs fostering dependence [source: Sprich].

Session structure (individual)

Review the diary card.
Pick the highest target that occurred since last session.
Do a chain analysis of it.
Weave in solution analysis and skills.
Move down the hierarchy to quality-of-life problems and skills. [source: UNC overview]

Agree the agenda at the start. If a life-threatening behaviour occurred, it takes precedence over the client's preferred topic [synthesis, consistent with hierarchy].

Criteria for moving between phases

Pretreatment to Stage 1: the client has been oriented and has made an explicit commitment to the treatment goals, including working to reduce suicidal and self-harm behaviour, and has agreed to the treatment agreements, e.g. attendance, diary cards, team consultation [source: Mishne; Pattie Part 2].
Stage 1 to Stage 2: life-threatening behaviour is under control, therapy-interfering and severe quality-of-life behaviours are stable, and the client has enough skills to tolerate emotion work. The sources give no numeric criterion; judge clinically and agree it with the team [synthesis; uncertain].
Dropout rule: in the programme agreement, missing four consecutive scheduled sessions counts as dropping out, and return is negotiated after an agreed period. The same rule is widely attributed to Linehan 1993 [source: Mishne; Linehan 1993: uncertain].
Length: contracts are time-limited and renewable, e.g. one year for adults or 6 months for adolescents in one programme [source: Mishne]. Renewal depends on progress [synthesis].

3. Guiding principles

Dialectics: no absolute truth; look for what is left out and build syntheses. In practice: say "and" rather than "but", and hold "you are doing your best" and "you need to do better" together [source: Behavioral Tech; Sprich; Vaughn, Psychotherapy Academy; Pattie Part 1].
Acceptance–change balance: too much push for change leaves clients feeling misunderstood, and too much acceptance leaves them stuck. In practice: pair every change request with validation, and the reverse [source: Behavioral Tech, What is DBT].
Behavioural science: behaviour is learned, maintained by its consequences and changeable through assessment. In practice: assess before you intervene, define targets specifically, and use chain analysis rather than interpretation [source: Behavioral Tech; UNC].
Biosocial non-blaming: problems come from a transaction, not a defect. In practice: explain the client's patterns as understandable outcomes of vulnerability plus invalidation [source: Linehan 2015 TOC ch. 6].
Clients are doing the best they can, and they want to improve. In practice: assume effort, not manipulation [source: UNC; Mishne].
Clients need to do better, try harder and be more motivated to change. In practice: hold high expectations alongside validation [source: UNC].
Clients may not have caused all their problems, but they must solve them anyway. In practice: move from fault-finding to problem solving [source: UNC; Mishne].
Suicidal clients' lives are unbearable as currently lived. In practice: the task is changing the life, not just stopping the behaviour [source: UNC; Mishne].
New behaviour must be learned in all relevant contexts. In practice: insist on in-vivo practice, homework and coaching [source: Behavioral Tech; UNC; Mishne].
Clients cannot fail in DBT. In practice: if the client does not improve, the treatment or the therapist has failed, so revise the plan rather than blame [source: UNC; Mishne].
Therapist assumptions: the most caring thing is to help clients change toward their own goals; clarity, precision and compassion matter most; the relationship is between equals; behavioural principles apply to therapists too; therapists need support; therapists can fail. In practice: use the team, and analyse your own therapy-interfering behaviour [source: UNC].
Life worth living: orient from session one toward the client's vision of a life worth living, and link every target to it [source: Pattie Part 1].
Primacy of the target hierarchy: in practice, the hierarchy, not the crisis of the week, sets the agenda [source: UNC; Sprich].
Validation as a core strategy: communicate what is valid in the client's responses without approving dysfunctional behaviour [source: Sprich; UNC].
Mindfulness for the therapist: the therapist practises the same skills taught. In practice: begin team meetings with mindfulness, and be nonjudgmental about clients and colleagues [source: Linehan 2015 TOC ch. 5 'Application of Fundamental DBT Strategies': uncertain].
Therapist dialectical dilemmas: balance nurturing vs benevolent demanding, change-orientation vs acceptance-orientation, and unwavering centredness vs compassionate flexibility [source: UNC].
Consultation-team agreements: dialectical (no absolute truth); consultation-to-the-patient (teach clients to deal with other team members rather than intervening for them); consistency (accept that team members will differ); observing limits (each therapist observes their own limits, and colleagues do not judge them); phenomenological empathy (look for the non-pejorative interpretation of client behaviour); fallibility (all therapists are fallible, so no need for defensiveness). In practice: review the agreements as a team regularly [source: Mishne, which lists the agreements with brief glosses; glosses on the last two are my paraphrase of standard descriptions: uncertain]. Mishne's programme added an anti-racism agreement; this is a local addition, not confirmed as standard [source: Mishne; uncertain].
Two-way agreements: clients agree to attend, work on therapy-interfering behaviour, complete diary cards and allow team discussion; therapists agree to make every reasonable effort, keep confidentiality within the team and get consultation [source: Mishne; therapist side from Linehan 1993: uncertain].

4. Intervention inventory

The inventory has three parts: A, pretreatment and individual-therapy strategies; B, the skills taught in skills training (Linehan 2015 module structure); C, team and case-management strategies. Strategy group names follow the chapter structure of Linehan 1993: dialectical, validation, problem solving, change procedures, stylistic, case management, structural and special strategies [source: Linehan 1993 TOC]. Where only the chapter title is sourced, the step detail is marked. All example language is mine and illustrative.

A. Pretreatment and individual therapy

A1. Orientation to DBT and the biosocial model

Purpose: give the client an informed choice and a non-blaming account of their problems. Done in the first 1–4 pretreatment sessions and repeated in group [source: Linehan 2015 TOC ch. 6 'Orientation', 'Biosocial Theory'; Mishne].
Steps: (1) Assess the main problem behaviours and suicide history. (2) Explain the modes, the time commitment, the target hierarchy and the agreements. (3) Explain the biosocial theory and ask the client to find their own examples of emotional vulnerability (high sensitivity, strong reactions, slow return to baseline) and of invalidation. (4) Explain that DBT treats self-harm and suicidal behaviour as attempts to solve problems, and teaches other ways to solve them [synthesis of listed contents; step detail: uncertain].
Example language (illustrative): "From what you've told me, your emotions come on fast, hit hard and take a long time to settle, and the people around you often told you you were overreacting. That combination makes it very hard to learn how to manage feelings. It isn't a character flaw."
Watch for: the client recognises themselves in the model and feels less shame. If they hear the model as blaming their family, reframe it as a transaction in which no one is the villain.

A2. Life-worth-living goals

Purpose: anchor the treatment in the client's own vision so that targets have a reason [source: Pattie Part 1].
Steps: (1) Ask what others have that the client lacks. (2) Ask what life would look like if the key problems were solved. (3) Turn broad values (e.g. "peace") into specific goals over the first few sessions. (4) Link each target behaviour to how it blocks those goals. (5) Use the spectrum from misery to the life you want: skills, exposure and mindfulness move the client toward the goals, while avoidance, numbing and acting on urges move them toward misery [source: Pattie Part 1; Pattie Part 2 'linking behaviours to goals'].
Example language (illustrative): "Imagine a year from now this therapy worked. What are you doing on an ordinary Tuesday?"
Watch for: goals the client owns, not ones the therapist hopes for. If hopelessness blocks goal setting, validate it as understandable; arguing the client out of it does not work [source: Pattie Part 1].

A3. Treatment agreements

Purpose: make the structure explicit and two-sided.
Steps: go through each agreement, ask for a verbal or written commitment and record it. The client agrees to: attend all modes for the agreed term; work on therapy-interfering behaviour; complete daily diary cards and chain analyses; use coaching to generalise skills and repair relationships; allow team discussion; and use skills and the safety plan rather than self-harm. The client is told the four-missed-sessions rule [source: Mishne]. The therapist's reciprocal commitments come from Linehan 1993, which is not drawn on here [uncertain].
Example language (illustrative): "These agreements protect the work. Which one looks hardest for you?"
Watch for: reservations nobody has voiced. Ask "What would get in the way?" before the client signs.

A4. Commitment strategies (used in pretreatment, and again whenever commitment slips)

[source for all items: Pattie Part 2; Mishne; Vaughn, Psychotherapy Academy]

Pros and cons: list the benefits and costs of the target behaviour, of changing, and of DBT itself, short-term and long-term. Example (illustrative): "What does cutting do for you? And what does it cost you?" Working when the client volunteers costs themselves.
Devil's advocate: argue lightly against committing, e.g. that DBT is hard work, so that the client argues for it. Use it only when some commitment already exists. Example (illustrative): "Honestly, this is a lot of work. Why would you sign up for that?"
Foot in the door: ask for a small commitment first, then extend it (e.g. no self-harm for a month, then longer) [source: Pattie Part 2; Vaughn].
Door in the face: ask for a large commitment, then settle for a smaller one (e.g. a year rather than for life) [source: Pattie Part 2].
Connecting present to prior commitments: remind the client of hard things they have committed to and done before, and of what they said earlier in treatment.
Freedom to choose and absence of alternatives: stress that the choice is the client's, while being clear about what their life looks like without change [source: Pattie Part 2]. Example (illustrative): "It's completely your choice. I'm also not aware of anything else that's worked for you so far."
Cheerleading / generating hope: express confidence that the client can do it and that DBT has helped people with similar problems [source: Pattie Part 2].
Shaping: reinforce small approximations, e.g. simply attending [source: Pattie Part 2].
Watch for: strong commitment talk can be compliance. Test it with troubleshooting ("What will you do when the urge hits on Friday night?"). Expect to re-commit repeatedly [synthesis].

A5. Diary card

Purpose: daily self-monitoring of targets, urges, emotions and skill use. It drives the session agenda [source: UNC; Sprich; Pattie Part 2].
Steps: (1) Build the card with the client, listing their targets (suicidal ideation, self-harm urges and acts, substance use, other quality-of-life behaviours), emotions rated daily, and skills used. Link each item to a goal [source: Pattie Part 2]. (2) Have the client fill it in every day. (3) Review it at the very start of each session. (4) If it was not done, treat that as therapy-interfering behaviour: have the client fill it in from memory in session and analyse what got in the way [last step from standard practice: synthesis].
Example language (illustrative): "Let's look at the card first. I see Thursday the urge to self-harm was a 5 and you used opposite action. Tell me how you did that."
Watch for: blank or retrospective cards; ratings that don't match what the client reports in session. Notice and reinforce the effort that skill use took [source: Pattie Part 2].

A6. Behavioural chain analysis (problem-solving strategy)

Purpose: find what controls a specific instance of a target behaviour. Used for every occurrence of a higher-order target [source: UNC; Sidhu; Sprich; Linehan 2015 TOC ch. 6].
Steps [source: Sidhu, steps paraphrased]: (1) Define the problem behaviour in enough concrete detail to recreate it. (2) Identify the prompting event, even if it seems unrelated. (3) List vulnerability factors (illness, poor sleep or eating, substances, stress, prior emotions). (4) Track moment by moment the thoughts, emotions, body sensations, urges and actions linking prompt to behaviour; slow down at each link. (5) Record the consequences, immediate and delayed, for the client and others, including what may be reinforcing the behaviour [Sprich]. (6) Mark where a different response could have changed the outcome (feeds into A8). (7) Plan prevention to reduce vulnerability. (8) Plan repair of harmful consequences.
Example language (illustrative): "Take me back to just before. Where were you, what had just happened, and what was the very first thing you noticed in your body?"
Watch for: vague links ("I just got upset"); ask for the next thought or sensation. Several chains over time show patterns [source: Sprich]. Analysing the behaviour in detail can itself act as a mild aversive consequence for it, so expect some resistance [synthesis; uncertain].

A7. Missing-links analysis

Purpose: analyse why an expected effective behaviour (homework, skill use) did not happen [source: Linehan 2015 TOC ch. 6 'Analyzing Missing Links'; Pattie Part 2].
Steps: ask in order: did the client know what was expected? Were they willing? Did the idea of doing it occur to them? What got in the way? Then problem-solve the break point. This four-question sequence is my reconstruction of the handout, which is not drawn on [uncertain]. The analysis can be combined with a chain analysis [source: TOC ch. 6].
Example language (illustrative): "Did you know a diary card was due? Were you willing? Did it cross your mind? What stopped you?"
Watch for: the link where things broke; the solution differs for knowledge, willingness, remembering and obstacles.

A8. Solution analysis (problem-solving strategy)

Purpose: generate and commit to alternatives at each weak link of the chain [source: UNC; Sprich].
Steps: (1) Go link by link: which skill could replace this response? (2) Generate several options and evaluate them. (3) Pick one or two the client will use. (4) Troubleshoot what could get in the way. (5) Get a commitment and rehearse it in session (role-play or imagery) [steps 2–5: synthesis consistent with Linehan 1993 ch. 9 title; uncertain].
Example language (illustrative): "At the point where you got the text and felt shame, what could you have done instead? Let's practise it right now."
Watch for: solutions that are too general ("use skills"). Insist on specific skill names and behaviours.

A9. Didactic, insight and orienting strategies (problem-solving)

Purpose: give information (e.g. how emotions or reinforcement work); highlight recurring patterns; tell the client what a procedure involves and why before doing it [Linehan 1993 ch. 9 'Problem solving': uncertain].
Steps: keep explanations short; name a pattern only after several chains show it; orient before every new procedure (chain analysis, exposure, phone coaching).
Example language (illustrative): "I'm noticing the same thing in the last three chains: it starts when you feel left out."
Watch for: lecturing; insight given before the client can see the pattern themselves.

A10. Validation (core acceptance strategy)

Purpose: communicate that the client's emotions, thoughts or actions make sense. This balances change, regulates arousal and reinforces disclosure [source: Sprich; UNC; Behavioral Tech].
Levels (in order) [source: UNC]: (1) being present, i.e. unbiased attention; (2) accurate reflection; (3) reading what is unspoken (cues); (4) validating in terms of history or biology; (5) normalising: validating as reasonable now, for anyone; (6) radical genuineness: treating the client as a capable equal, not fragile. Validation can target emotions, behaviour and cognitions; cheerleading is listed alongside [source: UNC].
Steps: find the kernel of validity in the response, and validate that, not the dysfunctional part. Use the highest level that is accurate. Never validate the invalid (e.g. never call self-harm "the right thing to do").
Example language (illustrative): "Of course you were furious. Anyone who'd been cancelled on three times would be." (level 5)
Watch for: arousal drops and the client keeps talking. If validation turns into agreement with everything, rebalance toward change.

A11. Contingency management and observing limits (change procedure)

Purpose: use the therapist's responses and the treatment structure to reinforce adaptive behaviour and avoid reinforcing targets [source: UNC; Linehan 1993 ch. 10 'Contingency procedures (managing contingencies and observing limits)'].
Steps: (1) Find out what reinforces the target (from chains). (2) Reinforce progress: warmth, attention, more coaching availability. (3) Do not reinforce targets, e.g. keep contact after self-harm brief and matter-of-fact. (4) Use shaping [source: Pattie Part 2]. (5) Use aversive consequences sparingly, always paired with a way back (repair). (6) Observing limits: when a client's behaviour pushes a therapist's personal limits, the therapist says so openly as their own limit and problem-solves it, rather than pretending it is a rule of the treatment [source: Mishne, observing-limits agreement; step detail: uncertain].
Example language (illustrative): "I want to be the kind of therapist who's warm and available for you. When calls come at 3 a.m. after you've already acted, it gets hard for me to stay that way. Let's figure this out."
Watch for: inadvertently reinforcing crises with longer sessions or extra contact. Track whether the target's frequency falls.

A12. Exposure (change procedure) and Stage 2 trauma work

Purpose: reduce avoidance and unjustified emotion by contact with cues, without escape. Informal exposure runs throughout (e.g. chain analysis exposes the client to shame, and in-vivo practice builds confidence) [source: Pattie Part 2; Linehan 1993 ch. 11]. Formal PTSD treatment takes place in Stage 2, e.g. the DBT Prolonged Exposure protocol [source: UW BRTC list, Harned et al. 2012/2014; protocol: uncertain].
Steps (Stage 2 formal exposure, general): (1) Check readiness: recent life-threatening behaviour under control, the client willing, and enough skills to stay in emotion without acting on urges [readiness criteria from the DBT PE literature: uncertain]. (2) Get informed consent; explain that distress will rise temporarily and that the client controls the pace. (3) Agree a plan for urges to self-harm or use substances during the exposure phase. (4) Do the exposure (imaginal or in vivo), blocking escape and avoidance. (5) Process it afterwards and assign homework. (6) Monitor targets weekly. If life-threatening behaviour recurs, pause and return to Stage 1 [synthesis].
Contraindications and safety: recent suicide attempt or self-harm, active psychosis, ongoing contact with the perpetrator or current danger, and severe uncontrolled dissociation all mean delay or modify [synthesis; uncertain].
Example language (illustrative): "Your mind has learned to escape this memory, and the escape keeps the fear alive. We're going to stay with it together, at a pace you agree to."
Watch for: distress peaking and then declining within and across sessions, and less avoidance. Dissociation needs grounding (see section 5).

A13. Cognitive modification (change procedure)

Purpose: change interpretations, assumptions and expectations that drive emotion. In DBT this is done mostly through Check the Facts and contingency clarification, not extended cognitive restructuring [source: Linehan 1993 ch. 11; Linehan 2015 TOC ch. 9 'Check the Facts'; relative emphasis: uncertain].
Steps: identify the interpretation in the chain, check it against the facts, and generate alternatives. Clarify contingencies, i.e. what actually follows the behaviour.
Example language (illustrative): "What are the facts here, and what is the story your mind added?"
Watch for: the client hearing "your thoughts are wrong". Validate the reasons for the interpretation first.

A14. Dialectical strategies

[source for the list: UNC overview; Linehan 1993 ch. 7. Descriptions are my paraphrase of how they are standardly used: uncertain]

Entering the paradox: point out a real contradiction without resolving it, e.g. accepting yourself is necessary for change. Example (illustrative): "You'll need to accept exactly where you are in order to move from here."
Metaphor: use a story or analogy for a hard idea (e.g. skills as climbing gear on a cliff face).
Devil's advocate: argue an extreme version of the client's dysfunctional belief so that they argue the moderate position.
Extending: take the client's statement more seriously than they meant it, e.g. respond to "If you don't change my appointment I'll quit" by seriously exploring termination. This moves the client off the threat. Use only with an alliance in place.
Activating wise mind: ask the client to check with their wise mind (integrating emotion mind and reasonable mind).
Making lemonade out of lemons: find what is useful in a problem, e.g. a crisis as a chance to practise skills, while still validating the pain.
Allowing natural change: do not over-control the therapy's routine; varying it builds tolerance for change.
Dialectical assessment: keep asking what is being left out of the formulation, e.g. the environment, other people, biology.
Watch for: rigid either–or positions loosening; the client offering a "both–and".

A15. Stylistic strategies: reciprocal and irreverent communication

[source: Linehan 1993 ch. 12 'Stylistic strategies: balancing communication'; descriptions are standard paraphrase: uncertain]

Reciprocal: warm, responsive, genuine, with appropriate self-disclosure. Self-disclosure is used to model skills and to be transparent [source: Vaughn]. Example (illustrative): "When you said that, I noticed I felt worried about you."
Irreverent: an unexpected, matter-of-fact or offbeat response that jolts the client out of a rigid pattern; it treats the client as robust. Example (illustrative), after a threat to stop therapy: "Well, that would make it a lot harder to fire me."
When to use: balance the two styles. Use irreverence when the client is stuck or the therapist is being pulled into walking on eggshells; use reciprocity when the client is fragile or ashamed.
Watch for: irreverence that lands as mockery. Repair it immediately and validate.

A16. Suicidal-behaviour strategies (special strategy)

[source: Linehan 1993 ch. 15 'Special treatment strategies', target priority from UNC. The steps follow current standard risk-assessment practice: synthesis]

Purpose: respond to any life-threatening behaviour, ideation or communication as the first priority.
Steps: (1) Assess current risk directly (intent, plan, recent behaviour, access to means, protective factors). (2) Do lethal-means counselling focused on safe storage or removal, involving others if the client agrees. (3) Problem-solve the precipitating crisis using skills, and make a written safety or crisis plan. (4) Agree the next contact. (5) Escalate to emergency services if risk is imminent and the client cannot commit to safety. (6) At the next session, do a full chain analysis of the event. (7) Consult the team. The University of Washington's risk assessment and management protocol exists, but it is not drawn on here [uncertain].
Example language (illustrative): "Before anything else today, I need to understand the urges you rated on Tuesday. Are you thinking about killing yourself right now?"
Watch for: ideation used to avoid the agenda; therapist anxiety leading to over-reaction or under-reaction. Document and consult.

A17. Therapy-interfering behaviour (TIB) strategies

Purpose: treat anything by client or therapist that interferes with treatment (lateness, missed sessions, no diary card, hostility, a therapist being late or avoidant) as a target [source: UNC; Mishne agreement].
Steps: (1) Name the behaviour specifically and without judgement. (2) Do a brief chain analysis of it. (3) Problem-solve it. (4) Get a commitment. For therapist TIB, take it to the team.
Example language (illustrative): "You've been 20 minutes late three weeks running. That cuts our time for what matters to you. Can we look at what happens on Thursday afternoons?"
Watch for: TIB raised as criticism. Keep the tone matter-of-fact.

A18. Phone coaching (generalisation strategy)

Purpose: help the client use skills in the moment, ideally before a crisis peaks; also used to report good news and to repair the relationship [source: Chapman; Mishne].
Steps: (1) Orient the client: what calls are for and when to call (early, before acting). (2) On the call, ask what is happening now. (3) Pick one or two skills (e.g. TIP, STOP, self-soothe) and coach the client to use them right away. (4) Check commitment to the plan. (5) End within about 5–15 minutes [source: Chapman]. (6) Review the call at the next session.
Rules: many programmes add a rule that a client who self-harms waits a set period (often 24 hours) before calling for coaching, so that contact does not reinforce self-harm. Calls for medical or safety needs are always allowed. This rule is not given in the sources. Mishne's programme imposed a timed consequence and a required chain analysis and repair after self-harm without first seeking coaching [uncertain].
Example language (illustrative): "I'm glad you called before acting. On a scale of 0 to 100, where's the urge? Okay, go splash cold water on your face now and call me back in five."
Watch for: calls that turn into therapy sessions; very high or very low use. Fewer than half of clients may use coaching at all [source: Chapman, citing studies].

A19. Crisis strategies, relationship strategies and ancillary-treatment strategies

Crisis strategies (attend to the emotion, problem-solve the immediate crisis, focus on getting through until the next session), relationship strategies (accepting the relationship, problem-solving and repairing it, generalising from it) and ancillary-treatment strategies (medication, hospitalisation) are all covered in Linehan 1993 ch. 15. Its contents are not drawn on; apply them as above using validation, problem solving and consultation-to-the-patient [uncertain].

A20. Structural strategies

Beginning and ending each session (an agreed agenda, review of the diary card), targeting within sessions, ending treatment, and structuring the overall treatment are covered in Linehan 1993 ch. 14 [source: TOC; detail: uncertain]. Ending a session (illustrative): "What's one skill you'll practise this week, and when exactly?"

B. Skills training (the skills taught in group, coached in individual therapy and on the phone)

The list of skills follows Linehan 2015, chapters 6–10 [source: Linehan 2015 TOC]. The handouts are copyrighted, so all descriptions below are my own paraphrase. Where an acronym's expansion is not sourced, it is marked.

Running a skills session (applies to every skill below): (1) Open with a short mindfulness practice. (2) Review homework, with every member reporting their practice. (3) Teach the new skill: rationale, then the steps, then a demonstration and in-session practice. (4) Assign specific homework [source: Sprich]. Group structure and leader roles are covered in Linehan 2015 chs. 2–5, which are not drawn on here. Conventionally a leader teaches while a co-leader tracks the group and handles members who are distressed [uncertain]. Teaching skills uses acquisition (instruction, modelling), strengthening (rehearsal, feedback) and generalisation (homework, coaching) [synthesis consistent with Behavioral Tech's 'new behaviours in all relevant contexts'].

B1. General skills: goals of skills training, orientation, biosocial theory, chain and missing-links analysis

Purpose: orient new members; teach clients to analyse their own behaviour [source: Linehan 2015 TOC ch. 6].
Steps: (1) Set the goals: behaviours to increase and to decrease [source: UNC 'behavioural targets']. (2) Explain the biosocial theory. (3) Teach the client to do their own chain analysis (A6) and missing-links analysis (A7) on worksheets.
Example language (illustrative): "Skills group is a class, not group therapy. We learn, practise and troubleshoot."
Watch for: members expecting process groups. Re-orient them.

B2. Mindfulness: states of mind and Wise Mind

Purpose: the core skill, taught at the start of every module. It distinguishes reasonable mind (logic, facts), emotion mind (mood-driven) and wise mind, the integration of the two that includes intuitive knowing [source: Linehan 2015 TOC ch. 7; Sidhu, 'three states of mind'].
Steps: (1) Describe the three states and ask for examples of each. (2) Practise accessing wise mind, e.g. attending to the breath and asking a question inwardly, then waiting [exercise form: uncertain].
Example language (illustrative): "Emotion mind says quit. Reasonable mind lists pros and cons. What does wise mind say when you're quiet for a moment?"
Watch for: clients who say they have no wise mind. Treat it as a skill that grows with practice.

B3. Mindfulness "what" skills: Observe, Describe, Participate

Purpose: what you do when practising mindfulness [source: TOC ch. 7; Sidhu].
Steps: Observe: notice sensations, thoughts and emotions without adding words or pushing them away. Describe: put words to what was observed, facts only, labelling a thought as a thought. Participate: throw yourself fully into an activity without self-consciousness. Practise each separately, e.g. observing a sound or object, then describing it, then a participation exercise.
Example language (illustrative): "Just notice the sensation in your hands. Now put words to it, sticking to what you can actually observe."
Watch for: describing interpretations ("he hates me") instead of observations ("he didn't reply").

B4. Mindfulness "how" skills: Nonjudgmentally, One-mindfully, Effectively

Purpose: how you practise [source: TOC ch. 7; Sidhu].
Steps: Nonjudgmentally: stick to facts and consequences instead of good or bad labels, and don't judge your judging. One-mindfully: do one thing at a time with full attention. Effectively: do what works toward your goals rather than what is "right" or "fair". Teach by catching judgements in group and rephrasing them.
Example language (illustrative): "Instead of 'I'm pathetic', try 'I stayed in bed till noon and I feel ashamed about it.'"
Watch for: clients judging themselves for judging. Gently describe that too.

B5. Other mindfulness perspectives: spiritual perspective, loving kindness, skillful means, walking the middle path

Purpose: the 2015 edition adds optional skills [source: TOC ch. 7]. These are: mindfulness from a spiritual perspective; loving kindness practice (wishing others and oneself well), used for anger and self-hatred; skillful means, which balances "doing mind" (goal-driven) and "being mind" (experiencing); and walking the middle path, which avoids extremes.
Steps: loving kindness, for example: choose a person (start easy), silently repeat warm wishes toward them, then extend the wishes to oneself and to difficult people [exercise form: synthesis].
Example language (illustrative): "Bring to mind someone easy to care about, and silently wish them well."
Watch for: grief or anger that gets stirred up. Offer an easier target.

B6. Interpersonal effectiveness: factors reducing effectiveness and clarifying goals

Purpose: identify what gets in the way (lack of skill, worry thoughts, emotions, indecision, environment) and set priorities. The three priorities are objective (getting what you want), relationship, and self-respect [source: TOC ch. 8; DEAR MAN/GIVE/FAST mapping per Sidhu].
Steps: before an interaction, the client writes the outcome they want, how they want the other person to feel about them afterwards, and how they want to feel about themselves, then ranks the three.
Example language (illustrative): "What matters most here: getting the refund, keeping the friendship, or respecting yourself?"
Watch for: unclear priorities, which produce mixed messages.

B7. DEAR MAN (objectives effectiveness)

Purpose: ask for something or say no effectively [source: TOC ch. 8; Sidhu for the expansion].
Steps: Describe the facts; Express feelings and opinions ("I feel", not "you make me"); Assert by asking clearly or saying no clearly; Reinforce by saying what's in it for the other person; stay Mindful (the "broken record" technique, ignore attacks); Appear confident; Negotiate by offering alternatives. Write the script, then role-play it in group.
Example language (illustrative), client script: "The rent was due on the 1st and it's the 10th. I'm worried. I need you to pay your share by Friday. Then I can stop chasing you."
Watch for: apologising, or scripts that collapse into accusation.

B8. GIVE (relationship effectiveness)

Purpose: keep or improve the relationship during a request or refusal [source: Sidhu].
Steps: be Gentle (no attacks, threats or judgements); act Interested (listen); Validate the other person's view; use an Easy manner (light, with humour).
Example language (illustrative): "I get that you've been swamped at work."
Watch for: the client giving up their objective to keep the peace.

B9. FAST (self-respect effectiveness)

Purpose: keep self-respect [source: Sidhu].
Steps: be Fair to yourself and the other; no unnecessary Apologies; Stick to values; be Truthful.
Example language (illustrative): "I'm not going to say sorry for asking."
Watch for: lying to get out of situations, and over-apologising.

B10. Evaluating options: how intensely to ask or say no

Purpose: choose a level of intensity that fits the situation [source: TOC ch. 8].
Steps: the client weighs factors such as their own priorities, the other person's capability, timing, rights, authority, the relationship, whether reciprocity is due, and their own preparation. The result sets intensity on a scale from very low to very high. The factor list is reconstructed from standard descriptions of the handout [uncertain].
Example language (illustrative): "Is this a 'hint gently' situation or an 'insist firmly' one?"
Watch for: all-or-nothing intensity.

B11. Troubleshooting interpersonal effectiveness

Purpose: analyse why a skill failed: missing skill, worry thoughts, emotion, indecision or environment [source: TOC ch. 8].
Steps: go through the factors one by one and plan a fix for each. Watch for: blaming the skill itself.
Example language (illustrative): "Did you have the words, or did fear take over first?"

B12. Building relationships and ending destructive ones: finding friends, mindfulness of others, ending relationships

Purpose: 2015 additions for loneliness and for harmful relationships [source: TOC ch. 8].
Steps: Finding friends: find places with frequent contact and similarity, start conversations, join groups. Mindfulness of others: observe and describe others nonjudgmentally, with curiosity. Ending relationships: decide in wise mind, rehearse with DEAR MAN, GIVE and FAST, and prioritise safety in abusive relationships [steps: synthesis from section names; uncertain].
Example language (illustrative): "Where do you see the same people regularly?"
Watch for: safety risks when the client ends a violent relationship. Do safety planning.

B13. Walking the Middle Path: dialectics, validation, behaviour change

Purpose: in Linehan 2015 this is part of interpersonal effectiveness; in adolescent DBT it is a separate module taught to teens and parents together [source: TOC ch. 8; Sprich].
Steps: Dialectics: practise seeing more than one truth, using "and" statements, and finding the middle between extremes. Validation: validate others and oneself, and recover from invalidation. Behaviour change: teach reinforcement, shaping, extinction and punishment (punishment used sparingly) for changing one's own and others' behaviour [source: Sprich].
Example language (illustrative): "You can be angry at your dad and love him too. Both are true."
Watch for: parents using "validation" as a technique without listening.

B14. Understanding and naming emotions

Purpose: learn what emotions do (communicate, motivate, organise action), what makes them hard to regulate, and a model of emotions (prompting event, interpretation, body changes, urges, expression, after-effects) [source: TOC ch. 9; model components: standard description, uncertain].
Steps: walk through the model with a recent episode, then have the client name the emotion from its components.
Example language (illustrative): "Your face was hot, you wanted to hit something, you thought 'he's disrespecting me'. What emotion is that?"
Watch for: "I feel bad" or "upset" as the only labels. Build vocabulary.

B15. Check the Facts

Purpose: test whether an emotion and its intensity fit the facts [source: TOC ch. 9].
Steps: (1) Name the emotion. (2) Identify the prompting event. (3) Separate interpretations and assumptions from facts. (4) Ask whether a threat or catastrophe is actually likely. (5) Ask whether the emotion and its intensity fit the facts. If they do, use problem solving; if they don't, use opposite action.
Example language (illustrative): "What would a camera have recorded? Does fear fit that?"
Watch for: using Check the Facts to invalidate emotions that do fit.

B16. Opposite Action

Purpose: change an emotion that does not fit the facts (or is not effective) by acting opposite to its action urge [source: TOC ch. 9; Sidhu].
Steps: (1) Identify the emotion and its urge (fear: avoid; shame: hide; anger: attack; sadness: withdraw). (2) Check that the emotion does not fit the facts or isn't effective. (3) Do the opposite all the way: body posture, voice, thoughts (e.g. approach what you fear; gently avoid the person you're angry at and do something kind). (4) Repeat until the emotion changes.
Example language (illustrative): "Shame says hide. If it doesn't fit, the opposite is to stand tall and keep doing what you were doing."
Watch for: half-hearted opposite action, e.g. approaching while holding on to judgemental thoughts.

B17. Problem Solving (emotion regulation)

Purpose: change the situation when an emotion does fit the facts [source: TOC ch. 9].
Steps: describe the problem; check the facts; identify the goal; brainstorm; choose a solution that fits the goal; act; evaluate the result.
Example language (illustrative): "Your fear fits: the rent is overdue. So what's the problem to solve?"
Watch for: active passivity, i.e. waiting for others to solve it.

B18. Reducing vulnerability: Accumulating positive emotions (short and long term), Build mastery, Cope ahead

Purpose: reduce vulnerability to emotion mind; known as the "ABC" skills [source: TOC ch. 9; 'ABC' label: standard, uncertain].
Steps: Short term: schedule pleasant events daily and attend to them mindfully, without worrying about when they'll end. Long term: identify values, set goals from them, and take small action steps; avoid avoiding. Build mastery: plan one thing a day that gives a sense of accomplishment, a little harder than easy. Cope ahead: describe a feared situation, choose skills, rehearse them in imagination (including problems arising), then relax.
Example language (illustrative): "Let's rehearse Sunday dinner with your mother in your imagination, including the moment she criticises you."
Watch for: pleasant events spoiled by worry or self-judgement; mastery tasks that are too hard.

B19. PLEASE: taking care of your mind by taking care of your body

Purpose: reduce biological vulnerability [source: TOC ch. 9; Sidhu for the components].
Steps: treat physical illness; balanced eating; avoid mood-altering substances not prescribed; balanced sleep; exercise. Track these on the diary card. No specific dietary or exercise targets are given here: individualise them, and liaise with medical providers for any eating disorder.
Example language (illustrative): "Before we work on the argument, how much did you sleep and eat yesterday?"
Watch for: PLEASE turning into rigid rules or compensatory exercise in clients with eating problems.

B20. Nightmare protocol and Sleep hygiene protocol

Purpose: 2015 additions for sleep problems that feed dysregulation [source: TOC ch. 9].
Steps: Nightmares: write out the nightmare, choose a changed outcome, write the new version, rehearse it with relaxation before sleep (imagery-rehearsal style). Sleep hygiene: regular schedule, a wind-down routine, bed for sleep, getting up if you can't sleep, and less caffeine and screens [steps: standard content: uncertain].
Example language (illustrative): "Rewrite the ending any way you like, then rehearse that version each night."
Watch for: trauma nightmares overwhelming the client. Introduce rescripting gradually, and consider whether Stage 2 work is needed.

B21. Mindfulness of current emotions

Purpose: reduce suffering by experiencing an emotion without blocking it or acting on it ("letting go of emotional suffering") [source: TOC ch. 9; Sidhu].
Steps: observe the emotion as a wave; notice the body sensations; don't push it away or hold on to it; remember you are not your emotion.
Example language (illustrative): "Notice where sadness sits in your body. Let it rise and fall without doing anything."
Watch for: rumination dressed up as mindfulness.

B22. Managing extreme emotions and troubleshooting emotion regulation

Purpose: recognise the skills breakdown point, when emotion is too high to use complex skills, and switch to crisis survival skills; work through failures of emotion regulation step by step [source: TOC ch. 9; term 'skills breakdown point': standard, uncertain].
Steps: at very high arousal, use TIP and other distress tolerance skills, then go back to emotion-regulation skills. For troubleshooting, check biology, skill knowledge, the environment reinforcing the emotion, mood-dependent behaviour, emotional overload, and myths about emotions.
Example language (illustrative): "At a 9 out of 10, your thinking brain is offline. Body skills first."
Watch for: pushing cognitive skills in a crisis.

B23. Distress tolerance: knowing a crisis and STOP

Purpose: survive a crisis without making it worse. STOP is for impulsive moments [source: TOC ch. 10].
Steps: define a crisis (short-term, high stress, needs resolving now). STOP: Stop (freeze); Take a step back; Observe; Proceed mindfully [expansion: standard, not sourced; uncertain].
Example language (illustrative): "Freeze. Take your hands off the keyboard. What's happening? Now, what would wise mind do?"
Watch for: using crisis skills for chronic problems, where problem solving is needed.

B24. Pros and cons (distress tolerance)

Purpose: decide between acting on a crisis urge and resisting it [source: TOC ch. 10; Sidhu].
Steps: a four-cell grid: pros and cons of acting on the urge, and pros and cons of resisting it. Write it before a crisis and carry it.
Example language (illustrative): "Read your card. What did you write as the cons of using?"
Watch for: pros of acting only listed short term. Add the long-term column.

B25. TIP skills for extreme arousal

Purpose: rapidly lower physiological arousal [source: TOC ch. 10].
Steps: Temperature: cold water on the face while holding the breath, to trigger the dive reflex and slow the heart; Intense exercise, brief and matched to the client's physical ability; Paced breathing, slowing the out-breath; Paired muscle relaxation (tense, then release while breathing out). Component names are standard, not sourced [uncertain].
Safety: the cold-water component slows the heart, so clients with heart conditions, low weight or an eating disorder, or on beta-blockers should check with a physician first [standard caution: uncertain]. Intense exercise has no set target; match it to health status.
Example language (illustrative): "Fill a bowl with cold water, lean in and hold your breath for a short count. Then tell me your number."
Watch for: arousal falling within minutes; then move on to other skills.

B26. Distracting with Wise Mind ACCEPTS

Purpose: short-term distraction from crisis urges [source: TOC ch. 10; Sidhu for the expansion].
Steps: Activities; Contributing; Comparisons; opposite Emotions; Pushing away; other Thoughts; intense Sensations. Make a personal list for each letter in advance.
Example language (illustrative): "Pick two from your ACCEPTS list and do them for 15 minutes."
Watch for: distraction becoming avoidance of every emotion. It is meant for crises only.

B27. Self-soothing

Purpose: comfort yourself through the five senses (vision, hearing, smell, taste, touch) [source: TOC ch. 10; Sidhu]. Some versions add body scan meditation [uncertain].
Steps: build a self-soothe kit and use it mindfully.
Example language (illustrative): "What's one smell, one sound and one texture that calm you?"
Watch for: clients who feel they don't deserve soothing. Treat that as a target.

B28. IMPROVE the moment

Purpose: replace negative events with positive ones in a crisis [source: TOC ch. 10; Sidhu].
Steps: Imagery; Meaning; Prayer; Relaxing actions; One thing in the moment; Vacation (a brief, planned break); Encouragement (self-cheerleading) [expansion: standard; uncertain].
Example language (illustrative): "Imagine a safe place in detail. What do you see?"
Watch for: "vacation" turning into whole days of avoidance.

B29. Reality acceptance: Radical Acceptance, Turning the Mind, Willingness

Purpose: reduce suffering over facts that can't be changed [source: TOC ch. 10; Sidhu].
Steps: Radical acceptance: completely accept, with mind, body and spirit, the facts as they are, without approving them. Turning the mind: notice non-acceptance and choose acceptance again, repeatedly. Willingness: do what is needed, as opposed to willfulness (refusing, sitting on hands). Practise with small and then larger facts.
Example language (illustrative): "Accepting that it happened isn't saying it was okay. It's stopping the fight with what already is."
Watch for: acceptance mistaken for resignation or approval of abuse. Pair it with change where change is possible.

B30. Half-smiling and Willing hands

Purpose: use the body to support acceptance [source: TOC ch. 10; Sidhu].
Steps: relax the face with a slight upturn of the lips; hands open and palms up, resting on the thighs. Use them while thinking of a resented person or fact.
Example language (illustrative): "Unclench your hands, palms up, and let your face soften."
Watch for: a forced grin, which defeats the purpose.

B31. Allowing the mind: mindfulness of current thoughts

Purpose: let thoughts come and go without suppressing them or believing them literally [source: TOC ch. 10].
Steps: observe thoughts as sensations of the mind and label them ("a thought arose that..."); don't analyse or block them.
Example language (illustrative): "Notice: 'I'm having the thought that I'll fail.'"
Watch for: fusion with suicidal thoughts. Assess risk in parallel.

B32. When the crisis is addiction: Dialectical abstinence, Clear mind, Community reinforcement, Burning bridges and building new ones, Alternate rebellion, Adaptive denial

Purpose: 2015 additions for substance use and other addictive behaviours [source: TOC ch. 10].
Steps: Dialectical abstinence: commit fully to abstinence, and if a lapse happens, respond with harm reduction and an immediate return to abstinence. Clear mind: aim between "addict mind" and "clean mind" (the complacent belief that the risk has passed). Community reinforcement: replace substance-related reinforcers with abstinence-supporting ones. Burning bridges: actively cut off access to the addictive behaviour (e.g. delete dealer contacts) and build new imagery and connections. Alternate rebellion: rebel in harmless ways. Adaptive denial: reframe a craving as a craving for something else, or for the substance just not right now [content from standard descriptions: uncertain].
Example language (illustrative): "Let's commit to not using, starting today. If you slip, call, and we'll get you back on track that same day."
Watch for: lapses kept secret out of shame. Make it explicit that you expect and welcome hearing about them.

C. Case management and team strategies

C1. Consultation-to-the-patient

Purpose: teach the client to deal with their own network (other providers, family, agencies) rather than the therapist intervening for them. This builds capability and cuts down on "splitting" [source: Mishne, team agreement; Behavioral Tech, 'teach clients to be their own case manager'; Linehan 1993 ch. 13].
Steps: (1) When the client wants the therapist to contact someone, ask what outcome they want. (2) Coach them in how to get it themselves, with DEAR MAN and a role-play. (3) Debrief afterwards. Team members do not speak for one another to the client [synthesis].
Example language (illustrative): "Rather than me calling your psychiatrist, let's plan exactly what you'll say to her, and practise it now."
Watch for: the client reporting success in dealing with providers directly.

C2. Environmental intervention

Purpose: intervene directly in the client's environment only when the outcome really matters and the client can't achieve it themselves, e.g. imminent risk to life, or a powerful institution that won't respond to the client [source: Behavioral Tech, 'only when absolutely necessary'; criteria detail from Linehan 1993 ch. 13: uncertain].
Steps: check the criteria, tell the client what you're doing, do it with the client present where possible, and then go back to consultation-to-the-patient.
Example language (illustrative): "This is one of the rare times I'll call the hospital directly, and I'd like you on the call with me."
Watch for: a creeping slide into routine intervention.

C3. Therapist consultation team

Purpose: treat the therapists. The team monitors fidelity, builds skill, and sustains motivation for working with high-risk clients [source: Behavioral Tech].
Steps: (1) Meet weekly for about 1.5–2 hours [source: Sidhu]. (2) Open with mindfulness and read an agreement [read-out practice: uncertain]. (3) Set an agenda by priority: therapists with clients at high risk, then therapist therapy-interfering behaviour, then other cases [ordering: synthesis]. (4) Use DBT strategies with each other: validation, chain analysis of a therapist's behaviour, and nonjudgmental, phenomenologically empathic interpretations of clients. (5) Keep to the agreements (section 3).
Example language (illustrative): "I'm noticing I've been dreading Tuesday's session and shortening it. I'd like help with my TIB."
Watch for: pejorative talk about clients, a team that has stopped asking for help, or drift toward case-review only.
Fidelity and training: Behavioral Tech offers intensive team training, and certification is linked to Linehan. One programme used two 5-day intensives with implementation in between [source: Mishne; certification body detail: uncertain].

5. Handling problems

For each problem, the tags show what is sourced and what is my own synthesis.

Low or wavering commitment

Go back to the commitment strategies (A4). Use pros and cons, devil's advocate, and freedom to choose with absence of alternatives [source: Pattie Part 2]. Link the target to the client's life-worth-living goals [source: Pattie Part 1].
If the client won't commit to reducing suicidal behaviour, stay in pretreatment rather than starting Stage 1 by default, and look for a smaller foot-in-the-door commitment [synthesis].

Stuck clients: no change after several weeks

Repeat chain analyses to find the controlling variables; several chains reveal patterns [source: Sprich].
Use dialectical assessment: ask what is missing, such as an environmental reinforcer, a medical issue, or a substance [source: UNC list; application: synthesis].
Check whether the problem is a skill deficit (teach), emotional inhibition (exposure), contingencies (contingency management) or cognitions (cognitive modification), and switch procedures to match [synthesis based on the four change procedures, source: UNC].
Remember that the client cannot fail. Take the case to the team and revise the treatment [source: UNC; Mishne].

Resistance, hostility, or a polarised "you're wrong" stance

Validate the valid part, then use irreverence, extending or devil's advocate to get out of a power struggle [source: strategy list, UNC; application: synthesis].
Avoid "but"; use "and" [source: Vaughn; Sprich].

Overwhelm, high arousal or dissociation in session

Move to body-based crisis skills: TIP, paced breathing, holding cold, naming five things you see. Once arousal is lower, resume the chain [source for the breakdown-point logic: Linehan 2015 TOC ch. 9; specific grounding steps: synthesis].
In exposure, lower the intensity rather than stopping completely, and get agreement on how to proceed [synthesis].
If dissociation recurs, add it as a target and do a chain analysis of it [synthesis].

Non-adherence: diary card or homework not done

Treat it as therapy-interfering behaviour. Have the client complete the card in session, then do a missing-links analysis [source: Linehan 2015 TOC ch. 6; Pattie Part 2]. Acknowledge that homework is hard, and frame practice as the route to competence [source: Pattie Part 2].
Shape: begin with filling in one row a day, and reinforce every partial completion [synthesis].

Missed sessions and dropout

Make the four-consecutive-misses rule clear in pretreatment. Phone the client after a first miss to problem-solve [source for rule: Mishne; outreach: synthesis].
When a client has dropped out, return is negotiated, not automatic [source: Mishne].

Ruptures in the therapeutic relationship

The client may use phone coaching to repair a rupture before the next session [source: Chapman; Mishne]. At the session, name the rupture, do a chain analysis of both parties' behaviour, repair, and own any therapist error. The fallibility agreement applies [source: Mishne for fallibility; procedure: synthesis].
When the therapist's limits are being crossed, observe your limits openly as your own, not as rules of the treatment [source: Mishne; wording: synthesis].

Crisis-driven sessions: the "crisis of the week"

Hold to the target hierarchy. Briefly attend to the crisis, then link it to a target and the skills for it [source: UNC; application: synthesis].
Reduce how much crises are reinforced: don't give longer sessions only during crises [synthesis based on contingency management].

Phone coaching problems

Overuse: orient the client again to what coaching is for and keep calls short, at 5–15 minutes [source: Chapman]. Observe your limits and problem-solve together; a small group of clients makes most of the calls [source: Chapman, citing Oliveira & Rizvi 2018].
Underuse: do a chain analysis of what stops the client calling (shame, fear of being a burden), and schedule practice calls [synthesis].
Calls after self-harm: follow your programme's stated rule. Medical safety always comes first [source for such a rule: Mishne; the 24-hour rule is not sourced: uncertain].

Group-specific problems

A member in acute crisis in group: the co-leader steps out with them briefly and coaches crisis skills; the leader continues teaching [synthesis; uncertain].
Describing self-harm in detail in group: redirect to the individual therapist, and keep the group focused on skills. Many programmes have a guideline about not discussing self-harm with other members, which is not drawn on from Linehan's group guidelines [uncertain].
Members not doing homework: shape with partial credit, and use missing-links analysis [synthesis].

Therapist burnout, fear or judgemental attitudes

Bring them to the team as therapist TIB. Use phenomenological empathy to re-interpret client behaviour, and use validation and support for the therapist [source: Behavioral Tech; Mishne team agreements].

Hospitalisation and other providers

Use consultation-to-the-patient; intervene directly only when the criteria for environmental intervention are met [source: Mishne; Behavioral Tech; criteria detail: uncertain].
Avoid making hospitalisation a reinforcer for suicidal behaviour: plan admission criteria with the client in advance, and orient them to skills use on the ward [synthesis; uncertain].

Partial or adapted DBT

Running skills groups alone, without the other modes, is not comprehensive DBT. The slides note that no component has been shown to work on its own [source: Sidhu; Behavioral Tech, 'briefer versions' for particular populations]. If you deliver a standalone skills group, screen out clients at high suicide risk or make sure they have individual risk management elsewhere [synthesis].
School-based skills programmes: one school-based skills adaptation has been recorded with null or possibly harmful effects. That study is not drawn on [uncertain]. If you adapt DBT skills for a universal or school setting, monitor outcomes, watch for increased distress, and keep referral routes for students at risk [synthesis].
Adolescents: include parents through multifamily group, parent coaching and family sessions, and teach Walking the Middle Path. Use the adolescent dialectical dilemmas to guide parenting work [source: Sprich].

Cultural fit and invalidation from outside therapy

Validate experiences of racism and marginalisation as real invalidating environments, not distortions. One programme formalised this as a team agreement on functional validation and anti-racism [source: Mishne; generalisation: synthesis].

Sources

Sources:

Further reading (not drawn on):

Linehan, M. M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. Guilford Press.
Linehan, M. M. (1993). Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press.
Linehan, M. M. (2015). DBT Skills Training Manual (2nd ed.) and DBT Skills Training Handouts and Worksheets (2nd ed.). Guilford Press. A revised edition of the manual was published in 2025.
Harned, M. S., Korslund, K. E., Foa, E. B., & Linehan, M. M. (2012). Treating PTSD in suicidal and self-injuring women with BPD: development and preliminary evaluation of a DBT Prolonged Exposure protocol. Behaviour Research and Therapy, 50(6), 381–386.
Miller, A. L., Rathus, J. H., & Linehan, M. M. (2007). Dialectical Behavior Therapy with Suicidal Adolescents. Guilford Press.
Rathus, J. H., & Miller, A. L. (2015). DBT Skills Manual for Adolescents. Guilford Press.

A Guilford sample chapter (preface and ch. 2 of the revised manual) was found but returned no readable text. Step-level details attributed to the full manuals are marked [uncertain] above.

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