# DBT skills

> An introduction to DBT skills, from mindfulness to emotion regulation, and how clinical psychologist Jess Chadakorn uses them in Rosanna and Warrandyte.

Source: https://jess.ac/approaches/dbt-skills/

Dialectical behaviour therapy (DBT) was first developed for people experiencing intense emotions that were hard to manage. Its skills are now used much more widely, by teenagers and adults with many different experiences. DBT asks you to hold two ideas at once, accepting yourself as you are while also working towards change.

## Where DBT comes from

Marsha Linehan, a psychologist at the University of Washington, developed DBT over the late 1970s and 1980s while working with people in severe emotional pain, many of whom had a diagnosis of borderline personality disorder. The cognitive behaviour therapy of the time focused mainly on change, which some of her clients experienced as criticism, so Linehan added acceptance, drawing partly on her study of Zen meditation.

Linehan published the treatment manual in 1993, with a separate skills training manual that she revised in 2015. DBT has since been studied with many groups, including people experiencing depression, eating difficulties or substance use. The strongest evidence is for the full program, particularly for people with a diagnosis of borderline personality disorder, and research on the skills taught on their own is more limited but growing.

## Acceptance and change together

The word dialectical comes from philosophy, where it refers to seemingly opposed ideas that can both hold some truth and, brought together, produce something new. In DBT the central pair is acceptance and change, often expressed by using “and” in place of “but”, as in “I am doing what I can, and I want some things to change.” The therapist looks for what makes sense in how you feel and react, which DBT calls validation, while you work together on new ways of handling the hardest moments.

## The four skill areas

DBT skills are grouped into four modules. Mindfulness is central, because the other skills depend on noticing what is happening in the moment. Mindfulness and distress tolerance lean towards acceptance, while emotion regulation and interpersonal effectiveness lean towards change. Some skills are for calmer periods, such as noticing patterns in your mood. Others are for getting through a crisis without making it worse. DEAR MAN, from interpersonal effectiveness, is an acronym for a structured way to ask for something or say no (describe, express, assert, reinforce, stay mindful, appear confident, negotiate).

## DBT skills in individual therapy

Outside a full DBT program, skills are usually taught one or two at a time within individual therapy. A session might start with a chain analysis, which slows a recent difficult moment down step by step to identify what came first, such as a passing thought or a change in your body. You and your psychologist then choose a skill that could help next time and rehearse it together. Practice between sessions, often tracked on a diary card (a weekly chart of emotions, urges and skills used), helps the skills become more familiar.

## DBT skills for teenagers

In the mid-1990s, psychologists Alec Miller and Jill Rathus began adapting DBT for adolescents in New York, later writing about the approach with Marsha Linehan. Their version uses a smaller set of skills and invites parents or carers to learn them too. It adds a fifth module, Walking the Middle Path, which helps teenagers and parents find middle ground on issues such as independence and house rules, and teaches validation within the family. Several randomised trials, mostly of the full program, have found encouraging results with teenagers, although more research is needed.

## Key ideas

- **Mindfulness.** Noticing what is happening inside and around you, right now, without judging it. DBT also describes wise mind, the overlap of emotion mind and reasonable mind, where feelings and facts both count.
- **Distress tolerance.** Skills for getting through painful moments that cannot be fixed straight away. They include paced breathing, self-soothing through the senses and radical acceptance (acknowledging what cannot change right now, without approving of it).
- **Emotion regulation.** Understanding what prompts an emotion and what it urges you to do. Skills include looking after sleep and eating, and opposite action (acting against the urge when the emotion does not fit the facts).
- **Interpersonal effectiveness.** Skills for asking for what you need or saying no, with both the relationship and your self-respect in mind. GIVE focuses on keeping the relationship, and FAST on staying true to your values.

## The STOP skill

STOP is a distress tolerance skill that puts a pause between a strong feeling and your response, giving your thinking time to catch up.

1. Practise first in calmer moments, with a minor annoyance such as a slow queue, so the skill is familiar under pressure.
2. S stands for stop. When you notice a strong urge to react, pause before you say or do anything.
3. T stands for take a step back. Breathe out slowly and, if you can, step away from the situation for a minute.
4. O stands for observe. Notice your thoughts and feelings, and what is happening around you, keeping to the facts.
5. P stands for proceed mindfully. Consider what you want from the situation, then choose a response that fits.
6. Afterwards, review how it went without criticising yourself.

_This exercise is general information and cannot replace individual care; in a crisis, call Lifeline on 13 11 14 or Kids Helpline on 1800 55 1800, or 000 in an emergency._

## How Jess uses DBT skills

Jess chooses which skills to teach according to her assessment and your goals. A teenager whose emotions escalate quickly at home might start with STOP, while an adult who finds it hard to say no at work might focus on DEAR MAN. For neurodivergent clients, she can adapt skills with visual reminders or a simpler diary card.

Often used for: Intense or fast-changing emotions; Getting through overwhelming moments; Strain and conflict in relationships; Low mood and depression; Trauma-related distress; Strong emotions that can come with ADHD.

## Questions

### Is using DBT skills the same as doing a full DBT program?

A full DBT program usually combines weekly individual therapy, a weekly skills group, phone coaching between sessions and a consultation team for the therapists, often over six months to a year. Jess teaches DBT skills within individual therapy, without the group or phone coaching, and can discuss whether a full program would suit you better.

### Do I need a diagnosis to learn DBT skills?

No. DBT was first developed with people who had a diagnosis of borderline personality disorder, and its skills are now used widely by people with and without a diagnosis.

### Does DBT try to get rid of strong emotions?

No. DBT regards emotions, including painful ones, as useful information. The skills aim to help you notice emotions earlier and understand what they are communicating, leaving more room to choose how to respond when they run high.

## Further reading

- [Dialectical behaviour therapy (DBT)](https://www.healthdirect.gov.au/dialectical-behaviour-therapy-dbt) (healthdirect)
- [Dialectical behaviour therapy (DBT)](https://www.sane.org/information-and-resources/facts-and-guides/dialectical-behaviour-therapy-dbt) (SANE Australia)
- [About DBT, from the university where it was developed](https://depts.washington.edu/uwbrtc/about-us/dialectical-behavior-therapy/) (University of Washington)