DBT for BPD worksheets

Dialectical behavior therapy (DBT) is an evidence-based treatment for borderline personality disorder (BPD). This article provides an overview of DBT and example DBT exercises for BPD to suggest to clients.

We’ve included free downloadable DBT for BPD worksheets to save to your electronic health record (EHR) and use in your practice.

What is DBT?

DBT is a psychotherapy for mental health conditions that feature emotional dysregulation. A 2016 review of DBT and schema therapy describes it as effective especially for borderline personality disorder, and Harvard Health notes it is also used for depression, post-traumatic stress disorder, eating disorders, and substance use disorders.

Common symptoms of borderline personality disorder, according to the National Institute of Mental Health, include:

• Unstable sense of self

• Fear of abandonment

• Emotional lability

• Chaotic relationships

• Harmful and impulsive behaviors, like self-injury, binge eating, and alcohol or drug misuse

DBT aims to reduce high-risk behaviors, help clients experience their emotions, improve functioning, and strengthen their sense of self, which can ease feelings of loneliness or emptiness.

DBT is delivered in individual therapy and group skills training. Additionally, telephone coaching may be offered to clients outside of sessions in times of distress or crisis.

The core components of DBT include:

1. Mindfulness: Enhances the ability to be present to emotions, bodily sensations, and one’s environment, which helps foster mindful decision-making and observing emotions with curiosity.

2. Emotion regulation: Provides psychoeducation about emotions and problem-solving to help individuals gain perspective, create more adaptive behaviors, and reduce their emotional vulnerability.

3. Interpersonal effectiveness: Teaches assertive communication strategies and conflict resolution skills.

4. Distress tolerance: Teaches how to survive crises through acceptance, self-soothing, and adaptive distraction.

Dialectical behavior therapy is one of the most studied treatments for BPD, according to a 2020 review. Yale Medicine notes that research has shown improvements in people who undergo DBT, including reduced self-harm behaviors and lower hospitalization rates, though results vary by individual. While it is not a cure for BPD, one 2014 German outpatient study showed that 77% of the 47 patients who completed a year of DBT treatment no longer met criteria for a BPD diagnosis.  

List of DBT exercises for BPD

DBT exercises for BPD teach clients how to change behavioral, emotional, and thinking patterns.

Some of these skills include:  

Interpersonal effectiveness exercises

Interpersonal effectiveness exercises include:

DEAR MAN

This activity helps to clarify your objectives in a conversation through assertively communicating a desire and being willing to negotiate a fair outcome confidently. The acronym stands for:

• Describe: Objectively describe the situation by sticking to the facts and avoiding subjective information.

• Express: Assert your feelings and emotions about the situation clearly, without assuming the other person knows how you feel.

• Assert: Use assertive language, like “I statements” to describe your requests or refusal, as clearly and directly as possible, while respecting the other person.

• Reinforce: Ensure you communicate the positive effects of agreeing to your request.

• Mindful: Be mindful of your tone of voice, posture, and body language while staying focused on your goal for the conversation. Try to avoid overreacting to others if they become unreasonable by threatening, distracting, avoiding, or being defensive.

• Appear: Maintain an appearance of confidence, assertiveness, and competence by retaining the same neutral tone of voice, eye contact, and assertive posture. Avoid looking away, retreating, crossing your arms, stammering, or silencing yourself.

• Negotiate: Stay open to communication about your request, or negotiation, and be willing to compromise (unless it is something you feel uncomfortable compromising on, like a value or personal boundary).

GIVE

This tool helps to enhance relationship effectiveness through teaching active listening, respect for others' points of view, and fostering healthy interactions. The acronym stands for:

• Gentle: This means being respectful, communicating effectively, and avoiding attacks, threats, and judgments. This doesn’t mean being passive. Instead, the goal is to use your communication skills to assert your feelings and needs, or explain how you have felt hurt. It can be helpful to use “I statements” here instead of blaming, threatening, or judging others, even if they have harmed you.

• Interested: By practicing active listening, you’re showing the other person that you’re interested in what they are saying and their perspective. You can practice this by avoiding interrupting, maintaining eye contact, and waiting your turn to speak.

• Validate: When you acknowledge another person’s point of view, even if you disagree with it, they can feel validated because you have heard what they have to say. You could simply say, “I hear that you said X, and that it led you to feel Y.”

• Easy manner: Show kind regard, which could mean smiling, being lighthearted, or using humor.

Check out our DBT interpersonal effectiveness worksheet for more DBT skills, or download our DBT for BPD worksheets to practice them.

Distress tolerance activities

Distress tolerance skills include:

• Self-soothing: This exercise involves using your resources to provide calm and comforting stress relief.

• ACCEPTS skill: The ACCEPTS tool is one of several practical techniques used to manage stress and difficult emotions. It helps to accept present conditions as they are. ACCEPTS stands for: activities, contributing, comparisons, emotions, pushing away, thoughts, and sensations.

• TIP: A tool to help calm an overwhelmed body by using temperature, exercise, breathing, and muscle relaxation techniques. TIP stands for: temperature, intense exercise, paced breathing, and paired muscle relaxation.

• STOP: This tool is an acronym for:

  • Stop: When feeling intense emotions, the idea is to pause to prevent reactions.

  • Take a step back: To take a moment to breathe and figure out the situation.

  • Observe: Once calm, there is an opportunity to observe thoughts, check facts, and ensure you don’t jump to conclusions or overreact to the situation.

  • Proceed mindfully: Consider possible outcomes from a place of calm and mindfulness.

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Emotion regulation skills

Emotion regulation skills and activities include:

• Opposite Action: This skill encourages you to choose the opposite of an emotion’s action urge when acting on it wouldn’t be effective. For example, if feeling sad, the opposite action would be to move your body and socialize. When feeling anger, the opposite action is to consider the situation from another perspective and find ways to respond with empathy.

• PLEASE: This tool emphasizes healthy habits to improve emotion regulation. The acronym stands for:

  • PL: Treat physical illness

  • E: Eat in a balanced way

  • A: Avoid mood-altering substances

  • S: Get enough sleep

  • E: Exercise

Mindfulness skills

DBT mindfulness skills include:

• Wise Mind: This technique helps individuals make informed decisions by balancing rational thoughts and emotions. In DBT, there are three states of mind:

  • Emotional mind: Allowing emotions to control behavior and decision-making.

  • Reasonable mind: The logical mind considers facts but discounts emotions when making decisions.

  • Wise mind: Balances emotions with reasoned thinking and intuition to reach an informed, healthy decision.

• “What” skill: This skill involves:

  • Observe: Notice thoughts, events, and bodily sensations.

  • Describe: Use nonjudgmental language to describe internal or external experiences. For example, instead of saying, “I am sad,” you might say, “I notice sadness” or “a heavy feeling in my chest.”

  • Participate: Engage fully in the present moment and go with the flow, letting go of self-consciousness.

• “How” tool: Using mindfulness to observe facts, be present with one thing at a time, and take meaningful action. The steps of this technique involve:

  • Nonjudgmentally: Observe and describe experiences without value labels to collect the facts.

  • One-mindfully: Give your full attention to the present moment, putting aside worries about the future and instead engaging in the activity before you. For instance, instead of worrying about your to-do list, you might spend time mindfully having breakfast with your family, noticing the texture and flavor of the food, and feeling a connection with family members.

  • Effectively: Do what works in the present moment to achieve the outcome you want, instead of focusing on “what’s right” or rigid or preconceived ideas.

How can therapists use the DBT therapy worksheets?

You can download and use the DBT for BPD worksheets in several ways:

• Use the BPD DBT worksheets to provide psychoeducation about core DBT skills.

• Complete the DBT exercises for BPD collaboratively in session and give the client a copy of the worksheet to take home.

• Ask the client to reflect on the worksheet and complete the exercises between sessions and report their findings at their next therapy appointment.

• Use the BPD therapy worksheets in group therapy sessions to encourage clients to share more about themselves with other participants.

• Combine these DBT for BPD worksheets with other DBT-related worksheets, including assertive communication worksheets and assertive communication examples.

• Share the worksheet with coworkers or leave copies in your office.

• Use this worksheet to provide training to interns or supervisees on borderline personality disorder or dialectical behavior therapy.

Sources

• Corliss, J. (2024). Dialectical behavior therapy: What is it and who can it help? Harvard Health Publishing.

• Fassbinder, E., Schweiger, U., Martius, D., Brand-de Wilde, O., & Arntz, A. (2016). Emotion regulation in schema therapy and dialectical behavior therapy. Frontiers in Psychology.

• May, J. M., Richardi, T. M., & Barth, K. S. (2016). Dialectical behavior therapy as treatment for borderline personality disorder. The Mental Health Clinician.

• National Institute of Mental Health. (n.d.). Borderline personality disorder.

• Stiglmayr, C., Stecher-Mohr, J., Wagner, T., Meißner, J., Spretz, D., et al. (2014). Effectiveness of dialectic behavioral therapy in routine outpatient care: The Berlin Borderline Study. Borderline Personality Disorder and Emotion Dysregulation.

• Yale Medicine. (n.d.). Dialectical behavior therapy (DBT).

• Zeyrek Rios, E. Y. (2020). Dialectical behavior therapy in the treatment of borderline personality disorder. Journal of Cognitive Behavioral Psychotherapy and Research.

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