behavioral therapy homework

• Last edited on September 9, 2020

Homework in CBT

Table of contents, why do homework in cbt, how to deliver homework, strategies to increase confidence.

Homework assignments in Cognitive Behavioural Therapy (CBT) can help your patients educate themselves further, collect thoughts, and modify their thinking.

Homework is not something that you just assign randomly. You should make sure you:

• tailor the homework to the patient
• provide a rationale for why the patient needs to do the homework
• uncover any obstacles that might prevent homework from being done (i.e. - busy work schedule, significant neurovegetative symptoms)

Types of homework

Types of homework assignments.

You should also decide the frequency of the homework should be assigned: should it be daily, weekly?

If your patient does not do homework, that’s OK! Explore as a team, in a non-judgmental way, to explore why the homework was not done. Here are some ways to increase adherence to homework:

• Tailor the assignments to the individual
• Provide a rationale for how and why the assignment might help
• Determine the homework collaboratively
• Try to start the homework during the session. This creates some momentum to continue doing the homework
• Set up systems to remember to do the assignments (phone reminders, sticky notes
• It is better to start with easier homework assignments and err on the side of caution
• They should be 90-100% confident they will be able to do this assignment
• Covert rehearsal - running through a thought experiment on a situation
• Change the assignment - It is far better to substitute an easier homework assignment that patients are likely to do than to have them establish a habit of not doing what they had agreed to in session
• Intellectual/emotional role play - “I’ll be the intellectual part of you; you be the emotional part. You argue as hard as you can against me so I can see all the arguments you’re using not to read your coping cards and start studying. You start.”

A Comprehensive Model of Homework in Cognitive Behavior Therapy

• Original Article
• Published: 03 July 2021
• Volume 46 , pages 247–257, ( 2022 )

Cite this article

• Nikolaos Kazantzis   ORCID: orcid.org/0000-0001-9559-4160 1 , 2 &
• Allen R. Miller 2  

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This article contributes a comprehensive model of homework in cognitive behavior therapy (CBT). To this end, several issues in the definition of homework and homework compliance are outlined, research on homework-outcome relations is critiqued, before an overview of classical and operant conditioning along with various cognitive theories are tied together in a c omprehensive model. We suggest engagement represents a more clinically meaningful construct than compliance (or adherence). We describe how established behavior and cognitive theories are relevant for understanding patient engagement and what between-session and in-session processes are useful in a comprehensive model. Our primary conclusion from the review of this literature is that current research has focused on limited aspects of homework and missed theoretically meaningful determinants of engagement. Further, little research has sought to examine the role of the therapist in facilitating these theoretically meaningful determinants. The literature on homework is the most advanced of the process research in CBT; the comprehensive model presented here offers clarity for the practicing clinician and represents a testable model for researchers interested in quantifying determinants of homework engagement and the process of integrating homework into CBT.

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Acknowledgements

The authors thank Aaron T. Beck and Judith S. Beck for helpful discussions and guidance on the topic of integrating homework into CBT.

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Further to the signed Conflict-of-Interest Disclosure Forms submitted by the authors Nikolaos Kazantzis, Allen R. Miller on this manuscript, the senior author Nikolaos Kazantzis reported being the Australian delegate for the International Association of Cognitive Therapy, which has a strategic partnership with the Academy of Cognitive Therapy; being a consultant to the Australian Psychological Society Institute; serving on the advisory board, being a member of the faculty, and fees from the Beck Institute for Cognitive Behavior Therapy and Research; receiving compensation from Springer Nature; receiving royalties from Springer Nature, Guilford, and Routledge.

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Kazantzis, N., Miller, A.R. A Comprehensive Model of Homework in Cognitive Behavior Therapy. Cogn Ther Res 46 , 247–257 (2022). https://doi.org/10.1007/s10608-021-10247-z

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Supporting Homework Compliance in Cognitive Behavioural Therapy: Essential Features of Mobile Apps

1 Discipline of Psychiatry, Department of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada

David Kreindler

2 Division of Youth Psychiatry, Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

3 Centre for Mobile Computing in Mental Health, Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

4 Department of Psychiatry, University of Toronto, Toronto, ON, Canada

Cognitive behavioral therapy (CBT) is one of the most effective psychotherapy modalities used to treat depression and anxiety disorders. Homework is an integral component of CBT, but homework compliance in CBT remains problematic in real-life practice. The popularization of the mobile phone with app capabilities (smartphone) presents a unique opportunity to enhance CBT homework compliance; however, there are no guidelines for designing mobile phone apps created for this purpose. Existing literature suggests 6 essential features of an optimal mobile app for maximizing CBT homework compliance: (1) therapy congruency, (2) fostering learning, (3) guiding therapy, (4) connection building, (5) emphasis on completion, and (6) population specificity. We expect that a well-designed mobile app incorporating these features should result in improved homework compliance and better outcomes for its users.

Homework Non-Compliance in CBT

Cognitive behavioral therapy (CBT) is an evidence-based psychotherapy that has gained significant acceptance and influence in the treatment of depressive and anxiety disorders and is recommended as a first-line treatment for both of these [ 1 , 2 ]. It has also been shown to be as effective as medications in the treatment of a number of psychiatric illnesses [ 3 - 6 ]. Homework is an important component of CBT; in the context of CBT, homework can be defined as “specific, structured, therapeutic activities that are routinely discussed in session, to be completed between sessions” [ 7 ]. Completion of homework assignments was emphasized in the conception of CBT by its creator, Aaron Beck [ 8 ]. Many types of homework are prescribed by CBT practitioners, including symptom logs, self-reflective journals, and specific structured activities like exposure and response prevention for obsessions and compulsions. These can be divided into the following 3 main categories: (1) psychoeducational homework, (2) self-assessment homework, and (3) modality-specific homework. Psychoeducation is an important component in the early stage of therapy. Reading materials are usually provided to educate the client on the symptomatology of the diagnosed illness, its etiology, as well as other treatment-relevant information. Self-assessment strategies, including monitoring one’s mood using thought records, teach the patients to recognize the interconnection between one’s feelings, thoughts, and behaviors [ 8 ]. For example, depressed patients may be asked to identify thinking errors in daily life and document the negative influences these maladaptive thinking patterns can produce on their behaviors. Various psychiatric disorders may require different types of modality-specific homework. For example, exposure to images of spiders is a treatment method specific to arachnophobia, an example of a “specific phobia” in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) [ 9 ]. Homework is strategically created by the therapist to correct and lessen the patient’s psychopathology. The purpose of these exercises is to allow the patients to practice and reinforce the skills learned in therapy sessions in real life.

Homework non-compliance is one of the top cited reasons for therapy failure in CBT [ 10 ] and has remained a persistent problem in the clinical practice. Surveys of practitioners have suggested rates of non-adherence in adult clients of approximately 20% to 50% [ 10 , 11 ] while adherence rates in adolescents have been reported to be approximately 50% [ 12 ]. Many barriers to homework compliance have been identified in the literature; to facilitate discussions, they can be divided into internal and external factors. Internal factors originate from a client’s own psychological environment while external ones are created by external influences. Internal factors that have been identified include lack of motivation to change the situation when experiencing negative feelings, the inability to identify automatic thoughts, disregard for the importance or relevance of the homework, and the need to see immediate results [ 12 - 14 ]. Various external factors have also been identified, including the effort associated with pen-and-paper homework formats, the inconvenience of completing homework because of the amount of time consumed, not understanding of the purpose of the homework, lack of instruction, and failure to anticipate potential difficulties in completing the homework [ 14 - 16 ]. There is strong evidence suggesting that homework compliance is integral to the efficacy of CBT in a variety of psychiatric illnesses. In the treatment of depression with CBT, homework compliance has been correlated with significant clinical improvement and shown to predict decreases in both subjective and objective measures of depressive symptoms [ 17 - 23 ]. Similarly, homework compliance is correlated with short-term and long-term improvement of symptoms in anxiety disorders, including generalized anxiety disorder (GAD), social anxiety disorder (SAD), hoarding, panic disorder, and post-traumatic stress disorder (PTSD) [ 17 , 24 - 32 ]. Fewer studies have been done on homework compliance in other psychiatric conditions, but better homework compliance has been correlated with significant reductions in pathological behaviors in psychotic disorders [ 33 , 34 ], cocaine dependence [ 35 , 36 ], and smoking [ 37 ]. Two meta-analyses further support the notion that greater homework adherence is associated with better treatment outcomes in depression, anxiety-related disorders, and substance use [ 38 , 39 ].

The Utility of Technology in Enhancing CBT Homework

Despite its demonstrated efficacy, access to CBT (as well as other forms of psychotherapy) remains difficult due to the limited number of practicing psychotherapists and the cost of therapy sessions [ 40 ]. With the rise of mass-market mobile communication devices such as the iPhone or other kinds of mobile devices with app capabilities (smartphones), new solutions are being sought that will use these devices to provide therapy to patients in a more cost-effective manner. Mobile phones with app capabilities are portable devices that combine features of a cellphone and a hand-held computer with the ability to wirelessly access the Internet. Over time, ownership of mobile phones in North America has grown [ 41 , 42 ] and progressively lower prices have further reduced barriers to their use and ownership [ 43 , 44 ]. As more and more people acquire mobile phones, the acceptance of and the demand for mobile health solutions have been on the rise [ 45 ]. Boschen (2008), in a review predating the popularization of the modern mobile phone, identified the unique features of the mobile telephone that made it a potentially suitable vehicle for adjunctive therapeutic applications: portability, acceptability, low initial cost, low maintenance cost, social penetration and ubiquity, “always on,” “always connected,” programmability, audio and video output, keypad and audio input, user-friendliness, and ease of use [ 46 ]. Over the last decade, modern mobile phones have supplanted the previous generation of mobile telephones; progressive increases in their computing power, ongoing advances in the software that they run and interact with (eg, JAVA, HTML5, etc.), common feature sets across different operating systems such as Google Inc.'s Android or Apple Inc.'s iOS, and adoption of common hardware elements across manufacturers (eg, touch screens, high-resolution cameras, etc) have enabled the development of platform-independent apps for mobile phones, or at least apps on different platforms with comparable functionality (eg, apps written for Apple's HealthKit or the apps written for Microsoft's HealthVault).

The popularization of the smartphone presents a unique opportunity to enhance CBT homework compliance using adjunctive therapeutic applications such that well-designed mobile software may be able to diminish barriers to CBT [ 40 ] by making CBT therapists' work more cost-effective. However, there are no guidelines and no existing research that directly address the design of mobile phone apps for this purpose. Given this gap in the literature, we searched MEDLINE (1946 to April 2015) and PsycINFO (1806 to April 2015) for all articles related to “cognitive behavioral therapy”, “homework”, “mobile applications” and “treatment compliance or adherence”, and reviewed articles related to (1) mobile technologies that address homework completion, (2) essential features of therapy, or (3) barriers to homework completion in CBT. In this article, we propose a collection of essential features for mobile phone-based apps that will optimally support homework compliance in CBT.

A Proposed List of Essential Features for Mobile Apps That Optimally Support CBT Homework Compliance

In order to be effective for patients and acceptable to therapists, an optimal mobile phone app to support CBT homework compliance should conform to the CBT model of homework while addressing barriers to homework compliance. Tompkins (2002) provides a comprehensive guideline on the appropriate ways to provide CBT homework such that homework should be meaningful, relevant to the central goals of therapy, salient to focus of the session, agreeable to both therapist and client, appropriate to sociocultural context, practiced in session to improve skill, doable, begin small, have a clear rationale, include written instructions, and include a backup plan with homework obstacles [ 47 ]. In addition, the therapist providing the homework needs to be curious, collaborative, reinforce all pro-homework behavior and successful homework completion, and emphasize completion over outcome [ 47 ]. By combining Tompkins' guidelines with the need to reduce barriers to homework compliance (as described above), we obtained the following list of 6 essential features that should be incorporated into mobile apps to maximize homework compliance: (1) congruency to therapy, (2) fostering learning, (3) guiding therapy, (4) building connections, (5) emphasizing completion, and (6) population specificity.

Congruency to Therapy

Any intervention in therapy needs to be relevant to the central goals of the therapy and salient to the focus of the therapeutic session. A mobile app is no exception; apps have to deliver useful content and be congruent to the therapy being delivered. There are different types of homework in CBT, including (1) psychoeducational homework; (2) self-assessment homework; and (3) modality-specific homework. Which types are assigned will depend on the nature of the illness being treated, the stage of treatment, and the specific target [ 48 ]. An effective app supporting homework compliance will need to be able to adjust its focus as the therapy progresses. Self-monitoring and psychoeducation are major components in the early stage of therapy. Thought records can be used in depression and anxiety while other disorders may require more specific tasks, such as initiating conversation with strangers in the treatment of SAD. Therefore, the treatment modules delivered via mobile phones should meet the specific needs of therapy at each stage of therapy, while also providing psychoeducation resources and self-monitoring capabilities.

Psychoeducational Homework

While there are large amounts of health-related information on the Internet, the majority of information is not easily accessible to the users [ 49 ]. Mobile apps can enhance psychoeducation by delivering clear and concise psychoeducational information linked to the topics being covered in therapy. As psychoeducation is seen as a major component of mobile intervention [ 50 ], it has been incorporated into several mobile apps, some of which have been shown to be efficacious in treating various psychiatric conditions, including stress [ 51 ], anxiety and depression [ 52 ], eating disorders [ 53 ], PTSD [ 54 ], and obsessive compulsive disorder (OCD) [ 55 ]. For example, Mayo Clinic Anxiety Coach is a mobile phone app “designed to deliver CBT for anxiety disorders, including OCD” [ 55 ]. The app contains a psychoeducational module that teaches the user on “the use of the application, the cognitive-behavioral conceptualization of anxiety, descriptions of each anxiety disorder, explanations of CBT, and guidance for assessing other forms of treatment” [ 55 ]. The benefits of delivering psychoeducation via a mobile phone app are obvious: the psychoeducational information becomes portable and is easily accessed by the patient. Furthermore, the information is also curated and validated by proper healthcare authorities, which builds trust and reduces the potential for misinformation that can result from patient-directed Internet searches. However, psychoeducation on its own is not optimal. Mobile interventions that also incorporate symptom-tracking and self-help interventions have resulted in greater improvement when used for depression and anxiety symptoms than those that deliver only online psychoeducation [ 50 ].

Self-Assessment Homework

In contrast to conventional, paper-based homework, mobile apps can support in-the-moment self-assessments by prompting the user to record self-report data about the user’s current state [ 56 ]. While information collected retrospectively using paper records can be adversely affected by recall biases [ 57 ], mobile apps enable the patient to document his or her thoughts and feelings as they occur, resulting in increased accuracy of the data [ 58 ]. Such self-assessment features are found in many mobile apps that have been shown to significantly improve symptoms in chronic pain [ 59 , 60 ], eating disorders [ 61 ], GAD [ 62 ], and OCD [ 55 ]. Continuing with the previous example, the Mayo Clinic Anxiety Coach offers a self-assessment module that “measures the frequency of anxiety symptoms” with a self-report Likert-type scale [ 55 ]. The app tracks users’ progress over time based on the self-assessment data; users reported liking the record of daily symptom severity scores that the application provides.

Modality-Specific Homework

Evidence suggests that a variety of modality-specific homework assignments on mobile apps are effective, including relaxation practices, cognitive therapy, imaginal exposure in GAD and PTSD [ 54 , 57 ], multimedia solutions for skill learning and problem solving in children with disruptive behavior or anxiety disorders [ 63 ], relaxation and cognitive therapy in GAD [ 62 ], or self-monitoring via text messages (short message service, SMS) to therapists in bulimia nervosa [ 61 ]. Mayo Clinic Anxiety Coach, for example, has a treatment module for OCD that “guides patients through the use of exposure therapy” [ 55 ]; patients can use this to build their own fear hierarchies according to their unique diagnoses. Users reported liking the app because it contains modality-specific homework that can be tailored to their own needs. Novel formats, such as virtual reality apps to create immersive environments, have been experimented with as a tool for facilitating exposure in the treatment of anxiety disorders with mostly positive feedback [ 64 - 66 ]. Apps that provide elements of biofeedback (such as heart rate monitoring via colorimetry of users' faces using the mobile phone's camera), have recently begun to be deployed. So-called ”serious games,“ (ie, games developed for treatment purposes), are also showing promise in symptom improvement in certain cases [ 51 , 67 , 68 ].

Fostering Learning

Doing CBT homework properly requires time and effort. As noted above, any sense of inconvenience while doing the homework may hamper a patient’s motivation to complete the homework. While patients may appreciate the importance of doing homework, they often find the length of time spent and the lack of clear instructions discouraging, resulting in poor engagement rates [ 49 , 52 ]. Therefore, it makes sense that the tasks should be simple, short in duration to begin with, and include detailed instructions [ 47 ], since homework completion rates have been shown to be correlated with patients’ knowing exactly what to do [ 33 , 69 ]. Many apps incorporate text messaging-based services or personalized feedback to encourage dynamic interactions between the therapist and the client [ 59 ]. However, the types of homework delivered by these apps are fixed. An app that adapts the contents to the user’s progress in learning homework tasks would be more engaging and effective since therapy should be a flexible process by nature. Ideally, the app would monitor and analyze the user’s progress and adjust the homework's content and difficulty level accordingly. While the effectiveness of this type of app has not been studied, a similar app has been described in the literature for treating GAD [ 62 ]. This app, used in conjunction with group CBT, collected regular symptom rating self-reports from patients to track anxiety. Based on patients’ ratings, the app would respond with encouraging comments and invite patients to practice relaxation techniques or prompt the patient to complete specific built-in cognitive therapy modules if their anxiety exceeded a threshold rating. Despite the simple algorithm used to trigger interventions, use of the app with group CBT was found to be superior to group CBT alone.

Guiding Therapy

Therapists have a number of important roles to play in guiding and motivating clients to complete homework. First, the therapist needs to address the rationale of the prescribed homework and work with the client in the development of the treatment plan [ 47 ]. Failure to do this has been identified as a barrier to homework compliance. Second, the therapist should allow the patient to practice the homework tasks during the therapy sessions [ 47 ] in order to build confidence and minimize internal barriers, such as the failing to identify automatic thoughts. Lastly, the therapist has to be collaborative, regularly reviewing homework progress and troubleshooting with the patients [ 47 , 70 ]; this can be done during or in between homework assignments, either in-person or remotely (ie, via voice or text messaging) [ 60 , 71 ].

Reviewing and troubleshooting homework has been seen as a natural opportunity for apps to augment the role of therapists. Individualized guidance and feedback on homework is found in many Internet-based or mobile apps that have been shown to be effective in treating conditions such as PTSD [ 72 ], OCD [ 55 ], chronic pain [ 59 , 60 ], depression and suicide ideation [ 71 ], and situational stress [ 73 ]. Moreover, providing a rationale for homework, ensuring understanding of homework tasks, reviewing homework, and troubleshooting with a therapist have each individually been identified as predictors of homework compliance in CBT [ 74 , 75 ]. However, despite incorporating a variety of features including self-monitoring, psychoeducation, scheduled reminders, and graphical feedback [ 52 ], automated apps with minimal therapist guidance have demonstrated elevated homework non-completion rates of up to 40%, which is less than ideal.

Building Connections

The effects of technology should not interfere with but rather encourage a patient’s ability to build meaningful connections with others [ 76 ]. The therapeutic alliance between the therapist and the client is the strongest predictor of therapeutic outcome [ 77 ] and has been suggested to predict level of homework compliance as well [ 78 ]. While there is no evidence so far to suggest that technology-based interventions have an adverse effect on the therapeutic alliance [ 79 , 80 ], this conclusion should not be generalized to novel technologies as their impact on therapeutic alliance has not been well studied [ 81 ].

An arguably more significant innovation attributable to technology has been its potential to allow patients to form online communities, which have been identified as useful for stigma reduction and constructive peer support systems [ 82 ]. Online or virtual communities provide patients with a greater ability to connect with others in similar situations or with similar conditions than would be possible physically. Internet-delivered CBT that includes a moderated discussion forum has been shown to significantly improve depression symptoms [ 83 ]. Furthermore, professional moderation of online communities increases users’ trust of the service [ 84 ]. Therefore, including social platforms and online forums in a mobile app may provide additional advantages over conventional approaches by allowing easier access to social support, fostering collaboration when completing homework, and enabling communication with therapists.

Emphasizing Completion

A patient’s need to see immediate symptomatic improvement is an impediment to homework compliance since the perception of slow progress can be discouraging to the user [ 35 ]. To address this issue, it is important for both therapists and mobile apps to emphasize homework completion over outcome [ 47 ]. While a therapist can urge the client to finish uncompleted homework during the therapy session to reinforce its importance [ 47 , 85 ], there is little a therapist can do in between therapy sessions to remind clients to complete homework. In contrast, a mobile app can, for example, provide ongoing graphical feedback on progress between sessions to motivate users [ 52 , 86 ], or employ automatic text message reminders, which have been demonstrated to significantly improve treatment adherence in medical illnesses [ 87 ]. These features have previously been incorporated into some technology-based apps for homework adherence when treating stress, depression, anxiety, and PTSD [ 52 , 54 , 88 ] with significant symptom improvement reported in one paper [ 71 ].

Population Specificity

Homework apps should, where relevant or useful, explicitly be designed taking into account the specific characteristics of its target audience, including culture, gender, literacy, or educational levels (including learning or cognitive disabilities). One example of how culture-specific design features can be incorporated can be found in Journal to the West, a mobile app for stress management designed for the Chinese international students in the United States, which incorporates cultural features into its game design [ 89 ]. In this game, breathing activity is associated with the concept of “Qi” (natural energy) in accordance with Chinese traditions; the name of the game itself references to a famous Chinese novel and the gaming environment features inkwash and watercolor schemes of the East Asian style, making the experience feel more “natural” as reported by the users. A different approach to tailoring design is taken by the computer-based games described by Kiluk et al [ 68 ] that combine CBT techniques and multi-touch interface to teach the concepts of social collaboration and conversation to children with autism spectrum disorders. In these games, the touch screen surface offers simulated activities where children who have difficulties with peer engagement can collaborate to accomplish tasks. Children in this study demonstrated improvement in the ability to provide social solutions and better understanding of the concepts of collaboration. Although the population-specific design is intuitively appealing, the degree to which it can enhance homework compliance has yet to be investigated.

Other Considerations

There are several additional issues specific to mobile apps that should be carefully considered when developing mobile apps for homework compliance. Because of screen sizes, input modes, the nature of electronic media, etc, standard CBT homework may need to be translated or modified to convert it into a format optimal for delivery via a mobile phone [ 47 ]. The inclusion of text messaging features remains controversial, in part because of concerns about client-therapist boundary issues outside the therapy sessions [ 90 ]. One potential solution is to use automated text messaging services to replace direct communication between the therapist and the client so the therapist can't be bombarded by abusive messages [ 52 , 61 , 91 , 92 ]. Privacy and security issues are also real concerns for the users of technology [ 93 ], although no privacy breaches related to text messaging or data security have been reported in studies on mobile apps so far [ 88 , 94 - 98 ]. Designers of mobile apps should ensure that any sensitive health-related or personal data is stored securely, whether on the mobile device or on a server.

Finally, while this paper focused on “essential” features of apps, this should not be misunderstood as an attempt to itemize all elements necessary for designing a successful piece of software. Good software design depends on many important elements that are beyond the scope of this paper, such as a well-designed user interface [ 99 ] that is cognitively efficient relative to its intended purpose [ 100 ] and which makes effective use of underlying hardware.

The popularization and proliferation of the mobile phone presents a distinct opportunity to enhance the success rate of CBT by addressing the pervasive issue of poor homework compliance. A variety of barriers exist in traditional, paper-based CBT homework that can significantly hamper clients’ motivation to complete homework as directed. The 6 essential features identified in this paper can each potentially enhance homework compliance. Therapy congruency focuses the features of the app on the central goal of therapy and fostering learning eases engagement in therapy by reducing barriers. Apps should help the therapist guide the client through therapy and not hinder the therapeutic process or interfere with patient’s building connections with others. It is crucial that homework completion be emphasized by the app, not just homework attempting. Population-specific issues should also be considered depending on the characteristics of targeted users.

As an example of how this applies in practice, “Mental Health Telemetry-Anxiety Disorders” (MHT-ANX) is a new mobile app developed by the Centre for Mobile Computing in Mental Health at Sunnybrook Health Sciences Centre in Toronto that helps patients monitor their anxiety symptoms using longitudinal self-report. The symptom log is therapy congruent to the practice of CBT since it promotes patients' awareness of their anxiety symptoms and the symptoms’ intensity. The simplicity of the app makes it easy for patients to learn to use, consistent with the need for fostering learning and increasing compliance. The MHT-ANX app was designed to share patient data with their clinicians, helping clinicians guide patients through therapy and more readily engage in discussion about symptom records, thus potentially enhancing the therapeutic relationship. Homework completion is emphasized both by automated text message reminders that the system sends and by questions presented by MHT-ANX that focus on how homework was done. While there are few population-specific design issues obvious at first glance in MHT-ANX, the focus groups conducted as part of our design process highlighted that our target group preferred greater privacy in our app rather than ease of sharing results via social media, and prioritized ease-of-use. While not yet formally assessed, reports from staff and early users suggest that MHT-ANX has been helpful for some patients with promoting homework compliance.

Limitations and Future Challenges

The feature list we have compiled is grounded in current technology; as technology evolves, this list may need to be revised. For example, as artificial intelligence [ 101 ] or emotional sensing [ 102 ] develops further, we would expect that software should be able to dynamically modify its approach to the user in response to users' evolving emotional states.

This paper presents our opinion on this topic, supported by a survey of associated literature. Our original intention was to write a review of the literature on essential features of apps supporting CBT homework compliance, but there was no literature to review. The essential features that are the focus of this article are summaries of key characteristics of mobile apps that are thought to improve homework compliance in CBT, but randomized trials assessing the impact of these apps on homework compliance have not yet been done. We would anticipate synergistic effects when homework-compliance apps are used in CBT (eg, if measures of progress collected from an app were used as feedback during therapy sessions to enhance motivation for doing further CBT work), but the actual impact and efficacy of therapy-oriented mobile apps cannot be predicted without proper investigation.

Abbreviations

Conflicts of Interest: None declared.

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What Is Cognitive Behavioral Therapy (CBT)?

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Rachel Goldman, PhD FTOS, is a licensed psychologist, clinical assistant professor, speaker, wellness expert specializing in eating behaviors, stress management, and health behavior change.

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• Effectiveness
• Considerations
• Getting Started

Cognitive behavioral therapy (CBT) is a type of psychotherapeutic treatment that helps people learn how to identify and change the destructive or disturbing thought patterns that have a negative influence on their behavior and emotions.

Cognitive behavioral therapy combines cognitive therapy with behavior therapy by identifying maladaptive patterns of thinking, emotional responses, or behaviors and replacing them with more desirable patterns.

Cognitive behavioral therapy focuses on changing the automatic negative thoughts that can contribute to and worsen our emotional difficulties, depression , and anxiety . These spontaneous negative thoughts also have a detrimental influence on our mood.

Through CBT, faulty thoughts are identified, challenged, and replaced with more objective, realistic thoughts.

Everything You Need to Know About CBT

This video has been medically reviewed by Steven Gans, MD .

Types of Cognitive Behavioral Therapy

CBT encompasses a range of techniques and approaches that address our thoughts, emotions, and behaviors. These can range from structured psychotherapies to self-help practices. Some of the specific types of therapeutic approaches that involve cognitive behavioral therapy include:

• Cognitive therapy centers on identifying and changing inaccurate or distorted thought patterns, emotional responses, and behaviors.
• Dialectical behavior therapy (DBT)  addresses destructive or disturbing thoughts and behaviors while incorporating treatment strategies such as emotional regulation and mindfulness.
• Multimodal therapy suggests that psychological issues must be treated by addressing seven different but interconnected modalities: behavior, affect, sensation, imagery, cognition, interpersonal factors, and drug/biological considerations.
• Rational emotive behavior therapy (REBT) involves identifying irrational beliefs, actively challenging these beliefs, and finally learning to recognize and change these thought patterns.

While each type of cognitive behavioral therapy takes a different approach, all work to address the underlying thought patterns that contribute to psychological distress.

Cognitive Behavioral Therapy Techniques

CBT is about more than identifying thought patterns. It uses a wide range of strategies to help people overcome these patterns. Here are just a few examples of techniques used in cognitive behavioral therapy. 

Identifying Negative Thoughts

It is important to learn what thoughts, feelings, and situations are contributing to maladaptive behaviors. This process can be difficult, however, especially for people who struggle with introspection . But taking the time to identify these thoughts can also lead to self-discovery and provide insights that are essential to the treatment process.

Practicing New Skills

In cognitive behavioral therapy, people are often taught new skills that can be used in real-world situations. For example, someone with a substance use disorder might practice new coping skills and rehearse ways to avoid or deal with social situations that could potentially trigger a relapse.

Goal-Setting

Goal setting can be an important step in recovery from mental illness, helping you to make changes to improve your health and life. During cognitive behavioral therapy, a therapist can help you build and strengthen your goal-setting skills .

This might involve teaching you how to identify your goal or how to distinguish between short- and long-term goals. It may also include helping you set SMART goals (specific, measurable, attainable, relevant, and time-based), with a focus on the process as much as the end outcome.

Problem-Solving

Learning problem-solving skills during cognitive behavioral therapy can help you learn how to identify and solve problems that may arise from life stressors, both big and small. It can also help reduce the negative impact of psychological and physical illness.

Problem-solving in CBT often involves five steps:

• Identify the problem
• Generate a list of potential solutions
• Evaluate the strengths and weaknesses of each potential solution
• Choose a solution to implement
• Implement the solution

Self-Monitoring

Also known as diary work, self-monitoring is an important cognitive behavioral therapy technique. It involves tracking behaviors, symptoms, or experiences over time and sharing them with your therapist.

Self-monitoring can provide your therapist with the information they need to provide the best treatment. For example, for people with eating disorders, self-monitoring may involve keeping track of eating habits, as well as any thoughts or feelings that went along with consuming a meal or snack.

Additional cognitive behavioral therapy techniques may include journaling , role-playing , engaging in relaxation strategies , and using mental distractions .

What Cognitive Behavioral Therapy Can Help With

Cognitive behavioral therapy can be used as a short-term treatment to help individuals learn to focus on present thoughts and beliefs.

CBT is used to treat a wide range of conditions, including:

• Anger issues
• Bipolar disorder
• Eating disorders
• Panic attacks
• Personality disorders

In addition to mental health conditions, cognitive behavioral therapy has also been found to help people cope with:

• Chronic pain or serious illnesses
• Divorce or break-ups
• Grief or loss
• Low self-esteem
• Relationship problems
• Stress management

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Benefits of Cognitive Behavioral Therapy

The underlying concept behind CBT is that thoughts and feelings play a fundamental role in behavior. For example, a person who spends a lot of time thinking about plane crashes, runway accidents, and other air disasters may avoid air travel as a result.

The goal of cognitive behavioral therapy is to teach people that while they cannot control every aspect of the world around them, they can take control of how they interpret and deal with things in their environment.

CBT is known for providing the following key benefits:

• It helps you develop healthier thought patterns by becoming aware of the negative and often unrealistic thoughts that dampen your feelings and moods.
• It is an effective short-term treatment option as improvements can often be seen in five to 20 sessions.
• It is effective for a wide variety of maladaptive behaviors.
• It is often more affordable than some other types of therapy .
• It is effective whether therapy occurs online or face-to-face.
• It can be used for those who don't require psychotropic medication .

One of the greatest benefits of cognitive behavioral therapy is that it helps clients develop coping skills that can be useful both now and in the future.

Effectiveness of Cognitive Behavioral Therapy

CBT emerged during the 1960s and originated in the work of psychiatrist Aaron Beck , who noted that certain types of thinking contributed to emotional problems. Beck labeled these "automatic negative thoughts" and developed the process of cognitive therapy. 

Where earlier behavior therapies had focused almost exclusively on associations, reinforcements , and punishments to modify behavior, the cognitive approach addresses how thoughts and feelings affect behaviors.

Today, cognitive behavioral therapy is one of the most well-studied forms of treatment. It has been shown to be effective in the treatment of a range of mental conditions, including anxiety, depression, eating disorders, insomnia, obsessive-compulsive disorder , panic disorder, post-traumatic stress disorder , and substance use disorder.

• Research indicates that cognitive behavioral therapy is the leading evidence-based treatment for eating disorders .
• CBT has been proven helpful in those with insomnia, as well as those who have a medical condition that interferes with sleep, including those with pain or mood disorders such as depression.
• Cognitive behavioral therapy has been scientifically proven to be effective in treating symptoms of depression and anxiety in children and adolescents.
• A 2018 meta-analysis of 41 studies found that CBT helped improve symptoms in people with anxiety and anxiety-related disorders, including obsessive-compulsive disorder and post-traumatic stress disorder.
• Cognitive behavioral therapy has a high level of empirical support for the treatment of substance use disorders, helping people with these disorders improve self-control , avoid triggers, and develop coping mechanisms for daily stressors.

CBT is one of the most researched types of therapy, in part, because treatment is focused on very specific goals and results can be measured relatively easily.

Verywell Mind's Cost of Therapy Survey , which sought to learn more about how Americans deal with the financial burdens associated with therapy, found that Americans overwhelmingly feel the benefits of therapy:

• 80% say therapy is a good investment
• 91% are satisfied with the quality of therapy they receive
• 84% are satisfied with their progress toward mental health goals

Things to Consider With Cognitive Behavioral Therapy

There are several challenges that people may face when engaging in cognitive behavioral therapy. Here are a few to consider.

Change Can Be Difficult

Initially, some patients suggest that while they recognize that certain thoughts are not rational or healthy, simply becoming aware of these thoughts does not make it easy to alter them.

CBT Is Very Structured

Cognitive behavioral therapy doesn't focus on underlying, unconscious resistance to change as much as other approaches such as  psychoanalytic psychotherapy . Instead, it tends to be more structured, so it may not be suitable for people who may find structure difficult.

You Must Be Willing to Change

For cognitive behavioral therapy to be effective, you must be ready and willing to spend time and effort analyzing your thoughts and feelings. This self-analysis can be difficult, but it is a great way to learn more about how our internal states impact our outward behavior.

Progress Is Often Gradual

In most cases, CBT is a gradual process that helps you take incremental steps toward behavior change . For example, someone with social anxiety might start by simply imagining anxiety-provoking social situations. Next, they may practice conversations with friends, family, and acquaintances. By progressively working toward a larger goal, the process seems less daunting and the goals easier to achieve.

How to Get Started With Cognitive Behavioral Therapy

Cognitive behavioral therapy can be an effective treatment choice for a range of psychological issues. If you or someone you love might benefit from this form of therapy, consider the following steps:

• Consult with your physician and/or check out the directory of certified therapists offered by the National Association of Cognitive-Behavioral Therapists to locate a licensed professional in your area. You can also do a search for "cognitive behavioral therapy near me" to find local therapists who specialize in this type of therapy.
• Consider your personal preferences , including whether face-to-face or online therapy will work best for you.
• Contact your health insurance to see if it covers cognitive behavioral therapy and, if so, how many sessions are covered per year.
• Make an appointment with the therapist you've chosen, noting it on your calendar so you don't forget it or accidentally schedule something else during that time.
• Show up to your first session with an open mind and positive attitude. Be ready to begin to identify the thoughts and behaviors that may be holding you back, and commit to learning the strategies that can propel you forward instead.

What to Expect With Cognitive Behavioral Therapy

If you're new to cognitive behavioral therapy, you may have uncertainties or fears of what to expect. In many ways, the first session begins much like your first appointment with any new healthcare provider.

During the first session, you'll likely spend some time filling out paperwork such as HIPAA forms (privacy forms), insurance information, medical history, current medications, and a therapist-patient service agreement. If you're participating in online therapy, you'll likely fill out these forms online.

Also be prepared to answer questions about what brought you to therapy, your symptoms , and your history—including your childhood, education, career, relationships (family, romantic, friends), and current living situation.

Once the therapist has a better idea of who you are, the challenges you face, and your goals for cognitive behavioral therapy, they can help you increase your awareness of the thoughts and beliefs you have that are unhelpful or unrealistic. Next, strategies are implemented to help you develop healthier thoughts and behavior patterns.

During later sessions, you will discuss how your strategies are working and change the ones that aren't. Your therapist may also suggest cognitive behavioral therapy techniques you can do yourself between sessions, such as journaling to identify negative thoughts or practicing new skills to overcome your anxiety .

If you are having suicidal thoughts, contact the  National Suicide Prevention Lifeline  at  988 for support and assistance from a trained counselor. If you or a loved one are in immediate danger, call 911.

For more mental health resources, see our  National Helpline Database .

Hofmann SG, Asnaani A, Vonk IJ, Sawyer AT, Fang A. The efficacy of cognitive behavioral therapy: A review of meta-analyses . Cognit Ther Res . 2012;36(5):427-440. doi:10.1007/s10608-012-9476-1

Merriam-Webster. Cognitive behavioral therapy .

Rnic K, Dozois DJ, Martin RA. Cognitive distortions, humor styles, and depression . Eur J Psychol. 2016;12(3):348-62. doi:10.5964/ejop.v12i3.1118

Lazarus AA, Abramovitz A. A multimodal behavioral approach to performance anxiety . J Clin Psychol. 2004;60(8):831-40. doi:10.1002/jclp.20041

Lincoln TM, Riehle M, Pillny M, et al. Using functional analysis as a framework to guide individualized treatment for negative symptoms . Front Psychol. 2017;8:2108. doi:10.3389/fpsyg.2017.02108

Ugueto AM, Santucci LC, Krumholz LS, Weisz JR. Problem-solving skills training . Evidence-Based CBT for Anxiety and Depression in Children and Adolescents: A Competencies-Based Approach . 2014. doi:10.1002/9781118500576.ch17

Lindgreen P, Lomborg K, Clausen L.  Patient experiences using a self-monitoring app in eating disorder treatment: Qualitative study .  JMIR Mhealth Uhealth.  2018;6(6):e10253. doi:10.2196/10253

Tsitsas GD, Paschali AA. A cognitive-behavior therapy applied to a social anxiety disorder and a specific phobia, case study . Health Psychol Res. 2014;2(3):1603. doi:10.4081/hpr.2014.1603

Kumar V, Sattar Y, Bseiso A, Khan S, Rutkofsky IH.  The effectiveness of internet-based cognitive behavioral therapy in treatment of psychiatric disorders .  Cureus . 2017;9(8):e1626.

Trauer JM, Qian MY, Doyle JS, Rajaratnam SMW, Cunnington D. Cognitive behavioral therapy for chronic insomnia: A systematic review and meta-analysis .  Ann Intern Med . 2015;163(3):191. doi:10.7326/M14-2841

Agras WS, Fitzsimmons-craft EE, Wilfley DE.  Evolution of cognitive-behavioral therapy for eating disorders .  Behav Res Ther . 2017;88:26-36. doi:10.1016/j.brat.2016.09.004

Oud M, De winter L, Vermeulen-smit E, et al.  Effectiveness of CBT for children and adolescents with depression: A systematic review and meta-regression analysis . Eur Psychiatry . 2019;57:33-45. doi:10.1016/j.eurpsy.2018.12.008

Carpenter J, Andrews L, Witcraft S, Powers M, Smits J, Hofmann S. Cognitive behavioral therapy for anxiety and related disorders: A meta‐analysis of randomized placebo‐controlled trials .  Depress Anxiety . 2018;35(6):502–14. doi:10.1002/da.22728

National Institute on Drug Abuse (NIDA).  Cognitive-behavioral therapy (alcohol, marijuana, cocaine, methamphetamine, nicotine) .

Gaudiano BA. Cognitive-behavioural therapies: Achievements and challenges . Evid Based Ment Health . 2008;11(1):5-7. doi:10.1136/ebmh.11.1.5

Beck JS. Cognitive Behavior Therapy: Basics and Beyond .

Coull G, Morris PG. The clinical effectiveness of CBT-based guided self-help interventions for anxiety and depressive disorders: A systematic review . Psycholog Med . 2011;41(11):2239-2252. doi:10.1017/S0033291711000900

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

How Much Does Homework Matter in Therapy?

What research reveals about the work you do outside of therapy sessions..

Posted April 16, 2017 | Reviewed by Ekua Hagan

• What Is Therapy?
• Find a therapist near me

Homework is an important component of cognitive behavior therapy (CBT) and other evidence-based treatments for psychological symptoms. Developed collaboratively during therapy sessions, homework assignments may be used by clients to rehearse new skills, practice coping strategies, and restructure destructive beliefs.

Although some clients believe that the effectiveness of psychotherapy depends on the quality of in-session work, consistent homework during the rest of the week may be even more important. Without homework, the insights, plans, and good intentions that emerge during a therapy session are at risk of being buried by patterns of negative thinking and behavior that have been strengthened through years of inadvertent rehearsal. Is an hour (or less) of therapeutic work enough to create change during the other 167 hours in a week?

Research on homework in therapy

Research on homework in therapy has revealed some meaningful results that can be understood collectively through a procedure called meta-analysis. A meta-analysis is a statistical summary of a body of research. It can be used to identify the average impact of psychotherapy homework on treatment outcomes across numerous studies. The results of four meta-analyses listed below highlight the value of homework in therapy:

• Kazantzis and colleagues (2010) examined 14 controlled studies that directly compared treatment outcomes for clients assigned to psychotherapy with or without homework. The data favored the homework conditions, with the average client in the homework group reporting better outcomes than about 70% of those in the no-homework conditions.
• Results from 16 studies (Kazantzis et al., 2000) and an updated analysis of 23 studies (Mausbach et al., 2010) found that, among those who received homework assignments during therapy, greater compliance led to better treatment outcomes. The effect sizes were small to medium, depending on the method used to measure compliance.
• Kazantzis et al. (2016) examined the relations of both quantity (15 studies) and quality (3 studies) of homework to treatment outcome. The effect sizes were medium to large, and these effects remained relatively stable when follow-up data were collected 1-12 months later.

Taken together, the research suggests that the addition of homework to psychotherapy enhances its effectiveness and that clients who consistently complete homework assignments tend to have better mental health outcomes. Finally, although there is less research on this issue, the quality of homework may matter as much as the amount of homework completed.

To enhance the quality of homework, homework assignments should relate directly to a specific goal, the process should be explained with clarity by the therapist, its method should be rehearsed in session, and opportunities for thoughtful out-of-session practice should be scheduled with ideas about how to eliminate obstacles to completion.

To find a therapist, please visit the Psychology Today Therapy Directory .

Kazantzis, N., Deane, F. P., & Ronan, K. R. (2000). Homework assignments in Cognitive and Behavioral Therapy: A meta‐analysis. Clinical Psychology: Science and Practice, 7(2), 189-202.

Kazantzis, N., Whittington, C., & Dattilio, F. (2010). Meta‐analysis of homework effects in cognitive and behavioral therapy: A replication and extension. Clinical Psychology: Science and Practice, 17(2), 144-156.

Kazantzis, N., Whittington, C., Zelencich, L., Kyrios, M., Norton, P. J., & Hofmann, S. G. (2016). Quantity and quality of homework compliance: a meta-analysis of relations with outcome in cognitive behavior therapy. Behavior Therapy, 47(5), 755-772.

Mausbach, B. T., Moore, R., Roesch, S., Cardenas, V., & Patterson, T. L. (2010). The relationship between homework compliance and therapy outcomes: An updated meta-analysis. Cognitive Therapy and Research, 34(5), 429-438.

Joel Minden, Ph.D., is a clinical psychologist, author of Show Your Anxiety Who’s Boss , director of the Chico Center for Cognitive Behavior Therapy, and lecturer in the Department of Psychology at California State University, Chico.

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20 DBT Worksheets and Dialectical Behavior Therapy Skills

If you’re as lost as I was when I first heard the term, then you’ve come to the right place. In this piece, you will learn what DBT is, how it works, and some of the most useful and applicable components of treatment.

Whether you are someone who is thinking about participating in Dialectical Behavior Therapy, a therapist who is looking for DBT worksheets to use with clients, or just a curious individual, read on to learn more about it.

Mindfulness is critical to DBT. Before you read on, we thought you might like to download our three Mindfulness Exercises for free . These science-based, comprehensive exercises will not only help you cultivate a sense of inner peace throughout your daily life but will also give you the tools to enhance the mindfulness of your clients, students or employees.

This Article Contains:

• What is Dialectical Behavior Therapy? A Definition
• About the Founder by Marsha Linehan

DBT vs. CBT: How Do They Differ?

4 essential dbt skills & techniques to master.

• 4 DBT Worksheets, Handout and Manuals (PDF)

What Is The Diary Card All About?

The 4 best books on dbt, treatment methods based on dbt and emotion regulation, certification possibilities & courses.

• What is DBT’s Role in Mindfulness?

A Take-Home Message

What is dialectical behavior therapy a definition..

Dialectical Behavior Therapy (DBT) is a type of cognitive-behavioral therapy that focuses on the psychosocial aspects of therapy, emphasizing the importance of a collaborative relationship, support for the client, and the development of skills for dealing with highly emotional situations (Psych Central, 2016).

DBT was created for the treatment of individuals struggling with suicidal thoughts but has matured into a treatment for a range of other conditions that involve dysfunctional emotional regulation. It is currently considered the “gold standard” for borderline personality disorder and has even been applied to the treatment of substance abuse and eating disorders (Linehan Institute, n.d.).

DBT is generally characterized by its two main components:

• Individual weekly therapy sessions;
• Weekly group therapy sessions.

Individual Weekly Therapy Sessions

These individual sessions are an opportunity for the therapist and client to address the issues and solutions that came up over the last week, with special attention paid to self-destructive or potentially self-harmful behaviors. These behaviors are targeted not only because they are inherently worrisome, but also because they can seriously disrupt the treatment process and undermine treatment goals.

Clients and therapists work as a team in these individual sessions, with the focus on learning and improving social and coping skills . They may also discuss more general issues relevant to improving the client’s quality of life, or more specific issues like post-traumatic stress disorder .

Weekly Group Therapy Sessions

These sessions are usually scheduled for two and a half hours and generally focus on developing skills from one of four skill areas:

• Interpersonal effectiveness ;
• Distress tolerance/reality acceptance skills;
• Emotion regulation;
• Mindfulness skills.

Skill Modules

These four skill modules cover a wide range of useful skills that can be applied in daily life:

1. Interpersonal Effectiveness Module

The skills in this module are related to interacting with others, especially in difficult or potentially damaging situations.

These skills are intended to help clients function effectively when trying to change something (e.g., making a request) or in trying to resist changes (e.g., refusing a request). The intention is to aid the client in meeting their goals in each situation while avoiding any damage to the relationship or to the client’s self-respect (Psych Central, 2016).

2. Distress Tolerance Module

This module includes skills that are extremely important yet often overlooked: skills relating to accepting, tolerating, and learning from suffering.

Many other mental health treatment regimens focus on avoiding pain, changing difficult situations, or walking away from circumstances that cause suffering, but the distress tolerance skills taught through Dialectical Behavior Therapy focus on dealing with the pain and suffering that is inevitable to the human condition.

The distress tolerance module is split into four crisis survival strategies:

• Distracting;
• Self-soothing;
• Improving the moment;
• Thinking of pros and cons.

In addition, there are many skills that relate to accepting and tolerating the current situation, like radical acceptance and willingness vs. willfulness.

3. Emotion Regulation Module

Many clients who participate in DBT are struggling with personality or mood disorders and can benefit immensely from emotion regulation skills.

Some of these skills that can help clients deal with their  emotions include:

• Identifying and labeling emotions;
• Identifying obstacles to changing emotions;
• Reducing vulnerability to “emotion mind;”
• Increasing positive emotional events;
• Increasing mindfulness to current emotions;
• Taking the opposite action;
• Applying distress tolerance techniques (Psych Central, 2016).

4. Mindfulness Module

Readers of this blog are likely already aware of the numerous mindfulness-related skills that can benefit them in their daily life.

These skills include “what” skills or skills that answer the question “What do I do to practice core mindfulness skills?” like observing, describing, and participating. There are also “how” skills or skills that answer the question “How do I practice core mindfulness skills?”, like non-judgment and practicing “One-mindfully” effectively.

Many of these mindfulness skills feed into skills from the other modules; for example, the nonjudgment encouraged in mindfulness is also encouraged in distress tolerance, and the observing and describing skills can be helpful in identifying and labeling emotions.

About the Founder Marsha Linehan

Dialectical Behavior Therapy was developed by Dr. Marsha Linehan.

She is a Professor of Psychology and adjunct Professor of Psychiatry and Behavioral Sciences at the University of Washington and Director of the Behavioral Research and Therapy Clinics, a research consortium that explores treatments for severely disordered and suicidal individuals (The Linehan Institute, n.d.).

Dr. Linehan is dedicated to promoting effective and accessible resources for the treatment of individuals who are struggling.

Dr. Linehan founded Behavioral Tech LLC, an institute focused on developing and sharing treatment tools for DBT training, consultation, and treatment. Behavioral Tech Research, Inc., was also established by Dr. Linehan in an effort to incorporate online and mobile technology into the successful practice of DBT.

Dr. Linehan approaches her scientific research and development from a perspective that is relatively uncommon in the sciences: one based in spirituality. She has trained with a number of spiritual leaders and influential thinkers, including a Zen master.

This may help explain her affinity for mindfulness, which grew to prominence through a collaboration of traditional Buddhist philosophy and the modern scientific paradigm (The Linehan Institute, n.d.).

Of course, DBT is a type of CBT, so similarities are understandable. But DBT also has distinct features that set it apart from most CBT approaches.

DBT, like CBT, focuses on helping people address their dysfunctional thinking and behavior through modification of their thought patterns and, through changing their thoughts, their behavior as well. However, CBT is usually confined to a limited period of time and is often applied with one or two specific goals in mind.

On the other hand, DBT narrows the focus to psychosocial aspects of daily life. Many people have trouble with their thought and behavior patterns, but these issues are often at their most disruptive in the context of relationships with others. DBT was created to approach treatment from this angle, one that is often incorporated in general CBT but is not typically the main focus (Grohol, 2016).

This emphasis on relating to others is what explains the DBT-specific treatment component of group therapy sessions. The benefits of additional therapy to the treatment of severe emotion regulation dysfunction are clear, but it’s the group aspect that really helps explain its importance.

Adding group dynamics to the learning setting offers clients an opportunity to practice relational skills in a safe and supportive environment, a practice that has been shown to be extremely effective.

DBT also differs from general CBT in the use of clients’ history. Both incorporate the past in striving for a healthier future, but this discussion is not a focus of the therapy in DBT as it often is in CBT (Grohol, 2016). The perspective of DBT is that one can learn from their past, but that problems are inevitably rooted in current thoughts and behaviors, and the present is where these will be addressed.

We won’t go into all of them in detail, but these are the main skills and techniques applied in DBT.

Interpersonal Effective Skills

1) objectiveness effectiveness “dear man” skills.

• Appear confident;

2) Relationship Effectiveness “GIVE” Skills

• Interested;
• Easy manner.

3) Self-Respect Effectiveness “FAST” Skills

• Apologies / no apologies;
• Stick to value;

Distress Tolerance Skills

1) crisis survival “accepts” skills.

• Activities;
• Contributing;
• Comparisons;
• Pushing away;
• Sensations.

2) Self-Soothing Skills

3) improve the moment “improve” skills.

• Relaxation;
• One thing at a time;
• Encouragement.

4) Pros and Cons / Accepting Reality Skills

• Willingness;
• Turning your mind;
• Radical acceptance.

Download 3 Free Mindfulness Exercises (PDF)

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Emotion Regulation Skills

1) reducing vulnerability skills.

• Treat physical illness;
• Altering drugs (only those prescribed by a doctor);

2) Build Mastery Skills

• Build positive experiences;
• Be mindful of current emotion;
• Opposite to emotion action.

Mindfulness Skills

1) “what” skills.

• Participate.

2) “How” skills

• Non-judgmentally;
• One-mindfully;
• Effectively (Dietz, 2012).

As you can see, acronyms are front and center in DBT treatment, in part because it makes remembering these skills in important moments easier.

You may also notice that many of these skills are generally considered effective skills , rather than specific skills for specific problems. While Dialectical Behavior Therapy focuses on the treatment of severely distressed individuals, the means of working towards these goals are not mystical or mysterious. The methods of furthering treatment are grounded in common sense and the straightforward practice of skills.

In fact, these skills are so generally applicable that many of them have practical applications for everyone.

Mindfulness

Mindfulness is such a simple and beneficial practice that it’s hard to sum up the potential positive impacts in one section, let alone one article (but we gave it a shot anyway – see our piece on the benefits of mindfulness ).

“Mindfulness can be described as simply living your life in the present instead of being stuck in the past or the future. Practicing mindfulness helps us become more aware of our thought patterns, our emotions, and how our thoughts and feelings affect our reactions to events” (Tartakovsky, 2015A).

If your mind has you jumping on the thought train (i.e., one thought leads to another, which often leads to a “should” thought, which can lead to judgment), try to detach yourself from the thought by telling yourself about the thought you are having (e.g., “There’s a thought about the errand I need to run after work”).

This can help you refocus on your current practice and remind yourself that you have thoughts, but you are not your thoughts (Tartakovsky, 2015A).

If you’re interested in learning more about how to practice mindfulness, check out our post on mindfulness exercises and techniques .

Reality Acceptance

Accepting reality is an effective antidote for a common problem in our society: struggling against the pain and suffering that is inherent to life as a human. DBT and Acceptance and Commitment Therapy (ACT) have this in common – both teach that accepting our reality, including the unpleasant aspects of it, is the only way to thrive.

This skill can be harder to practice and build than it seems since there are all sorts of sneaky ways we find to deny the reality of our situation.

These examples from Psych Central can shed some light on when we fight reality and how we can stop this tendency:

• You need to rush home, but you’re catching every red light. Instead of getting frustrated, you take a deep breath and tell yourself: “ It is what it is. I’ll get home when I get there .”
• You need to fill up your car, but gas prices have skyrocketed. Again, you breathe deeply, and say to yourself: “ There’s nothing I can do about it. I need gas. Getting angry isn’t going to help. ”
• You have to walk to work because your car is in the shop. It’s not far, but it’s pouring. You take a deep breath and say: “ It’s just rain. I’ll bring a towel, and I’ll dry off when I get to work ” (Tartakovsky, 2015A).

The part-humorous, part-helpful Tumblr blog “ Shit Borderlines Do ” provides some steps towards practicing this skill in the moment:

• Observe that you are fighting the reality of your situation. Acknowledge that you are reacting to something that you cannot change;
• Remind yourself what the reality is, even if it’s difficult or upsetting;
• Consider the causes of the current reality and incorporate the skill of non-judgment to remind yourself that this is a random occurrence set in motion by a million other factors that are outside of your control;
• Accept this reality with your whole being, or your mind, body, and spirit. Pay attention to the bodily signs of fighting reality (e.g., posture, “fight-or-flight” response) as well as the spiritual signs (you may “know” that this is real, but you don’t “feel” like it’s real).

These steps are by no means exhaustive or required to accept reality, but they can be helpful in the moment.

Radical Acceptance

Dialectical Behavior Therapy’s radical acceptance technique can help in these situations.

Radical acceptance is simply acknowledging the reality of your circumstances instead of fighting it by thinking “ This shouldn’t be happening ” or “ This isn’t fair. ”

It can be difficult to accept pain, but fighting the reality of your pain only creates more pain, and this pain is optional. Instead of fighting pain, radical acceptance offers a way to accept it and address it.

In the words of psychotherapist Sheri Van Dijk:

“If you don’t like something, you first have to accept that it is the way it is before you can try to [change] it. If you’re not accepting something, you’ll be so busy fighting that reality that you don’t have the energy to put towards trying to change it” (Tartakovsky, 2015).

This explanation shows us that not only can radical acceptance help us accept the reality of things that we cannot change, it can also help us to realize what can be changed.

Non-judgmental Stance

Being non-judgmental means that you avoid assigning value to events and feelings.

Instead of facing a difficult situation and thinking “ This is awful ,” practicing non-judgment allows us to take a step back and realize that the value judgments we make are based on facts (the facts of what is happening) and the emotions we are feeling in reaction (Tartakovsky, 2015B).

For example, you may be stuck in accident-related traffic and thinking “People are such idiots.” If you make an effort to be nonjudgmental, this may translate to “ I’m stuck at a standstill in traffic because of an accident up ahead. This makes me frustrated and upset. ”

When you break a judgment down into a fact and your emotional reaction, you not only reduce the emotion(s) you are feeling, you can also be empowered to think about ways to solve the problem and make healthy decisions.

Say you are thinking about how selfish your significant other is being right now. Instead of stopping at “ My partner is so selfish ,” practicing non-judgment may lead to articulating the issue (“ My partner is not helping me with this problem, and that makes me angry and disappointed ”) and finding a way to solve it (“ This is not a wise use of my time and energy. I will talk to my partner about how his/her unwillingness to help me with this problem makes me feel, and try to negotiate a solution with him/her ”).

Handling emotional situations in this manner can not only help you reduce your emotional reaction and find smart solutions to problems, it can also improve your self-esteem and self-respect when you handle the issue in a way that makes you proud of yourself (Tartakovsky, 2015B).

4 DBT Worksheets, Handout, and Manuals (PDF)

This is where Dialectical Behavior Therapy worksheets, handouts, and manuals can prove to be extremely effective tools in building your skills and improving your ability to accept your situation, deal with difficulty, and solve problems.

We’ll go over some of the most popular and effective ones below.

DBT Interpersonal Effectiveness Skills

This handout lists and describes the interpersonal effectiveness skills we outlined earlier, and also provides useful tips to put these skills into practice.

For example, the section on objective effectiveness (the DEAR MAN skills) lists the following tips:

• Use clear and concrete terms to describe what you want;
• Don’t say: “Could you please clean?”;
• Do say: “Could you do the dishes before going to bed?”
• Let others know how a situation makes you feel by clearly expressing your feelings;
• Don’t expect others to read your mind;
• Try using this line: “I feel ___ because ___.”
• Don’t beat around the bush—say what you need to say;
• Don’t say: “Oh, well, I don’t know if I can cook tonight or not;”
• Do say: “I won’t be able to cook because I’m working late.”
• Reward people who respond well, and reinforce why your desired outcome is positive;
• This can be as simple as a smile and a “thank you.”
• Don’t forget the objective of the interaction;
• It can be easy to get sidetracked into harmful arguments and lose focus.
• Consider your posture, tone, eye contact, and body language.
• No one can have everything they want out of an interaction all the time;
• Be open to negotiation;
• Do say: “If you wash the dishes, I’ll put them away.”

The Wise Mind

It is a balance between the two minds and is characterized by the ability to recognize and respect your feelings, but also respond to them in a rational manner .

The worksheet offers space to describe an experience that you have had with each of these three “minds” to further your understanding of the minds and how they have come into play in your life.

Function of Emotion Worksheet

The Function of Emotion Regulation  worksheet helps you to identify the function of an emotional reaction you have had over the last week.

The worksheet moves through the following questions and steps:

• What was the prompting event?
• What was your interpretation?
• What was the emotion and intensity (0-100)?

Use the following to identify the function(s) of the emotion:

• Did the emotion communicate something to others or influence their behavior? If so, describe;
• Did the emotion organize or motivate you to do something? If so, describe;
• Did the emotion give you information, color your perception, or lead you to any conclusions? If so, describe.

These questions aid the individual in making the connections between a galvanizing event and the reaction s/he had to the event, as well as understanding how the emotional reaction impacts the self and others.

DBT Skills Training Manual: Second Edition

For a resource that can help you apply general DBT treatment, check out this manual from Dr. Linehan herself. It’s not free, but it is an extremely valuable resource for applying DBT with your clients.

This manual is separated into two parts: the first describes DBT and provides instructions on how to set up a treatment program and manage the problems that can arise, while the second gives detailed notes on teaching each DBT skill.

Check out the manual, buying options, and reviews from some very satisfied readers here .

According to dbtselfhelp.com :

“You use the card to track your urges, moods, how you did or did not use DBT Skills, your feelings, and whatever else is helpful to you. You bring these cards with you to your DBT therapist every week to help you look for behavior patterns and triggers that occur in your life. Such information is invaluable to help you to help yourself live a life worth living.”

There are many possible layouts for a diary card (see here , here , and here ), but they generally contain the same fields:

• Day/date of urge or behavior;
• Emotions felt;
• Actions taken or skills used (or not used);
• Triggers for the urges.

The diary card may also include space for a general rating for the day and any medications or substances used (legal or illegal).

The client is encouraged to fill out this card regularly and faithfully. While it is important that the client does so, they should know that no one is going to score them or judge them based on their diary card. It is not an assignment to be completed and graded, but a way for them to track their experience and evaluate their progression through DBT treatment and, hopefully, self-improvement.

Diary Card App

As with most problems or issues, technology is making an impact on how people keep diary cards.

If you hate to waste paper, don’t like getting ink on your hands, or just get tired of writing, there’s a diary card app that you can use instead.

Check out the app created by a licensed clinical psychologist here .

If you’re interested in learning more about Dialectical Behavior Therapy, as a client, therapist, or just a curious person, there are several books available.

Listed below are some of the most popular and highly reviewed books on DBT out there, and they’re all available for purchase on Amazon.com:

1. The Dialectical Behavior Therapy Skills Workbook – Matthew McKay, Jeffrey C. Wood, and Jeffrey Brantley

It walks the reader through descriptions of DBT and how it can help, introductory exercises, and more advanced skill chapters. This can be an excellent resource for any individual considering DBT or for therapists to recommend to their clients.

Available on Amazon .

2. DBT Made Simple: A Step-by-Step Guide to Dialectical Behavior Therapy – Sheri Van Dijk

It includes a section on the theory and research behind DBT and how it grew from traditional CBT approaches, as well as strategies for working with clients, an explanation of the four skill modules, and several handouts, case examples, and some sample therapy dialogue.

3. The Mindfulness Solution for Intense Emotions: Take Control of Borderline Personality Disorder with DBT – Cedar R. Koons and Marsha M. Linehan

It teaches readers about the seven powerful skills related to mindfulness and emotion regulation that can help people cope with a borderline personality disorder (BPD), post-traumatic stress disorder (PTSD), severe depression, and other emotion regulation problems.

4. Calming the Emotional Storm: Using Dialectical Behavior Therapy Skills to Manage Your Emotions and Balance Your Life – Sheri Van Dijk

With a rating of over 4.5 out of 5 stars from nearly 50 customers, it sounds like the description is accurate.

These books are an excellent start to learning about DBT and applying the skills in your clients’ lives, but if you’re looking for even more, visit this website to learn about other helpful books.

• Understanding one’s emotions;
• Reducing emotional vulnerability;
• Decreasing emotional suffering (Bray, 2013B).

There are several ways to work toward these goals.

One of the websites we mentioned earlier, dbtselfhelp.com , offers an outline of how to build emotion regulation skills:

Interpreting Emotions

We all have emotions, but there is a theory that there are only a few basic emotions while the rest is interpretation and evaluation.

You can work on your skills related to interpreting emotions by completing a writing challenge described here .

Describing Emotions

Emotions involve action urges, prompts to perform certain behaviors. These urges are not part of the emotion but can feel like they are. There is often a prompting event, followed by interpretation, body changes in response to the emotions, and action urges.

This can lead to an effective or dysfunctional expression of emotions, which can have a wide range of consequences. To work on describing emotions, try to describe the qualities of your emotions and pay attention to things that may interfere, like secondary emotions that spring from the original emotion.

Follow this link for more information on describing emotions.

Function of Emotions

Emotions have three major functions in DBT:

• They communicate to and influence others;
• They organize and motivate action, and;
• They can be self-validating.

You can learn about the function of emotions by answering questions like “What are some examples of situations where your expressions of emotion were misread?” and “Can you think of some times when you misread the emotions of someone else?”

See this page for more information.

Reducing Vulnerability

We are all vulnerable to negative emotions, but we can build our skills related to reducing vulnerability. You can keep track of the factors that affect your physical and mental wellbeing, like your diet, any mood-altering drugs, sleep, and exercise.

Refer to these skills in the emotion regulation module for more information.

Paying Attention to Positives

Increasing positive emotions can be an effective method for dealing with difficult emotions. To build this skill, focus on the positive experiences you have throughout the day (short-term experiences) and the bigger, more impactful ones (long-term experiences).

Focus on building and maintaining positive relationships, and give mindfulness a try to savor positive experiences.

Letting Go of Painful Emotions

On the flipside of savoring the positive, letting go of the negative also has a place in emotion regulation. While accepting that pain happens is healthy, dwelling on negative emotions is dysfunctional.

Practice observing your emotions, describing and accepting them but not allowing yourself to be overwhelmed by them.

See this page for more information on letting go.

Opposite to Emotion Action

This technique is used to change painful emotions that are harmful rather than helpful. It is not about suppressing our emotions, but accepting the emotion and using it to take a different action.

To practice this technique, list some examples of when you have acted opposite to your current emotion. Describe a situation in which it is not appropriate to act opposite to your emotion to help you learn about the difference between each situation.

Check out this handout for more information.

What is Dialectical Behavior Therapy for adolescents (DBT)? – UC San Francisco

Dialectical Behavior Therapy is a recognized treatment that is well supported by the evidence. There are many ways to learn about applying DBT, but getting certified is a great option. There are courses and online DBT training for both individuals interested in practicing DBT and for therapists and other mental health professionals who wish to apply DBT in their work.

For Therapists and Other Mental Health Professionals

Dr. Linehan’s Behavioral Tech Research Institute provides information on Dialectical Behavior Therapy certification for therapists. The certification is available through the DBT-Linehan Board of Certification and requires the following:

• A graduate degree in a mental health-related field from a regionally accredited institution of higher education;
• A mental health practitioner license;
• A minimum of 40 didactic training hours specific to DBT Clinical experience with DBT (at least three clients);
• DBT team experiences (at least 12 months of preparation and current participation on a DBT team);
• DBT skills knowledge/experience;
• You must have read the Skills Training Manual for Treating Borderline Personality Disorder by Marsha Linehan, completed all the homework assignments in the manual, and taught or participated in all modules of skill training;
• Successful pass of exam based on the Cognitive-Behavioral Treatment of Borderline Personality Disorder by Marsha Linehan;
• Letter of recommendation from your team leader;
• Work product demonstration (videotapes of three consecutive live therapy sessions);
• Mindfulness experience (at least one of the following: a mindfulness retreat, formal practice community participation, formally a student of a recognized Zen/contemplative teacher, or at least one formal training in mindfulness).

You can also become certified through the Dialectical Behavior Therapy National Certification and Accreditation Association (DBTNCAA). This allows you to list a specialized certification in DBT when you apply to Health Care Providers and HMO networks.

What is DBT’s Role in Mindfulness?

While DBT and mindfulness are not synonymous, they are certainly linked.

DBT is a therapy based on identifying, describing, and modifying thoughts and feelings. Mindfulness has clear applicability in this therapy, through its ability to help practitioners to become more aware of their feelings, thoughts, impulses, and behaviors (Bray, 2013A).

One description of the benefit of mindfulness in Dialectical Behavior Therapy is that it provides the individual with the ability to take control of the mind instead of having the mind control the individual.

Practicing mindfulness helps the individual in DBT to direct their attention to observing, describing, and participating in a nonjudgmental way, which enhances the individual’s skills and leads to improved ability to focus on the positive, let go of the negative, and regulate emotions.

As we’ve said before, mindfulness is an extremely useful skill for individuals dealing with difficult emotions or situations, but it can be an even more effective tool for people struggling with a diagnosis.

Top 17 Exercises for Mindfulness & Meditation

Use these 17 Mindfulness & Meditation Exercises [PDF] to help others build life-changing habits and enhance their wellbeing with the physical and psychological benefits of mindfulness.

Created by Experts. 100% Science-based.

The intention of this piece was to provide an overview of Dialectical Behavior Therapy and outline the skills and tools that can help you or your clients to address emotion regulation issues. I hope it has met this goal, and that you know much more about Dialectical Behavior Therapy than you did when you started!

I hope you also keep in mind that the skills involved in DBT are applicable for those that are not suffering from a diagnosed mental health issue as well. Skills like mindfulness, focusing on the positive, letting go of the negative, and accepting the reality of your situation have clear benefits for everyone, not just those who are in the midst of suffering.

Have you tried DBT? Have you applied DBT with your clients? As always, please let us know about your experiences in the comments.

Thanks for reading!

We hope you enjoyed reading this article. Don’t forget to download our three Mindfulness Exercises for free .

• Bray, S. (2013A). Core mindfulness in Dialectical Behavior Therapy. GoodTherapy. Retrieved from http://www.goodtherapy.org/blog/core-mindfulness-dialectical-behavior-therapy-0215134
• Bray, S. (2013B). Emotion regulation in Dialectical Behavior Therapy. GoodTherapy. Retrieved from www.goodtherapy.org/blog/emotion-regulation-dialectical-behavior-therapy-dbt-0318135
• Dietz, L. (2012). DBT skills list. DBT Self Help. Retrieved from www.dbtselfhelp.com/html/dbt_skills_list.html
• Grohol, J. (2016). What’s the difference Between CBT and DBT?  Psych Central. Retrieved from https://psychcentral.com/lib/whats-the-difference-between-cbt-and-dbt/ Linehan Institute
• Psych Central. (2016). An overview of Dialectical Behavior Therapy. Psych Central. Retrieved from https://psychcentral.com/lib/an-overview-of-dialectical-behavior-therapy/
• Tartakovsky, M. (2015A). 3 DBT skills everyone can benefit from. Psych Central. Retrieved from https://psychcentral.com/blog/archives/2015/08/28/3-dbt-skills-everyone-can-benefit-from/
• Tartakovsky, M. (2015B). What it really means to practice radical acceptance. Psych Central. Retrieved from https://psychcentral.com/blog/archives/2015/10/04/what-it-really-means-to-practice-radical-acceptance/
• The Linehan Institute. (n.d.).  Linehan Institute. Retrieved from http://www.linehaninstitute.org/about-Linehan.php

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Article feedback

What our readers think.

I appreciate you giving this information. In our online treatment, dialectical behavioral therapy is used. It works incredibly well for depression, substance abuse, and borderline personality disorder. Even the most serious cases respond very well to DBT, and we treat a wide range of clients.

I’ve been looking for this info!!! DBT saved my life and I believe EVERYONE could benefit from it. The reason I’ve been searching is for my boys. I never meant to pass that part of me to any of my children but I see it in them. I’m trying for them to avoid the wrong roads I took. I barely escaped the darkness. I couldn’t bare to see them in that place. So ty!! I can’t say it enough.

I have recently completed a DBT group therapy course which I found extremely helpful in managing my BPD and PTSD.

I would love to teach these skills to others worldwide, is it a requirement that you have a certain level of certification to teach cbt/dbt and if so what qualifications are required to go on to teach these skills to others online?

I believe I have enough personal experience, understanding and now knowledge of the skills and mental illness, but am confused on the law of teaching these skills without official certification, or even if that’s a must?

Please help

That’s great your experience was so helpful for you! To teach CBT and DBT skills to support people with mental illnesses, you need to become a licensed therapist or psychologist. This requires that you complete a master’s qualification. You can learn more about the process in our dedicated blog post: https://positivepsychology.com/how-to-become-a-therapist/

Hope this helps!

– Nicole | Community Manager

I have the same question. I work in mental health as a life coach and yoga instructior. I do not want to teach the program. My intention is to use the “My life Vision” worksheet and the wise mind model. What is the legal implications? I would sight the source while being clear on my role and title. The client would be provided resources for a licensed therapist.

This is outstanding!!!!!!

Just curious, you mention in the section – Working with Primary and Secondary Emotions While – “this webpage” but then there is no link to the webpage the article is referencing. I am wondering if you would direct me to the webpage please for further reference. As well, in the following paragraph on Emotion Regulation, again you mention “this worksheet” but don’t link a worksheet. Are you able to reference these for follow-up, please and thank you?

Hi Heather,

Thank you so much for being so observant and bringing this to our attention.

These links went to other websites, which may have restructured their content and caused dead links on our side. I have unfortunately not been able to trace the original worksheets discussed, but have amended our copy to prevent any further confusion.

Apologies for not being able to help you further.

Regards, Annelé

I wish DBT was more available in standard mental health services. In the UK, it’s thin on the ground.

BPD is prolific and causes so much suffering. Yet still much ignorance and stigma remains.

I hate the way so many blame and shame such lonely and fragile people.

We want love, but are terrified of our vulnerability being abused. I wish I could’ve got this treatment. My partners would not have had to put up with so much, maybe.

Damaged people damage people.

Thank you for sharing your thoughts on the availability of Dialectical Behavior Therapy (DBT) and the challenges faced by individuals with Borderline Personality Disorder (BPD). It is indeed disheartening to hear that access to this valuable treatment is limited in the UK and that stigma continues to surround BPD.

The importance of raising awareness about mental health conditions and advocating for better access to evidence-based treatments, such as DBT, cannot be overstated. It is essential to create a more understanding and compassionate society that supports individuals with mental health challenges instead of perpetuating shame and blame.

I encourage you to check out Psychology Today! It has a great directory you can use to find therapists in your local area. Usually, the therapists provide a summary in their profile with their areas of expertise and types of issues they are used to working with.

Please know that your voice matters and your experiences can contribute to raising awareness, challenging stigmas, and ultimately improving mental health care for those who need it most.

Warm regards, Julia | Community Manager

I have been waiting a very long time for DBT therapy for diagnosed Borderline Personality Disorder, being unable to work for 20 months now. I have finally been assigned a place but am unable to purchase DBT Skills Training Handouts and Worksheets Second Edition. Seeking help from so many places, I can’t even find a Microsoft Word version of the worksheets that I can complete online in order to participate in the group therapy. As a result, I cannot have the therapy I desperately need. I know this is a long shot, but does anyone have a version in Word (or Open.Office) that they can send to me?? Otherwise, I will continue to suffer as the NHS has taken so long to help me with a condition I have had for decades, together with my depression and anxiety. Thanking you in advance.

I’m sorry to hear you’ve had so much trouble receiving support. Please let me know which specific worksheet(s) you are trying to open, and I will let you know the best way to do so with free software.

Thank you for providing this information.

This sums up the group therapy session I have just graduated from! Modalities were based from Marsha’s core theories; it is alot of skills to practice.

Courtney, everything you wrote on this page IS TRUE, well written for any level audience. Well done.

Radical Acceptance, and Emotional identification is THE HARDEST part of BPD and DBT. I find it hard now to identify why I am in an “emotional crisis”, since I want to “Name it, to Tame it”. I really can’t identify why I become so deeply emotional (rage, crying, worthless…) but the emotions are EXTREME. I can’t identify what I was so emotional about, why I became so emotional in the first place ONCE I GET CAUGHT IN “THE DARK HOLE” as my husband refers to my “emotional crises”.

Just thought I would share my own personal experience; FYI I am an ongoing work in progress. Still have many ups and downs; however I can reflect on these events (usually AFTER the fact, but LIVE AND LEARN).

Super frustrting that it says “We hope you enjoyed reading this article. Don’t forget to download our 3 Mindfulness Exercises for free.” but you enter your information and then it tells you it cost $27.00. Why the false advertising…why say free just to get another person email to spam?

My apologies! Please try visiting this link to access the free downloads. The three exercises are definitely free! But if there’s a link in the text that tries to point you toward a paid resources, please let us know where it is so we can correct this 🙂

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