Dialectical Behavior Therapy Initials Date Finished How often did you fill out this card?
ard? 1 2-4 5-6 7 Filled out in session? Y N
(DBT) Diary Card Target Behavior: ___________________________________________________
Target Behavior Emotions Skills
How strong was your urge to Rate how intense your emotions was each day * Use this scale to rate how you used your skills.
use (or avoid) your target Check “R” if you reinforced yourself for using skills.
behavior? Did you?
(0=least intense and 5 = most intense)
Day Urge Action Rx Pain Sad Shame Anger Fear Joy Skills R *USED SKILLS
✓ 0 = Not thought about or used
1 = Thought about, not used, didn’t want to
Sun 2 = Thought about, not used, wanted to
Mon 3 = Tried but could not use them
4 = Tried, could do them but they didn’t help
Tues 5 = Tried, could use them, didn’t help
6 = Didn’t try, used them, didn’t help
Wed 7 = Didn’t try, used them, helped
Thurs
Fri
Sat
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
SKILLS:
Wise Mind S M T W R F S
Core Mindfulness
Observe: just notice (urge surfacing)
What Skills Describe: put words on
Participate: enter into the experience
One Mindfully: in the moment
How Skills Non-judgmentally: just the facts (Don’t) judge judging, separate facts from interpretations
Effectively: focus on what works
Prioritize: among interpersonal goals
Consider options for intensity: Priorities, Capabilities, Timeliness, Homework, Authority,
Interpersonal
Rights, Relationship, Reciprocity, Goals, Respect
Saying “no” and observing limits
Objectives Effectiveness: DEAR MAN (Describe, Express, Assert, Reinforce, Mindfully,
3 goals of Acting Confident, Negotiating
interpersonal
Relationship Effectiveness: GIVE (Gentle, Interested, Validating, Easy Manner)
effectiveness
Self-Respect Effectiveness: FAST (Fair, No Apologies, Stick to values, Truthful)
Model of Emotions
Function of Emotions
Take Care of Physical Illness
Emotional Regulation
Balanced Eating
PLEASE
Avoid Alcohol/Mood Altering Drugs
Master Balanced Sleeping
Balanced Eating
Increase Positive Emotions/Events*
Experience my emotion as a wave (Let it come & go, just observe, don’t amplify or
suppress)
Practice loving my emotions (step back, experience, accept, don’t judge)
Activities*
Contribution
Distract Comparison/Count Blessings
Skills Opposite Emotions (Actions Opposites)
Wise Mind Pushing Away
ACCEPTS Thoughts (Think about something more pleasant)
Sensations
Distress Tolerance
Self-Soothe with 5 senses
Imagery
Meaning
Prayer
IMPROVE
Relaxation
the Moment
One thing in the moment
Vacations
Encouragement
Pros/Cons
Observe the Truth
Half-Smile
Radical Acceptance, Willingness, Turning the Mind
Building Structure: Work
DBT’ S
Building Structure: Relationships
Building Structure: Time
Building Structure: Place
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