Marsha Linehan developed Dialectical Behaviour Therapy (DBT) for people whose emotions run hot and are hard to bring down. At its centre sit acceptance (you make sense, exactly as you are) and change (and some of what you do is hurting you). Every client on this page is a fictional training example; names, places and details are invented.
A word on safety first. Several scenarios involve urges to self-harm. We never describe methods, and in role-play you should not ask for method detail either. When risk is live, a sound DBT response asks directly about self-harm and suicidal thoughts, then builds or reviews a collaborative safety plan in the same session, as NICE guidance on self-harm (NG225) describes. With young people, confidentiality has limits and safeguarding procedures apply, and the rules differ by country. In India the Protection of Children from Sexual Offences Act (2012) requires any person to report sexual offences against a child. The UAE's child rights law (Wadeema's Law, 2016) also places duties to report child abuse. In the UK, statutory safeguarding guidance applies. Know the rules where you practise, and explain the limits to young clients at the start.
All clients on this page are fictional training examples, written to realistic clinical presentations. They are for learning, not clinical advice.
Core skills to practise
- Validation. Linehan (1997) describes six levels, from listening without bias up to radical genuineness. Validate what is valid. Usually that is the emotion, not the harmful behaviour.
- Behavioural chain analysis. A moment-by-moment account of one problem behaviour, link by link.
- The Stage 1 target hierarchy. Work targets in strict order: (1) life-threatening behaviours, which include suicidal thoughts, self-harm and strong urges to self-harm; (2) therapy-interfering behaviours; (3) quality-of-life-interfering behaviours; (4) increasing behavioural skills. If self-harm or a high urge is on the diary card, it comes first, even when the client wants to talk about something else.
Skills named in these role-plays
The acronyms come from Linehan's DBT Skills Training Manual (2nd ed., 2015).
- DEAR MAN (getting what you want): Describe, Express, Assert, Reinforce, stay Mindful, Appear confident, Negotiate.
- FAST (keeping self-respect): be Fair, no (unneeded) Apologies, Stick to values, be Truthful.
- TIP (changing body chemistry fast): Temperature (cold water on the face), Intense exercise, Paced breathing, Paired muscle relaxation. Very cold water lowers the heart rate quickly and intense exercise raises it. The handout says to consult a doctor first if the client has a heart or other medical condition, a lowered resting heart rate because of medication, takes a beta-blocker, is allergic to cold or has an eating disorder, and to keep the water above 10 degrees Celsius (50 degrees Fahrenheit). Paced breathing carries no such caution and is a safe first choice.
DBT role-play scenarios
Every client is fictional.
Scenario 1
An urge to self-harm, with no act
Meera, 24, a postgraduate student in Kochi, Kerala. Her diary card shows a strong urge to self-harm on Thursday (80 out of 100). She did not act on the urge.
“I didn't do anything. I just really wanted to. Can we not make a big deal of it?”
- Diary card review
- Direct risk question
- Chain analysis of an urge
- Reinforcing skilful behaviour
A strong response: Reinforce the fact that she did not act, ask about risk now, then chain the urge: a strong urge sits under life-threatening behaviour, and that is target one.
Common pitfall: Letting it go because "nothing happened". An 80 is high on the hierarchy.
Scenario 2
FAST: saying no without apologising
Rahul, 33, an engineer from Kerala working in Dubai. His flatmate keeps borrowing money. Rahul says yes, then stays angry for days and drinks more at weekends.
“Sorry, sorry, I know it's a small thing. I just can't say no to him, and then I'm angry the whole week.”
- FAST
- Self-respect effectiveness
- Rehearsal with feedback
A strong response: Point out the apologies kindly, then rehearse a FAST script with feedback letter by letter.
Common pitfall: Spending the session on the flatmate instead of rehearsing.
Scenario 3
A crisis coaching call at high arousal
Sophie, 22, a part-time student in Manchester. Her housemate has just said she is moving out. Sophie rings her therapist between sessions with self-harm urges at 85 out of 100. She has not hurt herself.
“I'm shaking, I can't think, she's leaving and I can't do this. Can you just stay on the phone all night?”
- Distress tolerance
- TIP
- Risk check
- Keeping the call brief
- Safety plan review
A strong response: Brief validation, a calm direct question about suicidal thoughts and whether she has hurt herself, then one skill coached step by step. Before cold water or intense exercise, check the medical cautions; paced breathing needs none. End with a short plan, the contacts on her safety plan and a set time to check in.
Common pitfall: Turning the call into a chain analysis of the argument. At 85 she cannot use insight. One skill, now. The chain belongs in the next session.
Scenario 4
Confidentiality with a teenager
Emma, 14, in Leeds. Referred by her school after a teacher saw marks on her arm, now in DBT for Adolescents.
“If I tell you something, are you going to tell my mum?”
- Confidentiality and its limits
- Safeguarding
- Engaging a reluctant teenager
A strong response: Tell her the truth: most of what she says stays private, with clear exceptions such as a serious risk to her life or someone hurting her. Wherever possible she would hear first and have a say in who needs to know.
Common pitfall: Promising total secrecy, or saying everything goes to her parents. The first breaks your safeguarding duties. The second ends the conversation, probably for good.
Behavioural chain analysis example
Meera from the first scenario, using the components described by Rizvi and Ritschel (2014). The problem behaviour is named at behaviour level only. No method detail, here or in your own role-plays.
- Vulnerability factors: four hours of sleep, no lunch, exam week.
- Prompting event: her mother phoned and said, "Your cousin got a job. What are you doing with your life?"
- Links: "I'm a failure." Shame at 90, tight chest. Then "Nobody would care." The therapist stops here and asks directly about suicidal thoughts, then and now. Meera says she had none and has none now. The therapist reviews her safety plan with her before going on.
- Solution analysis: a DEAR MAN asking her mother to stop the comparisons; TIP when shame is very high, after checking the handout's medical cautions; text her sister, who is on her safety plan.
DBT session example
The start of Meera's session, fictional.
Therapist:Your card shows an 80 on Thursday, and you didn't act on it. That's a big deal, in a good way.
Diary card first, and the skilful part reinforced.
Client:It doesn't feel like a big deal. I just went to bed.
Therapist:Before we look at Thursday, I want to ask you directly. Right now, are you having any thoughts of hurting yourself, or of not wanting to be alive?
Life-threatening behaviour is first in the hierarchy, so it is first in the session.
Client:No. Not now. Thursday was bad, though.
Therapist:Thank you for telling me. Let's go back to Thursday, slowly. What was happening earlier that day?
The chain starts with vulnerability factors.
Client:Exams. I'd barely slept. I hadn't eaten since breakfast.
Therapist:So you were running on empty. Then what happened?
Client:My mother called. She said my cousin got a job and asked what I'm doing with my life.
Therapist:What went through your mind, in that moment?
Client:That I'm a failure. That I'll never be enough.
Read more about Dialectical Behaviour Therapy, the evidence behind it and the skills you practise.