DBT Therapy Note

Symptom Description and Subjective Report

• Pt (28yo F, BPD) presented on time for individual DBT session. Mood reported as "anxious and irritable" (7/10); affect constricted but reactive. Denies SI/HI or NSSI urges this wk. Compliant with lamotrigine (Lamictal) 100 mg PO daily.
• Pt actively participated in a 5-min "Observe and Describe" exercise. Reported initial difficulty focusing due to racing thoughts about work, but successfully redirected attention to breath and ambient sounds without self-judgment by the end of the exercise.
• Homework was reviewed in detail. Pt presented completed DBT Diary Card and TIPP skill worksheet. Reported utilizing the "Temperature" skill (cold water facial immersion) on 14/05/2026 at 21:30 following an interpersonal conflict with her partner, which reduced emotional distress from 9/10 to 5/10 and prevented an angry outburst.
• Pt engaged well with psychoeducation on "Radical Acceptance." Verbalized understanding of the concept ("accepting reality as it is without fighting it"), though expressed resistance to applying it to her current job dissatisfaction. Identified two personal examples where fighting reality increased her suffering vs pain.

Objective Content

• Clinician introduced and led a 5-min sensory-based mindfulness exercise ("Observe and Describe" using an object in the room), instructing pt to separate objective physical traits from subjective evaluations or labels.
• Homework from the previous session (DBT Diary Card and Distress Tolerance TIPP worksheet) was reviewed.
• Clinician provided psychoeducation on Distress Tolerance: Radical Acceptance. Explained the distinction between pain and suffering (Pain + Non-acceptance = Suffering), clarified that acceptance does not equal approval or passivity, and reviewed the 10 steps toward practicing radical acceptance.
• Clinician assigned daily completion of the DBT Diary Card and the "Practicing Radical Acceptance" worksheet (Emotional Regulation Handout 11B), instructing pt to log at least two minor daily inconveniences and one major stressor to practice acceptance statements.

Interventions Used

• Mindfulness training ("Observe and Describe" sensory exercise)
• Behavioral chain analysis and DBT Diary Card review
• Positive reinforcement of adaptive skill use (TIPP skill)
• Psychoeducation on Distress Tolerance (Radical Acceptance)
• Cognitive restructuring regarding acceptance vs approval
• Homework assignment for skill generalization