What should a DBT individual therapy session note include?

A DBT individual session note should document in priority order: (1) diary card review — what the client tracked, highest-priority target behavior flagged on the card; (2) which item from the DBT target hierarchy was addressed (life-threatening behaviors first, then therapy-interfering, then quality-of-life); (3) chain analysis if a target behavior occurred — the full behavioral chain from vulnerability factors through the prompting event, links, problem behavior, and consequences; (4) skills used or absent — which DBT skills were attempted, which were missing in the chain, which were assigned; (5) commitment work, validation, and dialectical strategies used; (6) plan for next session and any phone coaching agreements. The diary card is a clinical document — documenting that it was reviewed and what it showed is part of the standard of care in DBT.

How do you document a DBT chain analysis?

A chain analysis documents the full sequence of events leading to a target behavior. Document each link: (1) vulnerability factors — what made the client more susceptible that day (sleep, illness, alcohol, prior emotional dysregulation, recent stressors); (2) prompting event — the specific event that started the chain (be concrete and behavioral, not 'she felt triggered'); (3) links — the sequence of thoughts, feelings, sensations, and behaviors between prompting event and target behavior (this is the longest and most clinical part); (4) target behavior — what specifically happened, when, where, severity; (5) consequences — what followed, including reinforcing consequences that make the behavior likely to repeat. The chain analysis should be specific enough that a different clinician could understand exactly what happened and where skills could have been inserted.

What do you document in a DBT skills training group note?

Skills training group notes have two levels: (1) group note — session number in the module, module being covered (Mindfulness, Distress Tolerance, Emotion Regulation, Interpersonal Effectiveness), skill taught, teaching method (didactic, roleplay, whiteboard, worksheets), group participation level, any safety concerns at the group level; (2) individual addendum for each member — homework review (did they practice, what happened), skill application this session, individual participation, any clinical concerns requiring follow-up. The group note does not include identifying details about individual members. Note: in standard DBT, skills trainers do not conduct individual therapy with group members and have limited access to individual therapy information — document only what you observed in group.

How do you document the DBT treatment target hierarchy in session notes?

The DBT target hierarchy (life-threatening behaviors > therapy-interfering behaviors > quality-of-life behaviors > skills acquisition) should be explicitly reflected in your session notes. Document: (1) which level of the hierarchy was addressed this session and why; (2) if a higher-priority target was present but not addressed, document the clinical rationale; (3) if you moved down the hierarchy (e.g., chose to address quality-of-life when no life-threatening behavior occurred this week), that's appropriate — document what informed that decision. When a session covered multiple targets, document them in hierarchy order. This makes it clear that treatment is structured and target-driven, not session-by-session reactive.

DBT Session Notes: Chain Analysis, Skills Training Documentation, Templates

DBT documentation differs from standard session notes in a key way: the structure of the treatment determines the structure of the note. DBT has an explicit target hierarchy, a specific assessment tool (the diary card), and a core intervention (chain analysis) that each require their own documentation format. Generic SOAP or BIRP notes don’t capture what DBT treatment actually involves.

Short answer: DBT individual sessions require diary card review documentation, target hierarchy documentation (which level was addressed and why), and — if a target behavior occurred — a full chain analysis. Skills training groups require a group note plus an individual addendum for each member. The diary card is a clinical document; not documenting its review is a documentation gap.

DBT Has Two Clinical Contexts

Context	Who runs it	What to document
Individual DBT therapy	Individual therapist	Diary card review, target hierarchy, chain analysis, skills, phone coaching
DBT skills training group	Skills trainers (separate from individual therapist in standard DBT)	Group note + individual addendum per member

In standard DBT, the individual therapist and skills trainers are different people. The individual therapist has access to the full clinical picture; skills trainers document only what they observe in group.

The Diary Card: A Clinical Document

The DBT diary card is not homework — it’s a clinical assessment tool. Documenting the diary card review is part of the standard of care.

DIARY CARD REVIEW
Card completed: □ Yes  □ Partially  □ No — reason: __________
Days tracked: ___ / 7

Target behaviors this week:
Suicidal ideation (0-5 scale): Mon__ Tue__ Wed__ Thu__ Fri__ Sat__ Sun__
NSSI: □ None  □ Episodes: ___________________________________
Urges (highest this week): SI urge ___  NSSI urge ___
Misery rating (0-5): ___

Skills used (from card): □ Yes  □ No  Details: _______________
Medications taken as prescribed: □ Yes  □ No  □ N/A

Highest-priority item on card: __________________________________
Addressed this session: □ Yes  □ No — reason: _________________

DBT Target Hierarchy: Document Which Level You Addressed

Every DBT session note should reflect the treatment hierarchy:

DBT TARGET HIERARCHY — THIS SESSION

1. Life-threatening behaviors (suicidal/homicidal behavior, NSSI)
   Present this week: □ No  □ Yes: _________________________
   Addressed: □ Yes  □ N/A

2. Therapy-interfering behaviors (TIBs)
   Present: □ No  □ Yes: __________________________________
   (TIBs = behaviors that disrupt therapy — late cancellations,
    not completing diary card, dissociation in session, etc.)
   Addressed: □ Yes  □ No — reason: _______________________

3. Quality-of-life behaviors
   Focus this session: ______________________________________

4. Skills acquisition / generalization
   Skills targeted: ________________________________________

SESSION FOCUS (highest-priority item addressed):
□ Level 1 — life-threatening behavior
□ Level 2 — therapy-interfering behavior
□ Level 3 — quality-of-life target: ________________________
□ Level 4 — skills work

Chain Analysis: Full Template

The chain analysis is the core individual DBT intervention. Document it in full when a target behavior occurred.

CHAIN ANALYSIS

TARGET BEHAVIOR: ___________________________________________
Date/time of behavior: ______________________________________
Severity / specifics: _______________________________________

1. VULNERABILITY FACTORS
(What made client more susceptible that day?)
Physical: □ Poor sleep  □ Illness  □ Substances  □ Skipped meds
          □ Hunger/fatigue  □ Other: _______________________
Emotional: ________________________________________________
Recent stressors: __________________________________________

2. PROMPTING EVENT
(The specific event that started the chain — concrete, behavioral)
What happened: ____________________________________________
When: ____  Where: ____  Who was involved: _________________

3. LINKS
(The chain of thoughts, feelings, sensations, behaviors between
 prompting event and target behavior — be specific)

Link 1: [Thought / feeling / sensation / behavior]
→ Link 2:
→ Link 3:
→ Link 4:
→ Link 5:
→ [Continue as needed]

4. TARGET BEHAVIOR
What exactly happened: _____________________________________
Duration: ___  Intensity: ___

5. CONSEQUENCES
Immediate consequences: ____________________________________
Reinforcing consequences: __________________________________
(What made the behavior more likely to happen again?)
Short-term relief / escape: _________________________________

SKILLS GAPS IDENTIFIED (where could a skill have broken the chain?)
After Link ___: Skill that could have been used: _____________
After Link ___: Skill that could have been used: _____________

SOLUTION ANALYSIS
Skills to practice before next session: _____________________
Commitment from client: ____________________________________

Individual DBT Session Note Template

DATE: _______  SESSION #: ___  DURATION: ___ min
FORMAT: □ In-person  □ Telehealth

DIARY CARD REVIEW
[See diary card section above]

TARGET HIERARCHY
[Document which level was addressed — see hierarchy template]

CHAIN ANALYSIS (if target behavior occurred)
[See chain analysis template above]

SKILLS WORK
Skills reviewed from last session: __________________________
Client's practice between sessions: ________________________
New skill introduced / practiced this session: _______________
Skills coaching strategies used: □ Validation  □ Cheerleading
                                  □ Problem-solving  □ Other: _

DIALECTICAL STRATEGIES / VALIDATION
Validation level(s) used: □ 1 □ 2 □ 3 □ 4 □ 5 □ 6
Dialectical strategy: □ Devil's advocate  □ Wise mind
                       □ Extending  □ Other: ________________

COMMITMENT WORK
Commitment elicited: □ Yes  □ No  □ N/A
Content: _________________________________________________

RISK ASSESSMENT
SI: □ None  □ Passive  □ Active — plan: ____________________
NSSI urges: □ None  □ Present: ____________________________
Safety plan reviewed: □ No  □ Yes  □ Updated

PHONE COACHING AGREEMENT
□ No changes  □ Updated: __________________________________
Calls this week: ___  Content: _____________________________

PLAN
Next session focus (if no new crisis): ______________________
Skills assignment: _________________________________________

DBT Skills Training Group Note

Group Note

DATE: _______  SESSION #: ___  MODULE: ____________________
(Mindfulness / Distress Tolerance / Emotion Regulation / IE)
Skill(s) taught: ___________________________________________
Trainers: _________________________________________________
Members present: ___ / ___  Members absent: ________________

TEACHING METHOD
□ Didactic  □ Whiteboard  □ Roleplay  □ Worksheet  □ Video
□ Mindfulness exercise: ____________________________________

GROUP PROCESS
Participation level: □ High  □ Moderate  □ Low
Group dynamics: ___________________________________________
Significant moments (anonymized): __________________________

GROUP-LEVEL SAFETY
□ No safety concerns at group level
□ Concern: _______________________________________________
  Action taken: ___________________________________________

PLAN
Next session: Module ___ / Skill: __________________________
Homework assigned: ________________________________________

Individual Addendum (per member)

MEMBER: _________  SESSION: ___  DATE: ___________

HOMEWORK REVIEW
Assigned: ________________________________________________
Completed: □ Yes  □ Partially  □ No
What happened (if practiced): ______________________________
Obstacle if not practiced: _________________________________

PARTICIPATION THIS SESSION
Level: □ Active  □ Moderate  □ Minimal  □ Absent
Specific contribution: _____________________________________
Skill application observed: ________________________________

CLINICAL CONCERNS
□ None  □ Safety: _________________________________________
□ Therapy-interfering behavior in group: ___________________
□ Referral to individual therapist: □ Yes  □ No

PLAN
□ No follow-up needed
□ Contact individual therapist: ___________________________
□ Outreach before next group: _____________________________

Filled Example: Chain Analysis

Client: 26F, BPD diagnosis, 8 months of standard DBT. Target behavior: NSSI (cutting, superficial) — occurred Tuesday evening.

Target behavior: NSSI (superficial cutting, left forearm, 3 cuts). Tuesday at approximately 9:30 PM.

Vulnerability factors:

Physical: 4 hours of sleep previous night (stayed up after conflict with roommate); skipped dinner; no mindfulness practice in 3 days.
Emotional: residual shame from previous week’s session (chain analysis on prior NSSI felt “humiliating”).
Recent stressors: upcoming performance review at work (Thursday); roommate conflict Monday.

Prompting event: Tuesday 7:15 PM — text from roommate saying “we need to talk” with no further explanation. Client interpreted this as confirmation that roommate wants her to move out.

Chain:

(Thought) “She’s going to kick me out. I knew this was coming.” → (Emotion) fear + shame spike
(Behavior) Attempted to text roommate back, no response for 40 minutes → (Emotion) fear escalated to terror; (Thought) “Silence means the worst”
(Behavior) Googled “how to find emergency housing” → (Emotion) overwhelm; (Thought) “I can’t handle this”
(Thought) “I ruin everything. I’m going to be alone forever.” → (Emotion) shame intensified; dissociative symptoms (zoning out, “watching myself from above”)
(Behavior) Went to bathroom, retrieved razor kept “for emergencies” → urge intensity 8/10
(Target behavior) NSSI — cutting. Immediate relief from dissociation; brief reduction in emotional pain.

Consequences: Immediate — emotional pain reduced from 9/10 to 4/10; returned to “present.” Reinforcing consequence — avoidance of thinking about housing situation. Later consequence — shame about NSSI; hid cuts from roommate when she finally called (roommate wanted to talk about shared grocery expenses — not eviction).

Skills gaps:

After Link 2: TIPP skills (Temperature — ice water) — not attempted. Client stated “I forgot.” Last practiced in session 3.
After Link 4: Opposite Action (acting opposite to shame — reaching out instead of isolating) — not attempted. Client stated “It felt impossible.”

Solution analysis: Re-practice TIPP this session. Client commits to putting ice pack in freezer as environmental prompt. Agreed to remove razor from bathroom before next session — environmental control. Phone coaching agreement reviewed: client will call if urge reaches 6/10 before acting.

Filled Example: Skills Training Group Note

Group: Emotion Regulation module, Session 4 of 8. “Checking the Facts” skill. 7 members present, 1 absent.

Group note:

Skill taught: Checking the Facts (Emotion Regulation) — identifying whether emotion fits the facts, and whether its intensity fits the facts.

Teaching method: Didactic introduction (10 min), whiteboard mapping of “emotion → assumed facts → actual facts” with group-generated examples (20 min), paired practice with worksheet (15 min), debrief (10 min).

Group process: High engagement. First half of session: two members dominated discussion with personal examples — gently redirected twice without disrupting group flow. Second half: paired practice produced strong participation from typically quieter members. One member (M.) appeared visibly distressed during the “shame” example used in didactic portion — monitored, no crisis intervention needed, made note to flag to individual therapist.

Group-level safety: No crisis. Member M. — distress response to shame example — monitoring note to individual therapist.

Homework: Complete “Checking the Facts” worksheet for one emotion experienced this week.

Individual addendum — Member T.:

Homework (Opposite Action from last session): Partially completed. Practiced 2 of 3 assigned situations. Did not practice in family context — stated “the situation didn’t come up.” Identified this as avoidance in debrief.

Participation: Active. Offered example from work situation that was well-used by group. Demonstrated understanding of skill distinction (emotion fits facts vs. intensity fits facts).

Clinical concerns: None.

In TheraMemory, the client card’s «Important Information» section is a practical place to store the client’s current DBT stage, active target from the hierarchy, current module in skills group, and primary chain links from recent analyses — visible at the start of every session without reconstructing from notes.

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DBT stage, current hierarchy target, and active chain links stored in the client card — visible at every session. Session chronology tracks behavioral patterns across the full course of DBT treatment.

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DBT Session Notes: Individual Therapy and Skills Training Documentation

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