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From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permis -
sion to photocopy this worksheet is granted to purchasers of this book for personal use only (see copyright page for details). Purchasers may 
download a larger version of this worksheet from www.guilford.com/dbt-  
worksheets .interpersonal effectiveness WorksHeet 5   (I. E. Handouts 5, 6, 7)
Tracking interpersonal e ffectiveness Skills u se
Due Date:       Name:                   Week Starting:  
Fill out this sheet whenever you practice your interpersonal skills and whenever you have an oppor -
tunity to practice, even if you don’t (or almost don’t) do anything to practice. Write on the back of this 
sheet if you need more room.
promp TinG evenT  for my problem: Who did what to whom? What led up to what?
 OBJECTIVES  IN SITUATION  (What results I want):
 RELATIONSHIP  ISSUE  (How I want the other person to feel about me):
 SELF- RESPECT  ISSUE  (How I want to feel about myself):
my priori TieS in this situation: Rate priorities 1 (most important), 2 (second most important), 
or 3 (least important).
  O BJECTIVES       R ELATIONSHIP       S ELF- RESPECT
imbalances and conflic TS in prioriT ieS that made it hard to be effective in this situation:
What i S aiD or D iD in the situation: (Describe and check below.)
Dear man (Getting what I want):
   Described situation?                Mindful?                   
   Expressed feelings/opinions?            Broken record?