Dialectical Thinking in DBT Trauma Work: TOM and Fortunately-Unfortunately Skills


United States Department of Homeland Security

Key Points

  1. Dialectical thinking is particularly important with clients who tend toward extreme thoughts.
  2. The TOM skill stands for thought, opposite, and middle. The idea is to walk the client through each extreme (the original thought and its complete opposite) in order to realize that neither are accurate. You then develop a middle thought together which is both more accurate and less distressing.
  3. In the fortunately-unfortunately intervention, the therapist and client improvise a story by beginning sentences alternately with the words “fortunately” and “unfortunately”. This exercise helps the client to become more dialectical.

Maria benefited from dialectical thinking skills, as her thoughts were starting to become delusional and a little paranoid. It’s common to see paranoid ideation in clients with PTSD.

Meeting in the Middle

One extreme thought Maria was having was, “I’ll never get out of this place, I’ll be stuck here for the rest of my life.” If you’re trained in cognitive behavioral therapy, you’ll know that as thoughts aren’t always accurate or realistic, we’re meant to challenge and correct them.

That approach works with some clients. With a client who isn’t stable, however, it may backfire, as they might feel invalidated. The more you try to convince them their thinking is illogical or irrational, the more invalidating it can feel. So in DBT, we take the TOM approach.

  1. Thought: simply acknowledge the thought.
  2. Opposite: consider the complete opposite of it.
    • The opposite of, “I’ll never get out of this place, I’ll be stuck here for the rest of my life,” can be, “I’ll complete the entire asylum process, become a US citizen, and learn perfect English by tomorrow.” That’s not realistic either. Maria will come to realize that her original thought wasn’t very realistic, because its complete opposite is also unrealistic.
  3. Middle: then move to the middle.
    • This thought-opposite-middle check is like a dance. We’re not forcing the client to change her thinking, we’re just dancing with her thoughts, a three-step dance.
    • When we’ve identified the two end zones, what’s something in the middle? Maria and her therapist brainstormed the following middle thought:
      • “Immigration is always a long and challenging process. However, I’m safe in this setting, I have all the resources I need, and I’ll be released as soon as the paperwork has been processed.”
    • The middle thought is more logical and realistic than the two extremes. The client got here by identifying those and developing a middle thought, not by trying to convince herself or having her arm twisted.


Fortunately-unfortunately is a great intervention to do with kids, but adults can also benefit. For this exercise, you and the client improvise a story. One of you starts each sentence with, “Unfortunately …”, and the other responds with sentences beginning with, “Fortunately …”.

You can also get the client to tell the whole story, playing both parts. The point is to help them see that in life there are both good and bad things. In other words, we’re helping them become more dialectical. In Maria’s case, her own life story was the source material.

Unfortunately, I was molested as a child. Fortunately, I also have some good memories of my childhood. Unfortunately, my boyfriend was not the person I thought he was. Fortunately, I was able to escape and now I’m here in the US. Unfortunately, I was gang-raped in Mexico. Fortunately, the recent rape will expedite my asylum case. Unfortunately, I’m stuck in this place until my papers get cleared. Fortunately, I’m safe here and all my needs are being met.”

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