Return to site

Emotional Regulation Skills in Dialectical Behavior Therapy (DBT) 

Dr. Melanie du Preez

1. Introduction to Emotional Regulation in DBT

In order for emotion-related work with clients to be successful, they must have significant affect activation in sessions. Behavior cannot be regulated through discussions about skills or techniques without the necessary arousal. As the treatment progresses, the relationship formed with the client often becomes a source of arousal. It becomes a mutually therapeutic setting, which is a nonspecific factor in the process. The significant response is also often about adverse or conflicting consequences. Behavior and emotion can both act as biological reinforcers of that person which is regulating. The arousal from a session may also facilitate the development of anger and a sense of entitlement. The therapist and client can then work to promote their rights in a particular situation. The therapist works to avoid creating inconsistencies and instead points out the opportunities for change. Mentally the client may also envision using a behavior to attain reinforcement in anticipation of a mood change. This type of visualization facilitates the development of new and more acceptable responses.

Behavior problems in clients are often worsened by the difficulties they have managing their emotions. Whether the mood factor is chronic and considered a "disorder" or it is situational and based on reactive and unskillful coping, emotions can become both the trigger for dangerousness as well as events which impede progress. The information processing system requires affect regulation in order to facilitate adaptive thinking and subsequent problem-solving. Your ability to sit quietly and think about a problem may depend on how much personal and interpersonal noise is standing in the way. The more thoughts are experienced as a barrage from within or as a commentary from others, the less clear and concise thinking will be, the more time and effort it will take to understand the nature of the provocation, and the more personal and intellectual difficulties will be encountered.

1.1. Importance of Emotional Regulation in DBT

As BPD patients are seen as emotionally sensitive individuals, many factors within the environment may powerfully affect their emotional states, including the therapist. For the development of a sufficiently therapeutic relationship with a therapist to occur, a patient may need to learn some control over their powerful emotional reactions to the apparent loss of control that may occur within such interactions. They need to be able to tolerate the arousal that can be experienced when being encouraged to deal with their cognitions without having to resort to self-harming behaviors or suicidal threats to regain the safety of the invalidating and/or abusive environment. Therefore, the development of some basic emotional control skills can itself be therapeutic. These include the ability to accurately label one's emotions, to identify when and why they have arisen, and the ability to engage in some simple distress tolerance techniques.

The enhancement of emotional regulation skills in patients is considered by some as the central aspect of the process of DBT. Emotional dysregulation is seen as pivotal within BPD, as it is hypothesized that, by definition, the individual may have a genetic vulnerability to developing high emotional sensitivity, which is then combined with certain types of invalidating childhood experiences. These experiences are postulated to actually inhibit or prevent the normal development of a capacity to engage in emotional control strategies, leaving an individual with a powerful emotional reaction to many stimuli but few available emotional coping mechanisms to manage such powerful reactions.

2. Core Skills in Emotional Regulation

One of the four sets of core skill modules in DBT, for these reasons, and because clients struggle with the described different problems on an ongoing basis in the internal, skills module is taught first, as part of the initial phase of DBT, within the first 6 months. Several researchers note that a significant part of the success of DBT is due to the emphasis throughout the program of fostering social skills in clients. Linehan (1993) describes these core skills as the ability to: 1) experience and process emotion without anxiety and mood dependence in the absence of self-harmful behavior originating from deficits in the regulation of emotion; 2) praising, acknowledging, and validating patients when they use appropriate coping skills; 3) teaching patients coping skills using relaxation techniques, cognitive restructuring, targeting and changing behaviors that predict negative emotions before symptoms develop; and 4) preventing overwhelming emotions by developing strategies for avoiding self-harm by developing or improving coping skills. DBT was developed by Marsha Linehan in response to problems associated with treating patients with borderline personality disorder (BPD) with certain characteristics on personality organization.

Frequently, in response to a distressing stimulus or emotion, people think, feel, and act in a way that is both unproductive and may lead to short- and long-term negative consequences. Simply put, acting with certain negative emotions quickly can often create problems that need to be learned how to respond in a way that will be much more effective. A major focus of DBT is on helping clients to learn effective emotional regulation skills. This set of emotional regulation skills is highlighted because having poorly developed or severely compromised skills in this area leads to many of the problems that clients bring to treatment. Problems with understanding and managing emotions result in damaged relationships, lost jobs, missed opportunities, being less productive, increased psychiatric symptoms, and a life that is much less meaningful. Several different dialectical sets are addressed directly in DBT skills training. In emotional regulation skills, these dialectical sets are: emotional grief versus emotional self-punishment and the dialectic between patients' inability to change their inadequate emotional responses to events on the one hand and how an intense focus on emotional arousal sometimes leads patients to escalate emotions further or to 'get stuck' on the other hand.

2.1. Identifying and Labeling Emotions

Hence, it is important that the client be able to identify and label their emotions first, as affect minimization is a learned process. Often, people are accustomed to denying their emotional pain, not understanding it, or not knowing what they are feeling. They will find themselves questioning what they are feeling, what name does this emotion have, altering or distorting their emotions, or seeing only anger. This is then a huge task to expect people to accept these emotions that they are denying exist. Furthermore, this may help people refute their beliefs that emotions are overwhelming, uncontrollable, or confusing.

In DBT (Dialectical Behavior Therapy), the third module helps clients to identify and label emotions. This appears to be the first step in emotional regulation, to clearly differentiate between a range of emotions. Clients learn a range of emotions and how to identify them in themselves. It is intended to assist clients to label their emotions specifically and accurately, even under circumstances that become emotionally charged. This leads to greater self-acceptance of their emotional states, in themselves, and their ability to regulate such experiences. Validation also occurs regularly as a part of the group process to identify and label emotions. Consequently, clients are able to explain their emotional states with more ease and take responsibility for them rather than deny or distort their emotions. This is helping the client accept their emotional life as part of who they are.

2.2. Understanding the Functions of Emotions

The therapist will also often help the patient focus on intense emotional experiences that are difficult for the patient to tolerate, labeling the emotion and examining the function and reality of the experience. The therapist uses the emotion to explore the function/off function of cognitions and suggests different and more adaptive behaviors. These treatments fit into the broader context of the cognitive-behaviorist approach, which pays considerable attention to the frequently intolerable arousal of dysfunctions associated with a variety of emotional states peculiar to the disorder being treated. Therapy may then focus on resolution of trauma experiences, common in chronic PTSD, or the treatment of social phobia or specific phobia.

Most contemporary approaches to the treatment of the more severely disordered individuals advocate a significant focus on the emotional arousal of patients. Both in cognitive behavior therapy (CBT) and interpersonal therapy (IPT), the physician often directly targets the arousal and experience of specific emotional states, including hopelessness, anger, or frustration. In CBT, the therapist uses a range of techniques such as pro and contra, behavioral tests, automatic thoughts, and Socratic questioning aimed at helping patients to rethink long-established negative thoughts, appraisals, and core beliefs. Commonly, the treatments will try to change negative thought processes and dysfunctional thought patterns about self, the world, or attitudes towards others. There may be a further modulation of the emotional states through behavior inhibition (reliving memories or experiencing current situations that are anger-provoking) or encouragement (urges in bulimia patients).

2.3. Opposite Action

In this dialectical theory of change, believing that behavior controls emotion is key. Linehan uses a chart that breaks down the action urge of emotion and its opposite action, emotion experienced after acting on the urge, and situations that would be appropriate for opposite action. This allows for an extended explanation and application of the skill.

In other words, if a situation causes an individual to feel dejected or hinders them from engaging in activities due to debilitating emotional pain, these feelings are increased and prolonged by inactivity. When an individual experiences frustration or envy and sulks, morosely withdraws and feels sorry for themselves, the envy will start to become all-consuming. It is only when an individual acts opposite to their emotion that negative emotions begin to decrease. When one is feeling sad, they act in a way that they normally would if they were acting happy, and in time they will begin to feel better.

When one is suffering from depression, they often do not have enough energy to do much. Consequently, they stay home, in bed, dissociate, and dwell on their sadness all the time. This perpetuates the depression because they never give themselves a chance to have positive experiences that could help raise their energy level, accomplish necessary tasks, distract themselves from the depression, etc., and climb up the emotional ladder to a place of contentedness.

Dr. Marsha Linehan, a renowned psychologist known for her work in Dialectical Behavior Therapy (DBT), coined the term "opposite action" and included the coping skill in her manual. Opposite action is when an individual is asked to act opposite to the current emotion. This skill is particularly helpful for individuals struggling with depression. It is also useful for anxiety, fear, or any other emotion that hurts the individual more than it helps. Almost all such problems become counterproductive at some point, creating more misery and pain.

2.4. Building Mastery

Mastery is at the core of DBT. It suggests that we help clients achieve a sense of gradually building self-efficacy as they develop new skills and use them to build lives worth living. As part of that priority, we help clients set goals, and gain a clear understanding of what has stopped them from achieving their goals up to this point. The intensity of emotions can significantly disrupt a person’s sense of identity and ability to function. DBT provides many strategies to help clients regulate emotions, but one of the most influential is the skills module known as Building Mastery. Building Mastery focuses on teaching clients how to find achievable goals and sustain them. In this example, the lady might work with her therapist to change her overall goals, which might now be realistic given her resources. These changes would have allowed her to start recognizing her own limitations.

The concept of building mastery involves setting patient-assisted goals and creating an achievable plan to reach them. As therapists encourage patients to pursue their goals, patients develop a greater sense of self-efficacy. Additionally, as they work to achieve their goals, the likelihood of experiencing and reducing extreme emotional states is significant. As a guideline to fulfilling goals effectively, it is important to implement specific behavioral skills to prevent crises that can obstruct goal attainment. It is recommended for one to improve self-care practices or engage in pleasant activities as well as reduce vulnerabilities. This aspect of self-care is more effective if goals are set and then broken down into manageable portions. Reminding oneself not to overextend oneself after a stressful event, introduction of physical exercise to prevent tension, maintenance of a healthy lifestyle by self-monitoring, and cultivating self-esteem and self-empowerment are also vital to achieving set goals that would create opportunities for one to experience a greater sense of peace, joy, and success.

3. Practical Techniques for Emotional Regulation

The PLEASE effectiveness acronym has to do with focusing on maintaining mental stability without overuse of Mind Altering Substances. The O stands for Observe (describing a current emotion without using emotion words), because you cannot control a situation until you can accurately name it, and it is hard to decrease the emotions if you do not know the word for it, and difficult to decrease life interfering behaviors if you don’t know your feelings. The P stands for Prevent emotional suffering. Prevent emotions from becoming worse. Not preventing emotional suffering can lead to worsening situations. The S stands for Self-soothe in how you use the BATH skills. Take care of your physical wellbeing with regular activities such as exercising, bathing, or resting. The E stands for Effectiveness, and eating right, getting enough sleep, making time for pleasurable experience, being able to think clearly, and reducing using alcohol and drugs will provide for effectiveness during an emotionally driven situation, and will give you the energy you need to react more effectively.

Finally, let's talk about the Emotion Regulation Handouts. The following handouts are given to all individuals receiving DBT to help them understand the emotion regulation process of DBT more fully, to make new behaviors oriented around emotion regulation more likely, and to enhance the benefits of the bi-weekly group skills training as well as individual psychotherapy sessions. There are five emotion regulation handouts: (1) PLEASE effectiveness, (2) DEARMAN effectiveness, (3) Opposite action effectiveness, (4) Crisis Survival strategies, and (5) Distracting. Emotional regulation skill handouts are given in the first four weeks of Emotion Regulation Module.

3.1. Mindfulness Practices

Emotion Regulation Skills of Marsha Linehan's dialectical behavior therapy have been shown to be effective in the treatment of borderline personality disorder. A person who wants to change their behavior must become aware of their behavior by becoming aware of the behavior. If recognition does not expand, perception is reduced to feeling thoughts and feelings; feelings reduce the chance of making healthy choices at any given time and develop strategies to support healthy action. DBT Emotion Regulation skills are part of the change skills that can help a person develop a healthy identity; it is the aspect that helps the person achieve healthy integration. Emotional regulation skills, as well as promotion and promotion in daily behavioral choices, react effectively to therapy and reinforce the therapist's effects in other areas. The therapist helps through psycho-education and skill training until those self-help skills are used.

While the core characteristic of borderline personality disorder is the inability to regulate emotions, as is evident in all emotion-related psychosocial problems, a problem of mainly emotional dysregulation is diagnosed in other personality disorders: impulsive behavior, dysfunctional interpersonal relationships, and chronic crises related to undesirable behaviors. In emotion regulation, the problem of self-regulation can be observed in common psychopathological interactions across diagnostic models. Stressful emotional states increase the chance of further emotional crises. The person who has emotional crises suffers further, and their social support network suffers. Since emotional experiences and acute crises make something required, radical behavior occurs; inadvertent behavior will worsen the situation experienced and increase the risk of recurrent undesirable states, relatively similar to that already experienced.

3.2. Emotion Regulation Worksheets

Coping happens. This is where your skills of make or break coping attempts will be. There are tons of ways to make sure you'll more likely come out unharmed when struggling with things that are truly difficult, totally disagreeable, and simply aren't comforting. What strategies are going to keep you out of hot water during the indicated time, in order to meet your goals? What coping strategies consistently interfere with your ability to reach your goals (see myths and facts about suicide, below, for a starter about the advantages of staying alive)? While these forms are designed to help you cope during given timeframes, they are infinitely adaptable and can be used in a broader range of contexts.

Clients get homework assignments such as "coping ahead" and "coping with current and accumulated stress" (using pros and cons) at times problematic for DBT. Complete the left-hand columns, and then figure out what might work best. Gather any needed supplies and practice, practice, practice! Certainly, there are numerous other ways to regulate emotions. You would, then, just write about them. Examine your list and consider the pros and cons before deciding what to do next. Coping ahead is all about preparing for a predictable crisis when your typical reactions (e.g. suicide attempts, self-injury, or using drugs) put you right where you don't want to be! This isn't about being in a crisis and then trying to full yourself into believing things will go well with these coping tactics. This is about thinking ahead, figuring out what usually fails, and then figuring out something practical that often does work. Since the right-hand side of the page isn't as relevant to coping ahead, you will likely ignore that section entirely.

3.3. Coping Strategies for Intense Emotions

Distress Tolerance – DBT has coping strategies to help get you through the times that you feel overwhelmed, without making your life worse in the long run. This often revolves around DBT skills that are grouped into the acronym TIP which stands for: Temperature, intense Exercise, Paced breathing and Paired muscle relaxation. When you are feeling overwhelmed the best thing for you to do may be to engage in a different distracting behavior. The goal is to distract your mind long enough so that you can cheerfully label your emotion and make steps to begin to change your mood. Skills training manual for treating borderline personality disorder by Marsha Linehan is the recommended book used to educate individuals about Dialectical Behavior Skills.

Complex PTSD Recovery Online Summit will take place August 20-22, 2021 and is free to watch live. The topic I am presenting on is Emotional Regulation Skills in Dialectical Behavior Therapy (DBT). Dialectical Behavior Therapy uses a broad set of coping skills to manage very distressing symptoms such as intense anger or self-harm impulses that are often associated with complex post-traumatic stress disorder. If you are interested in speaking with a Dialectical Behavior Therapist or contacting a program where you are, I would suggest you go to Behavioral Tech and look for resources there. A majority of DBT work revolves around helping you learn to regulate your emotions by teaching you skills to replace the harmful ones that you were initially able to rely on.

4. Applying Emotional Regulation Skills in Real Life

Skills to Build Positive Experiences and That Are Fun Alternatively, you or a friend may decide for personal reasons that you do not want to be in control when feeling empty inside or scared to death, and you do not want to be distracted from it while feeling that way. As you realize your feeling of emptiness or fear intensifying, you will be in the mood to experience some kind of opposite extreme. It may be difficult, but it may be helpful for reflecting upon such thoughts as, "To feel empty inside is to recognize that I am very much alive," "To be afraid of living life is to appreciate life's untold beauties," or "To lack pride is to recognize how precious your pride really is." When you are ready, your participation will be totally voluntary, and you may simply decide to do just the opposite of what you accepted to be good for your emotional and mental stability.

Skills to Refocus Your Mind At various times, you will become painfully aware that you are feeling empty inside or are close to a panic, and you absolutely do not want to wallow in it. At such times, applying Wise Mind ACCEPTS, or deliberately engaging in an activity that can distract you from the mental anguish, may prove very helpful to take your mind off your state long enough for the emotion to pass.

Let's look at how you can apply the emotion regulation skills that you will acquire. Specifically, you will be encouraged and learn how to respond to extreme emotional reactions by focusing your mind, building positive experiences, distracting yourself, and comparing life with extremes to keep a balanced perspective. Remember to breathe deeply through your belly, as if you are smelling food, or to do paced breathing as you are practicing these emotional regulation skills.

5. SUMMARY

Increasing self-acceptance through enhanced participation in life is a critical DBT goal for all client populations. Such growth requires the integration of many DBT skills and requires extensive modeling, self-disclosure, and the offering of numerous other learning opportunities to the client by the therapist. Personal and therapist courage, compassion, and dialectical thinking allow such opportunities to emerge, be fully embraced, half accepted and revisited or half rejected and revisited, and often eventually become embraced in full by the client as part of the journey toward living life more effectively.

This blog reviews three skills modules from an emotion regulation skills group that are offered within a larger dialectical behavior therapy (DBT) program. The three skills groups taught are modules that address: (1) shifting to a more positive emotive state (seeking-in), (2) increasing distress tolerance while negating negative emotional arousal (seeking-out), and (3) enhancing self-acceptance while being under stress (building a life worth living). The problematic behaviors we hope to change with each of these respective modules are: cutting interpersonally, flailing interpersonally, and failing to express one's presence.

This post is for informational purposes only. It should not be considered therapy. This blog is only for informational and educational purposes and should not be considered therapy or any form of treatment. We are not able to respond to specific questions or comments about personal situations, appropriate diagnosis or treatment, or otherwise provide any clinical opinions. If you think you need immediate assistance, call your local doctor/psychologist or psychiatrist or the SADAG Mental Health Line on 011 234 4837. If necessary, please phone the Suicide Crisis Line on 0800 567 567 or sms 31393. 

This blog is only for informational and educational purposes and should not be considered therapy or any form of treatment. We are not able to respond to specific questions or comments about personal situations, appropriate diagnosis or treatment, or otherwise provide any clinical opinions. If you think you need immediate assistance, call your local doctor/psychologist or psychiatrist or the SADAG Mental health Line on 011 234 4837. If necessary, please phone the Suicide Crisis Line on 0800 567 567 or sms 31393.