Dialectical Behavior Therapy for Emotion Dysregulation
Lorie A. Ritschel, Alec L. Miller, and Victoria Taylor
Dialectical behavior therapy (DBT; Linehan, 1993a, 1993b) is an evidence- based treatment originally developed for chronically suicidal adults with borderline personality disorder (BPD). BPD can be thought of as a disorder of emotional, behavioral, cognitive, intrapersonal, and interpersonal dysregulation (Linehan, 1993a); thus, the overarching goal of treatment is to intervene on this pervasive dysregulation and to help individuals with BPD modulate their emotions without engaging in ineffective compensatory or regulatory behaviors (e.g., suicidal or nonsuicidal self-injurious behaviors [NSSI]). According to DSM-5 (American Psychiatric Association, 2013), a diagnosis of BPD requires the presence of at least five out of a possible nine criteria, meaning that considerable variation in symptom presentation exists among individuals with BPD. Moreover, many individuals with BPD also meet criteria for comorbid Axis I disorders (Lieb, Zanarini, Schmahl, Linehan, & Bohus, 2004). In order to treat the myriad areas of dysregulation found among suicidal individuals diagnosed with BPD, Linehan designed DBT (1993a), a multimodal therapy that is both comprehensive and flexible.
DBT synthesizes four distinct theoretical foundations: dialectics, Zen philosophy, behaviorism, and the biosocial theory of emotion dysregula- tion. The term dialectical refers to the philosophy that there is no absolute truth; that is, seemingly opposite ideas (i.e., thesis and antithesis) can both be true at the same time, and their convergence produces a synthesis out of which a new dialectic may arise. As it applies to the practice of psychotherapy, a dialectical philosophy highlights the need for clients to work on simultaneously accepting and changing their thoughts, emotions, and behaviors. DBT therapists teach their patients to move away from black-and-white, “either-or” thinking and instead to view the world in accordance with the idea that there is no absolute truth. For example, a therapist might say, “I believe that you are doing the best you can; and, at the same time, you must do better at tolerating your distress if you want to reach your goals.” By learning to reduce polarized thinking, clients achieve the ability to find a middle path, opening up novel pathways to problem solving and reducing cognitive rigidity.
At its core, DBT is a well-balanced blend of acceptance- and change- based strategies (Linehan, 1993a, 1993b). Acceptance-based interventions are primarily informed by the principles of Zen mindfulness practice and teach patients how to accept their reality without trying to change it (including their behaviors, emotions, and circumstances) through mindful and nonjudgmental participation. The change-based interventions used in DBT are largely predicated on the principles of behaviorism and include techniques such as exposure, contingency management, problem solving, and cognitive restructuring. For individuals with BPD, both strategies should be woven together in an iterative, balanced fashion, because individuals with BPD tend to find change without acceptance to be invalidating of their difficulties. At the same time, they are likely to find acceptance without change insufficient in helping them achieve the life they want (and invalidating in its own right).
Linehan’s (1993a) biosocial theory posits that BPD emerges from the transaction between biological dysfunction in the individual’s emotion regulation system and an invalidating environment. We describe these two elements in turn. Biological dysfunction comprises three components: high emotional sensitivity, pronounced emotional reactivity, and slow return to baseline (Linehan, 1993a). First, individuals with BPD tend to operate in a state of physiological hyperarousal (Ebner-Priemer et al., 2007; Kuo & Linehan, 2009), leaving them more vulnerable to emotional triggers and cues (both intra- and interpersonally). Second, individuals with BPD tend to be more reactive to emotional events than individuals without BPD (Bland, Williams, Scharer, & Manning, 2004; Ebner-Priemer et al., 2007). Given their higher level of emotional sensitivity, this reactivity can result in extreme emotional experiences, such as rage, panic, and profound dysphoria. Third, once dysregulated, individuals with BPD tend to take longer than individuals without BPD to return to emotional baseline (Kuo & Linehan, 2009; Yen, Zlotnick, & Costello, 2002). To draw an analogy, life for individuals with BPD is the emotional equivalent of going to the beach when you already have a sunburn (high baseline arousal), forgetting your sunscreen (greater reactivity to triggers), and having the kind of skin that takes a long time to get back to normal after a sunburn (slow return to baseline).
The second component of the biosocial theory is the invalidating environment. This term refers to any environment that negates, punishes, ignores, or corrects a person’s emotions or behaviors independent of the actual validity of the emotion or behavior. In essence, an invalidating environment communicates that the individual’s perceptions of and responses to the world simply do not make sense. Take the example of a child who is teased at school and reports to her parents that she feels sad when other kids make fun of her. Her parents respond by telling her it is stupid or wrong to feel sad about that and that instead she should be angry with the other kids and with her teachers for not protecting her from such bullying. What results is a mismatch between what the child is feeling and what she is told she should feel, which can lead to confusion about emotions and ambivalence about how to respond to a similar trigger (i.e., bullying) in the future. Alternatively, consider the teenager who struggles in his math class and has repeatedly asked his parents for help with homework or to get him a tutor. He comes home at the end of the week having failed a test for which he studied every day and is told that he should have “tried harder.” As another example, when teens engage in NSSI, parents often remark that they are “just being manipulative” without recognizing that most teens engage in NSSI as a way to downregulate negative affect (Nock & Prinstein, 2004). These kinds of environments fail to teach the child to recognize, label, and respond to emotions appropriately, and they often inadvertently reinforce ineffective behavior on the part of the child. It is important to note that invalidating environments can include but are not limited to families, peers, school personnel, coaches, and mental health and medical providers (Miller, Rathus, & Linehan, 2007). In sum, the biosocial theory posits that the emotional and behavioral difficulties associated with BPD arise when a child who has difficulty regulating emotion is placed in an environment that pervasively and chronically communicates that the child’s responses are inappropriate, faulty, inaccurate, or otherwise invalid (Koerner, Miller, & Wagner, 1998).