Emphasis on the primacy of affect
In comparison to many cognitive-behavioural treatments, and particularly cognitive therapies, DBT especially emphasizes the role of affect as a key causal variable. Unlike some forms of cognitive-behavioural treatment, DBT does not necessarily require cognition as a mediating variable between prompting events and affect. DBT conceptualizes affect as the totality of the internal system response following a prompting event. Linehan (1993a) hypothesized that a heightened vulnerability to these systemic responses and the inability to regulate such responses leads to many of the behaviours associated with BPD.
Emotion as a total system response
DBT emphasizes the totality of the multi-system response to affective cues. In this conceptualization, emotions comprise internal biological responses (e.g. changes in neurotransmitters, changes in blood flow and muscle tension), internal sensations (e.g. “butterflies” in the stomach, experience of the face flushing, sensation of experiencing the emotion—in other models this sense experience is often referred to as the “emotion”—and action urges associated with the emotion), external changes in behaviour (e.g. facial movement, verbal behaviour and overt actions) and cognitions. Linehan highlights that this multi-system response may be more of an automatic response to the prompting event in some circumstances (e.g. flight/ fight responses, classically conditioned responses) and may be mediated by online cognitive processing (e.g. judgements, interpretations) in others. At different times, DBT therapists attend to all aspects of the emotional response and to modifying affect, regardless of the level of automaticity of the response. DBT identifies two particular problems with the affective system for clients with BPD: emotional vulnerability and an inability to modulate affect.