This feature by Lorne Korman, PhD, R.Psych. is Part 1 of 2 in a series about DBT and Anger. In this first part, Lorne addresses how DBT offers a practical and theoretical framework for treating people with anger problems and those who have multiple comorbidities.
I first encountered DBT in the late 1990s when I was working at the Addiction Research Foundation and later the Centre for Addiction and Mental Health in Toronto. Like many other clinicians during this period, I found the arrival of DBT to be a revelation. DBT was the first intervention that had any evidence of being helpful to people with borderline personality disorder. Many of our more difficult-to-treat clients with addictions had borderline personality disorder. During my own training as a psychologist, I had been exposed to a pervasive sense of dread and hopelessness among clinicians treating people with BPD. People who received this diagnosis, mostly women, were seen as alternately mysterious, untreatable, manipulative, and the architects of their own misery. In contrast, DBT provided a compassionate understanding of these individuals and their problems. More importantly, DBT offered an effective framework for treating these individuals and supporting clinicians in their work.
Anger was frequently a problem among our clients seeking help for their addictions. This comorbidity presented a significant challenge in our consideration about how best to go about treating these clients. A common limitation of research on treatment efficacy is the tendency to screen out individuals with more than one mental health or addiction problem. For example, many existing treatments have been based on clinical research trials and have screened out participants who were suicidal. Clinical studies on the treatment of depression, anxiety, and other problems have often excluded people with substance use problems. Residents and doctoral students in our training programs frequently expressed frustration that the gold standard treatments for anxiety problems could not easily be applied when their clients presented with other problems. Not surprisingly, many of the empirically supported treatments for these problems often do not lend themselves well to helping individuals who have multiple comorbidities. These were the folks in our clinics – not individuals with one discrete problem but rather people with serious anger problems who also presented with other issues like substance use, mood, anxiety, interpersonal problems.
When I agreed to build a clinic for individuals who had comorbid anger and action problems, many aspects of DBT were appealing. One of things I liked most about DBT was that DBT research had an unusually high amount of ecological validity. This was also the case for individuals in anger research. These were the very individuals who we were charged with treating – clients with comorbid anger and addiction problems, many of whom also had personality disorders and other comorbidities.
DBT offered a practical and theoretical framework for treating people with anger problems who had multiple comorbidities. Among other things, this included a guiding target hierarchy, a set of interventions to track, analyze, and troubleshoot diverse behavioral problems, and a flexible framework that incorporated existing CBT interventions for mood, anxiety, substance use, and other problems. DBT also included built-in interventions that acknowledged and addressed low client motivation, behaviors interfering with treatment, ruptures in the working alliance, and waning therapist morale – all of these were issues prevalent in our work with clients who had serious anger problems.
Anger problems are one of the diagnostic criteria for borderline personality disorder. Perhaps the most appealing feature of DBT in our work with anger problems was its focus on emotions. Linehan views borderline personality disorder as involving a pervasive dysfunction of the emotion regulation system. Behavioral problems are seen largely as the consequences of dysregulated emotions and/or attempts to re-regulate emotion. DBT included skills modules focused on improving clients’ ability to regulate their emotions and their capacity to tolerate intense emotions and distress with acting. Another module of skills largely focused on helping clients navigate conflict effectively. Thus, many DBT skills directly addressed the regulation of anger and other emotions as well as the capacity to deal with conflict in a non-hostile fashion.
Ironically, most treatments for problem anger have largely neglected emotions. For example, CBT approaches to anger management have tended to focus on targeting client’s cognitions. The notion underlying this approach is that distorted cognitions engender problem anger and that the identification, analysis, and “restructuring” of these faulty ways of thinking will result in emotional and behavioral change. I have always thought that there were a number of shortcomings to this approach. For one thing, our perceptual processing activating emotions occur so quickly that we typically do not have access to the attendant cognitions until well after our emotions are evoked. Secondly, as Linehan pointed out, once a strong emotion is activated, the intensity of the affect is “self-validating,” and examining or implicitly questioning the accuracy of people’s take on personally meaningful events typically increases emotional arousal, making it even harder for clients to process new information in treatment. This is one of the reasons why validation is a key intervention in DBT. Even though Linehan initially listed “cognitive restructuring” as the indicated intervention for cognitive dysfunction, collaborative empiricism and restructuring never played prominent roles in DBT, and influencing clients’ ways of thinking is largely accomplished by other interventions like dialectical communication strategies and validation. Arguably, cognitive restructuring does not play much of a role in any of the scientifically supported treatments for borderline personality disorder.
Read here for part two, in which Lorne addresses the use of DBT in the treatment of anger problems.
Lorne Korman, PhD, R.Psych., is a registered psychologist and Clinical Associate Professor of Psychiatry at the University of British Columbia. Dr. Korman’s research has focused on adapting DBT to help adults and youth struggling with anger and addiction. Read his full bio here.
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