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The Role of Emotion Regulation in DBT (Part 2)

The Role of Emotion Regulation in DBT Part 2 - Blog

We sat down with Behavioral Tech Trainer Dr. Sara Schmidt to learn all about the role that emotion regulation plays in DBT.  In Part 1 of this interview, Sara took a deep dive into the idea of emotion regulation and what it means to experience emotion dysregulation, as well as a framework therapists can use to help their clients assess their emotions.

In part 2, we take a closer look at how we support clients in understanding those emotions and the specific DBT skills to give clients to help them regulate emotions and change problematic behaviors.

Question: How does biology factor into emotion regulation?

One of the primary ways we understand emotion dysregulation in DBT is through the biosocial model of disorder, which posits that a biological vulnerability to one’s emotions transacts with an invalidating environment, thus resulting in pervasive emotion dysregulation. 

Some people are biologically predisposed to be more vulnerable to their emotions. They are highly sensitive to emotional cues, and have extreme, and often long-lasting emotions. For those with high sensitivity to emotion, a little bit of stimulus causes an immediate reaction. That is, an event that may seem minor to someone else (e.g., someone cut you off in traffic; a friend didn’t immediately respond to a text message) would lead to an emotional response. I often describe this as like being an emotional burn victim; your emotional skin is so thin that you feel everything acutely. In addition to high sensitivity, many individuals who struggle with emotion dysregulation are highly reactive. They display escalated emotional responses. So, not only might they experience an emotion, but they experience it to such a high degree that it can interfere with processing. Finally, individuals may have what we call a slow return to baseline.  Their emotional reactions stay elevated, and thus what ends up happening is that they never quite return to “baseline” because they are still highly sensitive to emotional cues; there is always something else in the environment that is going to provoke a response.

Question: Can environment be a factor, as well?

Environment – or the “social” half of the biosocial theory – plays a key role in understanding emotion dysregulation. An invalidating environment is one that pervasively rejects both valid and invalid behaviors, regardless of the actual validity of the behavior. Most often, we think of the invalidating environment as parents, but it can also mean siblings, partners, teachers, peers; anyone in a person’s environmental orbit.

There are three characteristics of an invalidating environment. First, it rejects communication of internal – or private – experiences.  That is, it communicates to a person that what they are thinking or feeling is wrong; it doesn’t fit the facts.  Second, an invalidating environment intermittently reinforces escalated behavior. For example, a child who cries or says, “I feel sad,” doesn’t elicit a response from his parents, but sometimes when he says, “I want to kill myself,” the parents become hugely concerned, and provide care and support. The third characteristic is oversimplifying the ease of solving problems; “If you just try harder, I’m sure you can figure out how to pass your math test.”

Many of our clients have grown up in a household where there was abuse or neglect. This is invalidation to the extreme; the very people who were supposed to protect you did not do so.  But sometimes you have an “ordinary” family but there are so many other stressors (financial, medical) that they can’t deal with a child’s emotional needs. Or, there is a temperament mismatch; think, more stoic, non-emotionally expressive parents who are raising a child with a biological vulnerability to emotion. To be clear, we are all invalidating at times, and often with the best of intensions.

Question: What impact does all this have on a client?

Over time, the transaction of the biological vulnerability with the invalidating environment can lead to several problems for our clients. They have difficulty identifying and regulating their emotions. They learn to scan the environment for cues on how to respond in a given situation. They oscillate between escalated emotional responses and shutting down completely. They set unrealistic expectations for themselves. They internalize the invalidating environment and are quick to self-invalidate (e.g., “I overreact to everything;” “no one will ever love me.”)

From a behavioral standpoint, we believe that all behavior is caused – even when we don’t know the causes of behavior – and all behavior makes sense in context. Thus, when I explain the biosocial model of behavior to clients, they often find it resonates quite strongly and it can be incredibly validating for them to understand the development of their behaviors in this way. “It completely makes sense that you are looking to others to figure out how to respond because you’ve been told your whole life that you’re overreacting or making too big a deal out of things.”

I also think this can be incredibly useful and even validating to parents. It is so hard to be an emotionally vulnerable person walking around in this world and at the same time, it can be so hard to parent a person who is so vulnerable to emotions. Emotionally escalated responses (e.g, screaming, attacking, threatening self-harm) can pull for more invalidation from one’s environment and at the same time, our clients typically lack the skills to have their needs met in other ways.

Some of the skills our clients lack are the ones needed to effectively regulate their emotions; so many of their difficulties stem from problematic attempts to do so. They start treatment without the skills to label or describe their emotions. They maintain beliefs such as their emotions will last forever if they allow themselves to experience them. They have grown adept at avoiding their emotions in a variety of ways, such as by dissociating, self-harming, or using substances.

Question: So, what are the DBT tools that therapists use to deal with this?

We teach four primary sets of skills in DBT: mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. Since at its heart, DBT is a treatment that focuses on emotion, I could make the argument that all four sets of skills tap into components of emotion regulation. However, I’ll focus just on what we teach during the emotion regulation module.

First, we teach clients about the functions of emotions. That is, what do emotions do for you? We review myths of emotions (e.g., “some emotions are stupid;” “letting others know that I am feeling bad is a weakness”). We then teach a model for describing emotions, where clients learn how to break down their emotional response into different parts so they can understand all of the components that go into it.  This also helps our clients to see that the way they interpret a situation impacts the emotion that they will experience, and that you can experience an emotion without acting on it. We also walk our clients through several handouts that help them learn different ways to describe their emotions.

Next, we move into helping our clients change unwanted emotional responses. My favorite skill we teach here is opposite action, which is essentially exposure therapy in a skill. When your emotions do not fit the facts of the situation or acting on your emotion is not effective, how can you act opposite all the way (body language, vocal tone, actions) to that emotion urge?

We then teach skills for reducing emotional vulnerability, including accumulating more positive experiences, building mastery, and coping ahead for situations that might be difficult.  We talk about taking care of one’s mind by taking care of one’s body, and finally, we teach skills for managing extremely difficult emotions. I want my clients to learn that when an emotion pops up, they have the ability to sit with the emotion, experience the emotion, and not escape. This is often an incredibly scary – but powerful – experience for our clients.

Sara Schmidt, PhD is a Research Scientist, Trainer, and Consultant at Behavioral Tech, LLC, where she assists in developing training content, methods, and customized implementation plans, and provides training and consultation in both DBT and the DBT Prolonged Exposure (DBT PE) protocol for PTSD. Concurrently, she is a Research Scientist at the Seattle Institute for Biomedical and Clinical Research, part of the VA Puget Sound Health Care System, where she collaborates with Dr. Melanie Harned as a Co-Investigator on NIMH-funded research focused on the evaluation and implementation of DBT and DBT PE. Previously, Dr. Schmidt was a Research Scientist at the Behavioral Research and Therapy Clinics (BRTC) at the University of Washington, where she directed the graduate training program in DBT and currently maintains a Clinical Instructor position supervising advanced doctoral students.