Dialectical Behavior Therapy Skills Part 4: Distress Tolerance

Dialectical Behavior Therapy Skills Part 3: Emotion Regulation

Today’s article is part three of our series on DBT and will serve as a natural extension of the discussion of the last post on using entertainment media to manage our emotions. The third DBT module, emotion regulation, is geared towards teaching individuals skills to better understand and adjust their affective states. By the time a client reaches this component of DBT, she has received extensive training in mindfulness and interpersonal interactions. The disorders typically treated through DBT, however, are characterized by unstable, overwhelming emotions, so clients are generally eager to develop these skills.

The emotion regulation module generally begins with a discussion of the cycle that often characterizes emotional experiences. A prompting event triggers automatic thoughts, which lead to an emotional experience, which in turn prompts a response. The aftereffects of that response then start the cycle anew. As an example, if Amanda gets stood up for a date, she might experience an automatic thought along the lines of “I am fat and undesirable.” This thought will lead to highly aversive, intense feelings of shame and sadness. After brooding and wallowing in this upsetting series of thoughts and emotions, Amanda may then attempt to change her mood through behaviour like binge eating. Although this behaviour does offer immediate reductions in negative affect (Smyth et al., 2007), it is typically followed by additional intense negative feelings. These feelings may then lead Amanda to withdraw socially, calling in sick for work the next day and sitting at home by herself ruminating and likely engaging in additional, similar cycles of emotion.

DBT aims to prevent these cycles by educating clients about emotions and teaching them skills for more effective regulation. The discussion of the nature of these cycles is thus followed up with a basic discussion of identifying and labelling emotions. Alexithymia, defined as difficulty identifying, describing, and expressing emotions and somatic sensations (Sifneos, 1973), is common in borderline personality disorder (Barenbaum, 1996) and can result in a variety of maladaptive behaviours due to a resulting lack of skills with respect to effectively managing emotion. To address this, the emotion regulation module first teaches clients to effectively recognize and label emotions. Referring to your mood by saying “I feel bad” or “I’m in a mood” is discouraged, with more precise descriptions such as “I am feeling frustrated” encouraged instead. The purpose for this semantic shift is to prevent clients from viewing their emotions as vague, uncontrollable forces and to teach them to differentiate between different emotional states so as not to relate each negative emotion to all over negative things that have ever happened to them in the past.

Building off this point, the skills training co-leaders then discuss the difference between primary and secondary emotions. Primary emotions – our initial emotional response to stimuli – are a universal experience. Secondary emotions – emotional responses about emotional responses – however, are uniquely human and almost universally destructive. In other words, it’s one thing to feel sadness, but it’s significantly worse to feel shame about your sadness (see Why Zebras Don’t Get Ulcers, Third Edition for more information on secondary emotions). This secondary emotion serves no practical function, as there is no evidence that shame about sadness reduces the likelihood of experiencing sadness again in the same situation. Instead, the individual simply doubles the number of aversive affective experiences and increases negative automatic thoughts, thus heightening vulnerability to destructive behaviours. Clients are taught to label both their primary and secondary emotions and to work to accept and experience their primary emotions without judging themselves for having them in the first place.

Before moving on to specific skills for regulating emotions, the co-leaders spend time discussing one more pivotal, basic concept: why individuals have emotions in the first place. The evolutionary purpose of emotions is thus explained. Emotions serve as alert systems, telling us that something in our immediate environment is positive or problematic. We thus encode information about our environment in a salient, efficient manner that can be easily accessed the next time a similar environment is encountered. Additionally, emotions are used to communicate. Importantly, this communication occurs not only through verbal expression but also through body language and facial expressions. This is particularly true for babies, who respond to smiles and looks of fright from adults even before developing linguistic abilities. Clients are thus taught that feeling an emotion is never “wrong.” It simply is. You feel what you feel. The question is what you will do about it and how you will express it. Clients are taught to be mindful not only of what they say but also how they say it and how they present themselves in the process.

At this point, the co-leaders begin teaching specific methods for effective regulation of emotions. The first suggestion is to reduce vulnerability. Individuals are vulnerable to negative emotions in a variety of circumstances, including when they are hungry, sick, tired, and in pain. As such, clients are told to prioritize a consistent and healthy pattern of sleep, diet, and exercise.

FrazzledThe second specific skill is to build positive experiences, both short and long-term. Although at times we may find ourselves motivated to regulate negative emotions by simply doing whatever we can to immediately reduce them (Whiteside & Lynam, 2001), the best remedy for negative emotions is actually positive emotions. It thus follows theoretically that, by increasing the amount of time that an individual feels good, you will decrease the amount of time spent feeling bad. This may seem intuitively obvious, however, it is not the instinctual human response when we become stuck in a pattern of chronic negative affect. As such, clients are encouraged to plan daily, short-term positive experiences. They do not need to be overly indulgent, expensive, or time-consuming, but they need to be positive, healthy activities. This can mean going for a 10-minute walk each day, reading a chapter of a novel, calling a friend each night, or reading a silly magazine. Long-term positive experiences involve the identification of precise life changes clients would like to make, as well as incremental steps along the way that the client can make in an effort to eventually accomplish this goal. By incorporating both daily and long-term positive experiences into an individual’s life, the focus can be shifted away from all the imperfections that inevitably fill any life. During this section, clients are also taught that building mastery is a powerful emotion regulation tool. Feeling productive and effective can dramatically increase positive emotions and healthy behaviours.

The second specific skill taught is mindfulness of emotions, both positive and negative. Simply increasing positive experiences will not be particularly effective if we do not actually give those experiences our attention. When a client schedules a half-hour daily to read a fun book, she is told to think only about that experience while she does it. If she spends that time not really paying attention to the book, thinking instead about things she has yet to do or things she wishes went differently, she will experience an increase in negative emotions and miss out entirely on the potential positive experience. As such, the clients practice bringing their attention back to the positive activity and selecting new positive activities if they are unable to succeed with their initial choice. Additionally, if clients attempt to avoid negative emotions, they are unlikely to become adept at managing them. Instead, they are told to notice and accept the waves of negative emotions as they arrive but to view them as temporary states with no power to harm. Negative emotions are natural occurrences – accepting that they happen, whether or not we feel they “should” be there, will actually decrease the intensity and duration of the experience while teaching us not to be so overwhelmed by their presence.

The third specific skill taught is acting opposite to emotion. As we discussed in our article on rumination, when we are upset, we often feel compelled to wallow in those feelings. At times, we even believe this is a productive course of action. This, of course, is not actually true. Opposite to emotion thus encourage clients to respond to sadness with behaviors they would engage in while happy. It encourages clients to approach when afraid and to act civil when angry. The point isn’t to deny emotions – remember, clients are encouraged to be mindful to both positive and negative affect – but rather to ensure that nothing is done that will unnecessary prolong or increase the severity of negative emotions.

As described above, these skills can seem vague, but an important point to keep in mind is that, during the course of a skills training seminar, co-leaders often use roll playing as a teaching tool that enables clients to apply broad skills to their own lives and develop specific examples of ways to effectively implement the skills outside of the training session. In other words, rather than simply give a list of specific activities to be applied identically by every client, DBT offers a set of principles that are universal, but can be experienced through a variety of activities, some of which are more relevant than others to the lives of particular clients.

In Part 4 of this series, we will discuss the final module of DBT – distress tolerance. In the meantime, I would love to hear from you with suggestions for healthy, adaptive ways to regulate emotions. What do you do to feel better when you’re upset? What obstacles might prevent those behaviours from working for others and what do you suggest they try in order to overcome such difficulties? Remember, although these skills are described here as components of DBT, emotions are not restricted to those who meet the criteria for disorders treated with DBT, so an understanding of these skills can be beneficial beyond that particular subgroup.

This post is by Mike Anestis who is a doctoral candidate in the clinical psychology department at Florida State University

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