July Membership Meeting Write-Up — Madeline Taylor, LMFT

Dialectical Behavior Therapy for Emotion Regulation

Presented by Patty Gieselman, LMFT

I don’t know about you, but I always get stumped by the word, “dialectical.” It’s like a roadblock in my brain causing me to slow down and have to think . . .”What does that mean?” A dictionary definition describes “dialectical” as meaning, “concerned with opposing ideas.” Our July presenter, Patty Gieselman, helped considerably by explaining that in Marsha Linehan’s Dialectical Behavior Therapy, “dialectical” refers to a synthesis, perhaps a synthesis of opposing ideas.

According to Ms. Gieselman, Dialectical Behavior Therapy synthesizes therapeutic acceptance with developmental change. She illustrated the basic attitude which allows this synthesis to occur with the Serenity Prayer:

“God, grant me the serenity to accept the things I cannot change,
the courage to change the things I can,
and the wisdom to know the difference.”

Translating this sentiment into the language of psychotherapy, this prayer describes the therapist’s stance toward the patient; a stance which combines accepting the patient as he or she is while exploring dimensions of the patient’s experience which might be open to modification. It might also describe the stance towards oneself which might develop in patients who are treated by Dialectical Behaviorists. They take an accepting stance towards the patient as a whole while teaching skills which can help the patient with dis-regulated behavior, cognition, emotions, interpersonal relationships, and the patient’s sense of selfhood. The goal, as I understand it, is to aid patients in the working through of conflicting needs and dis-regulated feelings in an atmosphere of general warmth and acceptance.

Ms. Gieselman shared that earlier in her career she’d worked for a time with aggressive boys. She tried to teach them how to be in a bad situation without making it worse for themselves. She was able to reduce their propensity towards violent and belligerent behavior when she added DBT to her treatment protocol. She recognized that these boys had been raised in invalidating environments and hadn’t been able to learn successful social, emotional, and relational skills. DBT provided a way to understand and treat the developmental deprivations which left the boys disconnected from their affective selves and disconnected from the world of human relationships. Their own emotional and relational needs hadn’t been met during development, therefore they were angry and primed to experience others as emotionally dangerous.

One of the therapeutic goals of DBT is to promote the patient’s capacity for self-reflection, for mindful awareness of their feelings, and for tolerating unpleasant affect without immediately reacting from an unconscious, automatic place. Deeply engrained reactions such as interpersonal aggression, drug use, bodily self-harm, etc. can be reflected upon and lifted into higher degrees of conscious awareness in the medium of the therapist’s stance of acceptance. Acceptance doesn’t mean approval . . . it just means that we understand that the patient gets re-activated and gripped by unconscious impulses based on their history of having to protect themselves. Our non-judgmental acceptance of that reactivity, however, provides them with something they didn’t get as children, compassionate understanding for their feelings and needs.

DBT treatment provides a patient with a human environment which is accepting of their basic feelings and needs, structured in the teaching of social skills, helpful in the teaching of ways to manage intense feeling states, and soothing in its emphasis on mindfulness practices. Patients with childhood histories of abuse and neglect were not soothed sufficiently by their caregivers; they were not calmed and restored to a sense of emotional equilibrium on a regular basis, so they haven’t had the opportunity to develop self-regulating abilities. This is not their fault . . . it was a deficiency in the caregiving surround which left a baby or child on his own to calm down anyway he could.

For example, I have a patient who was left in her crib for hours by an overwhelmed, depressed mother and a disengaged father. She coped with her intense distress by pulling out her hair until by 12 months of age she was completely bald. Needless to say, this patient needs a lot of reassurance from her therapist which she’s never certain she really deserves. Gradually, over time however, she has developed new capacities for self-soothing, which, coupled with the security of an accepting therapeutic relationship, has afforded her a greater sense of emotional equilibrium and relational security.

DBT helps patients distinguish degrees of distress, ranging from no emotional reaction at all, to feeling distressingly out of control. They call these Subjective Units of Discomfort, or SUDS. It can help patients who are in disregulated states to offer them something to THINK about. Helping them think about the degree of distress they’re in and giving them guidelines as to what to do in different degrees of distress can help them focus their attention on themselves in an empathetic way. “OK, I’m going to take a breath and see what degree of distress I’m in, then I’m going to remember what my therapist suggested I do when I’m in this state.” I imagine that this could help someone tune into their emotional state, observe themselves non-judgmentally, remember the accepting/helpful voice of their therapist, and feel comforted by having a plan of action.

DBT also recognizes that thoughts, feelings, and behaviors get reactivated in particular contexts, unique to every patient. The therapist learns to search for the impetus behind the behavior, to attempt to understand the reason for the cutting, the drug relapse, the angry outburst, etc. What psychological function did it serve the patient at that moment? Was it unconsciously motivated by a deeper desire to decrease distress, avoid conflict, reduce shame or embarrassment, change behavior, or avoid punishment? Whatever the unconscious motivation, the reaction was probably a self-protective reflex…a pre-emptive strike because the patient felt unsafe . . . an automatic reaction to a perceived interpersonal threat . . . or something as yet undiscovered.

DBT therapists use other cognitive methods for helping patients interrupt unconscious, automatic behaviors so that they may learn how to tolerate certain dysphoric affect states. One example is The STOP Skill, standing for: Stop, Take a step back, Observe, and Proceed mindfully. Repeating this simple directive can become a helpful way to interrupt the old, automatic patterns of thought-feeling-behavior that are causing the patient trouble. Creating a new pattern won’t necessarily be easy and it might take time, but knowing that there is a pathway which might help them avoid the unintended consequences associated with the old patterns, could feel comforting.

These are only a few of the ways that dialectical behaviorists give their patients useful tools when disruptive feelings overwhelm them or they feel the urge to engage in behaviors which ultimately have unpleasant consequences for them. I sensed from Patty Gieselman’s presentation that Marsha Linehan’s DBT continues to evolve. Formally trained DBT therapists are required to be members of a therapist support group, a recognition that working with patients who were abused or neglected in childhood requires “a village.”

DBT also emphasizes the quality of attachment between therapist and patient. The listening stance of acceptance and exploration of the patient’s subjective world is a way to join with the patient, affording him or her a more secure base from which to experiment with modulating dysphoric affect, modifying painful thought patterns, and implementing alternatives to the automatic behaviors from which many patients ultimately want relief.

In other words, a dialectic, a synthesis between acceptance and change.

Madeline Taylor, PhD, LMFT, has been in practice for 40 years. She is associated with the Institute of Contemporary Psychoanalysis and has taught attachment theory, self-psychology, and intersubjectivity theory for 30 years. She has offices in Santa Monica and Calabasas, seeing adolescents, adults, and couples. “Nothing is as powerful as human understanding.” (George Atwood)