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Dialectical Behavioural Therapy: Practical Skills for Emotion Regulation

Dialectical Behavioural Therapy: Practical Skills for Emotion Regulation

Written by Evan Newton, Counsellor at Bellwood Health Services.

The development of dialectical behavioural therapy (DBT) was motivated by one psychiatrist’s desire to create a comprehensive toolkit of highly effective practical skills for people to manage even their most intense and uncomfortable emotions. In a similar way, if one were to boil it all down, the essence of all the work we do at EHN Canada is helping people learn skills to effectively manage their out-of-control emotions. 

Our operation comprises many different roles: counsellors, psychotherapists, psychiatrists, social workers, medical doctors, nurses, occupational therapists, cooks who prepare healthy food, housekeeping staff who maintain a clean and comfortable physical environment, the finance department, etc. All these moving parts are united in action by EHN Canada’s values: compassion, excellence in both patient outcomes and patient experience, and optimistic perseverance—we never give up!  The synergies between all the parts working together towards the same goal—helping our patients become their best selves—results in the exceptional transformations achieved by patients in our residential treatment programs. We teach our patients many practical, effective, healthy, and constructive skills for managing their emotions drawn from the dialectical behavioural therapy (DBT) repertoire. And gaining competency in emotion regulation skills, through consistent practice, is what builds the foundation of emotional stability that makes transformation possible.

Managing Emotions Can Become a Problem for Anyone

We have a patient who is a young man—since his twenties, he has struggled with intense depression. He’s tried therapy, medications, self-help books, meditation, exercise—and yet the intense negative emotions persist. He’s come to Bellwood because he wants to learn how to regain control of how he feels.

Another patient, a young woman, alternates between feeling numb and feeling extreme emotional pain—with no middle ground in between. She’s highly impulsive, which causes her to relapse frequently to drinking alcohol. And her relapses have been getting more dangerous and frightening each time. She’s come to Bellwood because she needs to understand the reasons behind the unusual way she experiences her emotions, which is both limited and extreme, and to develop better impulse control that will allow her to break her cycle of self-destructive behaviour.

A third patient is a middle-aged man. He feels unable to deal with his problems in healthy and constructive ways—instead, he uses gambling, sex, or cocaine to make himself feel better. His perpetual feelings of loneliness and inadequacy can be traced back to his lonely and invalidating childhood. He’s come to Bellwood to learn new coping skills that are both effective and healthy.

These three patients all have difficulties with emotion regulation. Emotion regulation is the ability to control or influence how one experiences and expresses one’s emotions. Emotion regulation is useful for reducing negative emotions and for creating or amplifying positive emotions. The following are common emotion regulation behaviours:

  • You feel stressed out, so you take a minute to do some deep breathing.
  • You’re feeling down, so you cheer yourself up by listening to your favourite upbeat song.
  • You feel bored, so you reach for your phone, or check Instagram, or Facebook, etc. 
  • You feel overwhelmed, so you call a friend. 

Managing Emotions, Addiction, and Mental Health

For patients in our Mood and Anxiety Program (MAP), their central issue is that their emotions have become unmanageable, and they are seeking to learn new skills to get them back under control. This is also the most constructive way to think about patients in our Addiction and Mental Health program: drugs and alcohol are ways of coping with intense emotions. As coping mechanisms, drugs and alcohol feel incredibly effective in the beginning—but are ultimately highly dysfunctional and destructive. You can think of it as outsourcing your emotion regulation to a toxic substance, rather than putting in the work to do it yourself.  

So we ask all our patients—“would you like to learn alternative, healthier methods for coping with intense feelings?” 

This is where dialectical behavioural therapy (DBT) comes in.  

Therapy Developed for Managing Intense Emotions

Dialectical Behaviour Therapy (DBT) was developed over the last 40 years by a woman named Marsha Linehan. She has dedicated her career to helping people suffering from borderline personality disorder (BPD). These people, usually young women who’ve grown up in chaotic, invalidating environments, describe intense emotional states that lead them to self-harm, suicidality, or other intensely self-destructive behaviours. Linehan noticed that the popular therapies of the day, namely psychodynamic therapy and cognitive behavioural therapy (CBT) gave her patients insight and understanding into their conditions. But she found that these treatments fell short precisely when her patients needed help the most—in instances when the levees broke, when they were overwhelmed by emotion, and they were desperate for something, anything, to relieve their pain. To address these needs, she developed dialectical behavioural therapy (DBT) to help people develop skills for handling intense emotions.  

People Are Trying Their Best

Since it was first developed, dialectical behavioural therapy (DBT) has been used and found to be very helpful for treating individuals with addictions and other mental health disorders. The central assumption of DBT is that people are trying their best to manage with the skills that they have. Their drinking, drug use, self-harm, or isolation are not bad habits or moral failings—they are simply the best tools that they currently have. This is a radical shift in perspective from seeing people in terms of stigmatizing labels such as “alcoholic” or “drug addict.” It allows patients, as well as clinicians, to be non-judgmental, compassionate, and curious about their substance use disorders. 

Dialectical Behavioural Therapy at Bellwood

Patients at Bellwood, whether in the Addiction and Mental Health Program or in the Mood and Anxiety Program (MAP) attend dialectical behavioural therapy (DBT) groups three times a week. I lead one of these groups and have witnessed how they contribute to patients’ progress. Patients themselves express appreciation and optimism, saying that they look forward to getting out into the world prepared with a toolkit of practical skills. 

DBT and self-help groups, such as 12 Step, are complementary and go very well together. Bellwood patients have the opportunity to attend 12 Step meetings every week. These meetings provide patients with meaning, a sense of community, and connection to a network of people to whom they can reach out after completing treatment. In contrast, DBT provides people with practical skills for handling cravings and intense emotions.  

4 Pillars of Dialectical Behavioural Therapy

(1) Mindfulness Skills

At the heart of dialectical behavioural therapy (DBT) are mindfulness skills. These have ancient origins, and are most commonly associated with the Buddhist tradition. I think mindfulness is described as cultivating non-judgmental awareness of whatever arises in the present moment. Mindfulness meditation is incredibly effective for helping people calm down and regulate their emotions. Consequently, it has been enthusiastically incorporated into Western mental health treatments, leaving the monasteries of Asia and entering Western hospitals and therapists’ offices. Mindfulness helps people develop a healthy relationship with their feelings. Mindfulness is about learning to approach, question, and accept what is going on inside of ourselves, without judgment. Every DBT group at Bellwood begins with a 5-to-7 minute meditation, grounding patients in the moment, and getting them in touch with their emotions and their bodies—reconnecting them with the very things they have been trying so hard to avoid. 

(2) Emotion Regulation Skills

Built on the foundation of mindfulness, emotion regulation skills help people manage their feelings, allowing them to make better decisions and overcome challenges. A patient might use this skill when they experience social anxiety related to some activity in treatment. For example, a patient was recently telling me how their fear was preventing them from participating the nightly Bellwood volleyball game—despite how much fun it seemed. She decided to practice a skill called Opposite Action—taking the action that’s the direct opposite of her initial urge. In this case her urge was to avoid the volleyball game and isolate herself, which would likely just reinforce her fear. The patient told me how she had pushed through her fear and joined a volleyball game. Despite her initial discomfort, she quickly started loving it. Opposite Action is one of several emotional regulation skills we teach our patients. 

(3) Distress Tolerance Skills

In more extreme situations where emotion regulation skills aren’t producing the desired results, distress tolerance skills are there as backup. In situations where you can’t change your emotions, distress tolerance skills improve your ability to tolerate them better and avoid acting in destructive ways. Once you accept that you’re experiencing an intensely uncomfortable—how do you live with it, for the time being? 

Some distress tolerance skills involve intentionally stepping outside of our minds. This can work well, because when we reach high levels of distress, our ability to think clearly, to rationalize, or even to just sit still goes out the window. Hence, many distress tolerance skills involve distracting one’s focus away from the emotion, through tasks that require focused attention, physical exertion, or that use different sensations such as intense cold or heat. 

Alternatively, Radical Acceptance is a distress tolerance skill for accepting that a situation can’t be changed and making peace with it. A patient in treatment might use this skill when they feel angry and fed up with being stuck in treatment, and are overwhelmed by a strong desire to just get up and leave. In such a scenario, they could practice Radical Acceptance, which has the following steps:

(i) Notice that you’re questioning or fighting reality.

(ii) Remind yourself that you cannot change reality or an event that has already occurred.

(iii) Remind yourself that the current reality is the result of causes and reasons.

(iv) Accept reality with your mind, body, and spirit, allowing yourself to experience grief and disappointment if necessary.

Through this process, the patient will likely be able to reduce the intensity of their anger and avoid acting on their desire to leave treatment.  

(4) Interpersonal Effectiveness Skills

When we allow negative emotions to drive our actions, we often interact with others in ways that are counterproductive, if not downright destructive. We either avoid completely or engage ineffectively. These dysfunctional styles of handling interpersonal conflict are very common among our patients and result in intense emotional distress. So instead we ask—how do you get your needs met in a way that is balanced, kind, and effective? The most important interpersonal skill is knowing what you want. To get your needs met, you must go into each interaction knowing what outcome you want and knowing how important it is to you, relative to maintaining a good relationship with the other person and maintaining your integrity.

Residential Treatment Provides Many Opportunities to Practice Skills

Oh, one other thing. A little secret—the wonderful thing about life in residential treatment is that there are numerous daily opportunities to practice dialectical behavioural therapy (DBT) skills. You’re emotionally unstable due to post-acute withdrawal—can you practice a distress tolerance skill? Your roommate keeps playing with the thermostat, or leaves puddles of water on the floor in the bathroom after they shower—can you practice some interpersonal effectiveness skills? 

Patients who practice DBT skills while they’re in treatment say that they feel better prepared to face the real world after completing their program. And patients who continue practicing their skills diligently after completing treatment have the best long-term outcomes. I often remind my DBT group: these skills are simple to understand, but mastering them requires practicing consistently and deliberately, for as long as it takes. And to keep practicing, until you can confidently overcome even the most intense challenges that you face—because ultimately, those challenges are the ones that count the most.

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