Regulating Emotion the DBT Way

A Therapist's Guide to Opposite Action

Christine Dunkley

• Publisher: Routledge
• Year: 2020
• eBook ISBN: 9781000177008
• Edition: 1
• Topic: Psychology
• Subtopic: Cognitive Behavioral Therapy (CBT)
• Index: Psychology

Regulating Emotion the DBT Way is a practical guide to the DBT skill of 'Opposite Action', which helps clients develop the skill of up- or down-regulating their emotions when necessary. It is the skill that fosters emotional literacy in clients who have learned to fear or avoid painful feelings.

Part A of the text introduces emotion theory, describes how to validate emotions, and explains how Linehan's 'Opposite Action' skill is used to regulate problematic responses. There are examples and analogies that can be shared with clients, and clinical examples to demonstrate the key points. There is a description of how DBT therapists contextualise emotion using chain analysis. Part B dedicates a chapter to each of the basic emotions and describes its signature features. A session scenario is included allowing the reader to see how the therapist coaches the skill of opposite action, elicits behavioural rehearsal, and gives corrective feedback. There are some tips on handling common issues specific to that emotion, based on the author's extensive experience.

This book will be of interest to any therapist who wants to learn more about a behavioural approach to emotion such as psychologists, nurses, social workers, psychiatrists, counsellors, cognitive therapists, prison staff, and occupational therapists. It is an accessible explanation of emotion regulation for people who have already undertaken DBT training.

PART
BRegulating
specific
emotions

All emotions are regulated differently, there is no one-size-fits-all.

In the next section the main emotions families are taken one by one and for each emotion the following information is given:

1. When the emotion fits the facts
2. The action urge of the emotion
3. The function of the emotion
4. The signature features
5. An example scenario from a therapy session showing how the therapist rehearses the skills
6. A list of special considerations for regulating the emotion
7. Examples of when the emotion requires up-regulating.

CHAPTER
6
Sadness

When does sadness fit the facts?

Sadness fits the facts when there is a loss. This may be loss of something the person had, or loss of something they anticipated having. For example, if we expect a promotion and don’t get it this can be experienced as loss.

In the sadness family: Disappointment, grief, despair, depression, rejection, let down, left out, abandoned, lonely.

Action urges: There are two phases to sadness: The first is to withdraw, and the second is actively seeking what has been lost. This might involve rekindling reminders of it or seeking out something similar to replace it.

Function of the emotion: Nature’s first priority is to inhibit further losses, making sure we conserve the resources we have. In this context withdrawing makes complete sense. The second function is to elicit help from others and set about finding or replacing what has been lost.

Signature features of sadness

• Temperature: Cool
• Facial expression: Downcast eyes, tearfulness, mouth turned down, flaccid lower lip, brow lowered
• Breathing: Sobbing, sighing, stilted in-breaths and long out breaths
• Muscle tone: Floppy, limbs hanging rather than held firmly
• Voice tone: When chronic, slow, low quiet tones. When acute, sobs, cries, whines, wails
• Posture: Drooping, hunched, downward looking
• Gesture: Shrugging, hand wringing, hand on brows
• Overt actions: Seeking isolation, not answering the phone, not eating, pining for the lost item, situation, or person. Fixating on reminders such as photos, music, or familiar places. Going over the events of the loss again and again.

Sadness example scenario

In the following example the client is keen to get back with her ex, but he just wants to be friends. She recently bumped into him in town and they went for coffee. Afterwards she walked home and burned her arm deliberately on a hot iron.

THERAPIST: So you didn’t harm yourself until you got home, but when did you first notice the urge? (T. draws C.’s attention to the context of the emotion.)

CLIENT: In the café, it was all going really well. We were laughing, like old times. I was thinking, surely he must realise we had something really good together? He wasn’t exactly flirting, but you know, he was relaxed and jokey like when we were first together. We’d finished our coffee and he said, ‘It’s been great to see you’. So I said, ‘I really enjoyed it too, we should do it again!’ Immediately I just saw this… look go across his face. His expression just froze. He kept his voice all cheerful and said, ‘We’re bound to bump into each other!’ Then he got up to leave. I went to hug him and he did hug me back, but I could tell… it was so stiff and awkward. Then he was gone.

THERAPIST: Oh no, just when you thought things were going well… (T. validates the disappointment). Was it after the hug that you first had the urge to burn yourself? (T. aims to pinpoint the timing of the urge.)

CLIENT: No, at first I was angry, I thought, so you’ve totally led me on for the last hour? And I felt ok, actually. But on the walk home the anger went, and I just thought, he doesn’t want me (becomes tearful).

THERAPIST: It must have been such a disappointment, I know how much he meant to you. Anyone would have been hurt at such a rapid change. (pauses). (T. Does little to interfere here, other than to validate the emotion, as the client has named the emotion and is acting appropriately.)

CLIENT: It was awful. I got in and went straight to heat up the iron.

THERAPIST: It sounds like burning yourself was at least partly to get away from the emotion, I’m guessing it was an overwhelming sadness? (T. hypotheses that the self-harm and emotional experience were linked.)

CLIENT: It was unbearable. I just thought, if I start crying I’ll never stop.

THERAPIST: A lot of people have that fear, and sadness is a very painful emotion. No wonder we want to avoid it. And yet if sadness fits the facts, we can run but we can’t hide. To get past this emotion in a healthy way we have to work out the amount of the loss, to see if our sadness is about right. Now the main thing here is to stay with what you have lost IN THAT MOMENT, when you were walking home? (T. highlights the dialectic, we don’t like the emotion and yet it is normal. Also teaches the client to assess the context of the emotion.)

CLIENT: I suppose I hadn’t lost anything, not really. I was no worse off after our coffee together than I was before.

THERAPIST: Ah, now see how quickly you moved to invalidating your emotion? Yet there WAS a very clear loss. What had you hoped to get from your ex, and ended up walking home without having achieved? (T. highlights the client’s self-invalidation, and coaches how to establish the reality of the loss. Many clients are dismissive of justified sadness.)

CLIENT: I wanted him to see me as a potential girlfriend again. I know it wasn’t exactly a date, but I thought it might lead to one…

THERAPIST: That’s right. These are genuine losses. I’m wondering, did you comfort yourself because of these losses? Were you tearful at the time? Did you get any help from others? (T. coaches the client to accept the loss and assesses for any current skills to manage sadness appropriately.)

CLIENT: No, I just wanted to get in the house and get the iron. I didn’t cry at all. I wanted to feel something else, anything else.

THERAPIST: Were you doing anything to actively inhibit sadness? (T. assesses the client’s behavioural responses to sadness.)

CLIENT: Like what?

THERAPIST: Common actions are tensing your body, clenching your jaw, holding your breath… these are in fact opposite actions to sadness.

CLIENT: I was doing all of those, so why didn’t the sadness go down?

THERAPIST: Because the emotion did fit the facts, so before we use any methods to feel less sad, we have to give voice to the bit that is entirely justified by the facts. This is what we mean by dialectical – that some of the sadness was too much, but some was really valid. We need something you can say to yourself that sums up what you had genuinely lost.

CLIENT: I’d lost everything! Any hope of a future with him, or anyone really – who would I find who is like him? We share so many memories, I was hoping we would get back together, have Christmases like we used to, go to gigs, go on that camper-van tour of France. That’s all gone.

THERAPIST: Whoa! This is an example of the pendulum swinging the other way – going from not wanting to feel any sadness at all, to feeling way too much. When sadness starts up it really runs away with you. Is that what happened on that day, as you walked home? (T. highlights more how sadness quickly escalates.)

CLIENT: It felt bigger and bigger until I thought I would burst.

THERAPIST: OK, so we might start with the skill of mindful describing, which is kind of validating yourself, that you have every right to feel sad. Say something about what made you sad, in that moment, but pare it down to the things that you’d lost on that day. Have a go. (T. outlines the skill of mindful describing and encourages behavioural rehearsal.)

CLIENT: ‘I wanted to meet up again, but he didn’t’.

THERAPIST: Now I want you to run this through your wise mind and see if it feels right, it has to really touch the truth of what you were sad about. (T. does not assume this is accurate but asks the client to assess. This is strengthening C.’s sense of self.)

CLIENT: No, it doesn’t, there’s something missing. That wasn’t the worst thing…

THERAPIST: Great observing. So add the worst bit in. ‘I’m sad because…’ (T. encourages C. to evaluate the accuracy for herself and to improve it.)

CLIENT: I’m sad because I really thought we had a chance (looks pained) and then his hug was so cold.

THERAPIST: That second attempt seems to get more of your dashed hopes into it. Only you know what was going on inside you, so you need to check it out, is that what was making you sad? (T. gives the message that it is C. who has the final say on her internal experience, and also this is acting as exposure to the sadness cue, allowing her to experience it without fear.)

CLIENT: I just thought we could be back as a couple, with all the things that go with it. I wanted him to want me. And I knew that he didn’t, well, he didn’t show it. (Client becomes tearful.)

THERAPIST: That was very mindful – and it IS sad, there’s no shame in wanting that closeness, the songbooks are full of anthems to unrequited love… films, poetry, everyone recognises this type of sadness. Just let the tears come… That’s great. (T. normalises sadness in this context and waits for the wave of sadness to subside. T. keeps a matter of fact tone, not overly sympathetic, so as not to flood the client with more cues to sadness. The aim is to allow behavioural rehearsal of experiencing the emotion.)

CLIENT: (Crying) I always think it’s just me, that everyone else is happily coupled up. So I try really hard not to cry, in case I never stop. If I burn myself it stops me wanting to cry, it’s like...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Acknowledgements
• Introduction
• PART A Emotion regulation theory
• PART B Regulating Specific Emotions
• Index