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Identifying novel applications of dialectical behavior therapy: Considering

emotion regulation and parenting

Article  in  Current Opinion in Psychology · March 2018

DOI: 10.1016/j.copsyc.2018.02.013

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Identifying novel applications of dialectical behavior therapy:

considering emotion regulation and parenting
Maureen Zalewski, Jennifer K Lewis and Christina Gamache Martin

Dialectical behavior therapy (DBT) is an effective treatment for as a review of recent research on emotion regulation as a
an increasing number of mental disorders. Its increased mechanism of change. Then by using an example, we
application to a range of disorders has been prompted by the illustrate how the mechanistic role of emotion regulation,
recognition that DBT targets emotion dysregulation, which is a defined as the ability to modulate emotional experiences
transdiagnostic feature underlying several forms of and expressions [2], aids in identifying another clinically
psychopathology. More recently, DBT has been used to target relevant target: parenting. The clinical application of
additional clinically relevant domains that are outside using DBT to potentially improve parenting, particularly
diagnostically bound categories, such as improving parenting for parents with psychopathology could yield significant
quality as a means of preventing psychopathology in children of preventative implications for children who are at elevated
parents with psychopathology. As the ability to regulate risk for developing psychopathology.
emotions is critical to parenting, this paper uses the connection
between DBT, emotion regulation, and parenting as an
illustration of how focusing on mechanistic features by which
The effectiveness of DBT for treating a wide
DBT is effective aids in strategically identifying areas by which
range of disorders across the lifespan
In terms of DBT’s efficacy within the population for
DBT may be a highly useful treatment option.
which it was first developed, individuals chronically at
high risk for suicidal behavior and those diagnosed with
Address BPD, DBT has consistently led to better treatment out-
University of Oregon, Eugene, OR 97403, USA
comes in comparison to control interventions. This find-
Corresponding author: Zalewski, Maureen ([email protected]) ing was supported in the most recent meta-analysis
examining psychotherapies for BPD [3], where DBT
was one of only two psychotherapies, the other being
Current Opinion in Psychology 2018, 21:122–126
psychodynamic approaches, which performed signifi-
This review comes from a themed issue on Personality disorders cantly better than control interventions in the treatment
Edited by Carla Sharp and Aidan Wright of BPD. DBT demonstrated a moderate effect size
(g = 0.34; 95% CI, 0.15–0.53), based on the nine random-
ized control trials included in the analysis. There were no
significant differences between DBT and the psychody-
https://doi.org/10.1016/j.copsyc.2018.02.013 namic approaches. Similar positive treatment effects in
2352-250/ã 2018 Elsevier Ltd. All rights reserved. terms of reductions in borderline symptoms and suicidal
ideation have been found within community mental
health programs, suggesting that the standard, full model
of DBT can overcome the implementation limitations
that arise in real-world settings outside of tightly con-
trolled studies [4]. At the same time, the limitations in
While dialectical behavior therapy (DBT) was originally implementing the standard model may impede some
developed to treat women with borderline personality treatment settings from offering DBT despite commu-
disorder (BPD) with chronic suicidality [1] in the past two nity need. Importantly, in Linehan and colleagues’ [5]
decades, the application of using DBT to treat various component analysis study of DBT, they found that DBT
mental health disorders has been widespread. Two sig- interventions that include the skills training group plus
nificant and broad categories of recent research progress case management and therapist consultation were equiv-
are in the areas of (1) determining the diagnostic bound- alent in effectiveness to the standard model, which also
aries for which DBT is effective and (2) examining includes individual DBT therapy and between session
various mechanisms by which DBT is effective. These telephone coaching, in terms of reducing suicidality, crisis
two areas of research are mutually informative. As the intervention services, and symptoms of depression and
‘mechanisms of change’ by which DBT operate are anxiety. This finding provides treatment providers with
identified, novel applications of DBT, potentially includ- flexibility in how DBT can effectively be implemented,
ing those that extend beyond traditional diagnostic for- overcoming some of the resource limitations that likely
mulations, will be revealed. In this paper, a review of the arise when implementing the standard model of DBT in
most recent findings is presented on DBT’s effectiveness the community. In conjunction with its established effec-
for treating various disorders across different ages as well tiveness in the domains it was developed to target and the

Current Opinion in Psychology 2018, 21:122–126 www.sciencedirect.com

 Manifestations of personality impairment severity Zalewski, Lewis and Martin 123

flexibility with which DBT can be implemented, DBT Although fewer studies have examined the mediating
has continued to evolve across developmental and diag- effects of emotion dysregulation on subsequent changes
nostic boundaries. in mental health symptoms, the present literature pre-
sents a convincing depiction of its mechanistic impor-
DBT has been utilized and adapted to treat a multitude of tance in DBT treatment. Mechanistic studies have docu-
psychological problems, resulting in its being conceptu- mented the mediating effects of emotion regulation in
alized as a transdiagnostic intervention, particularly for BPD samples, finding that various facets of emotion
clinical profiles considered difficult to treat. We briefly regulation (i.e., impulsivity, behavioral control, ratio of
review the most recent empirical findings for DBT out- positive to negative emotions, and anger) mediate the
side of the populations it was originally developed to effectiveness of the treatment [22–24]. It is posited that
treat, and thus, extend the findings of Cristea and col- DBT reduces reactivity and enhances effortful modula-
leagues’ [3] meta-analysis by incorporating studies not tion of emotional experiences and expressions through
included therein. In an extension from its original focus the use of skills, making skills use itself a form of emotion
on adults, DBT has been adapted to effectively treat regulation. Thus, the work showing the mediating effect
suicidal and self-harming adolescents [6,7], as well as of skills use on DBT outcomes provides additional sup-
preadolescents diagnosed with disruptive mood dysregu- port for the mechanistic properties of emotion regulation
lation disorder [8]. Similarly, in a pilot randomized trial for [19,25].
adolescents with bipolar disorder, DBT participants dem-
onstrated significantly fewer depressive, manic, and emo- While the majority of research in this area relies on self-
tion dysregulation symptoms, as well as less suicidal report measures, there is an emerging neural literature
ideation from pre-treatment to post-treatment [9]. A implicating the role of emotion regulation as a mechanis-
feasibility study for DBT skills group as an adjunct tic treatment process in DBT. These initial studies
treatment component for adults with bipolar has also appear to corroborate that emotion regulation may be
shown promising results for improving psychological an important treatment mechanism, having shown reduc-
well-being and decreasing emotional reactivity [10], tions in reactivity to emotional stimuli in brain regions
and two recent feasibility studies have shown promising associated with emotional response and sensitivity (i.e.,
results for conducting DBT skills training groups for amygdala, anterior cingulate, and insula), increased con-
attention-deficit/hyperactivity disorder treatment nectivity of the limbic–prefrontal network, and increased
[11,12], DBT has been deemed a possibly efficacious gray matter and gray matter volume in critically impli-
treatment option for bulimia nervosa and binge eating cated emotion regulation regions [26–30]. It should be
disorders [13] and has likewise shown promising support noted that these studies have examined neural networks
for substance abusing populations [14], specifically for of emotion regulation in BPD populations only, and to
American Indian/Alaska Native adolescents [15]. Effec- date, none of the studies have employed a randomized
tiveness for DBT has been demonstrated in various control trial design.
posttraumatic stress disorder (PTSD) populations, where
DBT has been adapted for adult survivors of sexual abuse Despite the theoretical and empirical support that
[16], for veterans with co-morbid PTSD and BPD symp- improvements in emotion regulation serve as a mecha-
toms, where DBT was implemented concurrently with nism by which DBT is effective, more work is needed in
prolonged exposure therapy [17]; and for suicidal and self- this area. Specifically, inconsistency in how emotion
injuring women with comorbid PTSD and BPD using a regulation is defined and measured creates difficulties
stage-based treatment approach where standard DBT in discerning whether emotion regulation broadly med-
was compared to DBT + DBT PE [18]. Finally, DBT iates treatment effects or whether particular aspects of
skills training has been shown to be an effective treat- emotion regulation (i.e., inhibitory control and reactivity)
ment of emotion dysregulation [19], as well as for reduc- underlie its mechanistic function. Future research should
ing anger suppression and psychological distress [20], in a employ multi-method approaches, incorporating self-
transdiagnostic sample of individuals diagnosed with an report, behavioral, and physiological measures of emotion
anxiety or depressive disorder, highlighting emotion dys- regulation, to enhance our understanding of its mecha-
regulation as one potential mechanistic process in DBT. nistic role.

Emotion regulation as a mechanism of change Novel applications: DBT and parenting

While additional mechanisms of change have been iden- By targeting emotion regulation, researchers and clini-
tified in DBT with BPD samples (i.e., skills use, thera- cians can systematically identify additional clinically rel-
peutic alliance and treatment investment) emotion regu- evant domains that DBT may be facilitative in achieving
lation is perhaps the most frequently identified improvements. We present one example, in the area of
mechanism of change [21]. As noted, many studies have parenting, as a means of illustrating how DBT may be an
identified DBT’s effectiveness for treating disorders in ideal clinical tool that reaches beyond treating traditional
which a hallmark feature is deficits in emotion regulation. diagnoses.

www.sciencedirect.com Current Opinion in Psychology 2018, 21:122–126

124 Personality disorders

There is a growing literature base documenting that the providing no additional parent training or child focused
ability to regulate emotions is critical for parenting effec- interventions [39]. A modified diary card, in which clients
tively [31]. Parents who struggle to manage their own track daily skill usage was provided so that mothers could
emotions may be more prone to engaging in negative or indicate whether the skills they were using were related
rejecting parenting practices, exhibit less warmth toward to parenting. This initial work demonstrated that partici-
their children, and at an extreme, are more prone to pating in DBT skills training was associated with
engaging in maltreatment [31]. Given the link between increases in positive parenting behaviors such as accep-
emotion dysregulation, parenting practices and psycho- tance, effective limit setting, and autonomy granting,
pathology, it is not surprising that there is a large evidence with change scores being similar to those reported in
base showing small to modest effect sizes between parent emotion coaching parenting interventions. Furthermore,
psychopathology and poorer parenting [32]. when reporting on DBT skill usage throughout the week,
mothers in the group endorsed using the skills in the
Emotion dysregulation in parents and poorer parenting context of parenting nearly half of the time. Future
are both linked to children exhibiting greater emotion studies need to employ a randomized control trial design
dysregulation [33]. For example, in a recent study of to test these effects and to determine if child outcomes
mother–preschooler dyads in which half of the mothers change as a result of parents receiving DBT. Additional
had elevated symptoms of BPD, maternal emotion dyr- application of using DBT principles have been consid-
egulation was associated with less supportive responses to ered in the parent management training literature as it is
children’s negative emotions and with children exhibiting well documented that the overall effectiveness of parent
less problem solving and more sadness in the context of a management training is reduced when parents are emo-
task designed to elicit frustration [34]. As the develop- tionally dysregulated or have psychopathology [40].
ment of emotion dysregulation is an early signal of Because of this, parent management training programs
emerging psychopathology, difficulties with emotion reg- are beginning to incorporate sessions devoted to teaching
ulation are believed to serve as one type of generational parents how to regulate their own emotions, with these
mechanism by which mental disorders are passed enhanced versions showing promise [40].
between parents and children, particularly in dyads in
which parents have BPD [35]. Theory suggests that Conclusion
parents who struggle to manage their own emotions are Emotion regulation is a core treatment target of DBT and
poorly equipped to help their children navigate this is increasingly documented as a crucial mechanism of
important developmental process [35]. Additionally, change that accounts for the treatment’s overall effec-
transactional models have demonstrated a pattern in tiveness. As researchers and clinicians alike encounter
which emotion dysregulation escalates in each member clinical issues in which improving emotion regulation is
of parent–child dyads, and that this transactional pro- needed to reduce symptoms or to improve interpersonal,
cesses accounts for higher rates of psychopathology in role, or other functional outcomes, DBT should strongly
children and adolescents [36]. be considered as a premier tool. Applying DBT to par-
enting, with an eye toward preventing emerging mental
Given the links between co-occurring psychopathology in health issues in children of parents with psychopathology
parents and children, and the role that emotion dysregu- represents one exciting new direction of how to system-
lation may have in this link, intervening on parents’ own atically advance DBT into novel domains. Overall,
emotion regulation skills may constitute an underutilized expanding the application of DBT to new treatment
method of preventative intervention for children. As targets, settings, or delivery options is encouraged,
DBT is a treatment that has a strong evidence base for although doing so must be balanced with remaining open
improving emotion regulation, researchers have begun to to its limitations as well.
consider how it might be applied in improving not only
psychopathology in adult clients who are parents, but Conflicts of interest statement
perhaps also improving parenting skills toward the goal of Nothing declared.
reducing emerging psychopathology in these children
[37]. It should be noted that although DBT has routinely
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