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METHODS
published: 14 September 2016
doi: 10.3389/fpsyg.2016.01373
EmotionRegulation in Schema
Therapy and Dialectical Behavior
Therapy
1 1 2 2
*
EvaFassbinder , Ulrich Schweiger , Desiree Martius , Odette Brand-de Wilde and
ArnoudArntz3
1 Department of Psychiatry and Psychotherapy, University of Luebeck, Luebeck, Germany, 2De Viersprong, Netherlands
Institute of Personality Disorders, Halsteren, Netherlands, 3Department of Clinical Psychology, University of Amsterdam,
Amsterdam, Netherlands
Schema therapy (ST) and dialectical behavior therapy (DBT) have both shown to be
effective treatment methods especially for borderline personality disorder. Both, ST and
DBT, have their roots in cognitive behavioral therapy and aim at helping patient to deal
with emotional dysregulation. However, there are major differences in the terminology,
explanatory models and techniques used in the both methods. This article gives an
overviewofthemajortherapeutictechniquesusedinSTandDBTwithrespecttoemotion
regulation and systematically puts them in the context of James Gross’ process model
of emotion regulation. Similarities and differences of the two methods are highlighted
and illustrated with a case example. A core difference of the two approaches is that
Edited by: DBT directly focusses on the acquisition of emotion regulation skills, whereas ST does
Alessandro Grecucci,
University of Trento, Italy seldom address emotion regulation directly. All DBT-modules (mindfulness, distress
Reviewedby: tolerance, emotion regulation, interpersonal effectiveness) are intended to improve
Gideon Emanuel Anholt, emotion regulation skills and patients are encouraged to train these skills on a regular
Ben-Gurion University of the Negev, basis. DBT assumes that improved skills and skills use will result in better emotion
Israel
Harold Dadomo, regulation. In ST problems in emotion regulation are seen as a consequence of adverse
University of Parma, Italy early experiences (e.g., lack of safe attachment, childhood abuse or emotional neglect).
*Correspondence: These negative experiences have led to unprocessed psychological traumas and fear
Eva Fassbinder
eva.fassbinder@uksh.de of emotions and result in attempts to avoid emotions and dysfunctional meta-cognitive
schemas about the meaning of emotions. ST assumes that when these underlying
Specialty section: problems are addressed, emotion regulation improves. Major ST techniques for trauma
This article was submitted to
Emotion Science, processing, emotional avoidance and dysregulation are limited reparenting, empathic
a section of the journal confrontation and experiential techniques like chair dialogs and imagery rescripting.
Frontiers in Psychology
Received: 27 April 2016 Keywords: emotion regulation, emotional avoidance, Schema therapy, dialectical behavior therapy, experiential
Accepted: 29 August 2016 techniques, skills
Published: 14 September 2016
Citation: INTRODUCTION
Fassbinder E, Schweiger U, Martius D,
Brand-de Wilde O and Arntz A (2016) Dialectical behavior therapy (DBT) and Schema therapy (ST) have both shown to be effective
Emotion Regulation in Schema
Therapy and Dialectical Behavior treatment methods especially for borderline personality disorder (BPD) (Zanarini, 2009; Stoffers
Therapy. Front. Psychol. 7:1373. et al., 2012), a disorder that is specially associated with emotional dysregulation. Although both, ST
doi: 10.3389/fpsyg.2016.01373 andDBT,haveacognitive-behavioralbackground,therearemajordifferencesinhowbothmethods
Frontiers in Psychology | www.frontiersin.org 1 September 2016 | Volume 7 | Article 1373
Fassbinder et al. Emotion Regulation in ST and DBT
deal with emotions and emotion dysregulation. This paper • Mindfulness is central to all skills in DBT. The mindfulness
provides an overview of background and theory of both skills derive from traditional Buddhist meditation practice,
treatment approaches, a model how both methods conceptualize though they do not involve any religious concepts. In DBT
emotiondysregulationandthemajortherapeutictechniqueswith it means the practice of being fully aware and present in
respect to emotion regulation. Further it is discussed how DBT the present moment, experiencing one’s emotions, thoughts
and ST concepts and techniques map onto the process model of or body sensations without judging and without reacting
emotion regulation from James Gross (Gross, 2015). Similarities to them. The mindfulness skills are divided into “what
anddifferencesofthetwomethodsarehighlightedandillustrated skills” (observing, describing and participating) and “how-
with a case example. skills” (non-judgmentally, one-mindfully and effectively). An
important concept of this module is “wise mind,” which
BACKGROUNDANDTHEORY allows to base decision making on a balance between
intuition and facts. The implicit goal is to provide the
Dialectical Behavior Therapy (DBT)– experience that emotions and cognitions are internal events
BackgroundandTheory that are a patterned response to external and internal stimuli.
Development of Dialectical Behavior Therapy and the Mindfulness allows watching cognitions and emotions from
Dialectic of Acceptance and Change an observer perspective as separate both from the external
DBT was developed in the late 1980s by Linehan (1993a,b), worldandtheself.
originally for chronically (para)suicidal patients, then extended • Emotionregulationcompromisesdetailedpsychoeducationon
to patients with BPD. To that time, these patients had been emotionsingeneralandabroadspectrumofspecificemotions
considered as “untreatable.” A focus on problem solving to foster an in depth understanding of emotions and emotion
or cognitive restructuring, according to standard cognitive regulation.Itteachesskillsinproblemsolving,checkingreality
behavioral therapy (CBT), had been experienced as potentially andtakingoppositeactiontobehavioraltendenciesassociated
invalidating by the patients and had led to frustration, angry with specific emotions as well as skills reducing emotional
reactions, resistance and treatment drop outs. On the other side, vulnerability. The module intends to give the patient a fresh
focusing on acceptance and validation has also been perceived as look on emotions and to decrease emotional and experiential
problematic by patients since their problems and behaviors did avoidance.Acriticalfeatureistoenablethepatienttomakean
not change. This led to one of the most important features of active choice between acting with an emotion or opposite to it.
DBT, the “dialectic” of acceptance and change. This means, that • Interpersonal effectiveness teaches how to obtain objectives
therapists, on the one hand accept patient as they are and provide skillfully and how to act effectively with respect to objectives,
validation for their thoughts, emotions and behaviors, while on relationship and self-respect. The implicit objective is to
the other hand therapists acknowledge the need for change and reduce interpersonal avoidance which is the key to change
foster the learning of new skills to deal with problems and to experiential and emotional avoidance and to increase
reach personal goals (Linehan and Wilks, 2015). This dialectic interpersonal behavior that has a high probability of being
stance has been inspired by principles of dialectic philosophy positively reinforced.
(e.g., everything is transient and finite, everything is composed of • Distress tolerance focusses on teaching crisis survival skills.
contradictions, passage of quantitative into qualitative changes, It fosters acceptance in situations that cannot be otherwise
change results from a helical cycle of thesis, antithesis and changed or avoided without making things worse. There
synthesis). is an emphasis on self-soothing, improving the moment
DBT is currently the most extensively studied and used and adaptive distraction. Important concepts are “radical
approach to treat BPD (Stoffers et al., 2012). In addition, acceptance”and“willingness.”Themoduleintendstodecrease
DBT has been adapted and successfully tested for BPD with self-destructive ways of emotional avoidance like self-injury,
several comorbidities and other psychiatric conditions in which substance abuse or distraction with risk taking behavior.
problems in emotion regulation lead to psychopathology such as
substancemisuse(Linehanetal.,1999,2002;DimeffandLinehan, Major Components of DBT
2008),eatingdisorder(Saferetal.,2001;Telchetal.,2001;Kröger In standard DBT there are four major components: skills
et al., 2010), post-traumatic stress disorder (Steil et al., 2011; training group, individual psychotherapy, telephone coaching,
Harned et al., 2012, 2014; Bohus et al., 2013), or depression andconsultation team.
(Lynchetal., 2007).
• DBT skills training group is usually carried out in a group
Skill Acquisition and the four Modules in DBT format with approximately eight patients and two skills
DBT conceives emotion regulation skills deficits as the core of trainers. The group follows a manualized protocol (Linehan,
BPD. Thus, the main focus of the treatment is the acquisition 2015a,b). In the original format group members meet once
of a functional emotion regulation. With its CBT background, a week for approximately two and a half hours, yet there
DBTdraws from a broad spectrum of cognitive and behavioral are varying adaptations to heterogeneous settings. The skills
treatment techniques to induce the development of skills training group focusses on psychoeducation and training
in emotion regulation. Skill training is embedded in four of behavioral skills in the four DBT modules mindfulness,
modules: interpersonal effectiveness, emotion regulation and distress
Frontiers in Psychology | www.frontiersin.org 2 September 2016 | Volume 7 | Article 1373
Fassbinder et al. Emotion Regulation in ST and DBT
tolerance. Homeworkassignmentsforpatientsaregivenevery CBT frame (especially attachment theory, Gestalt therapy). A
session and aim at practicing the learnt skills in everyday live. strong emphasis was placed on the biographical aspects for
• DBT individual psychotherapy is carried out by an individual the development of maladaptive psychological patterns through
therapist on a weekly basis with 50min sessions. The traumatization in childhood and frustration of basic childhood
individual therapist is the primary treatment provider and needs. The therapeutic relationship was conceptualized as
responsible for treatment planning, crisis management and “limitedreparenting” meaningthatthetherapistcreatesanactive,
decisions about individual modifications of treatment. caring, parent-like relationship with the patient (Young et al.,
The individual therapist supports the patient in the 2003).
implementation of the skills, he has acquired in the skills ST was developed as a transdiagnostic approach, but also
training group, helps with trouble shooting and removing provides disorder specific models for most PDs (see overview
obstacles to change and ensures generalization of change. The in Arntz and Jacob, 2012). Several studies have shown that
individual therapy follows a hierarchy with four stages and treatment based on that model is very effective for patients with
structured target levels for each stage. The idea is to optimize BPD(Giesen-Bloo et al., 2006; Farrell et al., 2009; Nadort et al.,
the change process and to begin the change process with 2009;DickhautandArntz,2013),butalsoforotherPDs(Bamelis
reducing life-threatening and therapy interfering behavior et al., 2013). Good results are also reported for depression, post-
and then proceed to support skills acquisition, treatment traumaticstressdisorder,eatingdisorders,andcomplexobsessive
of comorbid conditions, finding solutions for problems compulsivedisorders(Cockrametal.,2010;Simpsonetal.,2010;
in living and creating a life worth living. Basic treatment Malogiannis et al., 2014; Renner et al., 2016; Thiel et al., 2016).
strategies comprise specific dialectical strategies, validation,
behavior analysis, didactic strategies and problem solving, Central Concepts in ST: Schemas, Coping Strategies
commitmentstrategies, contingency management, observing- andModes
limits procedures, skills training, exposure-based procedures, STis based on the idea that aversive experiences and frustration
cognitive modification and stylistic strategies like reciprocal of basic childhood needs (e.g., safety, love, attention, acceptance,
communicationandcasemanagementstrategies. or autonomy) lead in interaction with biological and cultural
• DBT telephone coaching: In crisis situation patients can call factors to the development of maladaptive schemas. Schemas
their individual therapist outside the sessions and receive are defined as organized patterns of information processing
support in applying suitable skills. It was designed to help compromising thoughts, emotions, memories, and attention
generalize skills into the patient’s daily life. preferences (Young et al., 2003). Schemas have a strong impact
• DBTtherapistconsultationteam:Communicationbetweenthe onhowindividualsviewthemselves,theirrelationships to others
providers of individual therapy and skills training is very and the world. Young described 18 maladaptive schemas, e.g.,
important to support each other in providing the treatment. shame/defectiveness, social isolation, mistrust, or unrelenting
In standard DBT the therapists meet weekly and review standards (Young et al., 2003). If a maladaptive schema gets
which skills are currently the focus of the group sessions activated, associated painful emotions arise. In order to deal
and discuss any problems the patients have in applying the with these intensive emotions, coping strategies (surrender,
skills. The meetings safeguard that the therapists share a avoidance, overcompensation) are developed that attenuate
commonlanguage and a common knowledge about the skills aversive emotions but impair adaptive interpersonal and self-
communicatedtothepatients.Furthertheysupporteachother regulatory behavior.
to provide DBT. While working with BPD patients Young discovered that
the schema model was not optimal to explain and work
SchemaTherapy(ST)–Backgroundand with the quick mood and behavior changes of these patients.
Theory Thus, he extended the schema theory with the mode model
Development of ST approach, first for BPD later for narcissistic patients (Young
Schema therapy also derives from CBT and was originally et al., 2003). Since then, the mode model has be elaborated
developed by Young et al. (2003) for patients, which did and empirically tested with specific mode models for most PDs
not respond to standard CBT. These patients often had a (Lobbestael et al., 2008, 2010; Bamelis et al., 2011). A mode
comorbid personality disorder (PD) and showed complex, rigid, is a combination of activated schemas and coping strategies
and chronic psychological problems in emotion regulation and anddescribesthecurrentemotional-cognitive-behavioralstate.A
in interpersonal relationships, which in most cases could be mode can change quickly, while a schema is rigid and enduring
followedbackintotheirchildhood.Theseproblemsalsoimpaired (schemaDtrait,modeDstate;Youngetal.,2003).Itistherefore
the psychotherapeutic process as those patients had difficulties a convenient concept in clinical practice as it helps patients and
in forming a collaborative relationship with the therapist and therapists understand the sometimes quick emotional changes.
could not be reached with standard CBT techniques due to Modescanbedividedinto4broadcategories:
(anticipated) intensive emotional reactions and coping strategies (a) Dysfunctional child modes are activated when patients
such as avoidance or surrender. In the process of finding ways experience intense aversive emotions, e.g., fear or
to address the needs of these patients, Young integrated ideas abandonment, helplessness, sadness (vulnerable child
andtechniquesfromothertheoreticalorientationsintoaclassical modes), anger, or impulsivity (angry/impulsive child
Frontiers in Psychology | www.frontiersin.org 3 September 2016 | Volume 7 | Article 1373
Fassbinder et al. Emotion Regulation in ST and DBT
modes).Childmodesdevelopwhenmajorneeds,particularly emotional experiences. “Limited reparenting” provides empathy,
attachmentneeds,werefrustrated in childhood. warmth, protection and care for the patient. However, it may
(b) Dysfunctional parent modes (punitive or demanding) are also be necessary to set limits to the patient and to empathically
associated with self-devaluation, feelings of self-hatred, guilt, confronthimwiththeconsequencesofhisbehaviorandtheneed
shame,orextremelyhighstandards.Theyreflectinternalized to change.
negativebeliefs about the self, which the patient has acquired
in childhood due to the behavior and reactions of significant DBTANDSTMODELSOFEMOTIONAND
others (e.g., parents, teachers, peers). EMOTIONDYSREGULATION
(c) Dysfunctional coping modes describe the excessive use of the
coping strategies surrender (Compliant surrender mode), HowDBTConceptualizesEmotion
avoidance (e.g., Detached protector mode or Self-soother Dysregulation
mode),orovercompensation(e.g.,Self-Aggrandizermodeor
Bully-and-Attack-mode) in order to reduce the emotional DBT explains BPD and its symptoms as the consequence of a
pain of child and parent modes. These modes are usually severe disorder in the emotion regulation system. The genesis
acquired early in childhood to protect the child from further of these emotion regulation skills deficits is explained by the
harmandarethereforeconsideredas“survivalstrategies.” interplay of biological factors, learning history and social context
(d) The healthy modes of the healthy adult mode and the happy (biopsychosocial model). Symptoms such as self-injury, binge
child mode represent functional states. In the healthy adult eating, alcohol abuse, dissociation, or impulsive behaviors are
mode, people can deal with emotions, solve problems and regarded as coping strategies for intense emotions. Thus, a
create healthy relationships. They are aware of their needs, primary goal of DBT is to teach patients skill to tolerate and
possibilities and limitations and act in accordance with their regulate intensive emotions.
values, needs and goals. The happy child mode is associated DBT provides intensive psychoeducation on emotions and
with joy, fun, play, and spontaneity. The healthy modes are the (evolutionary) adaptive value of emotions. Emotions are
usually weak at the beginning of therapy. considered as complex, brief, involuntary, patterned, full-system
responsestointernalandexternalstimuli(EkmanandDavidson,
For a detailed description of all modes see Arntz and Jacob 1994). The DBT model of emotion and emotion regulation
(2012). contains six interacting subsystems (Linehan, 2015b):
(a) Emotionalvulnerability factors
Therapy Goals and Treatment Strategies in ST (b) Internal and external events that serve as emotional cues
The major goal in ST is helping patients to understand their (e.g., prompting events)
emotional core needs and learn ways of getting needs met in (c) Appraisal and interpretations of cues
an adaptive manner or to help them deal with the frustration (d) Emotional response tendencies (including physiological,
if needs cannot be satisfied. This requires breaking through cognitive, experiential responses and action urges)
long-standing emotional, cognitive and behavioral patterns, (e) Non-verbal and verbal expressive responses and actions
meaningchangeofdysfunctional schemas, coping strategies and (f) After-effects of the initial emotion, including
modes. According to the mode model there are specific goals secondary emotions and after-effects of problem
connected with every mode guiding the treatment: Child modes behavior like social isolation or problematic peer
are supported and comforted. Dysfunctional parent modes are relationships.
reduced, therapists even “combat” the punitive parent mode.
Dysfunctional coping modes should be reduced and replaced All DBT-modules (mindfulness, distress tolerance, emotion
by healthier, more flexible strategies. However, as these modes regulation, interpersonal effectiveness) are intended to improve
have served as “protective shield” for vulnerable child modes understandingofownandother’semotionsandlearningemotion
for such a long time, therapists have to proceed particularly regulation skills. Patients are encouraged to train these skills
careful. Only if the patient feels safe enough in the therapeutic on a regular basis. DBT assumes that expert knowledge on
relationship, the adaptive function of the coping modes has been emotions, improved skills and skills use will result in better
validated enough and their advantages as well as disadvantages emotionregulation.
have been reviewed cautiously, the patient will be able to reduce Although, this model was originally developed for patients
his “protective shield” and learn healthier strategies to deal with BPD, DBT has been applied in many other psychiatric
with emotions and relationships. A last important goal is to conditionswithdatasuggestingeffectiveness(seeabove).Thus,it
strengthen the healthy modes. To achieve these goals, mode- canbeseenandusedasatransdiagnosticmodelforoptimization
specific cognitive, experiential, and behavioral interventions are of emotion regulation skills in other clinical populations as well
used, with a strong emphasis on experiential techniques like as in healthy individuals.
chair dialogs and imagery rescripting. “Limited reparenting” HowSTConceptualizesEmotion
(behaving like a “good parent” toward the patient, within the
boundaries of the therapy relationship) is central to ST and Dysregulation
underliesalltherapeutictechniques.“Limitedreparenting”serves In ST problems in emotion regulation are mainly seen as a
as an antidote to traumatic experiences and leads to corrective consequence of adverse early experiences (e.g., lack of safe
Frontiers in Psychology | www.frontiersin.org 4 September 2016 | Volume 7 | Article 1373
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