Biosocial Theory
E Ulland, MD
Marsha Linehan, PhD theorized a biosocial model to understand what occurs for people who seemed too emotional to benefit from cognitive behavioral therapy. Cognitive Behavioral Therapy (CBT) has proven itself to be an evidence-based model with moderate efficacy for treating multiple disorders including depression, and anxiety disorders. Her concern was that CBT did not seem to work for individuals with severe emotional sensitivities. She wanted to understand why and how to make treatment more effective for those individuals. She realized CBT is firmly planted on one end of a dialect between acceptance and change. CBT is a type of treatment that consists mainly of evidence-based tools that work for anxiety and depression. It works by changing behaviors and thoughts by challenging them directly. Dr. Linehan discerned that some individuals needed acceptance prior to change and could see that therapists often were not meeting clients where they were at. She recognized individuals may lack skills others had learned through their life experience. CBT does not to focus on emotional processing as a central component of treatment, but changes in mood as a secondary outcome of changing maladaptive behaviors and thoughts. She realized that emotionally sensitive people need to have a firm understanding of their own emotions and regulation, an improved ability to be mindful, and an understanding of life from a dialectical frame of reference. Treatment providers and families benefit from the understanding and the use of these skills and philosophy; otherwise they emotionally reject the people they seek to help.
Biological
CBT works for individuals who are at a place of acceptance and willingness for change. Figure 1 shows a flow diagram for what likely happens hundreds of times, sometimes outside conscious awareness. Events occur in the world, which are filtered through our beliefs. Our beliefs are thoughts we realize through our lived experience. These thoughts typically concern ourselves, others, and the world. For instance: “I am a good person” or “I am a bad person,” “the world is safe” or “the world is unsafe,” and “I can trust others” or “I cannot trust other people.” These beliefs are learned over our life history—many times from our families of origin. They are often unspoken, and unconscious. With the practice of mindfulness, we are more likely to notice them.
Often emotions occur after being filtered through our cognitions. Emotions then influence our choice of action within the world. If we can tolerate an emotion and be effective, we are modulating affect. Affect modulation is the end result of many skills used in the moment to regulate our emotions, allowing us to be in wise mind, where we can choose our best response. Figure 1 we regard as the change loop of the Biosocial Theory. This is the place where change could most readily occur based on awareness, ability to tolerate emotion, and use of acquired skills.
Individuals who can modulate most of the time have a luxury of changing thought, or deciding to do things differently the next time. This leads to learning and growth. They will better tolerate a similar experience in the future. CBT assumes individuals are able and willing to tolerate emotions when thoughts and behaviors are challenged. Often, they are being asked to behave and think in ways that generate emotions they have been avoiding. They are only able to do this if they are not overwhelmed by the intensity of emotion when challenged. Some individuals struggle with tolerating emotion because ALL emotions are felt too intensely as a result of their biology.
Figure 1. The cognitive behavioral therapy loop. If one can tolerate their emotional reaction, they can modulate affect and change perspective or behavior effectively.
Marsha Linehan, PhD helped define emotional reactivity and how therapy failed to address it before DBT. Emotionally reactive people tend to generate more intense emotions in given instances than the average person. Emotional reactivity is defined by traits of sensitivity, intensity, and duration. It has been established that emotional reactivity is a heritable trait within families. Often enough, the parents of emotionally reactive children have had experiences with emotional reactivity themselves. Their parents may have found ways to compensate for their emotional reactivity in ways that have worked well enough for them within relationships. Likely, some of the ways they regulate are not effective for their child, and in some instances can lead their children to struggle. For instance, some adults allow themselves to be acceptably codependent within a relationship. However, this occurs after maturation of their identity. Emotionally sensitive people have a tendency towards codependency and merging, which at this stage interferes with developing a sense of identity. This is likely to lead to behaviors that put them at risk for trauma, since they may associate with at risk peers that model ineffective behaviors, and may find themselves in emotionally or physically abusive relationships. It is also possible not to be born with emotional reactivity. It can be caused by a mismatch between the individual and their environment. This is a high-risk situation for chronic invalidation which can cause emotional reactivity over time.
Emotionally reactive people are sensitive to their environment. They often sense another individual’s change in vocal tone, body language, or statements. They may not accurately assess why the other person is different, and usually believe they themselves are the cause. For instance, their father could come home slightly tired from work and give shorter responses with less eye contact. The child may then believe their father is angry at them for something that occurred previously.
Due to their sensitivity, emotionally reactive people are stimulated emotionally more often than the average person, and this is amplified by the second trait of emotional reactivity, which is the intensity of the emotion. The average person may experience an event with a tolerable 4 out of 10 anxiety response (10 being the most anxious they have ever felt). Sensitive individuals may feel that they are experiencing a 9 out of 10 for the same event. This is intolerable. This is why at times parents believe their children have appeared to "overreacted" in the past. For relatively less intense events, sensitive individuals are already experiencing physiological arousal. Any emotion experienced too intensely for a prolonged period of time will lead to an increased heart rate. If elevated enough, the individual transitions to the fight, flight, or freeze response. This is a result of autonomic hyperarousal. It is extremely uncomfortable to experience, and has been programmed over the course of evolution to represent threat in our body. By the point of fight, flight, or freeze, the individual is emotionally overwhelmed, and therefore no longer rational.
The third trait of emotional reactivity is a longer duration of emotional response. The average person experiences an emotion for approximately 90 seconds. This will occur when at the person is at their most regulated, having slept well, ate well, etc. This will occur only if they are willing to experience the emotion and allow it to be. Nonacceptance, such as avoidance, suppression, experiencing a secondary emotion, etc. will lead to a longer duration of emotional experience. Emotionally sensitive individuals experience emotions longer than the average person. This is extremely difficult for them, considering they also experience emotions more intensely and also are stimulated more often. Figure 2 shows how emotional reactivity leads to emotional dysregulation faster in emotionally sensitive individuals.
Figure 2. Avoidance due to the intensity of emotional reactivity. A baseline state of emotional reactivity, dashed box, predisposes an individual to a faster threat response of fight, flight or freeze, generally thought to be most impacted by increased heart rate.
Being stuck in an emotionally overwhelmed state can lead to confusion of emotions and avoidance of difficult emotions. Emotionally reactive individuals can become emotionally dysregulated. The emotion dysregulation worsens as autonomic hyperactivity increases. We expect three things to occur when individuals are becoming emotionally dysregulated. First, they may express more emotion than seems warranted to others. Second, they might not express emotion, which may mislead others to think they are more proficient at emotion regulation than they are. At the same time, they can also be near an emotional crisis without others being aware. Third, residents may be incongruent in their emotional responses. Incongruence occurs when an individual expresses an emotion that is not the emotion they are experiencing most profoundly. An example would be the use of sarcasm and humor when struggling with more negative emotions such as sadness, or shame. These incongruent responses are often not helpful to children, particularly because they model avoidance of emotion. Children will believe their families are unable to tolerate a certain level of emotion, and they will attempt to hide their own emotion, since they believe it is a weakness.
Ultimately, avoiding emotion will lead to distress. When in distress, a person has a choice to accept and tolerate distress or become behaviorally dysregulated. Prior to treatment, behavioral dysregulation occurs because individuals do not have skills or the capacity to tolerate the distress. Examples of behavioral dysregulation include: nonsuicidal self-injurious behavior, chronic suicidal ideation, suicide attempts, substance abuse, sexual promiscuity, outbursts of anger, sleeping all the time, etc. The behavioral dysregulation serves to reset the intensity of their emotions. After behavioral dysregulation, individuals are physiologically calmer. Afterwards, they experience shame for having acted ineffectively. Behavioral dysregulation also decreases the ability to learn from experience. Individuals are unable to see the chain of events that led to the ineffective behaviors, and it will likely happen again. Figure 3 shows the path of wasted pain and how emotional dysregulation paves the way through distress to at risk behaviors.
Figure 3. Wasted Pain. Initial avoidance of intense emotion leads to emotional dysregulation to a crisis point where residents become behaviorally dysregulated. This leads to wasted pain, since learning from the experience doesn’t happen and they are left feeling shame for the behaviors which are against their own values. The dysregulated behavior works by decreasing the physiological arousal, which is unconsciously reinforced. Their mind sees that when in distress, the behavior work to calm them, which occurs on a level outside of their own awareness.
Distress Tolerance
One of the most important skills in the initial phase of treatment is distress tolerance (Mindfulness is the core skill in DBT and meant to be used as often as possible, since it leads to choices through awareness, and direct improvements to emotion regulation itself. Also, it requires mindfulness to know that one is in distress). The first major goal is to be able to give clients skills that will immediately reduce heart rate so they can tolerate distress without becoming behaviorally dysregulated. We want them to be able to tolerate exposure to distress without losing control, and by doing this they develop more of a tolerance to their intensity of emotional experience. This is one of the ways in which they can decrease their hypersensitivity to their emotional experience. If they can learn to tolerate the distress by lowering the arousal from the emotion, they can fully experience the wave of emotion. They can now use other skills to regulate emotion and decide how they want to be in the relationship. Initially, we would expect that individuals use distress tolerance techniques as much as 80% of the time in the first couple weeks of treatment. This is due to how often they find themselves in distress. Eventually, they will not rely as much on distress tolerance skills, since they will do better at staying out of distress by being more skillful before moments that used to cause crisis. Distress tolerance skills are a bit like riding a bike. Clients typically don’t forget how to use them effectively if life ever surprises them with an intense experience.
Figure 5 is a roadmap for areas where skills are helpful. For instance, emotion regulation skills help with understanding and experiencing emotions in the body, and also caring for one’s internal milieu. This helps to have a higher tolerance for the stress of daily living. Interpersonal effectiveness skills help with managing relationships in a healthy way, fostering healthy connection with others. It also helps clients know how to set limits in relationships when necessary, while living to their values. Interpersonal skills help prevent social rejection, which is the largest risk factor for behavioral dysregulation. It also helps reduce unresolved conflicts. Towards the end phase of treatment, clients are working more with patterns of dialectical thinking. They become more phenomenological, recognizing that other minds view things differently. Different perspectives are important and not assumed to be less valid, or less interesting, than one’s own. Parents also learn to be more dialectical. An example would be nonjudgmentally reframing patterns of behaviors by their children, and not using words like “manipulative.” The family will work to reframe their child’s behaviors in a more helpful way with generous assumptions (discussed previously). There is wisdom in what children do, even if it is ultimately ineffective in the long run. Parents will find this challenging if they have more rigid beliefs, or often fall into arguments about “what really happened.” Arguing about reality by focusing on specific details in the external environment or in the past to prove their own perspective, is emotionally rejecting of others. If family members have a history of trying to change their child’s mind, they likely struggle with perspective taking. They might have a belief that changing their children’s mind might help their child feel better. In family therapy parents may find themselves emotionally dysregulating and need to regulate themselves.
Figure 4. The DBT road map for skills use. Mindfulness does not have a number since it is the core skill and is meant to be used as much as possible. Mindfulness makes the use of other skills possible.
Social
While dialectical behavioral therapy has an intense focus on the individual being able to accept difficulties in life and be willing for change, it also has a focus on the relationships within the client’s life. Emotional dysregulation is considered a transactional process. In DBT, no person is an island. Humans evolved to be highly social mammals. We affect each other constantly, usually at a level outside of awareness. Our biology makes us sensitive to our troop, and deeply we fear exile. Historically, exile, or rejection, was a death sentence for a human in a hunter gatherer society where we mostly evolved. Nowadays, this translates to clients being more reactive to the nonverbal and verbal behaviors of others. Most of their higher risk behaviors occur after emotional rejection. Because of their sensitivities, they are rejected far more often than the average person, and they feel it more deeply. They are hypersensitive to the idea of being alone and would do nearly anything to not have that experience.
Recall that during emotional dysregulation, any individual’s intense experience leads to expressing more emotion than the average person might, or no emotion at all, or an emotion different than what is being experienced (incongruence). This will then lead to invalidation from the environment. The use of dark, or cynical humor, within families is an example of this. How often do we make jokes when experiencing sadness, rather than sitting within someone else’s expression of sadness? Humor is a mature way to defend against life’s challenges if not overused. However, emotionally dysregulated individuals feel emotionally rejected or invalidated easily by incongruence. What they experience is the person making a joke moves on from the emotion, but the sensitive one cannot move on as fast. They experience loneliness because the emotional connection was lost. Frequently enough, shame is experienced because clients blame themselves for the loss of connection, which can dull the experience of loneliness. Shame is an attack on themselves which is easier to experience for them than loneliness.
Any time when we are connecting through emotion and the other person is unwilling to be with us or it is clear they do not understand, we are invalidated. Examples of invalidation would be to reflect back an emotion that was not the emotion expressed, not listening, providing problem solving, providing reassurance, meeting with negative energy, etc. Apologizing can also be invalidating if given too soon or if not requested. Invalidation leads to increased emotional dysregulation, bringing about distress much sooner. It also corrodes trust. Figure 5 shows how chronic invalidation from the environment leads to emotional hypersensitivity by increasing the intensity of emotional reactivity. Chronic invalidation can reach a level within a family system or school system where the individual has been branded “the sensitive one.” They may be treated with kid’s gloves or rejection. The individual will begin to experience confusion regarding emotions and many times their mind can disconnect from sensations in their bodies that alert them to their emotions. They do not recognize body sensations in a meaningful way to alert themselves to how they genuinely feel.
In addition to emotional rejection by their external environment, humans often enough emotionally reject themselves in the form of self-judgments through shame (Figure 4). Many clients had noted when younger that their emotional reactions were different from that of peers and family. An example could be a time when they watched a scary movie with peers. A startling event occurred in the film and the people around them laughed, while internally their heart was pounding and they were frightened as though the events were unfolding in real life. They notice these differences in themselves and then shame themselves for being “too scared,” “too sensitive,” and tell themselves “I shouldn’t feel this way, what’s wrong with me!?”
Figure 5. The social aspect of the Biosocial Theory. Because emotion dysregulation is transactional, we cannot overstate the importance of how individuals relate to the environments they are from and currently find themselves. Invalidation from family, peers, and school. Society at large is invalidating of emotionally reactive individuals. Residents learn from a young age that they experience emotions more intensely than others, judging themselves harshly for emotions. Chronic invalidation from others or themselves leads to hypersensitivity of their initial emotional reactivity. This increases the likelihood that they will become behaviorally dysregulated. Thick arrows symbolize where invalidation effects the process and dashed arrows represent the increase in speed/ intensity of behavioral dysregulation.
Focus on Skills in Therapy
It is thought that consistently high levels of emotional arousal interferes with learning social skills, and how to regulate emotion in general. It may not affect learning associated with academics; it appears that cognitive processes like logic are still able to compensate to learn in academic settings. The struggle arises in learning that requires emotional cognitions, and also within relationships which requires a high level of emotional processing. It is as if a client’s emotional circuit has been overwhelmed - it is overwhelming to process the level, intensity, and duration of their emotional responses since childhood. This leads to a skills deficit over time, which may go unrecognized. Many emotionally reactive clients in therapy do not improve clinically without learning these skills. Emotionally reactive people are as intelligent and sometimes more so than average, and it was easy for those around them to mistakenly believe they had more capacity for emotions than warranted. They were assumed to have the emotional regulation strategies of someone their age, but many times had the skill level of someone far less experienced. Once it was understood that this skills deficit interfered with therapy and relationships, the training of skills became ultimately important for emotionally reactive individuals in recovery. Skills groups are the center of focus for dialectical behavioral therapy. Without the generalization of skills, clients can be expected to struggle with being effective.
Many of the skills that are taught within DBT are used by effective adults who regulate emotions well and can share their emotions with others. They may not be aware of the acronyms or that the skills they use are "a thing." Because they were not emotionally overwhelmed when they were younger, they picked up skills naturally in the moment with less effort. One of the benefits of dialectical behavioral therapy is that clients will have significant experience with the skills. It is the hope with DBT that they begin generalizing skills. Their continued use will lead them to be more effective than others around them. DBT starts as a skills deficit model and becomes a strength-based model if clients continue to use the skills on a day-to-day basis past a point of “recovery.”
Processing Primary Emotion
Through dialectical behavioral therapy, we are intent on processing the primary emotion, this is an emotion that is deeply felt, often briefly the first emotion experienced. To learn from experience, we must be aware of the emotion and allow it to pass through. Things become confusing for individuals who may move rapidly into secondary and tertiary emotions when avoiding primary emotions. Non primary emotions interfere with resolution of primary emotions and prevent learning. Typically, one can expect that the primary emotion is an emotion that leaves one feeling exposed. It is an intense experience to remain vulnerable when one has been misunderstood so often in the past when feeling an intense emotion. Recall that avoidance of an emotion leads to hypersensitivity of that emotion. Secondary emotions are conceptually difficult to understand and see in the moment. Therapists help understand how clients shift between emotions and help them to stay with the primary emotion which will be most effective for the client most of the time.
Increasing Ability and Use of Validation
As you saw in Figure 5, invalidation worsens emotional dysregulation and can be dangerous. It also leads to feelings of rejection and thoughts of being alone, which is overwhelming for clients. Validation helps one feel connected to someone else, this is helpful during a time of suffering. Recall validation is helpful to reduce physiological arousal in the moment. All of us have had experiences in life where we were attempting to share in something difficult and felt worse, because of negative interactions. We’ve also experienced people in our lives who were helpful by allowing us to feel safe and understood when sharing our true emotional experience. Since validation lowers physiological reactivity, we view the use of validation as important as any biological treatment. Additionally, validation shows clients they are not alone in a moment of suffering, and that their experience makes sense in certain ways. Validation leads to a sense of emotional connection and builds trust within a relationship. Please refer to the section regarding validation. There is also a handout for building emotional safety in relationships, which is synonymous with the word “trust.” BRAVING is a helpful concept for increasing trust in relationships.