Dialectical Behavior Therapy: Shame, Guilt and Emotional Distress

Just as some people are born with heightened sensitivity to physical stimuli (loud noises, itchy labels on clothes…) others are born with heightened sensitivity to emotional stimuli.

These sensitivities are genetic predispositions that are heavily shaped (either enhanced or modulated) by the socio-cultural and familial environments. And those inputs will largely determine whether the individual develops adaptive or maladaptive behaviors to address their respective sensitivities.

Jeff Gill: Flickr.com

Jeff Gill: Flickr.com

The person with sensitivity to physical stimuli might cut all the labels out of the clothes before wearing them and she may wear noise-cancelling headphones at work (as just two examples of adaptive behaviors to support underlying sensitivity). 

When you have sensitivity to emotional stimuli, then the adaptive behaviors involve re-framing, distraction, self-compassion, dialectic thinking, and response prevention techniques.

Dr. Marsha Linehan, developer of dialectical behavior therapy (DBT), designed DBT to address what she refers to as “emotional dysregulation”. I would likely reframe it as emotional sensitivity clad in maladaptive behaviors.

What is emotional sensitivity? Negative emotions set off a kind of rogue wave of emotional response that creates an absolute drive to do anything and everything to stop the oncoming intensity in its tracks. A rogue wave, or freak or monster wave, is an open ocean phenomenon where a combination of strong winds and currents allow for waves to merge creating an exceptionally large single wave.  

The tryptophan hydroxylase-2 (TPH2) gene generates a rate-limiting enzyme for serotonin synthesis that modulates responses within the emotional structures of the brain. Initial genotype studies suggest the significant presence of variants of that TPH2 gene for patients dealing with emotional dysregulation (or sensitivity) when compared to healthy controls. 1

That possible genetic anomaly may combine with childhood environments that reinforce or activate the cascade of rogue-wave responses to emotional stimuli.

I’ve talked about the kindling model that is used in the description of epilepsy in the blog post Tummy Troubles as that model could be applied to our experiences with pain.

From a pain perspective, the Wall-Melzack gate-control theory suggests that thin unmyelinated and large myelinated nerve fibres carry distinct information from the injury site up through the spinal cord. The thin fibers communicate pain, and the larger fibers communicate touch, pressure and vibration. By stimulating the large nerve fibers, the thin nerve fiber communication is suppressed. Fast nerve signals close the gate so that slow nerve signals are blocked.

A good example of this in action is how you will instinctively rub your knee vigorously if you smack it hard on a table. The painful ache of the smack is eased with the fast signals of brisk rubbing.

In fact, this gate-control theory has enabled physicians to treat patients with excruciating constant back pain by implanting and electrode near the site of the pain and then the patient has an external push-button she can press. It delivers a sharp, buzzing and vibrating sensation (mild shock) and the stimulation of that fast nerve conductance allows her to often have hours of pain-free comfort without medication or its accompanying side effects.

But in addition to the fast and slow nerve fiber gate-theory, we know that nerve fibers can be injured such that they erroneously start to signal pain when a non-pain stimulus is introduced. Dr. Elliot Krane explains this phenomenon in his presentation The Mystery of Chronic Pain. I see many parallels to this kind of ‘re-wired’ pain response and how the kindling model works to explain epileptic seizure.

When it comes to emotional sensitivity, I would suggest that the sociocultural and familial environments might injure a response system that is already predisposed to sensitivity to the point where the system begins to signal (kindle) rogue-wave level emotion even in the absence of emotionally-distressing stimulus.

That’s where I think shame responses that are so dominant for those with emotional sensitivity might originate.

Shame’s Impact on Self is Culturally Determined

Although we all tend to use the words shame and guilt interchangeably, how we experience those emotions are distinct and also vary across cultures.

If you reside in cultures that value individualism and independence rather than collectivism, then it is guilt that will generate increased efforts to engage and rectify any perceived wrongs you may have wrought upon others. If, however, you live in collectivistic cultures, then shame will generate increased efforts to engage and rectify perceived wrongs you may have wrought upon others.

In an independent, individualistic culture, shame triggers behaviors of self-protection and disengagement from others. 2 In other words, many on this site who speak of feeling shame are experiencing a reaction of helplessness and powerlessness— they live in societies that revere individualism.

The non-basic or social emotions of shame, pride or guilt are not thought to emerge in development until the second year of life, but several researchers argue that they emerge much earlier than that. 3

If you’ve ever witnessed a toddler cover her face with her hands in response to interactions with others, you are witnessing shame at its inception. Given that our evolutionary path is one of being predominantly in collectivistic cultures (that’s how we survived), this social emotion allowed for a child to increase her survival chances. In collectivistic societies, a child that reacts to her own sense that she has displeased another in the group tends to be responded to with engagement and framing.

Tamang and Brahman Nepali children have culturally specific emotion scripts that may reflect different emotion socialization experiences. To study emotion socialization, the child–adult interactions of 119 children (3–5 years old) were observed and 14 village elders were interviewed about child competence in Tamang and Brahman villages. Tamang rebuke the angry child but reason with and yield to the child who appears ashamed. Brahmans respond to child anger with reasoning and yielding but ignore shame. Tamang practices are consistent with their view that competent children are socially graceful and never angry. Brahman practices appear to be consistent with the privileges and duties of high caste status.” 4

If you were born predisposed to emotional sensitivity then your social emotion development may have been more suited to collectivistic environments. Your early expressions of feeling ashamed in our individualistic societies may have been at best ignored and perhaps even likely ridiculed or belittled in some way.

And at that point your shame mechanisms may be re-wired to trigger when no shame stimulus is actually present— somewhat similar to someone who experiences excruciating pain when a feather is passed along her arm. Now you have rogue-wave intense responses in the presence of emotional stimulus and in the absence of emotional stimulus too.

Maladaptive Short-Term Survival

For some, restrictive eating behaviors are practiced and reinforced as a maladaptive way to not only handle a rogue wave of emotion, but to actually create an environment where a reaction to any emotional stimulus is not liable to occur in the first place. Hunger blunts the emotional stimulus response.

When you stop using a maladaptive behavior, then it has to be replaced with adaptive behaviors— that’s where the therapy comes in.

Dialectical Behavior Therapy

DBT integrates cognitive behavioral therapy with mindful awareness and distress tolerance techniques. The dialectic that is fundamental to this treatment modality is the balance of both acceptance and change strategies throughout the treatment process. It requires of the patient that she learn how to weigh and integrate conflicting or contradictory facts or ideas. Often a patient dealing with emotional sensitivity will experience sharp black-and-white thinking. If she fails to achieve a goal she has set for herself, then she becomes utterly despondent and believes herself incapable of any improvement at all. It takes practice to learn to accept falling short of a goal while also committing at the same time to keep trying and striving to achieve that goal moving forward from that moment.

If you are dealing with suicidality, self-harming behaviors, post-traumatic stress disorder, have a history of dealing with abuse in your childhood, and/or just feel that your emotional responses seem outsized, then DBT might offer you far better outcomes and an opportunity to reach remission from an eating disorder than CBT.

DBT has some initial clinical data to support its value in treating PTSD related to childhood sexual abuse. 5 Initial case studies and open trials associated with the application of DBT for eating disorders, when other treatments (such as CBT) have failed, appear to offer up reasonable outcomes in lowering symptoms associated with an eating disorder 6,7

DBT is necessarily of longer duration than CBT and involves more frequent individual sessions and additional group sessions. Recent studies are looking to shorten duration from 12 to 17 months to six months given. For a comprehensive list of studies on DBT please see

The Linehan Institute Behavioral Tech Research on DBT Summary

1. Gutknecht, Lise, Christian Jacob, Alexander Strobel, Claudia Kriegebaum, Johannes Müller, Yong Zeng, Christoph Markert et al. "Tryptophan hydroxylase-2 gene variation influences personality traits and disorders related to emotional dysregulation." International Journal of Neuropsychopharmacology 10, no. 3 (2007): 309-320.

2. Bagozzi, Richard P., Willem Verbeke, and Jacinto C. Gavino Jr. "Culture moderates the self-regulation of shame and its effects on performance: the case of salespersons in The Netherlands and the Philippines." Journal of Applied Psychology 88, no. 2 (2003): 219.

3. Draghi-Lorenz, Riccardo. "Young infants are capable of'non-basic'emotions." PhD diss., University of Portsmouth, 2001.

4. Cole, Pamela M., Babu Lal Tamang, and Srijana Shrestha. "Cultural variations in the socialization of young children's anger and shame." Child development 77, no. 5 (2006): 1237-1251.

5. Bohus, M., A. S. Dyer, K. Priebe, A. Krüger, N. Kleindienst, C. Schmahl, and R. Steil. "DBT for PTSD after childhood sexual abuse in patients with and without borderline personality disorder: A randomized controlled study." Psychotherapy & Psychosomatics 82 (2013): 221-233.

6. Salbach-Andrae, Harriet, Inga Bohnekamp, Ernst Pfeiffer, Ulrike Lehmkuhl, and Alec L. Miller. "Dialectical behavior therapy of anorexia and bulimia nervosa among adolescents: A case series." Cognitive and behavioral practice 15, no. 4 (2008): 415-425.

7. Kröger, Christoph, Ulrich Schweiger, Valerija Sipos, Sören Kliem, Ruediger Arnold, Tanja Schunert, and Hans Reinecker. "Dialectical behaviour therapy and an added cognitive behavioural treatment module for eating disorders in women with borderline personality disorder and anorexia nervosa or bulimia nervosa who failed to respond to previous treatments. An open trial with a 15-month follow-up." Journal of behavior therapy and experimental psychiatry 41, no. 4 (2010): 381-388.