If My Bipolar Meds Are Working, Why Am I Still So Emotional? A Crash Course in DBT Therapy
A Crash Course in DBT—and Why I Think It Matters for Bipolar
If my meds are working, then why am I always so emotional?
The answer is that mood regulation and emotional regulation are not the same thing. And it took me a decade after my diagnosis to understand this.
Bipolar disorder is a mood disorder: mania, hypomania, depression, and mixed episodes. We're all familiar with them, right? Those are sustained changes in mood, energy, sleep, thinking, and behavior that can last days, weeks, and sometimes months, as we've learned.
Emotions? Separate category, separate bucket.
These can be completely stable in my bipolar disorder and still get absolutely furious about something that happened five minutes ago. I can feel rejected. I can feel jealous. I can feel anxious. I can feel hurt. I can feel overwhelmed, embarrassed, and overstimulated.
Those emotions can be really intense, and the experience of them is very real. But it doesn't automatically mean that I'm manic. It doesn't mean that I'm depressed, and it doesn't mean that my medication isn't working.
Medication is a huge part of how I manage my mood disorder, but medication doesn't make me emotionally bulletproof.
So that's why I've had to learn emotional regulation skills, especially through DBT (dialectical behavior therapy), because bipolar stability doesn't mean I never have huge emotions.
And the goal isn't to stop them, right? We need to feel the emotions. The goal is to figure out what we can do about them. How can we deal with them?
So that's the main difference between having a big feeling and having a bipolar episode.
When I was diagnosed with bipolar disorder, the conversation was understandably centered around medication. Take your medication, protect your sleep, learn your triggers, watch for signs of mania and depression, and call your psychiatrist when something changes.
All of that matters. Medication is still one of the most important pillars of my stability. But medication couldn't teach me what to do when I was completely overwhelmed by an emotion, something I’ve struggled with my entire life.
It couldn't teach me how to stop myself from reacting impulsively, tolerate something uncomfortable without immediately trying to make it go away, communicate what I needed, or recognize when my emotions were driving my behavior.
That's where DBT came in.
DBT stands for Dialectical Behavior Therapy. It was developed by psychologist Marsha Linehan and was originally created to treat people experiencing chronic suicidality and borderline personality disorder.
Today, DBT and DBT-based skills are used much more broadly for people who struggle with emotional regulation, impulsivity, distress, and interpersonal relationships. There has also been research into using DBT as an additional treatment for bipolar disorder.
I want to be clear about the word additional, because I don't look at DBT as a replacement for medication or psychiatric care. DBT isn't going to correct the biological mechanisms involved in bipolar disorder, and learning a distress-tolerance skill isn't going to guarantee I never become manic or depressed again.
What DBT has given me is a set of skills for managing myself, my emotions, my reactions, and my relationships. This isn’t about not feeling big emotions; it’s about how to process them.
THE BIPOLAR MYTH
If my bipolar disorder is properly treated with medication, I shouldn't struggle so much with my emotions.
One of the most helpful things I've learned is the difference between mood regulation and emotional regulation. Bipolar disorder is characterized by mood episodes (mania, hypomania, depression, and mixed episodes) that can last for days, weeks, or much longer.
Emotions are different. I can be completely stable from a bipolar perspective and still get furious because of something that happened five minutes ago. I can feel rejected, anxious, overwhelmed, embarrassed, overstimulated, jealous, hurt, or afraid without being in a mood episode.
Research has found that difficulties with emotional regulation can persist in people with bipolar disorder even outside of acute mood episodes. And for me, this is where DBT becomes so relevant. My goal isn't only to prevent the next major bipolar episode. It's also to learn how to live inside my brain on an ordinary Tuesday when something pisses me off, scares me, disappoints me, or sends my nervous system into overdrive.
Because what I do in those moments matters. If I'm dysregulated and I pick a fight, stop sleeping, isolate, make an impulsive decision, turn to unhealthy coping mechanisms, or create a huge amount of stress in my life, those behaviors don't exist in a vacuum. They can affect the very stability I'm working so hard to protect.
DBT essentially gave me a toolbox for those moments. The full therapy is much more comprehensive than what I can cover in one newsletter, and needs to be facilitated by a therapist, but the skills are generally organized into four areas: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.
A quick note before we dive in: I’m not a therapist or mental health professional. I’m sharing what I’ve learned about DBT through my own lived experience with bipolar disorder and the tools that have helped me personally. This is for education and peer support, not therapy or medical advice.
1. MINDFULNESS: NOTICE BEFORE YOU REACT
I know the word mindfulness can immediately conjure up images of meditation cushions and sitting silently with your eyes closed for an hour, but that's not really how I use it. For me, mindfulness is much more practical. It's the ability to notice what is happening in my brain and body before automatically reacting to it.
What am I actually feeling right now? What happened immediately before I started feeling this way? What story am I telling myself about what happened? What do I actually know to be true? What am I assuming? What does this emotion make me want to do?
That pause has become incredibly important for me because a feeling can be real without every thought attached to that feeling being true. I can genuinely feel rejected without someone actually rejecting me. I can feel unsafe without being in danger. I can feel like someone is angry with me without having any evidence that they're angry with me. I can feel like something is an absolute catastrophe while recognizing that my brain may be catastrophizing.
Mindfulness doesn't require me to talk myself out of the emotion. It's more like stepping outside of it long enough to observe it. Instead of immediately going from "I feel this" to "therefore this is true" to "therefore I need to act," I get a little bit of space in between.
And sometimes that tiny bit of space changes everything.
2. DISTRESS TOLERANCE: I DON'T HAVE TO FIX THIS FEELING RIGHT NOW
This might be one of the biggest lessons DBT has taught me: discomfort is not always an emergency.
Sometimes something hurts; there’s a trigger or threat, and there isn't an immediate solution. Someone is upset with me. I'm waiting for an answer. I'm anxious about something I can't control. I've had a horrible day. I'm furious. I'm embarrassed. Something didn't go the way I wanted it to. My nervous system wants relief NOW, and every part of me wants to do something to change the feeling.
Distress tolerance is the ability to get through that moment without making it worse.
One of the simplest DBT tools for this is STOP. The acronym stands for Stop, Take a step back, Observe, and Proceed mindfully. If I'm highly activated, I don't have to send the text immediately. I don't have to make the decision. I don't have to continue the argument. I can stop, physically or mentally step away, and observe what's happening. What am I feeling? What's happening in my body? What am I telling myself? Most importantly, what am I being urged to do?
Then I can decide how I actually want to proceed.
The goal isn't to stop myself from feeling intensely. It's learning that I don't have to obey every urge that comes with an intense feeling.
3. EMOTION REGULATION: WHY IS MY THRESHOLD SO LOW TODAY?
Emotion regulation is probably the most obvious connection between DBT and bipolar disorder, but one of the things I love about it is that it goes deeper than simply telling us to "control our emotions." Instead, DBT asks us to understand them.
One concept that's been particularly helpful for me is looking at vulnerability factors. If my emotional threshold seems unusually low, I can ask myself what else is happening. Did I sleep badly? Have I eaten enough? Am I overstimulated? Am I under an unusual amount of stress? Have I been isolating? Is my schedule too full? Is something unresolved already taking up emotional bandwidth?
This overlaps enormously with the way I manage bipolar disorder because I've learned that regulation isn't something I do only after I become dysregulated. A huge part of regulation is reducing the conditions that make dysregulation more likely in the first place.
Another DBT concept I love is Opposite Action. Sometimes an emotion gives us an urge that, if followed, will actually make things worse. Depression tells me to stay in bed and disconnect from the world. Anxiety tells me to avoid the thing I'm afraid of. Shame tells me to hide. Anger tells me to attack. Opposite Action asks whether acting opposite to that urge might actually serve me better.
That doesn't mean blindly doing the opposite of every feeling. Emotions give us important information, and sometimes the urge absolutely fits the facts. If I'm genuinely in danger, fear is useful. If someone is violating a boundary, anger might be telling me something important. But when the emotion, or its intensity, doesn't fit what's actually happening, I don't necessarily have to follow where it wants to take me.
An emotional urge isn't automatically an instruction.
That has been a huge lesson for me.
4. INTERPERSONAL EFFECTIVENESS: PEOPLE AREN'T MIND READERS
Relationships can be one of the biggest sources of emotional activation, and DBT doesn't ignore that. Interpersonal effectiveness is essentially about learning how to ask for what you need, say no, maintain boundaries, handle conflict, and communicate effectively while still respecting yourself and the other person.
One of the best-known DBT skills is DEAR MAN: Describe, Express, Assert, Reinforce, Stay Mindful, Appear confident, and Negotiate. It's basically a roadmap for having a conversation when you need something instead of hinting, exploding, shutting down, or expecting the other person to somehow figure it out.
For example, if I've had three nights of poor sleep and I'm noticing that I'm becoming more emotionally reactive, I can describe what is happening without blaming anyone: I've slept badly for three nights, and I'm noticing that I'm feeling more fragile today. I can express how I feel: I'm overwhelmed, and I'm worried that pushing myself tonight isn't a good idea. Then I can actually assert what I need: I'd like to cancel our plans and stay home tonight.
This sounds basic. It wasn't basic for me.
One of the hardest things I've had to learn is that people aren't mind readers. If I need something, I have to communicate it. If I have a boundary, I have to state it. If I'm overwhelmed, I can ask for space instead of becoming resentful that someone didn't magically realize I needed space.
For someone trying to manage bipolar disorder, I think that matters enormously. My relationships are part of my environment. Conflict creates stress. Resentment creates stress. Constantly saying yes when I need to say no creates stress. And stress matters to my bipolar brain.
DBT ISN'T ABOUT NEVER BECOMING DYSREGULATED
This is probably what I appreciate most about DBT. The goal isn't to turn me into someone who never gets angry, anxious, overwhelmed, impulsive, hurt, or dysregulated.
That's not realistic.
For a long time, I thought recovery meant eventually becoming a person who just didn't struggle anymore. I thought if I found the right medication, the right therapist, the right routine, the right supplements, the right whatever, eventually I would arrive at some magical place where my brain behaved itself all the time.
I've stopped chasing that.
Today, stability means having systems and skills that help me respond when my brain doesn't behave the way I'd like it to.
Medication is part of that. Therapy is part of that. Sobriety is part of that. Lifestyle is part of that. Nervous system regulation is part of that. And emotional regulation skills are a HUGE part of it.
DBT gave me language for things I didn't understand and tools for moments when "just calm down" was never going to cut it.
I still get dysregulated.
I still react sometimes and think afterward, Well, Louise, that could have gone better.
I still have big emotions.
But I have a much bigger toolbox than I used to.
And that, to me, is the point.
JOURNAL PROMPT
Think about the last time you had a really strong emotional reaction to something.
What was the emotion? What did it immediately make you want to do? And before you acted, was there any space between the feeling and the behavior?
Then ask yourself one more question:
If I could replay that moment with a pause between the emotion and the action, what might I have done differently?
That pause is where so much of this work begins.
WANT TO TRY DBT?
I’m Bipolar. Now What? LIVE! is a private, anonymous weekly coaching community where we dive deep into actually learning skills and putting them into practice.
I hope you'll join us: I'm Bipolar. Now What? LIVE!
I'm Bipolar. Now What? LIVE!
WANT TO LEARN MORE ABOUT DBT?
Listen to Episode 107 of I'm Bipolar. Now What?: DBT Therapy Crash Course. Episode 107: DBT Therapy Crash Course
If you're interested in actually working with a DBT therapist, Psychology Today has a DBT therapist directory where you can search by location and then narrow things down based on insurance, virtual vs. in-person therapy, and other preferences. One thing to pay attention to: there's a difference between a therapist who uses some DBT skills and someone who is specifically trained in comprehensive DBT. Don't be afraid to ask a potential therapist what their DBT training looks like and whether they provide full DBT or incorporate DBT skills into individual therapy. (Psychology Today)
And you absolutely don't have to wait until you're in therapy to start learning these skills. These are a few of my favorite places to start:
Have a question for a future newsletter?
Ask me anything about living with bipolar disorder. Only I will see your question, and if it's selected, I'll answer it anonymously.
While I can't guarantee I'll be able to answer every question, I'll do my best to get to as many as I can over time.
Thank you for trusting me with your question.
