Affect Regulation

8/8/2019 Affect Regulation

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AFFECT REGULATION

TOOLBOX

Tenth International Conferenceon Ericksonian Approaches to Hypnosis & Psychotherapy

December 6 9, 2007

Phoenix, AZ

Presenter: Carolyn L. Daitch, Ph.D.

28592 Orchard Lake Rd., #301Farmington Hills, MI. 48334

www.anxiety-treatment.com

[email protected]

248-626-8151


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Topics

Over reactivity

Consequences of over reactivity

Interventions

Applications


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Over Reactivity: Definition

The distorted and unnecessarilyintense reaction to routine stimuli of

daily life and interpersonal contact withaccompanying psychophysiologicalhyper-arousal.


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Three Components ofOver Reactivity

Physiological

Psychological

Temperamental


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Over Reactivity: Experience

Frequently includes the internal

experience of being overwhelmed with

emotion and feeling out of control.

(Daitch, 2007)


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Flooding

One of the hallmarks of affectdysregulation is flooding.

Flooding leads to emotional (escape)conditioning.


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The Emotional Brain

Fear conditioning A process in which the amygdala plays a

crucial role (phobias)

Chronic Stress HPA Axis (G.A.D)

Impulsivity Prefrontal Cortex


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Fear Conditioningand the Amygdala

Brain is adept at storing long-termmemory events when experience fear

Amygdala plays a crucial role

Adaptive

Problematic for those with anxiety

disorders


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Normal Reactions vs.Over Reactions

The distinction between normalreactions and over reactivity is whenthe reactivity creates chronicdiscomfort, impedes life functioning,and/or seriously interferes withrelationships.


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Profile of theOver reactive Client

Experience a series of conflictedrelationships, particularly intimate

and/or work relationships.

Displays symptoms of anxiety.

Experience psychosomatic illnesses

and over reactions to bodily symptoms.


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Painful Consequencesof Over Reactivity

Excessive emotionality can disruptivethe accomplishment of goals

Intensity exhausts others

Parents lose effectiveness andcloseness with children

Leads to addictive behaviors as anattempt to self soothe


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Skills Needed

Remain calm and clear in the face of stress.

Observe and reflect on their emotions and

behavior.

Tolerate uncomfortable, negative affect or

concurrent conflicting emotions without

defensiveness.

Suspend judgment

Soothe themselves or their partners.


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Underlying Assumptions

Talk therapy is often insufficient. One must diffuse the stress response

first before a change of interpretation of

an event or reaction is possible. Rehearsal and practice of new

responses must be an integral part of

the treatment.


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Speed and Power

Since the over reaction is triggeredso quickly and powerfully, the

therapist must teach clients tointervene with rapidly induced calmstates.


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Transfer and Maintenance

Skills mastered in the therapeuticsetting often do not transfer into the

home.

Long lasting changes of interpersonal

patterns are hard to effect.


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The Toolbox


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The Affect Regulation Toolbox

The Affect Regulation Toolboxcomprises a collection of therapeutic

interventions consisting of fourcomponents or tiers to help clientsdevelop new ways of thinking, feelingand behaving.


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Toolbox Tiers

Tier 1: Recognition of an overreaction, andinitiation of a brief pause to interrupt it.

Tier 2: Standard hypnotic induction and

deepening techniques.

Tier 3: A set of tools aimed at shifting

unhealthy reactive styles. Tier 4: Tools to address therapeutic

transfer of suggestion and practice.


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Tier 1: Identify the Start of an OverReaction and Respond Appropriately

Tool 1: Recognizing somatic,

cognitive and emotional cues

Tool 2: Time out


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Tier 1: Time Out

Response patterns cannot bespontaneously altered.

Individuals must be trained to take animmediate cease fire.

Establish a habit of taking a time out topractice the self-regulation tools.

(Daitch, 2007)


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Tier 1: Interrupting andIdentifying Over reaction

Somatic cues

Dysfunctional cognitions

Emotions


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Tier 2: Focus, Calm, Deepen

Focus: These tools help clients narrow

and focus their attention on their internal

experience.

Calm: Eliciting a calm state is the first

goal of reversing the stress reaction.


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Tier 2: Deepen

Provide suggestions for deepening

the relaxation experience.

Facilitates optimal receptivity to

interventions in Tier 3.


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Tier 2: Tools for Deepening

Arm and leg heaviness

Hand warming

Elevator / Stairway


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Tier 3: Healing Strategies

Interventions designed to prepare theclient to regulate affect.

Include a variety of approaches that

incorporate imagery, cognitions and

affect.


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Tier 3: Therapeutic Objectives

Mindfulness

Sensory awareness and cues

Impulse control Coexisting affective states

Resource utilization Positive affect development


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Objective: Mindfulness

Development of mindful, detached

observation of transient affective

states.


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Mindfulness

Paying attention in a particular way on

purpose, in the present moment, and non-

judgmentally. Kabt-Zinn, 1994


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Mindfulness

I am my feeling

I breathe through my feeling

I am more than my feeling


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Objective: Sensory

Awareness and Cues

Develop awareness of bodily

expressions of stress

Regulate and modify somatic

expressions


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Objective:

Sensory Alteration: Anesthesia

Create tangible evidence for client that

the mind can alter ones response.

Make a link between physical and

psychological numbing.

(Edgette and Edgette, 1995)


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Objective: Impulse Control

Master a combination of regulatory

interventions for impulse control.


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Thought Stopping

Interrupt intrusive thoughts

Use cognitive, visual and kinesthetic

approaches


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Self-statements

I am fully present in this moment I choose to stay calm

I breathe through my fear (anger,irritation, impulse, etc.)

I can handle it

I release judgment of him/her Om grow up!


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Kinesthetic Cue

Goals: Quickly access a calm state.

Establish an anchor with an Ok

signal. Signal to him or herself that

everything is fine or OK in the

moment. Focus attention to the present

moment.


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Objective:Coexisting Affective States

The ability to have two conflictingfeelings or thoughts at the same time.


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Coexisting Affect States

Juxtaposition of two feelings

Ego states Switching channels

Alternating hands


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Juxtaposition of Two Feelings

Tolerate the juxtaposition of two opposingfeelings

Recognize that we can elicit an alternativeaffective state

Elicit a feeling of amusement to help softenreaction to a stressor or trigger

Know that there is always more than onefeeling available


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Alternating Hands

Experience the merging of negative

and positive feelings.


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Objective:

Resource Utilization

Imaginary support circle

Parts of self

Watchman


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Objective: Positive Affect

Gratitude incompatible withanxiety and conflict

Age regression Age progression


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Tier 4: Rehearsal and Practice

Behavioral Rehearsal

Practice Rehearsal


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Developing New Responses

Referring to yoga wisdom, internationally

recognized yoga teacher Shakta Kaur

Khalsa (2001) stated that it takes 40 daysto change a habit, 120 days for the new

habit to become who you are, and a

thousand days to master the habit.


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Practice

With repeated practice, we retrain our

neural pathways to respond differently.

Rehearse newly acquired behaviors andthe home practice sessions while still in

the hypnotic trance.


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Homework

and Success of Therapy

A clients willingness to engage in

therapeutic homework is directly

related to the success of the therapy.

f


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Why Hypnosis is Helpful with

Affect Regulation

Identifies diffuse physiological arousal

Calms arousal response with relaxation

Rehearse appropriate responses


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Why Hypnosis is Helpful (contd)

Hypnosis increases effectiveness ofcognitive behavioral treatment.

(Lynn, Kirsch & Rhue, 1996)

Hypnosis can help patients to notice

early warning signs and prevent full-blown flooding response.


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Applications of the Toolbox


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Applications

Anxiety disorders Marital relationships

Other relationships


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Anxiety Disorders


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Anxiety Disorders

Most common type of psychologicaldisorder affecting both children andadults

Often goes untreated Women are particularly

vulnerablethree times the rate of men


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Common Anxious Profiles

Specific phobias and aversiveassociations

Generalized anxiety

Somatic manifestations

Obsessive compulsive disorders

Post-traumatic stress


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Anxiety and the Brain

Anxiety is very easy to acquire, but oncethe brain circuits are in place they are very

difficult to delete.

The wiring of the brain at this point in our

evolution is established so that connections

from the emotional systems to the cognitivesystems are more developed.(LeDoux, 1996)

Components of the Anxiety


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Components of the Anxiety

Response

Overestimates risks Underestimates available resources

Repeats rigid behavior patterns(Yapko, 2003)

Ch t i ti f I di id l


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Characteristics of Individuals

Vulnerable to Anxiety and Phobias

Sensitivity to bodily stimuli

Unusual capacity for vivid imagery

Excellent focused-attention, absorption High hypnotic susceptibility

(Crawford & Barabasz, 1993)

Treatment Goals


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Treatment Goals

for Anxiety Disorders

Mastery over self with calming responses. Skills to interrupt negative and irrational

thoughts.

Diminishment of worry. Elimination of fear of future anxiety

reactions.

Increased resiliency in face of short- or long-term stress.


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Treatment Goals (Contd.)

Diminishment of restlessness and irritability. Diminishment of somatic expressions of

anxiety such as racing heart, sweating,

dizziness. Improved sleep and/or well-modulated

appetite.

Diminishment of obsessive thoughts.

Often Missed yet Critical


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Often Missed yet Critical

Aspects of Assessment

Assess for side effects of prescription

medications

Assess for over the counter drugs Assess caffeine consumption

Assess diet

Case Example:


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Case Example:

Using the four tiers of the toolbox

Client with G.A.D.

History of trauma

Temperament Life stress


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Treatment Goals

Proportional emotional reactions andworry to triggering events.

Diminishment of focus on the future.

Acceptance of uncertain outcomes.

Diminishment of somatic expressions.

Diminishment of irritability.


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Tier 3

Dialing Down Anxiety Think of a stressor. . .

notice what number

the needle on the dialis registering. . . use

the power of your

imagination to dial thenumber down. . .

Gratitude Intervention:


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Gratitude Intervention:

The Glass Half Full

After induction and deepening, patient istold that anxiety is incompatible with

gratitude.

Introduced the glass half full metaphor Client is directed to imagine a large glass (she

chose a large brandy snifter).

Spoke of glass half empty/half full themes. Directed to fill the glass with symbols, representing

the things in her life for which she was grateful.


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Mindfulness Intervention

Attending to the symptom inevitablysoftens its intensity.

I am aware of my anxiety.

I breathe through my anxiety. I am more than my anxiety.

Thought Stopping Intervention:


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Thought Stopping Intervention:

Interrupting Obsessive Thoughts

. . . and now Id like to teachyou three things for when you

are ruminating....Id like you to

bring your right arm up as if

youre stopping traffic...see

that stop sign....and say stop

it!...bring your right arm up as

if youre stopping traffic...seethat stop sign....and say stop

it!. (Daitch, 2007)

Rehearsal in Fantasy:


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Rehearsal in Fantasy:

Screen Technique

Imagine yourself on a screen, looking up

and seeing yourself beginning to have an

anxiety attack. Imagine three scenes in

succession with different ways you couldcope with it.

And you can be curious, about just how

easily you can develop strategies that willenable you to handle what ever emotions

arise.

Sensory Anesthesia for


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Sensory Anesthesia for

Diminishing Emotional Reaction

Numbing / Sensory Anesthesia

Hypnotic anesthesia diminishessensation. It is typically used in painmanagement but it can also be usedto diminish psychological suffering.

(Edgette and Edgette, 1995)


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Imaginary Support Circle

Client is directed to imagine a circle ofpeople who would be loving and supportive

to surround her when she was afraid.

Supporters could be people she actuallyknew, or people from history or religious

entities. In trance she was directed to

imagine her imaginary circle.

Tier 4: Behavioral and


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Practice Session Rehearsal

Extended time out

Mini sessions

When triggered or anxious When triggered or anxious but unable to

take a time out


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Rehearsal of Self-Talk

Direct client to see herself in a varietyof anxiety provoking scenes supporting

herself with affirming self-statements.

Setting the Right Tone


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g g

in the First Session

This initial session is particularlyimportant to the client who suffers from

anxiety because this population is

particularly reluctant to seek treatment. Anxious patients are typically in a hurry

to yield quick results from therapy.

Crucial that this session provides muchneeded reassurance.

Affect Regulation in


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Relationships

Couples Adult child/parent

Friendships

Siblings

Co-workers


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Treatment Goals for the Couple

Develop skills of self-soothing andsoothing of partner

Develop ability to tolerate vulnerability Diminish reactivity to slights and criticism

Develop attitude of curiosity

Challenges of Transfer and


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Maintenance of Skills

Skills mastered in the therapeuticsetting often do not transfer into the

home.

Long lasting changes of interpersonal

patterns in couples are hard to effect.(Jacobson and Addis, 1993)

Challenges of


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Relationship Therapy

The need to

Create a safe space for both people

Assist people to manage over-reactions

Help them survive power struggle withoutexiting the relationship

Case Example:


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A Couple in Conflict

Characteristics Flooding/withdrawal patterns

Minimizer/ maximizer dynamic


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Treatment Goals

Contain verbally damaging exchanges.

Increase empathy.

Close exits.

Establish date nights together, away from thechildren.

Develop positive expectations about the

relationships. Increase awareness of impact of verbal and

non-verbal communication.


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Interventions

Tier 1 Time Out

Tier 2

Arm and leg heaviness


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Tier 3

Parts of self Age progression


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Specific Strategies Are Needed

Transition to mature love cannothappen through insight alone

Specific hypnotic tools are useful todevelop new patterns

Tools must be practiced repeatedly (inand out of the office)


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Structuring the Sessions

Audio-tape the long trance sessions withthe recommendation that the client listensto the tape daily.

Practice quick interventions five timesdaily, or when symptomatic.

Provide the patient with notes that

delineate the steps of the self-hypnoticinterventions.


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The First Steps in Treatment

Setting the right tone

Psycho education

Structuring the session


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Setting the Right Tone

The therapist must communicate that theyare in capable hands with a clinician whohas a clear treatment plan to address andtreat their symptoms.

Build positive expectancy in the client. Milton Erickson suggested that a good

therapist should be utterly confident.

(Zeig, 1980, p. 61)


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Self-Care

All too often we teach well, but we dont

always practice what we teach.

Inward attention is mandatory when we

spend so much time with an external focus. Setting aside time each day for meditation

or self-hypnosis is crucial to maintaining

ones own equilibrium and for avoiding burn

out.


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References

Crawford, H.J., & Barabasz, A. (1993). Phobias and fears: Facilitating their treatment with hypnosis. InJ. Rhue, S. Lynn, & I. Kirsch (Eds.), Clinical handbook of hypnosis. (pp. 311-337). Washington, DC:American Psychological Association.

Daitch, C. (2007).Affect Regulation Tool Box: Practical and effective hypnotic interventions for theover-reactive client. New York: Norton.

Edgette, J.H., & Edgette, J.S. (1995). The handbook of hypnotic phenomena in psychotherapy. NewYork: Brunner/Mazel.

Gottman, J.M. (1998). Marital therapy: A research-based approach. Seattle: The Gottman Institute.

Jacobson, N.S., & Addis, M.E. (1993). Research on couple therapy: What do we know? Where are wegoing? Journal of Consulting and Clinical Psychology, 61(1), 85-93.

Khalsa, S. (2001). K.I.S.S. guide to yoga. London: Dorling Kindersley.

Lynn, S.J., Kirsch, I., & Rhue, J.W. (Eds.) (1996). Casebook of clinical hypnosis. Washington , DC:American Psychological Association.

LeDoux, J. (1996). The emotional brain: The mysterious underpinnings of emotional life. New York:

Simon & Schuster. Yapko, M.D. (2003). Trancework: An introduction to the practice of clinical hypnosis. (3rd ed.). New

York: Brunner/Routledge.

Zeig, J.K. (Ed., with commentary). (1980b).A teaching seminar with Milton H. Erickson. New York:Brunner/Mazel.

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Affect Regulation