第十章：整合所有内容

Chapter 10 Pulling It All Together At this point we’ve covered all the EET components and their related skills: emotion awareness, mindful acceptance, values-based action, and mindful coping. Additionally, we’ve covered how to help your clients practice the skills in an emotionally triggered state to enhance learning, retention, and recall. You also know how to help clients consolidate what they’ve learned to create an ongoing emotion efficacy practice. In this chapter we: provide a client handout to facilitate consolidated learning; provide a brief outline and eight-session schedule for delivering EET; address potential treatment challenges and opportunities you may encounter; offer tips for using EET in a group format; and give suggestions for assessing your clients’ levels of emotion efficacy to inform treatment planning. Consolidating Learning The work from here on is to help clients to consolidate their learning and identify what skills work best for them. Knowing they have a toolbox of skills they can use in triggering situations, and having many written down, will give them something to refer to when they need to review their choices in triggering situations. You can use the Emotion Efficacy Therapy Skills handout and Personalized Emotion Efficacy Plan worksheet (available, as with all session materials in this book, in Appendix C and at http://www.newharbinger.com/34039) to facilitate this process. Clients can complete this worksheet after session and then bring it to the last session for review. Emotion Efficacy Therapy Skills You now have a whole new set of skills to use to help you make choices that are effective and consistent with your values when you get triggered. Use the following list to review the EET skills you’velearned and to complete the Personalized Emotion Efficacy Plan worksheet. Mindful Acceptance Sensation Acceptance Feeling Labeling Thought Watching Urge Noticing Emotion Surfing Mindful Coping Relaxation Self-Soothing Pleasurable Activities Coping Thoughts Distraction Time-Out Values-Based Action Identify your value and the corresponding action in the moment of choice Personalized Emotion Efficacy Plan Use this list of EET skills to remember what works for you when you get emotionally triggered. In addition, there is space for you to write down what else you have learned or want to remember about your relationship with your emotions. Mindful Acceptance Skills (O + A) When I am triggered, I can practice the following mindful acceptance skills:Sensation acceptance: Identify any sensations, describe them to myself, make room for them to be exactly as they are, without reacting or judging. Feeling labeling: Identify any feeling labels, sit with the feeling, allow it to be exactly as it is without reacting or judging. Thought watching: Watch my thoughts as they arise, and then let them go. Notice any “sticky” thoughts and let them be exactly as they are, without reacting or judging. Urge noticing: Notice any urges to do something or not to do something. Notice what it’s like not to act on the urge. Values-Based Action (O + A + Choose Values- Based Action) When I’ve practiced mindful acceptance (observe + accept) and want to choose to move toward my values, I can choose the following values-based actions: Situation VBA Situation VBA Situation VBA Situation VBA Situation VBA Mindful Coping (O + A + Choose Mindful Coping) When I have practiced mindful acceptance and/or have tried to use values-based action and still feel at risk of acting on destructive urges, I can choose the following skills: Relaxation: Use diaphragmatic breathing, relaxation without tension, cue-controlled breathing, or the five-senses exercise to downshift emotion. Self-soothing: Stimulate each of my five senses to downshift emotion. Coping thoughts: Use a coping thought to reframe the situation and downshift emotion.Radical acceptance: Practice radical acceptance to allow difficult situations instead of resisting them, to downshift emotion. Distraction: Shift my attention to alternative present-moment experiences to downshift emotion. Time-out: Remove yourself from situations that are triggering where you risk making a difficult situation worse. Other: I want to remember the following about my relationship with my emotions: EET 8-Week Protocol Schedule The following schedule covers all the EET skills in eight sessions. Modifications can be made depending on whether treatment is being delivered in a group or individual format. For a step-by-step protocol, see Appendix C. Session 1: Emotion Awareness (chapter 2) Session 2: Mindful Acceptance with Emotion Surfing (chapters 3 and 4) Session 3: Values-Based Action, Part 1 (chapter 5) Session 4: Values-Based Action, Part 2 (chapter 6) Session 5: Mindful Coping Through Relaxation and Self-Soothing (chapter 7) Session 6: Mindful Coping Through Coping Thoughts and Radical Acceptance (chapter 8) Session 7: Mindful Coping with Distraction and Time- Out (chapter 9) Session 8: Consolidating, Troubleshooting, and Wrap- Up (chapter 10) Potential Treatment Challenges and OpportunitiesFollowing are guidelines and suggestions for working with common issues that may come up when doing EET with clients. Difficulty with Specific Skills When clients encounter difficulty with a skill, there may be valuable lessons for them. In other words, the skills that are more difficult may be the skills that can offer them the most emotion efficacy when mastered. For example, clients with a diagnosis of panic disorder may struggle with sensation acceptance. Given their propensity to interpret sensations as messages of danger, clients can experience alarm in the absence of an actual threat. Given this vulnerability, they may tend to avoid observing and accepting physical sensations even though this skill could be the most effective strategy when they get triggered. Helping your clients become attuned to this paradox can serve to increase their willingness to engage in the skills they find more difficult. Sensation acceptance can also be challenging for clients who struggle with chronic pain. The key, as with all clients, is to assess whether the skill can be effective for them when they are emotionally triggered. For clients with high levels of chronic pain, it may be more effective to choose an EET skill that doesn’t focus attention on their bodies, which can be triggering and further fuel the emotion wave. Similarly, clients who tend to ruminate may struggle with watching their thoughts. You should work with clients to help them see that their difficulty with thought watching is a sign that they may benefit even more over time from learning to observe and let go of their thoughts. In the short term, you’ll want to help clients learn to evaluate what works best for them in the moment of choice. Increased Awareness and DemoralizationNow that your clients have increased their emotion awareness, they are more likely to notice the times they choose to act on maladaptive emotion-driven behaviors. While they may actually be making fewer maladaptive choices when they get triggered, it’s possible for clients to feel frustrated and demoralized about how often they let their emotions drive their behavior. You may need to reassure clients that increasing emotion efficacy is a process. Remind them that not acting on their emotions will feel unnatural—especially in the beginning— but every time they choose mindful acceptance, values-based action, or mindful coping, it will get easier. In the same way it takes time to break old habits, it takes time to form new ones. They are building their emotion efficacy muscle. Tailoring Treatment for Clients, aka “The Stretch” The intention in each session should be to empower clients to engage with the skills to the fullest extent possible. The level of emotion efficacy clients come in with, and achieve during treatment, will vary greatly depending on their vulnerabilities, schemas, and coping patterns. In addition, clients come to treatment at varying levels of intellectual and cognitive ability, and social support, which can impact their ability to learn and, ultimately, the outcome of treatment. As with any intervention, EET will be most effective if clients set realistic goals that are challenging enough to yield new learning without overwhelming them. Finding this sweet spot requires regular inquiry around their emotional process and what’s possible. We refer to this possibility zone as a “stretch” in EET. For some clients, just learning to be present with their emotions will feel like a big stretch; for others, engaging in values-based action with their partners when they are triggered will be a stretch. Some clients will easily learn and assimilate EET skills; they will experience incredible breakthroughs in emotion efficacy during treatment. For others, the process of increasing emotion efficacy may be slower, more challenging, and morepainful. The key is to work with clients where they are while facilitating new learning opportunities through exposure and daily homework practice. You’ll want to check in weekly with clients to help them assess how they can “stretch” in their daily practice using one or more EET skills. Inducing Emotion Activation While most clients who seek treatment for emotion problems are able to access the difficult emotions that go with triggering thoughts or situations, some clients aren’t easily activated during exposure. They may struggle to reach emotion activation unless they experience an in vivo trigger. There are several possible reasons for this. They may not allow themselves to become emotionally activated because they fear getting overwhelmed and not being able to recover. Or they may be less vulnerable to internal triggers but are very sensitive to external triggers, which makes it difficult to induce distress during emotion or imaginal exposure. In the former case, the fear of overwhelm would likely improve during the course of treatment, especially as clients learn new ways of relating to their emotions. In the latter case, the exposure benefit may be more likely to come outside of session, when clients can seek out in vivo triggers to practice using the skills. Either way, you’ll become aware of their experience by assessing their SUDS level and working with them to achieve an optimal level of arousal. Assessment If you plan to track your clients’ progress during treatment (and we recommend that you do), you will want to administer outcome measures at the beginning of treatment and then regularly throughout. In addition to your own observations and experience with clients, you can also use a variety of self- report scales to track clients’ emotion efficacy by measuring distress tolerance, experiential avoidance, emotion dysregulation, values-based living, and related tracking measures.Gathering data will help you tailor ongoing treatment to meet the needs of your clients. For example, if you notice that clients are struggling with emotion avoidance, you can take extra time to review this with them. Or you may have clients who are improving but still suffer from a lack of confidence in their ability to use EET skills. You might take time to review and validate the ways clients are making better choices for themselves when they get triggered. If you have completed treatment, then you probably also have a good sense of what skills your clients have mastered and which are more difficult. This may be a good time to stop and do a more formal assessment if you haven’t been tracking outcomes throughout treatment. The following outcome measures are included in Appendix A for your use: Distress Tolerance Scale (DTS) (Simons & Gaher, 2005) Difficulties in Emotion Regulation Scale (DERS) (Gratz & Roemer, 2004) Valued Living Questionnaire (VLQ) (Wilson, Sandoz, Kitchens, & Roberts, 2010) Emotion Efficacy Scale (EES) Depression, Anxiety, and Stress Scale–21 (DASS–21) (S. H. Lovibond & P. F. Lovibond, 1995) Acceptance & Action Questionnaire (AAQ-2) (Bond et al., 2011) Keep in mind when using a symptom inventory, such as the DASS—or any symptom inventory for assessment of emotion efficacy—that sometimes symptoms may not significantly decrease. This isn’t necessarily an indication that clients are not benefiting from treatment. For example, clients with chronic pain may experience significant stress symptoms on a daily basis, and this may or may not change duringtreatment. However, emotion efficacy can still increase those clients’ ability to tolerate distress, make values-consistent choices, and regulate their emotions even when they’re triggered. Or clients may experience a reduction in symptoms during treatment but still choose emotion avoidance in very distressing situations. On a case-by-case basis, you’ll want to assess and think carefully about how to tailor treatment to best target growth edges for each of your clients. EET and Beyond If treatment with clients goes past the eight-week EET protocol timeline, you’ll want to continue to support them in increasing their mastery with EET skills. Practicing regular mindful acceptance in session will allow you to continue to track how your clients are working with their emotional experiences. You’ll also want to keep track of how effectively your clients are responding to emotional triggers outside of session, using a check-in to review how the week went, what triggers occurred, and how they were handled. In addition, validate and highlight what worked, and troubleshoot what didn’t. Keep coming back to the psychoeducation and skills practice, using exposure to practice a recent trigger or a future feared situation. Be sure to emphasize the benefits of daily practice. Remind clients that they are more vulnerable to emotional triggers when they are in a state of constant activation. One way clients can bring down their level of anxiety is to practice mindful acceptance, moment to moment, even when they aren’t emotionally triggered. Maintaining a lower baseline will have mental, physical, and social health benefits, in addition to lowering their vulnerability to become emotionally triggered. You can create a structure for your sessions to ensure that clients are using the skills both in and outside the session: Mindfulness practice Week in review: validate and highlight what worked; troubleshoot what was difficult or ineffectiveReview psychoeducation and an EET skill to practice in exposure Exposure practice with an identified past trigger or anticipated situation Homework planning with specific intentions and assignments It may also be helpful to remind your clients that emotion efficacy is a lifelong practice. The more they practice, the less their emotions will feel overwhelming—and the more fulfilling and meaningful their lives will be. Summary Following is a synopsis of content covered in chapter 10: Increases in emotion awareness can initially result in demoralization in clients who realize how often they are driven by their emotions. They may need reassurance that it takes time to build their emotion efficacy muscle. Sometimes the skills that are most difficult for clients are those that will be most beneficial for them. Each client will need to learn to identify what constitutes a “stretch,” or how far to push into the pain. Some clients struggle to become emotionally activated during imaginal and emotion exposure; they may need to focus on in vivo exposure practice outside of session. When conducting exposure with clients who are highly reactive, you’ll want to clearly outline how they can identify optimal scenes to work with in exposure as well as how they can ground when they come out of exposure.Using assessment during and after EET can help tailor treatment to meet a client’s specific needs. Conducting exposure in a group format requires having clear guidelines around confidentiality, disclosure, and participation. EET was designed to be delivered in an eight-session protocol, which can be modified for group or individual formats.