第一章：情绪效能疗法

Chapter 1 Emotion Efficacy Therapy Emotion efficacy is defined as how effectively a person can experience and respond to a full range of emotions in a contextually adaptive, values-consistent manner. As such, emotion efficacy encompasses both the beliefs people have about their ability to navigate their emotional life as well as their ability to do so. The more people can effectively experience difficult emotions, regulate their emotions through coping, and express their values, the higher their emotion efficacy. In conceptualizing emotion efficacy therapy (EET), we reviewed the full range of factors that make up a person’s relationship with his or her emotions, and we identified key factors implicated in emotion efficacy. We concluded that low emotion efficacy is likely to be the result of key vulnerabilities or patterns of maladaptive behavioral responses—behaviors enacted in response to emotional pain, or the desire to avoid pain, which fuel and maintain psychopathological processes. Some common vulnerabilities and patterns may take the form of one of more of the following: Biological predisposition or sensitivity that leads to high levels of reactivity Significant levels of emotion avoidance (sometimes also called experiential avoidance)—efforts to avoid experiencing uncomfortable sensations, emotions, and cognitions triggered by internal or external cues Significant levels of distress intolerance—the perception or the belief that one cannot tolerate aversive emotions Significant lack of downregulate emotion emotion-shifting skills toConsistent and environments significant socially invalidating Individuals with these vulnerabilities often develop significant emotion problems. They may also lack understanding of their emotional experience and the clarity or tools to either tolerate difficult emotions, make values- consistent choices, or regulate their emotions. Over time, these vulnerabilities and life-long patterns of maladaptive behaviors can result in chronic emotion dysregulation and its downstream symptoms of depression, anxiety, and stress. In fact, these maladaptive patterns become so ingrained that they are all but hardwired and very difficult to change, leaving individuals feeling trapped, stuck, and hopeless. In EET, we define emotion dysregulation as the full range of thoughts, feelings, somatic sensations, and behavioral urges that are contextually maladaptive. Emotion dysregulation is also problematic in that it frequently leads to behavior dysregulation—acting on emotion in contextually maladaptive ways. In this way, emotion dysregulation and behavior dysregulation lead to low emotion efficacy. The impact of low emotion efficacy is wide and far reaching. Some data suggest that low emotion efficacy creates and maintains tremendous suffering for the more than 75 percent of people who seek psychotherapy across multiple diagnostic categories (Kring & Sloan, 2010). In addition, pervasive emotion problems can significantly impact clients across multiple domains including interpersonal, work, school, and legal. Low emotion efficacy can significantly impair quality of life, and, in more extreme cases, it can be life interfering. For example, research shows emotion dysregulation has been correlated with higher levels of depression, anxiety, impulsivity, and suicide (Garnefski & Kraaij, 2007; Carver, Johnson, & Joormann, 2008; Kleiman & Riskind, 2012); reduced quality of life; increased distress and restricted life functioning; increased suffering and pain; impaired memory and problem solving; and diminished contact with meaningful and valued life activities (Richards & Gross, 2000;McCracken, Spertus, Janeck, Sinclair, & Wetzel, 1999; Marx & Sloan, 2002; Hayes, Luoma, Bond, Masuda, & Lillis, 2006). Additionally, emotion dysregulation has been linked to lower social skill functioning, substance abuse, low lifetime achievement, and low sense of self-efficacy (Berking et al., 2011; Eisenberg, Fabes, Guthrie, & Reiser, 2000; Caprara et al., 2008). Why Emotion Efficacy Therapy? Despite the prevalence of emotion-regulation problems, available treatments often treat just the symptoms and fail to identify and target the underlying drivers of the problem. In addition, treatments may teach clients how to use skills but can lack the experiential component essential to accelerate learning new ways of relating to and responding to difficult emotions. Even current evidence-based treatments show only modest treatment effects for improving emotion regulation and its downstream symptoms (Kliem, Kroger, & Kosfelder, 2010). Emotion efficacy therapy attempts to provide a more effective, portable, universal protocol for emotion problems. The underlying philosophical premise of EET is that while pain is unavoidable, suffering is not. Suffering comes, in part, from not knowing how to enact values that bring meaning to life. More often, it comes from the unwillingness to experience difficult emotions, which then fuels distress and leads to more suffering. Moreover, suffering is maintained and even increased when clients try to avoid or control their pain through maladaptive behavioral responses. To the extent that clients can learn how to powerfully navigate the space between being emotionally triggered and their response, they can be empowered to create lives that are increasingly values- consistent and fulfilling. We believe EET stands to help millions of people increase their emotion efficacy through increasing their ability to regulate their emotions and make choices that are consistent with their values and intentions. Ultimately, high emotion efficacy—the ability to experience a full range of emotions andrespond with mindful acceptance, values-based action, and mindful coping—means a world where more people create lives that are more authentic, powerful, and conscious. Emotion Efficacy Therapy: Foundational Elements EET was conceived as a transdiagnostic, theoretically driven, contextually based treatment integrating findings from affect science, traditional and third-wave cognitive behavioral therapies, and learning theory. As such, EET is an outgrowth of several cognitive behavioral therapies, integrating components of acceptance and commitment therapy (ACT) and dialectical behavior therapy (DBT) into an exposure-based treatment. ACT is a mindfulness-based therapy developed by Steven Hayes, Kelly Wilson, and Kirk Strosahl that teaches clients to accept distress instead of trying to control it, and to commit to action that originates from client values (Hayes, Strosahl, & Wilson, 1999). DBT was developed by Dr. Marsha Linehan and is used in treating severe and complex mental disorders involving serious emotion dysregulation (Linehan, 1993). The rationale for EET is based on research that supports foundational ideas for its treatment structure and content: TRANSDIAGNOSTIC EFFICACY TREATMENT TO TREAT LOW EMOTION Data suggests there are more commonalities than differences across diagnostic disorders, which further underscores the need for transdiagnostic approaches to treatment (McEvoy, Nathan, & Norton, 2009). Instead of focusing on reducing symptoms, as in diagnostic treatment, transdiagnostic formulation identifies and targets the mechanisms driving the symptoms as a focus of intervention. From a philosophical perspective, transdiagnostic formulation posits that suffering is not a result of a disorder and its originating pain but rather of the vulnerabilities and maladaptive behavioral responses to the pain. Further, research suggests that treatment that targets transdiagnostic, or underlying, drivers is more effective thancategorical diagnostic formulation (McEvoy et al., 2009; Frank & Davidson, 2014). Transdiagnostic approaches not only address the drivers of problems, they also allow for a single therapy for clients who present with a wide range of symptoms. In fact, a meta-analysis by McEvoy and colleagues (2009) found that unified (transdiagnostic) treatments for emotion disorders are correlated with symptom improvement, perform better overall than wait-list control groups, are associated with improvements in comorbid disorders, and may compare well with diagnostic-specific protocols. Emotion efficacy therapy targets the transdiagnostic drivers of low emotion efficacy. Instead of focusing on the reduction of emotion dysregulation and its downstream symptoms of anxiety, depression, stress, and impulsivity, EET skills focus on increasing distress tolerance and decreasing emotion avoidance. Using five components—emotion awareness, mindful acceptance, values-based action, mindful coping, and exposure-based skills practice—clients learn to expand their choices in the face of difficult emotions. Instead of reacting with ineffective, contextually maladaptive responses, they learn tools that allow them to develop a new relationship with their emotions. Since clients don’t often fit into one diagnostic category, or may fit into multiple categories, we believe it is imperative for treatment to identify and target the actual mechanisms that create and maintain suffering. EET targets two transdiagnostic drivers implicated in low emotion efficacy: distress intolerance—the perception or belief that one cannot experience distressing emotions—and emotional avoidance— attempts to avoid or change aversive emotional experiences. By teaching clients to tolerate distress instead of avoiding their emotional experience, they are empowered to choose to effectively respond to their emotions in a contextually adaptive, values-consistent manner. TRANSEMOTIONAL LEARNING AS THE KEY TO CHANGE Based on affect science, we know that patterns of behavior are the result of a confluence of factors that work on neural pathways both hardwired from birth (e.g., flight, fight, freeze)and created over time, making up experiences or preferences (Hanson, 2009). These pathways are created and maintained by learning and memory (e.g., when the dog growls at me, he is unpredictable, and I should avoid him; when mommy smiles she is open to hugs and giggles). After learning occurs, these pathways become reactivated in response to internal cues (cognitive, somatic, or affective) and external cues (in the environment) that are appraised as being “like” other events, so the emotional response is automatic. When the learned responses are maladaptive—meaning they fail to motivate effective values-consistent choices—they can cause suffering and play an etiological role across psychopathological disorders and processes (Tryon, 2005). Research shows that new learning is the key to change and is transemotional, including cognitive, affective, somatic, and behavioral components (Tryon, 2005; Lauterbach & Gloster, 2007). This means that in order to facilitate new responses to painful or feared experiences, new learning must take place. Because learning and memory are created through the encoding of experiences, it follows that utilizing all sensory and perceptual components (cognitive, somatic, and affective) is essential for new learning. In EET, transemotional learning occurs through the activation of all emotional components— thoughts, sensations, feelings, and urges—that build neural pathways around new behaviors. EXPOSURE-BASED SKILLS PRACTICE TO IMPROVE LEARNING, RETENTION, AND RECALL Grounded in theory and research that support the effectiveness of exposure therapy and state-dependent learning, exposure-based skills practice is the application of skills in an activated state of distress to facilitate transemotional learning (Szymanski & O’Donahue, 1995). In the last twenty-five years, exposure therapy has been increasingly recognized as one of the most effective therapy interventions for the treatment of anxiety. It’s also considered to be the gold-standard treatment for panic disorder. State-dependent learning is the concept that whatever state a person is in when learning occurs becomes encoded andpaired with the stimuli. This has several implications for the use of emotion in therapy. For instance, some research suggests that, in studies, participants had superior recall when the same affective state was induced at both exposure and retrieval, compared to those whose affective state was different between learning (exposure) and recall (retrieval) (Szymanski & O’Donahue, 1995). In addition, some studies show that mood may increase access to the neuronal networks that are online and paired with specific affect states (Persons & Miranda, 1992). EET leverages state-dependent learning through exposure, which facilitates new learning in emotionally activated states by increasing learning, retention, and recall of EET skills. Clients are guided using both emotion and imaginal exposure to face difficult internal and external emotional experiences while applying EET skills to enact contextually adaptive, values-consistent behavioral responses. Emotion Efficacy Therapy Protocol EET uses psychoeducation, skills practice, and experiential activities to increase emotion efficacy. By integrating the components of emotion awareness, mindful acceptance, values-based action, and mindful coping within exposure- based skills practice, clients learn to tolerate their distress, downregulate emotions when necessary, and make choices that are consistent with their values. The Five Components of EET Each session focuses on one or more of five treatment components that build on each other as follows: EMOTION AWARENESS Emotion awareness is the ability to make present-moment contact with emotion. Emotion is experienced through its four components, and clients learn to recognize how it manifests through thoughts, feelings, sensations, and urges. Often clients know they are feeling an emotion, but they’re not sure what it is. Or they may know the emotion but not realize how it ismanifesting in the components of emotion. Emotion awareness also entails understanding the origin or trigger of the emotion as well as the typical lifespan of an emotion wave. Having an awareness of one’s emotional experience is the first step toward increasing emotion efficacy. MINDFUL ACCEPTANCE Building on emotion awareness, mindful acceptance is the practice of nonjudgmentally and nonreactively observing one’s emotional experience and allowing (accepting) each of the components of an emotion: thoughts, feelings, sensations, and urges. Clients learn to tolerate a distressing emotion by learning to experience the emotion—and each of its components—without trying to alter it. Together, emotion awareness and mindful acceptance offer an alternative to emotion avoidance, giving clients concrete skills to practice in place of attempts to avoid or alter their emotional experience. Research suggests that both emotion awareness and mindful acceptance are components of effective transdiagnostic interventions for emotion dysregulation (Ruiz, 2010; Wilamoska et al., 2010). In fact, observing and accepting experience appears to enhance emotion regulation (Ruiz, 2010). These two core components form the foundation for emotion efficacy therapy. Emotion awareness and mindful acceptance position clients to identify the moment of choice— the space between an emotional trigger and a response—when they are able to choose how they respond to their pain. More specifically, clients learn to locate the moment of choice even in the face of difficult or aversive emotions. In this moment, they can choose to just “surf” the emotion wave instead of reacting to it or acting on it. VALUES-BASED ACTION (VBA) VBA is the practice of mindfully enacting a valued intention in the moment of choice. Having increased distress tolerance through emotion awareness and mindful acceptance, clients are now positioned to recognize a moment of choice and make values-consistent choices in the face of aversive emotions. With values-based action, clients first identify whattheir core values are in a variety of contexts, such as work, home, community, family, and so on. By naming what they value in each of these contexts, clients can then identify specific values-based actions that allow them to express themselves—in the moment of choice—in a manner consistent with their values. As with all the EET skills, clients practice choosing values-based actions in an activated state through exposure-based skills training. Some research shows that the enactment of values is correlated with psychological well-being and an increase in quality of life (Hayes, Strosahl, & Wilson, 1999; Ruiz, 2010). Because EET seeks not only to increase distress tolerance and emotion regulation but also quality of life, values-based action is a core EET skill. Further, VBA is essential to increasing emotion efficacy, as it enhances motivation to commit to new behavioral responses that are difficult. By choosing values- based action instead of reacting through maladaptive emotion- driven behaviors, clients further increase their distress tolerance as well as the quality of their life. MINDFUL COPING Mindful coping is developed through the practice of using mindful acceptance to recognize a moment of choice, and then utilizing coping skills to downregulate emotion. Sometimes individuals can become so overwhelmed by difficult emotions that they aren’t able to practice mindful acceptance and surf the emotion wave until it resolves, much less choose values- based action in the moment of choice. In these situations, they need strategies for regulating emotion to keep from making a bad situation worse (Linehan, 1993). When clients’ capacities to observe, accept, and/or choose values-based action are exceeded by emotional pain, they can choose mindful coping skills to downregulate emotion. While coping has been typically conceptualized as an attempt to change and alter emotional experience, mindful coping uses mindful acceptance as a portal to choosing emotion-regulation skills. Mindful coping begins with mindful acceptance—the practice of observing and accepting the emotion and its components. It follows with recognizing amoment of choice and choosing a coping skill as a way to downregulate emotion. The concept of mindful coping is new with EET and represents an attempt to give clients essential emotion- regulation skills in crisis situations, while also encouraging them to choose coping only as a last resort—after first practicing mindful acceptance. Instead of choosing coping skills to avoid or change aversive emotion, mindful coping is chosen with the intention of expanding choices and to help clients recover so they can choose values-based action. EXPOSURE-BASED SKILLS PRACTICE This practice refers to the use of EET skills in an activated state using both emotion and imaginal exposure (also called imagery-based exposure). In emotion exposure, clients learn to intentionally activate themselves as a way to practice mindful acceptance and mindful coping. In addition, clients learn to use imaginal exposure—using imagery from a situation to become emotionally activated, and then visualizing enacting values-based action. As previously discussed, practicing skills in an activated state improves learning, retention, and recall; creates new neural pathways; and makes it easier to enact effective choices in the face of distressing emotions. How Is Emotion Efficacy Therapy Unique? By teaching individuals that pain can be faced—that it will not destroy or overwhelm them, and that it doesn’t have to lead to more suffering or destructive behaviors—their motivation to tolerate distress will increase, opening the door to expanded choices for action. Through psychoeducation and skills training in an activated state, clients learn new ways of responding to difficult emotions. In the moment of choice, clients are able to choose to mindfully accept the present emotional experience, enact a values-based action, and/or downregulate their emotions. Using EET skills, clients are able to effectively experience difficult emotions, recover more quickly from beingemotionally dysregulated, break out of patterns of responding that are maladaptive, and express what they value in the face of distress—moment to moment. As clients practice EET skills when they get triggered by painful emotions, new choices become easier and easier. In a brief time, they can develop a new relationship with their emotions, giving them increased emotion efficacy in significant ways: Power to experience themselves as distinct from their emotions Power to experience intense emotions, instead of reacting and avoiding Power to choose values-based action, even when emotionally triggered Power to choose strategies to downregulate emotion and keep from making difficult situations worse While emotion efficacy therapy integrates components from acceptance and commitment therapy, dialectical behavioral therapy, and exposure therapy, several characteristics distinguish it from current treatments for emotion problems: EET is a unique hybrid. Emotion efficacy therapy combines emotion awareness, mindful acceptance, values-based action, and mindful coping to provide a range of tools for clients at all levels of emotion efficacy. EET uses exposure-based skills training. Emotion efficacy therapy uses both emotion and imaginal exposure to accelerate new learning and improve retention and recall. EET incorporates mindful coping. Rather than just offering coping skills to downregulate emotion, emotion efficacy therapy combines mindful acceptancewith select coping skills, allowing clients to first accept their emotional experience, identify the moment of choice, and then choose to intentionally and mindfully shift their emotion. EET is brief and portable. Unlike some treatments for emotion problems, emotion efficacy therapy can be administered in eight weeks and can be adapted for either a group or individual format. To date, EET has been shown to dramatically decrease emotion dysregulation (d = -1.21), increase efficacy with negative emotions (d = 1.38), increase distress tolerance (d = 1.34), and decrease experiential avoidance (d = -0.81). (For details, see Appendix B.) EET is brief, cost efficient, and available in both individual and group formats. How to Use This Book In this book we lay out how to use EET in both individual and group therapy format. Chapters 2 through 10 cover each of the EET processes, including psychoeducation on each of the treatment concepts, examples of therapist-client dialogues, handouts and worksheets you can use with your clients, and scripts for experiential exercises to teach and implement the new skills. In chapter 2, we cover the first EET skill, emotion awareness: the ability to identify and observe the four components of an emotional response. In chapter 3, we introduce the second EET component, mindful acceptance: to nonreactively and nonjudgmentally observe and accept emotions while emotionally triggered. Chapter 4 covers emotion surfing, which builds on the core skills of emotion awareness and mindful acceptance, applying them to the life cycle of an emotion, and recognizing a moment of choice. Chapter 5 introduces values and values clarification to help clients identify values-based action. Chapter 6 covers using values-based action in the moment of choice. Chapter 7 introduces mindful coping and covers the use of mindfulacceptance with relaxation and self-soothing coping skills. Chapter 8 covers the use of mindful coping through mindful acceptance and coping thoughts. Chapter 9 uses mindful coping through mindful acceptance and distraction. Chapter 10 maps out how to help your clients pull all of this together to develop customized emotion efficacy plans; it also offers tips for common issues that may arise in treatment. This book also has three appendices. Appendix A contains some outcome measures you may find helpful for assessing clients’ emotion efficacy before, during, and after treatment. Appendix B features research results from a quantitative outcome trial for EET. Appendix C provides single-page versions of the handouts and worksheets that you can photocopy, and outlines the eight-session protocol for using EET in a group therapy format. In addition, every handout and worksheet in this book is also available for download at http://www.newharbinger.com/34039. For each EET therapy session, you’ll follow a structured format to allow clients to practice skills, understand the rationale behind them, and do problem solving around any challenges. At the end of each session, you’ll review the skills practice assignments to be completed as homework between sessions and recorded on the Skills Practice Record. Following is the basic session structure for EET: Mindful acceptance practice Skills practice review and troubleshooting problems with homework Review of previous week’s skill(s) Psychoeducation on the new skill for the coming week Practice new skill(s) using exposure Homework via the Skills Practice RecordWe hope you find EET helpful for working with clients struggling with low emotion efficacy. We believe that when people experience increased choice about how they respond to life, they will find more freedom and power to express the best of themselves. With more freedom and power, they have a chance at a better, more meaningful life. Summary Following is a synopsis of content covered in chapter 1: Emotion efficacy is defined as how effectively a person can experience and respond to a full range of emotions in a contextually adaptive, values-consistent manner. Low emotion efficacy is a result of key biopsychosocial vulnerabilities and patterns of maladaptive responses. EET operates on the premise that pain is unavoidable but suffering is optional and can be mitigated and tolerated through the use of select skills. EET is a transdiagnostic, theoretically driven, contextually based treatment integrating findings from affect science, traditional and third-wave cognitive behavioral therapies, and learning theory. The rationale for EET is based on research of three foundational ideas for its treatment structure and content: a transdiagnostic approach is the most effective way to treat clients with emotion problems; transemotional learning, which involves all four components of emotion, is essential to learning; and new learning is enhanced in an activated state. Emotion efficacy can be increased through the use of skills that increase the ability to tolerate distressing emotions by responding through emotion awareness,mindful acceptance, values-based action, and mindful coping. Orienting clients to EET is an important part of treatment, especially for enhancing motivation for participation and willingness to try new behaviors. Each EET session is structured to facilitate skills practice, skills psychoeducation, skills review, feedback, and skills practice assignments.