第四章：情绪冲浪

Chapter 4 Emotion Surfing Once clients have learned to observe and accept their emotional experience, they are ready to learn about the life cycle of emotion and the next EET skill: emotion surfing. You will teach your clients how to surf their emotions as an alternative to three maladaptive responses that fuel and intensify the emotion wave: emotion avoidance, rumination, and emotion-driven behaviors. Using the emotion wave metaphor, clients will learn to ride their emotion waves until they dissipate. The wave metaphor works well for many clients because it’s an easy visual. Explain that an emotion, from a single trigger, is relatively short-lived (Ekman, 1994). Like a wave, emotion shows up with a leading edge of sharply escalating intensity. Then it peaks and gradually slopes downward—with a long, descending tail end. EET Skill Objective: Observe + Accept with emotion surfing All emotions show up, top out, and gradually diminish in this wave effect. Use the metaphor often, and reassure clients that they can learn to ride, or surf, these emotion waves rather than be churned up in them. Emotion surfing is like body surfing, whereby one can become skilled at rising on the leading edge of the wave, riding there for a while, and finally slipping over the crest to the relative calm of the back slope. Emotion surfing involves a similar skill set, requiring five key abilities: Observing and accepting the emotion wave as it comes. Locating oneself on the emotion wave. (Is the client on the rising edge, at the crest, or on the diminishing backslope of the emotion? You can use the subjective units of distress scale [SUDS], ranging from 0 to 10, to help calibrate wave intensity while the client surfs.) Noticing and watching thoughts without getting fused with them. Noticing any desire to escape the emotion, and continuing to observe it instead (not engaging in emotion avoidance). Noticing any urges or impulses to act on the emotion, and seeing the moment of choice (not engaging in emotion-driven behavior). We’ll cover how to teach emotion surfing in the following pages. But, first, you need to prepare for the question every client asks: “If my emotions are just a wave that will pass, why do they seem to go on forever?” This is important to address because clients often experience negative emotion as overwhelming and endless. They feel controlled by their emotions, with little choice about how long or how intensely they will last. How Emotion Avoidance Keeps Emotion at High Intensity The normal wave pattern of emotions will get interrupted and extended by three maladaptive coping strategies. The first is emotion avoidance. It’s important for clients to realize how the attempt to control and avoid emotions paradoxically maintains, even intensifies, emotional distress. The effort to suppress painful emotional experiences can take multiple forms (situational, cognitive, somatic, protective, and substitution-based avoidance), but the outcome is always the same: increased suffering. The following handout describes the forms of emotional avoidance and some of its possible negative consequences.Consequences of Emotion Avoidance There are at least five types of emotion avoidance that researchers believe are at the root of many emotion problems. Situational: people, places, things, and activities Cognitive: thoughts, images, and memories Somatic: internal sensations such as racing heart, palpitations, breathlessness, overheating, fatigue, or unwanted sexual arousal Protective: avoiding uncertainty through checking, cleaning, perfectionism, procrastination, or reassurance seeking Substitution: avoiding painful emotions with replacement emotions, numbing out, alcohol, drugs, bingeing, or gambling Why not just keep on avoiding? Because the consequences of emotion avoidance are usually worse than the experience of what we try to avoid. • Since distress, discomfort, and anxiety are all a guaranteed part of life, emotion avoidance is often only a temporary and superficial “solution.” • Emotion avoidance reinforces the idea that discomfort/distress/anxiety is “bad” or “dangerous.” It reduces your ability to face and tolerate necessary pain. • Emotion avoidance often requires effort and energy. It’s exhausting and time-consuming. • Emotion avoidance limits your ability to fully experience the present. • Emotion avoidance can keep you from moving toward important, valued aspects of life. • Emotion avoidance often doesn’t work. When you tell yourself not to think about something, you have to think about not thinking about it. When you try to avoid an emotion, you often end up feeling it anyway. • Emotion avoidance often leads to suffering: addiction, helplessness, hopelessness, depression, damaged relationships, and lost opportunities.By allowing yourself to experience fears—and difficult thoughts, feelings, sensations, and urges—you can learn to decrease your suffering. To help clients explore how emotion avoidance impacts their lives, have them identify one or two strong emotions that show up frequently. Then examine which strategies they typically use to avoid the emotional experience: Situational: avoiding people, places, or things Cognitive: avoiding thoughts, images, or memories Somatic: avoiding unpleasant physical sensations Protective: avoiding uncertainty through frequent checking, procrastinating, or assurance seeking Substitution: avoiding by numbing, suppressing, addictive behaviors, or replacement emotions (i.e., replacing shame with anger) When you’ve identified and listed frequently used avoidance strategies for a particular emotion, help clients examine consequences (see the Emotion Avoidance Consequences Worksheet). There will be advantages (pros) for avoidance. Be sure to acknowledge and list those. Usually the advantages are immediate (brief suppression of emotion) and short-lived, but they are real. It’s important to validate that there is often a short, positive effect from emotion avoidance. Now examine the disadvantages (cons) of avoidance. What negative outcomes have clients endured from their avoidance strategies? Have there been costs in the form of increased anxiety, depression, or shame? Have there been costs in the form of feeling stuck, damaged or lost relationships, or addictions? Finally, determine both advantages and disadvantages of experiencing this particular emotion.Document all the pros and cons on the following Emotion Avoidance Consequences Worksheet. Emotion Avoidance Consequences Worksheet Emotion Pros of Avoiding Cons of Avoiding Cons of Experiencing Pros of Experiencing Therapist-Client Dialogue Example: Introducing Emotion Avoidance The process of exploring avoidance in session is demonstrated in the following dialogue. The client has identified shame as an emotion he often runs away from. Therapist: Let’s look at some of the ways you might be avoiding shame. Are there situations—by that I mean people, places, activities—that shame makes you avoid? Client: A couple of my friends who’ve been super successful lately. And the gym, ’cause I’m ashamed of how I’ve gained weight. Therapist: Any thoughts you try to avoid—thoughts that trigger the shame? Client: I won’t talk to my girlfriend about my job because it sucks, and I feel like a loser to be doing it. Therapist: So thinking or talking about your job is hard. This may seem like a strange question, but I wonder if there are any physical sensations associated with shame that you avoid? Client: This hot flush I get when I’m embarrassed. It’s weird, it can happen at random times, but particularly if someone asks me a question about myself and the answer would make me feel vulnerable. Therapist: Remember, we talked about protective avoidance— checking, reassurance seeking, things like that? Does any of that happen around the shame?Client: I’m feeling ashamed right now. I do all of this crap— always asking my girlfriend if something I said or did was okay. I’m worried she’s going to be put off. Therapist: The shame you feel right now—are you trying to avoid that in some way? Client: I’m feeling angry. Therapist: Which is…? Client: I know. Substitution avoidance. Therapist: [Now, having explored some of the client’s avoidance strategies, the therapist can begin working with the Emotion Avoidance Consequences Worksheet.] If it’s okay with you, I’d like to look at some of the ways avoidance affects you. This worksheet can help us explore some of the good things—there can really be good things—and not so good things about avoidance. Let’s start with the pros of trying to avoid shame. Client: I guess for a minute I feel better. Less embarrassed. Therapist: Let’s write that down… Anything else? Client: I can just put off the bad feelings about myself. Sooner or later they come again, but I get a reprieve. Therapist: Got it. What about any cons of avoiding—avoiding your friends, avoiding the gym, avoiding talking to your girlfriend about your job? Client: I’m totally blimping out ’cause I don’t go to the gym. And sometimes I feel lonely, missing my friends. And I feel kind of alone with my girlfriend ’cause I can’t talk to her about the stuff that really bothers me. Therapist: Okay—I’m writing this down—you feel more alone, and it’s affecting your fitness and health. What about not talking about yourself to avoid the hot flush, or the reassurance seeking and substituting anger for shame? Are there consequences for that?Client: My girlfriend gets very annoyed with all of that. She gets pissed when I ask if things are okay, but I keep asking anyway. And she’s threatened to leave over my anger—the substitution thing. Therapist: So there’s a lot of downside for avoidance. Are there cons for experiencing the shame when it comes up? Client: [Mirthless laugh] Just pain. I’d say that is a con. Therapist: Absolutely—the pain of embarrassment. What about the pros of experiencing the shame? Client: Well, I wouldn’t have all the stuff you listed. The aloneness, the problems with my girlfriend, getting fat. Truthfully, I think I’d be less depressed, happier, if I stopped all the stuff I do to avoid. After clients have completed the worksheet, emphasize to them that emotion avoidance keeps the emotion wave going long after it would normally subside. Encourage them to find the evidence for this in their Emotion Avoidance Consequences Worksheet. The key lesson is this: when emotions occur, allow them to run their (usually) short course —without attempts at emotion avoidance or emotion-driven behavior. How Rumination Keeps Emotion at High Intensity Rumination is a maladaptive coping strategy to manage difficult emotions. As with emotion avoidance, the message to clients is that rumination intensifies and prolongs emotional suffering. And when we allow and face the emotion—without ruminative processes—affective episodes are brief and relatively less painful. The three main forms of rumination are: Judging: Judgments about self are an effort to fix or perfect one’s flaws. But the long-term outcome is a deeper sense of defectiveness and chronic depression. Judgments about others relieve feelings ofdefectiveness but result in chronic anger and damaged relationships. Predicting: Catastrophic predictions about the future provide a temporary hope that one can plan and avoid bad outcomes. But it is the royal road to chronic anxiety because the terrifying predictions create a constant sense of threat. Explaining: If one can answer the question “Why did this happen?” it provides the hope that painful experiences can be controlled. If one can find the cause, perhaps problems can be prevented or managed. But the “why” question often has no answer and results in a deep sense of helplessness. Or the answer is a personal flaw—bad things have happened through one’s own fault. In each case the result is a deepening depression. Clients need to learn that rumination—thinking about the bad things that either have happened or could happen— intensifies emotion. Rumination prolongs the wave of emotional pain, keeping people stuck at the crest and preventing natural habituation so the wave can subside. The role rumination plays in sustaining negative emotions makes it crucial for clients to learn how to label and let go of thoughts. Thought watching (see the handout Mindful Acceptance | Observe + Accept, in chapter 3, Apppendix C, and online) promotes the skill of observing thoughts without getting caught up in an endless cycle of content. Later in this chapter, we’ll introduce emotion exposure (called emotion surfing), a strategy whereby this same “labeling and letting go” of thoughts shows up again as a key component. You can use the following handout on rumination to talk with your clients about the role it plays in perpetuating their suffering. Rumination Rumination is thinking about something over and over until it becomes painful. Like emotion avoidance, the goal of rumination is toreduce emotional distress. But, paradoxically, rumination keeps you stuck at the top of the emotion wave. Here’s how: Judging thoughts can focus on yourself or others. When you judge yourself, the hope is to fix or perfect your flaws. But the eventual outcome is a deeper sense of defectiveness and chronic depression. Judging others can give you short- term relief from feelings of being defective or helpless. But they result in chronic anger and damaged relationships. Predicting thoughts help you peer into the future. Catastrophic predictions may give you temporary hope that you can plan for and avoid bad outcomes. But the constant drumbeat of future negative events creates chronic anxiety— because the terrifying predictions create a constant sense of threat. Explaining thoughts provide hope that painful experiences can be controlled. These thoughts answer the question “Why did this happen?” If you can find the cause for a painful event, perhaps it can be prevented or managed. But the “why” question often has no answer and results in feeling helpless. Or the answer is a personal flaw—bad things have happened through your own fault—which intensifies your emotions. Rumination—despite our hopes for fixing, solving, and controlling things—ends up fueling emotional pain. It keeps us stuck at the top of the wave in a chronic state of anxiety, sadness, or anger. Soon you will learn how to label and let go of thoughts—which will be a tremendous help in reducing rumination and the impact of painful thoughts. How Emotion-Driven Behavior Intensifies Emotion The third factor that prolongs an emotion wave is emotion- driven behavior. Every emotion has an urge. Anger pushes us toward aggression, anxiety toward avoidance, and sadness toward withdrawal and reevaluation. These hardwired responses are part of our survival programming; they help in crisis situations. But used habitually, emotion-driven behaviors have the paradoxical effect of making emotions worse. Thedata are in: aggression intensifies anger (McKay, Rogers, & McKay, 2003), avoidance creates anxiety disorders (Allen, McHugh, & Barlow, 2008), and withdrawal is the prime driver of depression (Zettel, 2007). Clients need to learn this fundamental truth: acting on urges strengthens emotions. Emotion-driven behavior, regardless of how right or natural it feels, regardless of the perceived imperative, just keeps clients stuck at the top of the wave. Instead clients can notice the urge and identify a moment of choice, when they can either act on the urge or choose to ride the wave, observing it until the emotion dissipates. Therapist-Client Dialogue Example: How to Talk About Emotion-Driven Behavior Therapist: When the shame shows up, what does it make you want to do? I’m wondering here about specific behavior. Client: Withdraw, hide. Therapist: Okay, let’s see where this goes. Something embarrassing happens. That feeling is pushing you to hide. What happens then, emotionally? You’ve pulled away from people, you aren’t letting anybody see you… What do you feel next? Client: Alone. Stupid. Like I’m this little, stupid person and everybody can see it. Therapist: So the emotion-driven withdrawing—it doesn’t… behavior—hiding, Client: It doesn’t do anything. I just keep twirling the baton in my shame parade. The Art of Emotion Surfing Emotion surfing, to be successful, has to eliminate the three emotion dysregulators (or maladaptive responses) just discussed: emotion avoidance, rumination, and emotion-driven behavior.This is where the three skills clients are developing in the mindful acceptance exercise (see the handout Mindful Acceptance | Observe + Accept, in chapter 3) become critical. The following points should be understood by clients before moving forward: Observing sensations and labeling feelings promotes acceptance rather than emotion avoidance. Thought watching and letting go reduces rumination— not just the frequency of thoughts but the degree to which the client believes and is captured by negative cognitions. Noticing urges and the moment of choice allows a client not to choose emotion-driven behaviors. The following handout may be useful to remind clients how to practice emotion surfing. The handout emphasizes watching the emotion go through its natural course by noticing thoughts, feelings, and sensations; noticing urges and the moment of choice; and noticing where one is on the wave, watching it evolve and finally diminish. How to Surf an Emotion Wave Learning to ride an emotion wave is a fundamental part of Emotion Efficacy Therapy. When an intense emotion is triggered—and your automatic response is emotion avoidance, rumination, or emotion- driven behavior—choosing to surf the emotion wave can actually prevent the emotion from intensifying. Using this skill can be daunting or even scary at first, but, with practice, surfing an emotion wave can be your best option. Riding the emotion wave involves practicing mindful acceptance skills. Here are the steps to take in the face of an intense emotion: Ride your emotion wave when triggered. Notice how emotionally activated you are (check your SUDS level). Identify the peak of the wave.Don’t fuel the emotion. Practice mindful acceptance, just allowing the emotion to be as it is, watching the emotion go through its natural course: • Watch and let go of thoughts. • Label feelings. • Accept sensations. • Notice urges. Continue mindful acceptance until the triggered emotion resolves. Therapist-Client Dialogue Example: How to Lead Emotion Surfing In the following dialogue, the therapist explains emotion surfing to the client. Therapist: Emotion surfing is basically practicing all the mindful acceptance skills you’ve learned: thought watching, noticing feelings and sensations, and watching action urges. Only now we’ll use them when you’re in the middle of an actual emotion surge. Client: We’ll do it here, in session? Therapist: Right. Client: How do we know I’ll have an emotion to work on? Most of the time I feel pretty calm in here. Therapist: There’s no way of knowing when an emotion will show up on its own. That’s right. So what we’ll do is use imagery—visualizing a recent scene when you were upset—to trigger an emotion in here. Then, once we have a moderate-level emotion—SUDS around 5 or 6—we’ll practice emotion surfing. Client: What happens after I’m triggered? What if I get overwhelmed, like usual? Therapist: I’ll help you not do any of the things that make emotions overwhelming and prolong the wave. Instead of ruminating, we’ll notice, label, and let goof thoughts. You’ll just say out loud, “I’m having a sad thought” or “I’m having a judgment thought,” or whatever it is. Then you’ll go back to observing your sensations and feelings, allowing and making room for them, and describing them out loud. Watching and labeling your feelings and sensations will keep you from emotion avoidance—less avoidance means the emotion will be less overwhelming. Client: I’m supposed to say everything that’s happening out loud to you? Therapist: Exactly. I’ll ask questions to prompt you. The last thing is noticing those action urges. Say what they are out loud, and then notice that you don’t have to act on them. Client: Okay. Then what? Therapist: Then we keep watching until the emotion calms down a bit—we’ll keep track of the SUDS—or changes into something else. Choosing the Exposure Image Imaginal exposure, in these early stages of emotion surfing, should focus on recent, emotionally provocative memories that fall in the midrange (5–6 SUDS). Ask clients to think back over the last week or two to a scene where something moderately upsetting happened. Encourage them to fully enter the scene, noticing the details of where they are, who they’re with, what is felt physically, and what is heard (people speaking, ambient sounds from the environment, etc.). Have clients stay in the scene until emotional distress reaches 5 or 6 SUDS—they should signal you at this point. As soon as clients reach the target distress level, have them shut off the scene. This is a brief exposure, so it’s crucial that the provocative scene be terminated before the emotion surfing exercise begins.Now, with the scene eclipsed, the clients begin focusing on internal states. Ask clients to notice any physical sensations and to describe them out loud. Now ask about feelings (emotions) that seem connected to the sensations. These should be verbalized as well. Encourage clients to label any thoughts that show up (“There’s a thought,” or “I’m having a judgment thought,” or “I’m having the thought that I need to escape”) and immediately return attention to sensations and feelings. You should also direct the clients’ attention to any action urges and have them describe the urges out loud. Return again and again to the clients’ sensations and feelings. Keep asking, “What are you noticing in your body?” or “What are you feeling right now?” This is the main focus of the exposure. But you’ll also continue to include requests throughout to label thoughts and urges. And periodically you’ll also ask clients to note SUDS and describe where they are on the wave. Script for Guided Emotion Surfing After the provoking scene is “shut off,” a typical emotion surfing exercise might look like this: What do you notice in your body right now? Can you describe the sensations? [Client responds.] What are the feelings that go with that? [Client responds.] If there are thoughts, can you just watch them and let them go? Any time a thought shows up, just say so. Any thoughts now? [Client responds.] See if you can just let go of any thoughts that arise. Where are you on the wave? [Client responds.] SUDS? [Client responds.] Any urges? Does the emotion make you want to do something? [Client responds.] Notice how you can just observe the urge. You don’t have to act on it. What’s happening in your body right now? [Client responds.]Can you label your feelings? [Client responds.] See if you can just allow the feelings without reacting to them. Remember to watch and let go of any thoughts. Are thoughts showing up? [Client responds.] Urges? Something the emotion wants you to do? [Client responds.] See what it’s like to just notice the urge without acting on it. Where are you on the wave? SUDS? [Client responds.] What are you experiencing in your body right now? [Client responds.] Can you make room for that and just allow that sensation? Your feelings? [Client responds.] Can you just allow that feeling? Can you let it be there without trying to control or stop it? Watch the thoughts and let them go. [Client responds.] Urges? [Client responds.] Check the wave. Where are you? [Client responds.] SUDS? [Client responds.] This process continues until the distress is diminished— down to 2 or 3 SUDS—and/or the feeling has morphed and become softer. Once an exposure session concludes, begin a discussion of what the clients have learned—so far—about emotion surfing. This is a crucial opportunity for the clients to consolidate and draw conclusions about their ability to tolerate affect and what actually happens when emotions are faced rather than avoided. Therapist-Client Dialogue Example: How to Consolidate Learning After Emotion Surfing Therapist: After we got into that scene where your girlfriend criticized you, we spent maybe ten minutes doing emotion surfing. What did you learn? Client: Like what?Therapist: Like how your emotions work, or how long they last, or what happens when you don’t ruminate, avoid, or act on urges? Client: Well, the shame feeling kind of dropped off a lot sooner than I thought. Therapist: So the emotion didn’t last as long? Anything else you noticed? Client: If I label my thoughts, I don’t get into them as much. Therapist: Meaning they seem less important or powerful? Client: Yeah. I guess what surprised me most is that the feeling—shame—didn’t ruin me. After a few minutes, it didn’t seem that terrible. Therapist: So you were able to tolerate it better than you would have thought. Anything else? Client: [Shrugs.] Therapist: These are some important things you’ve learned: that the emotional pain, when you surf the wave, doesn’t last as long; that thought watching helps with rumination; and that you could stand the shame feeling—you didn’t have to avoid it. Following is a handout clients can use to practice the skill of emotion surfing outside of session. Remember, a single- page version of the handout can be found in Appendix C and online at http://www.newharbinger.com/34039. Emotion Surfing Practice Once you’re emotionally activated, take note of your SUDS level and then begin to practice emotion surfing following the sequence below: Ask yourself, “What sensations do I notice in my body?” Ask yourself, “What’s the feeling that goes with it?” Watch and let go of thoughts. Notice urges. Locate the moment of choice instead of acting on the urges.Ask yourself, “Where am I on the wave?” Determine your SUDS rating. Ask yourself, “What’s happening in my body?” Ask yourself, “What’s happening to the feeling?” Try to allow and make room for that feeling. Watch thoughts and notice urges. Try not to get involved with them. Ask yourself, “Where am I on the wave?” Ask yourself, “What’s the sensation in my body?” Try to accept that sensation. Ask yourself, “What’s my feeling?” Try to allow and make room for that feeling. Watch thoughts and notice urges. Try not to get involved with them. Ask yourself, “Where am I on the wave?” Keep going until the distress improves or the emotion shifts. Record your SUDS level when finished. By this point in EET treatment, your clients should be working on mindful acceptance and emotion surfing. They should continue to do the mindful acceptance exercises for ten minutes daily and record their practice on their Skills Practice Record. This helps them practice key skills in a non-triggered state. However, state-dependent learning research tells us that skills acquired in a relaxed state are not always retrievable when in an activated, emotionally triggered condition (Szymanski & O’Donohue, 1995). That’s why practicing emotion surfing during triggered states is so crucial. Encourage clients to utilize emotion surfing whenever they experience emotional distress during the week. Instead of describing internal experiences out loud, they will simply notice their emotions and apply a label to them. Give them the Emotion Surfing Practice handout to remind them what to observe. Ask clients to keep track of their homework on their Skills Practice Record (see handout). In addition, they should note any emotional triggers that show up and activate painful affect on the Skills Practice Record.Emphasize to clients that they will not always remember to or succeed with emotion surfing. This is a new skill that will take time and practice. If clients don’t successfully surf during an in vivo upset, encourage them to relive the scene using imaginal exposure and do emotion surfing—just as they did during session. Summary Following is a synopsis of content covered in chapter 4: Emotion arises from a single trigger, and it is relatively short-lived (Ekman, 1994). Emotion surfing can be chosen as an alternative to three maladaptive emotional responses: emotion avoidance, rumination, and emotion-driven behaviors. Emotion surfing involves noticing the life cycle of the wave without avoiding, ruminating, or acting on urges through emotion-driven behaviors. Riding the emotion wave involves practicing mindful acceptance skills: labeling and letting go of thoughts; noticing and labeling feelings; accepting sensations; and watching urges. The five types of emotion avoidance are: situational, cognitive, somatic, protective, and substitution. The three types of rumination are: judging, predicting, and explaining thoughts. Acting on urges, or emotion-driven behaviors, fuels and intensifies emotion. Imaginal exposure is used to allow clients to practice using adaptive emotional response skills in an activated state to improve learning, retention, and recall.