Affect Regulation
Transcript of 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
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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g
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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g
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.