Douglas Mennin Presents Emotion Regulation Therapy
On Sunday, September 20, Douglas Mennin, Ph.D. addressed NJ-ACT on Emotion Regulation Therapy (ERT) for Refractory Anxiety and Depression. Research to date indicates that ERT is effective with chronically depressed and anxious patients. Dr. Mennin began by explaining that emotion motivates us in two directions:
- Toward safety and security
- Toward reward and fulfillment
One or both motivations may be present in any particular situation.
When motivation for safety and security is too strong, people experience anxiety, depression, boredom, or anger. Seeking safety and security, they avoid behaviors that lead to reward and fulfillment because in the short run, these behaviors may create unpleasant emotions such as fear, anxiety, shame, anger, or sadness.
Rumination, worry, self-criticism, and reassurance-seeking are attempts to achieve safety and security, and avoid the unpleasant emotions associated with seeking reward and fulfillment.
ERT is intended to be a refinement of CBT rather than a competing approach. ERT’s interventions help patients in 3 general areas: identifying emotions and emotional conflicts, regulating emotions, and engaging more effectively in the environment to achieve reward and fulfillment.
- Identifying Emotions and Emotional Conflicts
1.1 Orchestra Metaphor. When emotions are unclear or “muddy,” they create confusion and distress. Explain to patients that each emotion is like one instrument in an orchestra. Clearly experiencing all emotions creates a harmonious emotional experience, like a harmonious orchestral performance.
1.2 Security History. Ask patients to write for 15 minutes each day about how their motivation for safety and security has affected their life.
1.3 Motivational Anchoring. Think of a stressful life situation. On a scale of 1 to 10, rate how much this situation activates motivation for security and safety, and how much it activates motivation for reward and fulfillment. Then rate how much you would like this situation to activate the two types of motivations.
1.4 Formal Mindfulness Practice strengthens the ability to attend to emotions and brings clarity to “muddy” emotions. Because emotions have physiological components, mindfulness of the body encourages awareness and acceptance of emotions. ERT recommends daily mindfulness practice. Begin with mindful belly breathing and proceed to mindfulness of the body.
1.5 Obstacle Task. As in Gestalt Therapy, use two chairs to have a dialogue between an “obstacle voice” that expresses needs for safety and security, and a “values voice” that expresses the desire for yet-unattained rewards and fulfillment.
- Teaching Emotion Regulation
2.1 Mindfulness of Emotions. Think of a distressing experience and focus on the emotions that pull you toward safety and security. Then focus on the emotions that pull you toward reward and fulfillment. Next try to hold all your emotions and motivations in your mind simultaneously. If you can, hold on to this experience until the emotions diminish or disappear.
Mindfulness of Emotions makes patients uncomfortable, but the longer they experience fear, shame, disgust, anxiety, sadness, anger or any other emotion they habitually avoid, the sooner they will be able to pursue reward and fulfillment.
2.2 Emotion Regulation Techniques
Decatastrophize by following a concern through all its consequences to the feared outcome (e.g. failure, rejection.)
Half-Smile. Smiling like the Mona Lisa is an easy way to distance from and regulate strong emotions.
Worry Exposure to core fears (e. g. rejection, failure).
Mountain Meditation. Imagine yourself as a sturdy mountain that stands firmly as the seasons (i.e. emotional storms) pass over you year after year.
Observer’s Distance. Observe your thoughts and feelings as they emerge and place them on some object near you. Or, gesture throwing thoughts and emotions onto a wall where you can consider them from a distance.
Generate courageous and compassionate self-statements that help you tolerate painful emotions such as self-criticism. Write the self-statements on cards, put the cards in your pocket, and touch your pocket in time of need. Merely touching your pocket activates the courageous and compassionate self-statements.
Meditate on receiving courage and compassion in a time of need. Or, meditate of extending courage and compassion to others.
- Helping patients behave adaptively in spite of their motivation for safety and security.
3.1 Identify Values. What’s important to you in intimate relationships, parenting, social relationships, work and career, education, personal growth, and recreation and leisure? Pursuing these values means pursuing reward and fulfillment.
3.2 Catch Yourself Responding. Record trigger situations, emotions elicited (especially worry, rumination, and self-criticism), the level of motivation for safety and security, the level of motivation for reward and fulfillment, and the consequences of your response. Catch Yourself Responding teaches patients to attend to their emotions and distance from them. If an incident was particularly difficult, revisit it imaginally, first to clarify emotions, motivations, and consequences, and then to rehearse an adaptive response.
3.3 Imaginal Rehearsal. During a session, mindfully imagine the first step necessary to achieve a valued goal. Notice the smells, sounds, perceptions, sensations, thoughts, feelings, and sights that are present. (Details help evoke emotion.) Imagine performing each step toward the valued goal until it is completed.
3.4 On-the-Spot Emotion Regulation and Action includes the following steps that help patients choose behavior that is more likely to lead to reward and fulfillment.
Breathe and Notice: Take a breath and notice all of your sensations.
Pause and Allow: Keep your attention on important details of the situation. Notice the pull towards safety and security.
Speak Back: Give yourself a courageous or compassionate self-statement.
Act with Clarity: Having considered all aspects of this situation instead of only the ones that come to mind automatically, choose action that balances your need for safety and security with your desire to achieve reward and fulfillment.
Practice the On-the-Spot techniques in the office and then use them in the natural environment.