#34 Emotion Regulation and Awareness

In the last post, the subject was how to awaken emotions. In this one, we discuss what to do when emotions are already active and causing distress. Working with painful, uncomfortable, and overwhelming emotions is a large part of what we do. Sometimes strong emotions are what bring people to treatment. At other times feelings arise in the course of doing the work. Either way, when difficult emotions are activated we want to do something to help. What we focus on doing divides into two tasks. First, when emotions are dysregulated and the person is in survival mode, we need to bring down the level of arousal. Only when that task is accomplished, can we focus on healing or detoxifying the emotions and the specifics behind them. Let’s take these objectives one at a time.

Objective 3, arousal regulation

When emotions run too hot, the brain becomes dysregulated and moves into a protective mode that prevents other kinds of processing. At those times our objective is limited to arousal regulation. 

Unfortunately, each therapy tends to promote its own formula for handling this problem and would have the clinician believe that is the only way. The truth is that the differences are more in the words than the doing, and all strategies work pretty much the same. One way to capture the essence of this arousal regulation phase of working with emotion is to examine the normal dysregulation of the two-year-old temper tantrum.

The child is probably experiencing two life-threatening emotions at the same time. She is in a towering, hopeless rage on one hand, and simultaneously terrified that the rage will threaten her connection with a caregiver on whom her life depends.

The first thing to do is address both fears in a combined nonverbal way. We can do so by showing our determination to make sure no one gets hurt and showing that we will not allow the connection to be broken. With a two-year-old, that might mean a big bear hug that stops the child from doing harm and shows that we are still engaged. Accompanying the physical restraint, a warm, calm and firm tone of voice conveys both messages in a powerful way. Achieving this has been called “containment,” meaning that we have blocked the dual threats of destruction and alienation. What is left is pure emotion, still intensely distressing, but no longer life threatening. The next phase, where emotional intensity fades and regulation returns, may take a while as warmth and engagement begin to prevail. The rage subsides, tears begin, and the child can at last accept comforting.

It is only after the emotional storm, when the child is re-regulated and ready to accept help, that the painful issues that led to the trouble can, themselves, begin to be addressed.

Three stages of healing

Thus, addressing emotional storms in children can be divided into phases. Arousal regulation requires first containment, then bringing down the intensity. After re-regulation is achieved, true emotional healing begins. The specifics of the emotion and its sources can be worked with and ultimately resolved.

Adult hyper-arousal

When adults have temper tantrums, they are less overt and can be much harder to contain. They can last over days, months, and years. The destruction can be massive and irreparable. The alienation it causes can be real and devastating. In an earlier post (Adult Temper Tantrums) I suggested that they can be recognized by raging and destruction that are both harmful (including to the self) and resistant to change.

As with children, we need first to contain the destructiveness. That may mean threatening hospitalization or hospitalizing. It may require frank talk, since the destructiveness is often disguised, denied, or defended as harmful only to the self. It may be sustained and supported by outside factors as well. At times destructiveness is so well rationalized that we have no choice but to wait it out. Rarely, a last resort is to put the therapy on the line, indicating that we can’t work with someone who is unable to contain their destructive acting out. In doing that, we pit one fear, that of causing permanent harm against another, that of losing connection.

When containment has either been achieved or, in the absence of destructive acting out, is not required, we are no longer worried about irreparable damage or loss of the relationship. However, like the child, the patient is still engulfed by an intensity of feeling that prevents therapeutic progress. The brain may still be in a state of hyperarousal requiring regulation.

Autonomic re-regulation

When very strong emotions are dominating the picture, our sole objective is helping the patient to recover enough equilibrium to continue the work of healing. Like the child entering. the second stage, where rage and terror are contained but emotions are still too hot to touch, the client’s physiology is still dysregulated. For adults, like children, there are ways to put out the fire. 

Polyvagal Theory

To oversimplify, Porges’ Polyvagal theory says that humans are at their best when socially engaged. Like other mammals, under stress we revert to a more primitive fight-flight-freeze physiology. Dysregulation means we are in the latter state, where automatic protective mechanisms take over and the thinking, social brain is sidelined. From that state, we can become re-regulated and social in two ways. One is when nonverbal signals from the body (bottom up) tell the brain that the danger is over, and the other is top down, where signaling from cognitive faculties is what gives the OK.

Techniques for bottom up re-regulation, include measured breathing, vocalization, and body positions or movements among others. A 2018 article by Sullivan, M.B. et al (with Porges as one co-author), gives a broad account of this approach. 

The other route for re-regulation, according to Porges, is the top down route using cognitive intervention. This is where Polyvagal Theory intersects with more traditional approaches to intense emotion. At this point, even with containment achieved, brain physiology is still in a state of dysregulation. The top down component of our therapeutic approach is to communicate in a way that the client can accept, that the danger is over. 

As with the child there is a gradual transition from when tone of voice conveys safety and the person is still dysregulated, to where we can begin to talk about the issues. In this transition, we move seamlessly from arousal regulation into specific healing of painful issues and emotions.

Objective 4, detoxifying difficult emotions

The reason I use the words, “detoxifying” or “healing” to describe this process is that we are not seeking to eliminate painful feelings. Those are part of life. Rather, our goal is to help our patient get to the point where the emotion is no longer a threat in itself. One patient spent years energetically not remembering her worst early life trauma. Her mind treated the emotion as unbearable. When recall finally happened in a context of safety and connection, over a period of minutes, the unbearable became no more than a dull ache. The feeling was no long a threat in itself. That is what I call healing or detoxification. How did that happen? 

The magic of gaining perspective

Let’s return to how small children’s emotions can be transformed. As I have often described, the toddler who falls, before crying, makes eye contact with the mother. If she signals that it’s OK, the child goes back to playing. What happened is a complex exchange of information. The child asks, “am I alright?” The mother then gives her perspective, “Yes, it’s not serious.” The child takes in the mother’s perspective, and is calmed.

Gaining perspective comes in many flavors. When we talk to a patient about regulating hyper arousal with breathing or yoga, we are also pulling them out of themselves to see their own situation from an outside perspective. When we offer an “interpretation,” we are doing the same thing, asking them to look at themselves through our eyes. Mindfulness is the same. It means stepping out of yourself to see your own situation from outside. Observing ego is another word for this. Fonagy has built a whole approach to therapy on the idea of mentalization, meaning seeing one’s experience from a broader perspective.

The reason this is special is that, when we are stressed we lose perspective. Our primitive protective flight-fight-freeze system has kicked in and our focus is narrow, focused only on our immediate survival. There is no observing, only reacting. Gaining perspective engages an entirely different part of our nervous system, the observing part. Once that channel is open, it is possible to see that a seeming life-and-death threat is actually not.

How perspective leads to change

Simultaneously experiencing emotions and seeing them in perspective is an important formula. Achieving this dual experiencing fulfills the broad requirements for the corrective emotional experience and for enduring change. Emotions associated with a threat are activated when our mental processing, in the light of past experience, appraises danger. Both emotional and appraisal circuits are, at that time, in an active state that allows the change mechanisms of Memory Reconsolidation and Extinction to take operate.

That’s great, but we still need the antidote, that surprising new information that changes everything. Both basic change processes require simultaneous exposure to new information that contradicts old maladaptive stored patterns. And that is precisely what perspective brings to the party! Perspective consists of exactly that new, surprising information that creates prediction error and sets in motion processes for modifying an old response and replacing it with a new one.

This is why gaining perspective is not only soothing in the moment, but also leads to enduring change. As the two-year-old repeatedly cycles through temper tantrums the horror of disagreeing with Mom becomes less threatening and the fear of losing her less terrifying. Ultimately the child learns that losing a power struggle is not the end of the world. Imagine the benefits of not having to win every time and knowing that a difference of opinion does not mean the end of the relationship. And imagine, on the other hand, the ongoing stress of having to win every time and having to deny needing a relationship.

EMPs have structure

Putting this discussion in perspective, Entrenched Maladaptive Patterns, the subunits of pathology amenable to psychotherapy, are, in fact, responses to a threat. Importantly, it appears that the mind’s responses to threat, whether healthy or maladaptive, is mediated by emotion. When the mind evaluates circumstances as threatening, it must register its conclusion somewhere. This system has existed far longer than language. The presence of a threat is registered by the activation of “emotional” circuits deep in the brain in places like the amygdala. It is activation of those deep emotional circuits that triggers the response patterns that get us in trouble. Thus, we could say that emotion is the brain’s proxy for actual threat.

At least in humans, the distinction between actual threats and the emotions that stand for them is significant. The human mind can develop patterns to avoid emotions without even trying to mitigate the threat that led to the emotions being activated. A PTSD patient who dissociates from horrific fear develops a dangerous drug dependence to get away, not from danger, but from experiencing fear. The emotion has become de-coupled from the danger and is treated as a threat in itself.

The structure of EMPs is that they are responses to activation or predicted activation of deep emotions, which may or may not be experienced consciously as feelings. In the end, it would appear that every EMP is associated with a deep emotion and operates to reduce or eliminate precisely the deep emotion that triggered it, whether or not avoiding the emotion will actually result in prevention of harm.

Two ways emotions make us focus on regulation and healing

This brings us back to clinical psychotherapy in which emotions sometimes break through on their own or appear as a result of our success in helping our patient let go of an avoidance pattern. For example, the PTSD sufferer becomes abstinent from his drug abuse and begins to be troubled by anxiety attacks. While the addiction was raging, emotion was not a problem. Now it is the problem. When emotion is the problem, our first objective is to deal with dysregulation or excessive arousal. Then we can focus on the next objective, helping to heal or detoxify the emotion.

Conclusion

In the next post we’ll begin to look at objectives or tasks that are relevant when the problem is not emotion, but some pattern of avoidance. Such patterns are EMPs, problematic patterns consisting of maladaptive values, behaviors, and thoughts. We’ll look at what therapists can do to help clients come to where emotions are healed and avoidance is no longer needed or to where maladaptive patterns can be traded for more satisfactory responses.

Jeffery Smith MD

Reference

Sullivan, M. B., Erb, M., Schmalzl, L., Moonaz, S., Noggle Taylor, J., & Porges, S. W. (2018). Yoga therapy and polyvagal theory: The convergence of traditional wisdom and contemporary neuroscience for self-regulation and resilience. Frontiers in Human Neuroscience, 12, Article 67. https://doi.org/10.3389/fnhum.2018.00067

Photo by Nine Keeper on Unsplash

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