01 - 13. Emotions

13. Emotions

E motions are of primary importance in CBT. After all, a major objective of treatment is to help clients feel better by decreasing negative emotion and increasing positive emotion. Intense negative emotion is painful and may be dysfunctional if it interferes with a client’s capacity to think clearly, solve problems, act effectively, or gain satisfaction—­ all of which can be obstacles to achieving their goals. Clients with a psychiatric disorder often experience an intensity of emotion that can seem excessive or inappropriate to the situation. Abe, for example, felt enormous guilt and then sadness when he forgot he was supposed to go to his daughter’s house for dinner. He was also very anxious about calling the bank to straighten out an error. Yet the intensity and quality of Abe’s emotions made sense when I recognized how strongly he believed his automatic thoughts and beliefs and how strongly he held certain values. In addition, it’s important to recognize the positive functions of negative emotion. Sadness can be a signal to fill what you perceive is missing in life. Guilt can motivate you to do what is truly important to you. Anxiety can give you energy to deal with a challenge. Anger can provide energy to do the right thing in the right way in the service of your values. This chapter answers the following questions: How do you elicit and strengthen positive emotions? How do you help clients label their negative emotions? How do you guide clients to rate the intensity of their emotions? EMOTIONS

How are automatic thoughts different from emotions? How does the content of automatic thoughts match with emotion? When is it advisable to increase negative emotion? How can you identify and help clients test their beliefs about negative emotion? What techniques are useful in regulating emotion? ELICITING AND STRENGTHENING POSITIVE EMOTIONS Positive emotions promote a sense of well-being (both psychologically and physically) and resilience, both of which are important during treatment and after treatment has ended. When clients have a negative emotion, they often narrow their attention and experience autonomic arousal. Positive emotions broaden their attention, cognitions, and behavioral tendencies and decrease their arousal (Fredrickson, 2001). Recalling positive memories of how they have coped with difficulties in the past allows clients to cope better in the present (Tugade et al., 2004). You will actively work to elicit and increase clients’ positive emotions in the session and throughout the week by • discussing their interests, positive events that occurred during the week, and positive memories; • creating Action Plans aimed at increasing positive emotions by, for example, becoming engaged in social, pleasurable, meaningful and productive activities and giving themselves credit; and • helping clients draw adaptive conclusions about their experiences, for example, by asking: “What does this experience show you?” “What does it say about you that you [did             ]?” “How do you think             views you [as a result of this positive experience]?” “I think this [experience] points out             about you. Do you think I’m right?” It’s also helpful to have clients specify their positive emotions by asking: Cognitive Behavior Therapy: Basics and Beyond

“How did you feel when you did             [or when             happened]?” “How did you feel afterward?” Many clients have an impoverished vocabulary for positive emotions. Asking them to identify all the positive emotions they experienced in a situation can increase their ability to label these emotions and may also lift their mood, especially if you give them the list in Figure 13.1. If the list could be overwhelming to a client, whittle it down or provide them with a multiple choice: “When your friend finally called, did you feel glad? Relieved? Thankful?”; “When you watched your grandson score a goal, did you feel happy? Proud? Excited?” To increase the strength of their positive emotions in session, ask clients to imagine the situation as if it’s happening now, and see if they can reexperience those emotions. LABELING NEGATIVE EMOTIONS When clients have difficulty identifying their negative emotions, you can offer them a short multiple choice (“Were you feeling happy, sad, anxious, angry . . . ?”) They can also refer to a list of negative emotions (Figure 13.2). If clients still have difficulty differentiating their negative emotions, you can help them create a chart (Figure 13.3). You’ll ask clients to list current or previous situations in which they felt a particular emotion. Accepted, adventurous, affectionate, affirmed, agreeable, amazed, amused, appreciative, awesome, benevolent, blessed, bold, calm, capable, centered, cheerful, confident, content, creative, curious, delighted, dynamic, eager, elated, empowered, energized, enthusiastic, excited, fortunate, free, friendly, fulfilled, generous, grateful, happy, helpful, hopeful, in awe, in control, insightful, inspired, intelligent, interested, joyful, kindly, light, love, motivated, open, optimistic, passionate, peaceful, playful, pleasantly surprised, pleased, proud, reassured, relieved, resilient, respected, reverent, safe, satisfied, secure, serene, sincere, stimulated, supported, tender, thankful, thrilled, tranquil, understood, valuable, vibrant, virtuous, vital, wise, worthy, youthful, zany FIGURE 13.1.  List of positive emotions.

Emotions

Judith: I’d like to spend a few minutes talking about different emotions so we can both understand better how you feel in different situations. Okay? Maria: Yeah. Judith: Can you remember a time when you felt angry? Maria: Uh, yeah . . . When my friend cancelled plans to go to this concert; I forget which one, but I really wanted to go. Anyway, she told me she was going out with some other friends instead. Judith: And what was going through your mind? Maria: Who does she think she is? I wouldn’t do that to her. She should treat me better. Judith: And you felt— Maria: Mad. • Sad, down, lonely, unhappy, depressed • Anxious, worried, fearful, scared, tense, afraid, suspicious, tense, unsure, panicky • Angry, mad, irritated, annoyed, frustrated, misunderstood, resentful, wronged • Ashamed, embarrassed, humiliated • Disappointed, discouraged, in despair • Jealous, envious • Guilty • Hurt • Suspicious Directions: For each emotion below, fill in three situations in which you felt that emotion. Angry Sad Anxious Friend cancels plans with me Plans for evening fall through Seeing how low my bank account is Neighbor doesn’t return my suitcase Not enough money to go away on vacation Hearing that there might be a hurricane Driver plays music too loudly Nothing to do all weekend Finding a bump on my neck FIGURE 13.2.  Partial list of negative emotions. FIGURE 13.3.  Sample emotion chart for Maria. Cognitive Behavior Therapy: Basics and Beyond

Here I had Maria recall a specific event in which she felt a given emotion. From her description, it sounded as if she had correctly identified her emotion. Because I wanted to make sure, I asked her to identify her automatic thoughts. The content of the automatic thoughts did match her stated emotion. Next, I asked Maria to fill out the chart with other situations when she recalled feeling angry, sad, and anxious. I asked her to refer to the chart in session and at home whenever she was having difficulty labeling how she was feeling. RATING THE INTENSITY OF EMOTION At times, you’ll ask clients to not only identify their emotion but also quantify the degree of emotion they’re experiencing. For example, rating how strongly a client feels a certain emotion before and after a therapeutic intervention helps you decide whether to use additional interventions, so you can avoid prematurely moving on to another cognition or issue. Or the opposite can happen—­you may continue discussing a cognition or issue, not realizing that the client is no longer significantly distressed by it. Finally, gauging the intensity of an emotion in a particular situation helps you and the client determine whether it warrants closer scrutiny in the first place. A situation that is relatively less emotionally laden may be less valuable to discuss than one that is more distressing to the client, where important beliefs may have been activated. Most clients learn to judge the intensity of an emotion fairly easily. Judith: How did you feel when your friend said, “Sorry, I don’t have time now”? Maria: Pretty sad, I guess. Judith: If 10 is the saddest you ever felt and 0 is not sad at all, how sad did you feel right when he said, “Sorry, I don’t have time now”? Maria: About 7 or 8. Some clients have difficulty with or don’t like putting a specific number to the intensity of emotion. You can ask them to rate whether they experienced the emotion “mildly,” “moderately,” or “intensely.” If even that is difficult, drawing a scale can help. A little A medium amount A lot Completely 2 4 6 8 10

Emotions

Judith: How did you feel when your sister told you she wasn’t coming to visit after all? Maria: Sad. Judith: How sad did you feel, 0 to 10? Maria: I’m not sure. I’m not too good with numbers. Judith: Do you think you felt a little sad? Moderately sad? Intensely sad? Maria: What were the choices again? Judith: Here, let me draw a scale. Your sadness—­would you say (pointing to the scale) that you were a just a little, a medium amount, very sad, or completely sad? Maria: Oh, very sad; I guess an 8. Judith: Okay, we’ve got our scale now. Let’s see how useful it is. Were you sad any other times this week? Maria: Yeah, last night when Tanisha didn’t call me back. Judith: Can you use this scale as a guide? About how sad did you feel? Maria: A medium amount—­maybe 6. Judith: Good. Now, do you think you could use this scale when you’re trying to figure out how distressed you are? Maria: Yeah, I can do that. DIFFERENTIATING AUTOMATIC THOUGHTS FROM EMOTIONS It’s important for clients to recognize (and label) their negative emotions, especially when they pose an obstacle to taking steps to fulfill their goals. We don’t want to eliminate negative emotion. Negative emotions are as much a part of the richness of life as positive emotions and serve as important a function as does physical pain, often alerting us to potential problems we may need to address. But we do want to decrease excessive negative emotion. We don’t evaluate, challenge, or dispute clients’ emotions. Rather we acknowledge, empathize, and validate clients’ emotions and then collaboratively decide whether to evaluate the cognitions that led to their distress—­or intervene in another way, such as problem solving, turning attention to something else, accepting the negative emotion, or using other emotion regulation techniques. You won’t discuss all situations in which clients feel dysphoric—­ but you will use your conceptualization of the client to collaboratively decide which situations are most important to address, which goals to work toward and what obstacles could get in the way. Often the Cognitive Behavior Therapy: Basics and Beyond

greatest obstacles are associated with high levels of distress or dysfunction. At the beginning of treatment, many clients don’t clearly understand the difference between their thoughts and their emotions. You continually and subtly help clients view their experiences through the cognitive model. When clients describe an issue or obstacle, ask questions to organize the material into the categories of the cognitive model: situation, automatic thought, and reaction (emotion, behavior, and physiological response). One reason that clients confuse thoughts and emotions is that they sometimes use the word “feel” to indicate an emotion (“I feel anxious”). At other times, they use the word “feel” when they report a cognition (“I feel like I can’t do it”; “I feel like a failure”; or “I feel worthless”). At these times, based on the flow of the session, their goals, and the strength of the collaboration, you may decide to • ignore the confusion, • address it at the time (either subtly or explicitly), or • address it later. Most of the time, mislabeling a thought as a feeling is relatively unimportant in a given context, and you can make a subtle correction. Judith: You mentioned when we set the agenda that you wanted to talk about the phone call you had with your brother? Abe: Yeah. I called him a couple of nights ago and he sounded kind of distant. Judith: When he sounded distant, how did you feel? Abe: I felt like he really didn’t want to talk, like he didn’t really care whether I had called or not. Judith: So when you had the thoughts “He doesn’t really want to talk. He doesn’t really care that I called,” how did you feel emotionally? Sad? Angry? Anxious? Something else? In another session, I viewed the confusion as important because I wanted to teach Abe how to evaluate his thinking, using a Thought Record (pp. 267–268). I deliberately decided to distinguish thoughts from emotions. I didn’t want him to think that I was questioning what he had viewed as an emotion. I also judged that the interruption wouldn’t unduly affect the flow of the session and that we wouldn’t forget important data.

Emotions

Judith: Were there any times this week when you thought about going to the movies? Abe: Yeah, a few times. Judith: Can you remember one time specifically? Abe: Yesterday after lunch, I was cleaning up . . . I don’t know. Judith: How were you feeling emotionally? Abe: [expressing thoughts] Oh, I was feeling like it’s no use, that seeing a movie probably wouldn’t help. Judith: Those are important thoughts. We’ll get back to evaluating them in a minute, but first I’d like to review the difference between thoughts and feelings. Okay? Abe: Sure. Judith: Feelings are what you feel emotionally—usually they’re one word, such as sadness, anger, anxiety, and so on. (pause) Thoughts are ideas that you have; you think them either in words or in pictures or images, like “It’s no use. It probably won’t help.” (pause) Do you see what I mean? Abe: I think so. Judith: So let’s get back to yesterday when you thought about going out for a walk. What emotion were you feeling? Abe: Sad, I think. Judith: And your thoughts were “This is no use. I’ll never get better”? Abe: Yes. In the example above, Abe initially labeled thoughts as feelings. At times, clients do the reverse: that is, they label an emotion as a thought. Judith: As you walked into your empty apartment, Maria, what went through your mind? Maria: I was sad, lonely, real down. Judith: So you felt sad and lonely and down. What thought or image made you feel that way? MATCHING THE CONTENT OF AUTOMATIC THOUGHTS TO EMOTIONS You continuously conceptualize clients’ problems and the obstacles that interfere with goal attainment. You try to understand their Cognitive Behavior Therapy: Basics and Beyond

experience and point of view and how their underlying beliefs give rise to specific automatic thoughts in a specific situation, influencing their emotions and behavior. The connection among clients’ thoughts, emotion, and behavior should make sense. You will investigate further when clients report an emotion that doesn’t seem to match the content of their automatic thoughts. Judith: How did you feel when you realized you hadn’t heard back from your old boss? Abe: I was sad. Judith: What was going through your mind? Abe: I was thinking, “What if he doesn’t want to give me a good recommendation? What if I don’t get the job?” Judith: And you felt sad? Abe: Yes. Judith: I’m a little confused because those sound more like anxious thoughts. Was there anything else going through your mind? Abe: I’m not sure. Judith: How about if we have you imagine the scene? [helping Abe vividly recall the scene in imagery form] You said you were home, looking online for job possibilities. Can you see yourself? Where are you? Abe: At my desk. Judith: And you’re thinking, “What if he doesn’t give me a good recommendation? What if I don’t get the job?” And you’re feeling . . . ? Abe: Nervous, I guess. Judith: What else is going through your mind? Abe: I think I was remembering when my boss told me I was being laid off. I was feeling like such a failure. Judith: And how were you feeling emotionally? Abe: Sad. Real sad. This interchange started with a discrepancy. I was alert and so was able to pick up an inconsistency between the content of Abe’s automatic thought and the emotion associated with it. I was then able to help Abe retrieve an important image (a memory) and a key automatic thought by using imaginal recall. Had I chosen to focus on the anxious thoughts, I may have missed an important cognition.

Emotions

INCREASING NEGATIVE EMOTION Some techniques are actually designed to heighten negative affect. This is important when clients need • to gain greater access to their thoughts; • to change their cognitions at the emotional level; • to learn that emotions aren’t dangerous, uncontrollable, or intolerable; and/or • to examine the disadvantages or consequences of some of their maladaptive behavior. You can use imagery, exposure, or focusing on somatic sensations to increase the intensity of clients’ negative emotion. TESTING BELIEFS ABOUT NEGATIVE EMOTIONS Some clients have dysfunctional beliefs about experiencing emotion (Greenberg, 2002; Hofmann, 2016; Linehan, 2015), as illustrated with Maria, below. Maria: I didn’t end up calling my mother this weekend. Judith: What [obstacle] got in the way? Maria: I don’t know. I guess I got nervous. Judith: Did you make a prediction about what would happen if you called? Maria: I just thought I might get really upset. Judith: And then what could happen? Maria: I was afraid I just couldn’t stand it. If she got me upset, I might start crying and never stop. Like Maria, some clients believe that negative emotions are unsafe: “If I get upset,             ,” for example, “it will get worse and worse until I can’t stand it, I’ll lose control, it will never go away, or I’ll end up in the hospital.” These kinds of beliefs can interfere with working to achieve their goals. Clients may avoid situations in which they predict they will become upset. They may avoid talking about or even thinking about distressing problems. When clients have dysfunctional cognitions about experiencing negative emotion, they may not make much Cognitive Behavior Therapy: Basics and Beyond

progress in treatment. You can use standard cognitive restructuring techniques to help clients evaluate their beliefs. Doing a behavioral experiment using mindfulness (pp.  278–279) is especially effective. When clients successfully disengage from a thought process such as worry, you can guide them in changing their cognitions from “Worry is uncontrollable” to “I can choose to disengage in worry when I notice it has started.” TECHNIQUES TO REGULATE EMOTION Throughout this book, you’ll learn techniques to help clients regulate their emotions. For example: • Problem solving • Evaluating and responding to negative thoughts • Engaging in (and being fully mindful of) social, pleasurable, or productive activities • Exercising • Accepting negative emotion nonjudgmentally • Using mindfulness (to detach from upsetting thoughts) • Doing relaxation, guided imagery, or breathing exercises • Engaging in self-­soothing activities (walking in nature, taking a bath, hugging another person or a pet, listening to soothing music) • Focusing on one’s strengths and positive qualities, and giving oneself credit See Linehan (2015) for an extensive description of emotion regulation and distress tolerance techniques. For more techniques and helpful metaphors to help clients accept negative emotion, see Hayes and colleagues (1999). SUMMARY Emotional reactions always make sense, given what the individual is thinking. You will seek to promote positive emotions in and outside of sessions. When clients express significant negative emotion, you’ll conceptualize according to the cognitive model and you’ll often address the associated cognitions. Some clients need to modify dysfunctional beliefs about experiencing negative emotion itself. It’s important for clients to differentiate between their thoughts and their emotions and

Emotions

among different emotions. We empathize with clients’ emotions, and we don’t evaluate them. When needed, we help them to accept their negative emotions nonjudgmentally. A number of techniques help clients regulate their negative emotions and, when needed, develop greater tolerance of them. REFLECTION QUES TION What role do emotions play in CBT treatment? PRACTICE EXERCISE Do a role play in which you elicit a client’s dysfunctional belief about experiencing negative emotion. Also help the same client experience positive emotion in the session. Cognitive Behavior Therapy: Basics and Beyond