Therapist Materials for Countering Emotion-Driven Behaviors

The session in this chapter focuses on emotion-driven behaviors (EDBs) intended to escape from emotion. Such behaviors can be problematic when used exclusively for many emotions; when they become a self-perpetuating cycle; when they interfere with the opportunity to learn other healthy coping methods; and when they have negative physical consequences. The homework for this session is for the client to prepare to substitute opposite actions in place of the problematic EDBs. There are opportunities in this session to use mild imaginal exposures. The purpose of these exercises is to get in touch with urges, in order to examine the types of behaviors that happen in response to strong emotions, as well as the antecedents, consequences, and the way that moment felt to that client. This kind of insight-building exercise is extremely important therapeutic work for the clients to be doing.

How to Use This Manual

The authors have designed this manual to be utilized in many settings and modalities, by therapists from various disciplines, and at any frequency of session scheduling to facilitate use by the broadest range of therapists and clients. Research on implementation suggests that evidence-based interventions need to be adapted to the particular needs of a clinical population and setting to be maximally effective. Clinicians may share the impact that a part of a session has had on them or otherwise disclose their experience in the here and now. In the face of troubled emotions and the impulse to avoid, clients may employ “strategies of disconnection,” which may involve withdrawal, anger, or displays of emotional dysregulation. This treatment focuses on emotions and experiences that are by definition difficult for clients to tolerate, and clinicians may also have strong reactions to this process.

Therapist Materials for Core Beliefs

The session in this chapter looks at the concept of core beliefs and how negative automatic thoughts are related to negative core beliefs. Negative core beliefs are the roots from which different types of related automatic thoughts grow. Core beliefs arise from repeated similar experiences and powerful single experiences. Clients learn to identify their personal core beliefs (such as I am worthless, I am unlovable, I will go crazy) by using the downward arrow technique. Although arriving at a core belief and saying it out loud is an emotionally evocative experience, it’s a necessary part of the client’s work. It is also an opportunity for the therapist to hear the client and empathize with the client’s experience. Over time, the client builds a repertoire of experiences that allow for new core beliefs to form, making their original core beliefs less valid.

Introduction

The Renfrew Unified Treatment for Eating Disorders and Co-occurring Emotional Disorders (UT) is an integrative, transdiagnostic, principle-based approach to address patterns of emotion avoidance, emotion sensitivity, and negative affect that produce and maintain the symptoms of eating disorders and co-occurring emotional disorders. The UT model was developed through an extensive process of adapting the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) for use with patients with severe and diverse eating disorders. The modules of the UT are distinct from other approaches due to their cohesive (internal and collective) focus on how each module addresses these shared maintaining mechanisms. There is extensive evidence that eating disorders typically co-occur with other emotional disorders. There is also extensive evidence that eating disorders and other emotional disorders share common maintaining mechanisms, reflecting aspects of emotional functioning.

Therapist Materials for Countering Avoidant Behaviors

The session in this chapter looks at how suppression of thoughts and emotions can be counterproductive. Suppression or attempted avoidance may control things somewhat in the short term but rarely works in the long term, and it increases intensity of emotion when a similar situation is encountered in the future. Subtle behavioral avoidance, cognitive avoidance, and safety signals are introduced, and clients are asked to provide their own examples. Habitual avoidance of emotion creates negative messages about our capabilities and robs us of the chance to learn that the emotion is tolerable and will pass on its own without our efforts to avoid or escape. In this countering avoidant behavior session, clients are taught how to do the opposite of avoidance by developing a willingness to lean into emotions, or approach them, and thereby learn new lessons about emotion, situations, and themselves.

Therapist Materials for Mood Induction

The session in this chapter takes a deeper look at the principles of the natural course of emotions. There are three components of emotion (thoughts, physical sensations, behaviors/urges) that unfold over time. If we escape or avoid, we never learn that emotions pass on their own, and we end up reinforcing that emotions are scary and dangerous. Secondary emotions often lead to escaping or avoiding. If we stay with the primary emotion and do not react by escaping or avoiding, we can learn new things about the emotion, and it can pass on its own. The session continues by teaching how mood induction is intended to help promote new tolerance of emotion.

Therapist Materials for the Three Parts of Emotions (3-Component Model)

The session covered in this chapter looks at the three components of emotions, which are thoughts, physical sensations, and behaviors/urges. These components interact and unfold over time. With regard to thoughts, clients frequently know that they have thoughts, but they have difficulty putting the thoughts into specific words. With regard to physical sensations, clients are often least familiar with thinking about physical sensations as a part of emotion. With regard to behaviors, it is useful to think of urges as well as behaviors, and also to broaden thinking to a wide range of behaviors, including not doing certain things. It is particularly useful to identify the three components of emotion in different, recent situations where they experienced strong emotion or behavioral symptoms, such as binge eating, compensatory behavior, driven exercise, body checking, or skipping a meal.

Therapist Materials for Interoceptive Exposures

The session in this chapter focuses on the importance of learning to tolerate physical sensations of emotion and to identify automatic thoughts that accompany physical sensations of emotion. Clients learn this by repeatedly practicing interoceptive exposure exercises (such as hyperventilating and breathing through a thin straw) that stimulate sensations associated with negative emotions. The authors encourage the clinicians leading this treatment to always do the exercises along with their clients. This participation demonstrates the full effort of doing the exercise thoroughly by provoking strong physical sensations in the therapists themselves; models the potential for having a nonthreatening experience of physical sensations; and normalizes the challenge of this exercise. Client avoidance and emotion-driven behaviors are bound to emerge through the course of this session.

Therapist Materials for Regular Eating

Chapter 5 is a supplementary session designed for clients who are not receiving frequent, adjunctive treatment focused directly on eating regularly (such as meetings with a dietitian/nutrition counselor, residential treatment, or daily food coaching). Some clients may not require extensive attention to regular eating because they eat regularly already and have other issues. It is important to log eating and to monitor and discuss connections between eating, symptoms, and emotions. In addition to reviewing food logs, this chapter instructs clients on regular eating and helps clients to identify obstacles to regular eating and to develop specific plans to address those obstacles. Clients also learn to identify strategies to delay automatic compulsive eating between regular eating episodes.

Therapist Materials for Skills for Emotion Exposures

The session in this chapter introduces emotion exposures, which involve the planned introduction of a stimulus to provoke habitually avoided emotions in order to reduce avoidance and promote new learning. An emotion exposure can be designed to provoke any emotion, and can be situational or imaginal, in the therapy office or elsewhere. Clients in this treatment program plan emotion exposures for emotions associated with their eating disorder and other emotional issues that are involve patterns of emotional avoidance or suppression. In this session, clients begin filling out a personal emotion exposure hierarchy and learn to identify principles of planning an emotion exposure, as well as how to record before and after exposures.