Skills for Emotion Exposures

Emotion exposures are exercises specifically designed to provoke the emotional responses that maintain a client’s symptoms. This therapy has provided skills the client can use to cope with these responses in more adaptive ways. The emotion is the primary focus of the activity. The stimulus, which takes time to plan, is just a way of getting to the emotion. Emotion exposures can occur in external situations or in the context of internal situations, such as thoughts or memories. In this session, clients learn about emotion exposures, and they begin filling in their personal emotion exposure hierarchy. Clients are also taught skills for conducting emotion exposures, such as planning the right level of challenge, considering their expectancies beforehand, removing avoidance during the exposure, staying in the situation long enough, and practicing.

Tracking Emotions over Time (the “ARC”)

The primary goal for this session is for clients to explore and learn how emotional experiences unfold. This allows clients to learn from their emotional experiences and how these experiences can influence their later behaviors and emotions. During this session, clients learn the steps that unfold over time in emotions: antecedent (A, what happened before), response (R, which includes thoughts, physical sensations, and behaviors/urges), and consequence (C, what happens after). Clients learn to look for patterns in their emotional triggers. They also learn to explore short- and long-term consequences of their emotional responses. Form 8.1: The ARC of Emotional Experiences is introduced.

Continuing Progress into the Future

This final session looks at relapse prevention. Clients begin by reviewing the important takeaways from this treatment program, such as (1) all emotions provide information that can motivate us to take action in helpful ways; (2) staying present in the moment and taking a nonjudgmental view of our emotions can help to prevent emotions from increasing in intensity; (3) the way we think about a situation influences how we feel, and how we feel affects the way we interpret a situation; and (4) although avoiding uncomfortable emotion experiences can work well in the short term, it isn’t an effective long-term coping strategy. Clients then evaluate their progress, revisit their initial treatment goals, and develop a practice plan.

Countering Avoidant Behaviors

The key concept for this session is emotion avoidance, which means any strategies we use to avoid feeling strong emotions or to prevent our emotions from becoming more intense. Although these responses may be useful in some situations, they rarely work well in the long term, and they can increase the intensity of our emotions when we encounter a similar situation in the future. During this session, clients learn how suppression of thoughts and emotions can be counterproductive. Clients are taught to identify three types of avoidance, which are behavioral avoidance (obvious and subtle), cognitive avoidance, and safety signals.

Mindful Emotion Awareness

During this session, clients learn the concepts involved in mindfulness. One concept include the awareness of two types of emotion, primary and secondary. Primary is the initial reaction to the event, whereas secondary is a reaction to that emotion. Another concept is that mindful awareness is present-focused, not focused on the past or future. A third concept is that mindful awareness is involves being accepting of emotion rather than judgmental. It takes practice to develop awareness of the different parts of emotion, to develop a focus on the present moment, and to develop non-judgment of emotion. Clients participate in a guided mindfulness exercise as well as a nonjudgmental emotion awareness exercise.

Core Beliefs

During this session, clients learn about core beliefs, which are powerful beliefs that exist deep within our brains and influence how we think. They are at the root, or the core, of our automatic thoughts about ourselves, and they can be positive or negative. In this chapter, clients learn what core beliefs are and where they come from—specifically, they can come from repetitive early experiences, or from a single formative, highly emotional experience. They will also learn about the relationship between negative core beliefs and negative automatic thoughts—specifically, that negative core beliefs, though usually outside of awareness, influence or shape automatic thoughts. Clients are taught the downward arrow technique to identify their own negative core beliefs.

Countering Emotion-Driven Behaviors

One very important aspect of emotions is that they tell us to act in a certain way or drive certain behaviors. Emotion-driven behaviors (EDBs) are different from emotion avoidance in that EDBs happen in response to an emotion that has been triggered. Avoidance strategies tend to happen before an emotion has had a chance to occur. The same action can be avoidance or an EDB depending on when it takes place in the emotional process. Just like emotion avoidance, EDBs can become powerful habits in maintaining the cycle of emotions when the goal is to get away from the emotion. In this session, clients learn to identify EDBs and when and how these EDBs can become problematic. The homework for this session is to substitute opposite actions in place of problematic EDBs.

Automatic Thoughts and Thinking Traps

During this session, clients learn about automatic thoughts, which are fast, subjective interpretations of the world. Automatic thoughts are necessary to operate in a complex world, but emotional disorders typically involve negative automatic thoughts about particular situations, emotions, the future, and one’s self. Automatic thoughts influence and are influenced by emotion. There can be more than one interpretation of a situation, and cognitive flexibility involves being able to consider various interpretations. Clients also learn about two thinking traps (jumping to conclusions or probability overestimation, and thinking the worst or catastrophizing) and how these traps can influence thoughts to produce negative emotion.

Regular Eating

The session described in this chapter is a supplementary session directed toward 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). During this session, clients learn about regular eating, including the importance of regular eating and specifically what it would look like for the individual client. The basic framework for regular eating is three meals and two or three snacks a day at spaced intervals. Together with the therapist, the client will brainstorm ideas for overcoming obstacles to regular eating and look at strategies to tackle compulsive eating.

Interoceptive Exposures

In this session, clients practice tolerating physical sensations through interoceptive exposures and learn to recognize the role of such sensations in emotional experiences. If clients practice tolerating such sensations in a nonthreatening environment, they can learn that the physical sensations themselves, and the emotional reactions they have to them, can be reduced with repetition or practice. Clients also learn that they can tolerate those sensations better than they thought they could when they were avoiding them. The catastrophic emotional thoughts clients have about those situations are subjective and flexible, and just by practicing tolerance of the physical sensations, it is sometimes possible to reduce overall emotional distress.