Over the years, researchers and academics have had disagreements about emotion regulation, making it a controversial issue. Researchers have disagreed about whether emotion regulation includes an intentional process of change, whether it only refers to the behavioral outcome of emotion regulation, or whether it should include only automatic or intentional responses.

HEADS UP!

Before you continue reading, I want to give you a heads up that I’m a big proponent of:

– Normalizing emotion regulation as a natural, regular, and universal human process that we all go through, not only clients with BPD. Think about your day, for instance. Didn’t you have an emotion, whether mild, moderate, or intense, which you found yourself having to adjust to? Didn’t you have urges to act based on that feeling? If you recall your day again, didn’t you make a face, move around, or stand up when having a feeling? The truth is that we’re constantly adjusting our responses to our emotions, sometimes effectively, successfully, and in a manner consistent with the person we want to be, but at other times, we just become puppets of our emotions.

– Deconstructing the idea that emotion regulation problems are exclusive to clients with Borderline Personality Disorder (BPD). There are many other clinical presentations––post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), phobias, Asperger’s disorder, and substance abuse, to name a few––in which clients significantly struggle with managing their responses to their feelings.

– Understanding emotion regulation––not as a dichotomous construct in which a person either has emotion regulation problems or not––but as a continuum in which a person has different degrees of difficulty with handling different emotional states.

– Conceptualizing emotion regulation as an outcome, result, or consequence of other psychological processes. For instance, saying that a client is dealing with emotion regulation problems doesn’t tell us what is driving the client’s ineffective behavior in a given moment.

– Emphasizing that failures in emotion regulation are related to different topographical descriptions of psychological problems that range from depression and panic to borderline personality disorder.

– Rejecting the idea that emotions are “causes of behavior” and instead, proposing that “fusion with the story or rule about the emotion” causes behavior.

– Challenging the idea that behavioral dysregulation only refers to extreme impulsive behaviors, such as self-injury, suicidal gestures, or excessive drinking, and introducing the notion that it also refers to a pattern of unworkable behaviors that are inconsistent with a person’s values and vary in degrees from mild to severe.

WHAT IS EMOTION REGULATION?
Based on current advances in affective science, neuroscience, and clinical psychology, I generally conceptualize emotion regulation as a process by which a person attempts to modify, change, or alter any component of emotional experience through unworkable, ineffective, and incongruent behavior based on what matters to the person in a given contextual situation.

A few clarifications on this definition:

1. Emotion regulation is not a dichotomous construct that either people have or do not have. Those who have made categorical descriptions of psychological disorders have perpetuated the misleading notion that there is a division between people: those who have emotion regulation problems and those who do not. The reality is that we’re all constantly, 24/7 regulating our responses to our emotions: sometimes effectively and sometimes not; sometimes adaptively and sometimes not. When we engage in a high frequency of ineffective regulatory responses that lead us to have behavioral excesses, then that cluster of responses becomes a problem, a diagnosis.

I conceptualize emotion regulation on a continuum, in which a person has varying degrees of difficulties:

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Mild                                                                            Moderate                                                            Severe

No human being walks in life without responding to their emotional landscape.

2. Emotion regulatory processes can occur before a troublesome situation, at any point during it, or afterward. Responding to an emotional experience based on a triggering situation can happen before it occurs, during the triggering situation, or after the triggering situation. For instance, a person struggling with fears of public speaking when receiving an invitation to go attend a conference may feel anxious and start drinking to calm down the anxiety; or during the situation, the individual might carry a glass of wine to manage his fears. Another example is the same individual, after giving the presentation, may spend hours watching TV to distract himself from feeling frustrated about his performance.

3. Not all efforts to alter, change, or even suppress emotions are unworkable behaviors. Within Acceptance and Commitment Therapy (ACT), the effectiveness or workability of behaviors driven by those responses is defined based on the context in which they occur and a person’s values. For example, a person participating in a conversation with a friend who suddenly hears about a dead animal may have the thought, “I don’t want to think about it” along with feelings of frustration or sadness; that behavior is avoidance but in the context of continuing to talk to a friend, it’s not necessarily unworkable.

The above general definition of emotion regulation allows us to understand a wider range of problems a person struggles with within a given moment, as a trans-diagnostic process across different clinical presentations; it also allows me to invite you to consider different types of emotion regulation.

TYPES OF EMOTION REGULATION PROBLEMS
Emotion regulation can be considered a trans-diagnostic process that occurs across mood, anxiety disorders, BPD, and any other clinical presentation in which individuals make attempts to alter, change, modify, or suppress an emotion or engage in unworkable behaviors to do so given their personal values and the context and time in which these behaviors occur.

I’m proposing two types of emotion regulation problems.

SINGULAR EMOTION REGULATION PROBLEMS
When specific attempts to regulate or suppress a singular emotion occur, such as is seen in depression, social anxiety, and GAD, then we may consider singular emotion regulation problems.

For example, Annie, a person struggling with social anxiety, receives an invitation for a graduation party, feels scared about being misjudged by others, and quickly goes to grab a glass of wine to manage that fear. This is an example of how a natural process, Annie responding to the emotional state of fear, could become a problem. If Annie engages in that drinking behavior more often than not and avoids going to gatherings, hanging out with coworkers, attending family events, and so on, we could say that she has a singular emotion regulation problem.

You may wonder why. Keeping in mind the definition I suggested previously, Annie is responding to the emotional experience of fear in a non-effective manner because she’s engaging rigidly and inflexibly in behaviors, drinking, and avoiding situations, that are inconsistent with her desire to connect with others.

GENERALIZED EMOTION REGULATION PROBLEMS
An emotion regulation problem becomes a generalized emotion regulation problem when a cluster of emotional states drive rigidly, inflexibly, and with high frequency unworkable and ineffective behavior across a broad range of settings and contexts for a prolonged period.

Notice here that the keywords are “a cluster of emotional states” which basically differentiates this from singular emotion regulation problems described above; these refer to a bunch of emotional states that drive ineffective behaviors as seen in borderline personality disorder, eating disorders, substance abuse, or OCD, to name a few.

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Anya, a 26-year-old, was in charge of organizing the schedule for the annual camping trip with her college classmates. She was excited and ready to make phone calls and gather prices for transportation, camping sites, etc. But in the middle of preparing for those errands, she noticed a red stain on the hardwood floor of her house. Quickly her mind came up with the thought, “Did I step on it? What if it’s blood? What if I get an illness? Is it fresh blood?” Immediately, Anya jumped in the shower and washed her feet as carefully as possible in case her socks got contaminated and touched her skin. Afterward, Anya ended up throwing away her shoes.

Anya had unwanted thoughts about getting contaminated: What if I get an illness? What if I get contaminated?

Indeed, it’s very distressing for anyone to have their mind come up with that thought, but Anya’s mind was playing tricks with her. And because that obsession came along with so much fear, she got hooked on it and took it as the absolute truth. Immediately afterward, she started doing things to avoid getting contaminated or ill.

If you are familiar with Exposure Response Prevention (ERP) or exposure-based treatments, the frontline treatment for OCD and all forms of anxiety, you know that approaching a triggering situation, person, or activity and staying present with that experience is fundamental for treatment to be effective. And yet, at times my clients have started their sessions saying, “I’m doing all types of exposures, hundreds of them, every day, and I’m still struggling.”

What happens when our clients are doing exposures but they’re getting stuck? What if clients are doing exposures as a compulsion?

Here are some questions to unpack those moments of stuckness:

1. 1. What are you hoping to experience or accomplish when doing exposures?
   2. What’s your experience after completing your values-based exposure exercises?
   3. Preventing another OCD episode from coming in the future.
   4. Did you have any agenda, expectation, or hope, when practicing exposures?
      Check for the following responses: (a) Making your obsessions go away; (b) Making the anxiety, fear, panic, and other related feelings go down; (c) Answering a question about an obsession
   5. Invite clients to check, when practicing exposures, how would they describe their attitude towards it? For example, using the continuum below, ask clients to mark an “x” where it fits better:

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        Feeling better right away                 Hammering out                   Pushing through                 Flexibly choosing

If clients are practicing exposure exercise hoping for one or a combination of the items above, and pushing through or hammering out, chances are that they’re doing exposures as a compulsion.

If that’s the case, here is what you could do:

Ask clients to pause any exposure exercises right away.

Revisit the frame to do exposure work: e.g. why are you approaching this situation, activity, or thought that scares you? 

Link them up: practice an exposure as a move towards your values (values-guided exposures).

Mix them up: combine different ways of doing values-guided exposures.

Vary them up: practice values-guided exposures in different contexts.

Tune them up: adjust your values-exposure activities as needed.

Stay with them: watch out for subtle compulsions and avoidance when practicing values-guided exposures.

Be curious of them: watch what shows up when making exposures or W.I.S.E. M.O.V.E.S.

Give another trial to practice values-based exposures, but if they catch themselves doing them as something to completing and get it done, then pause again.

Remind clients that as much as there is an urgency to get the obsession-problem under control, it’s more important to find a rhythm that gets their life back on track, full of vitality, meaning, and presence instead of attempting to get their life back rushing through skills, with exhaustion, a scatterbrain, and full of fatigue.

Our brains are constantly trying to defend us from anything that could possibly go wrong. And by nature, some brains are just wired to be more reactive than others. So much that when a client approaches an exercise towards being the person our clients want to be, the tiny possibility of an obsession showing up makes their brain shout signs of danger at them, alerting them in a high pitch, high volume, and high speed. They end up practicing values-guided exposures as a control strategy to neutralize obsessions.

Our brain is an old device doing its job. However, none of this means that we cannot teach our clients to respond flexibly to those urges to tackle the obsession-problems, leave those obsessions unattended, and show up to their life as it matters to them.

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Based on: LivingBeyond OCD using Acceptance and Commitment Therapy & The ACT Workbook for Teens

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