Adolescent Affect Regulation Revisited

1. Adolescent Affect Regulation Revisited Charles Bonner, Ph.D Clinical Psychologist Private Practice Pittsburgh. PA

2. Interpersonal Neurobiology: 3 Principles • 1. The growth of the brain occurs in critical periods and is experience dependent • 2. Affect Regulation is a fundamental by-product of how a secure attachment benefits neurological development • 3. Effective psychotherapy transforms neurobiology through the mirror neuron system and other mechanisms of neural plasticity

3. The growth of the brain occurs in critical periods & is experience dependent (1) • “From late pregnancy through the second year the brain is in a critical period of accelerated growth, a process that consumes higher amounts of energy than any other stage in the life span ….” (Schore. A) • At birth, the neocortex is quite underdeveloped and is yet to be shaped through genetics and experience.

4. The growth of the brain occurs in critical periods & is experience dependent (2) • “In infants, the right hemisphere dominates growth during the first 3 years of life…. [affecting] non-verbal aspects of language (e.g. tone of voice, gestures), facial expression of affect, the perception of emotion, the regulation of the autonomic nervous system, the registration of the state of the body, and social cognition…” (Spiegel, D.)

5. Affect Regulation is a fundamental by-product of how a secure attachment benefits neurological development (1) • In the child’s first three years, affect regulation is particularly influenced by the brain’s right hemisphere, whose maturation is dependent upon daily interactions with affectively attuned caregivers. • The infant’s attachment experience & emergent affect regulation capacities are dramatically intertwined.

6. Affect Regulation is a fundamental by-product of how a secure attachment benefits neurological development (2) • “…. in infancy and beyond, the regulation of affect is a central organizing principle of human development and motivation.” (Schore, A.) • “Emotion is inherently integrative; it links subcomponents together in a functional whole” (Siegel, D.)

7. Effective psychotherapy transforms neurobiology due to neuroplasticity • “Psychotherapy which works is using an interpersonal relationship to change self-regulatory circuits of the brain…”, particularly due to neural plasticity, which is defined as “…the change in neural connectivity induced by experience…” (Siegel, D.)

8. The Mirror Neuron System and Psychotherapy (1) • Discovered in early 1990’s primate research, a mirror neuron fires both during the performance of an action and in the observation of the identical action • Mirror neurons seem to account for the remarkable ability of children to learn relatively complex activities simply by observing another person perform them.

9. The Mirror Neuron System and Psychotherapy (2) • Mirror neurons help account for the powerful intersubjective bonds between the brains of caregivers & their children, wherein a specific affect in one party directly evokes the same affect in the other simply through it being observed (such as through facial expression). Affect is contagious, both positive and negative (Neural WiFi: Goleman, 2006).

10. The Mirror Neuron System and Psychotherapy (3) • Same dynamic applies between therapist & patient, and has been referred to as “empathic resonance”. • “Being empathic with patients may be more than just something that helps them ‘feel better’; it may create a new state of neural activation with a coherence in the moment that improves the capacity for self-regulation” (Siegel)

11. Implications of Interpersonal Neurobiology for Psychotherapy (1) • Problems with emotion regulation are at the core of most psychopathology • We must employ therapeutic methods that tap into limbic system structures that overwhelm the cognitive capacities of the neocortex. • How can we refine psychotherapeutic interventions to reflect the lessons of interpersonal neurobiology?

12. Implications of Interpersonal Neurobiology for Psychotherapy (2) • E.G.-- The limbic system’s amygdala plays a substantial role in fear-conditioned learning, and 6 times more neuronal connections run from the amygdala to the neocortex than the converse. • How do we as therapists help our teen patients overcome this neocortical disadvantage & improve affect management skills?

13. Affect Management Skills Training (AMST)John Omaha, Ph.D. (1) • Rather than attempting to change emotions by changing behavior or cognitions, AMST seeks to regulate emotions more directly, by employing the same modalities the system uses in development:  images, memories, sensations, and affects.  • A departure from the basic theoretical & psychotherapeutic tenets of C.B.T., where cognition assumes supremacy.

14. Affect Management Skills Training (AMST)John Omaha, Ph.D. (2) • Images are theorized to more directly access the neurological pathways along which affect is generated—particularly the limbic system. • A.M.S.T. is particularly well suited for those teens whose problems with affect regulation appear to complicated by a trauma history (trauma coded affects).

15. The Distinction Between Affects and Emotions (1) • “Affect is biology, emotion is biography” (Nathanson) • The nine hard-wired affects (Omaha): 1) anxiety, 2) sadness, 3) anger, 4) shame, 5) disgust, 6) surprise-startle, 7) yearning, 8) interest-excitement, 9) enjoyment-joy (see Worksheet #1, A.M.S.T.-Teen Sample Tracking Sheet)

16. The Distinction Between Affects and Emotions (2) • Hard-wired affects can combine with each other, with cognitions, with appraisals, with memories, and with images to produce a range of emotions, each with a unique set of sensations that identify it (Omaha, J.) • Consistent with this terminology, the ultimate goal of the AMST protocol is affect regulation rather than emotion regulation, although in practice this distinction need not be explicitly stated.

17. Primary vs. Secondary Emotions (1) • Primary emotions: the most immediate reaction to an event contains adaptive motivational info. re: event's meaning. • Primary emotions are the bearers of what is valid or undistorted in the person's reaction. • Secondary emotions: reactions to or against primary emotions; often include distorted cognitive appraisals.

18. Primary vs. Secondary Emotions (2) • Secondary emotions inhibit or block the experience and expression of primary emotions. • Secondary emotions often motivate behaviors that have destructive consequences • All emotions may function as either primary or secondary emotions, or even as both at once-- eg fear of fear

19. The Shame-Rage Spiral in Teens • Anger is often a secondary emotion displacing a primary emotion (shame) that has not been acknowledged • Adolescence is a minefield for shame and its variants, which range from mild embarrassment to mortified humiliation. • The shame-rage spiral operates intrapersonally and interpersonally, often at the same time.

20. The Vitality Affects: Yearning-Longing, Enjoyment-Joy, & Interest-Excitement (1) • Yearning or longing for nurture from caregivers often underlies the more common presenting affects of anger and sadness (i.e. yearning is often the primary affect; also affects addictions). • In psychotherapy, teens will usually not become aware of their yearning affect until their secondary sadness or anger has been recognized & regulated.

21. The Vitality Affects: Yearning-Longing, Enjoyment-Joy, & Interest-Excitement (2) • Enjoyment-joy is the affect that is elicited when our yearning for connection is rewarded. • Joyfulness between infant & caregiver provides some of the essential experiences required to optimize the neurological developments upon which the affect regulation system is built. • Interest-excitement: The foundation of motivation (at deficit in depression)

22. Disgust: How Biology Becomes Biography (1) The disgust response to taste, texture, and smell is: • 1)Virtually instantaneous (mediated by the brain stem) • 2) Not mediated by cognitive appraisals (minimal initial neocortical activation). • 3) Often involves activation of various parts of the digestive tract, from the stomach up through the esophagus, mouth, tongue, and salivary glands.

23. Disgust: How Biology Becomes Biography (2) • What happens when the disgust affect is transferred to the interpersonal domain & people express disgust with one another or toward specific groups? • The phrase “broadcast disgust” describes the caregiver’s expression of disgust toward a child-- conveyed via words, tone, and facial expression. • Disgust + Anger = Hatred; Self-Hatred • Eating disorders include disgust affect

24. Surprise-Startle: Clinical Consequences of a Trauma Coded Affect  (1) • Surprise-Startle affect: Infants’ startle reflexes the earliest example. • An affect that is “trauma coded” has been experienced repeatedly in adverse circumstances & becomes neurologically encoded in ways that increase its likelihood of later being triggered by situations or relationships that may bear only a superficial similarity to the original traumatic reality.

25. Surprise-Startle: Clinical Consequences of a Trauma Coded Affect (2) • Surprise-startle has a greater chance of becoming “trauma-coded” when the person has low threshold for this affect (hard-wired affects have genetically determined thresholds for being evoked– differences in temperament). • The mind-blanking effect of startle affect may be the basis of the dissociative defenses (numbing, spacing out, exaggerated startle response in PTSD).

26. Emotion Recognition, Tolerance, and Regulation: The 3 Goals of A.M.S.T.-Teen • The A.M.S.T. skills capture the main skills emphasized in D.B.T. (Dialectical Behavior Therapy): emotion recognition, distress tolerance, mindfulness, and emotion regulation • “The purpose of these skills is to intervene in both the fast processing in the limbic system & the activation of the autonomic nervous system” (Omaha, J.)

27. The Neurobiology of A.M.S.T.-Teen: A Detour from Taking the “Low Road” • Fast processing has also been called taking the “low road”, which is “the direct pathway from perceptual receptor through the thalamus to the amygdala. The thalamic pathway is fast because it is direct” (Omaha) • A.M.S.T. skills seek to establish a parallel path that serves as a detour from the “low road” of rapid affect dysregulation

28. (1) The Positive Cognition (PC) & The “Validity of Cognition Scale” (VoC) • The Positive Cognition (PC) is an affirmation developed at the end of each AMST skill– e.g. “I’m learning how to decrease my angry feelings” • Purpose of the PC is to link adaptive cognitions with images, sensations, & affects to build self structure (to connect the neurological low and high roads).

29. (2) The Positive Cognition (PC) & The “Validity of Cognition Scale” (VoC) • The “Validity of Cognition Scale” (VoC) assesses the truth of a specific PC, using a 1-7 scale where “1” is completely false and “7” is completely true. • The VoC helps assess the teen’s progress in learning AMST skills & guide the therapist’s decisions about which step to follow next in the protocol.

30. AMST-Teen: Seven Essential Steps (1-3) • 1. The Container: Separating from and Storing Past Upsetting Stuff (especially traumatic memories) • 2. The Safe Place: Developing an Image & Sensations of Safety • 3. Sensation-Affect Identification: Emotion Recognition Skill (especially for the nine hard-wired affects)

31. AMST-Teen: Seven Essential Steps (4-7) • 4. Sensation as Signal for the Grounding Image: Distress Tolerance Skill • 5. Just Notice: Mindfulness of the Present Emotion  • 6. Disposal/Releasing Imagery: Emotion Regulation • 7. Increasing Positive Affects: The Gauge Resource

32. A.M.S.T.-TEEN: SUMMARY OF IMAGES & STEPS FOR MANAGING EMOTIONS My Container is: _______________________ My Safe Place is:_______________________ To Teen: When you feel the first sign of a strong emotion, usually a physical sensation, immediately follow these 3 steps: 1. Connect with your Grounding Image 2. Just Notice (observe & list the physical sensations, thoughts, action urges, images, and memories that are part of the emotion) 3. Dispose and/or Release Excess Emotion (through your disposal or releasing image) Repeat these 3 steps as many times as you need to decrease the emotion and help yourself make good choices about what to do next!