Skills in Cognitive Behaviour Counselling & Psychotherapy

1. Skills in Cognitive Behaviour Counselling & Psychotherapy CHAPTER 6: Skills for working with emotions in CBT

2. The nature and functions of emotion(In as far as we have any real understanding of it whatsoever!) • Emotion is a form of information about what is happening to us. It tells us that something in or around us may need attention. It often has evolutionary survival value. • Emotions often seem to help us identify what we really need. • Although emotions are often experienced as pure feelings, it is hard to make sense of them without attributing some element of cognitive appraisal and evaluation within them. • There are ‘slow-track’ and ‘fast-track’ ways of processing emotions. There can be conflicts between the need for speed of processing and the need for accuracy in processing (e.g., ‘I am not quite sure if it is a lion or a tiger but I’m going to run anyway!’).

3. Strategies for handling emotions in therapy • Suppression of negative emotions often produces a ‘rebound’ effect. • Therapeutically it is usually necessary to allow expression and encourage acceptance of emotions. • It is helpful to distinguish between; • primary and secondary emotions • healthy and unhealthy emotions • instrumental and other emotions

4. Primary and secondary emotions • There are a few primary emotions, such as sadness, anger, fear and shame, that appear regularly as main issues in therapy. • Secondary emotions may appear as emotions that ‘mask’ the primary emotions. • A classic example is hurt and anger: anger may be a secondary emotion, the expression of which acts as a way of drawing attention away from the primary hurt.

5. Healthy and unhealthy emotions • HEALTHY EMOTIONS may be negative but tend to have a sense of freshness and newness. They are less related to ‘stuff’ and seem to be clearly expressed and to push the client in a certain direction. They do not interfere with the client getting help. • UNHEALTHY EMOTIONS are negative but they are old and familiar. They feel ‘stuck’ and are often hazily expressed. They show destructive effects, including inhibiting the client from getting proper help. • INSTRUMENTAL EMOTIONS often function in an unhealthy way in that they be used in a covert way: e.g., crying as a way of eliciting sympathy.

6. A process map for working with emotions in CBT • IDENTIFYING the type of emotion. • HEALTHY EMOTIONS: the therapist can encourage the client to accept these emotions and allow them to be processed with fairly minimal intervention – e.g., the AWARE strategy. • PRIMARY UNHEALTHY EMOTIONS: consider emotional regulation, cognitive restructuring or ‘changing emotion with emotion’ (Greenberg, 2002). • SECONDARY OR INSTRUMENTAL EMOTIONS: the main strategy is to try to bring to the surface the primary emotion and deal with that. Other strategies include trying to find out what need is met by the secondary or instrumental emotion, and to help the client find another way of meeting that need: e.g., appropriate ways to seek people’s sympathy and time.

7. Focusing as a way of processing healthy emotions (Gendlin, 1998) 1. Finding a still place. 2. Scanning the body for tension and signs of bodily held emotions. 3. Focusing on the emotions and allowing them to speak. 4. Seeking to get a verbal handle on the emotion. 5. Allowing self to flow between feeling and verbal label, enabling emotions and meaning to unfold.

8. Cognitive-emotional processing • A variety of similar methods has been developed to allow for the more active processing or reprocessing of more negative emotions, especially those linked with PTSD. It is possible to see a generic form of cognitive-emotional processing that runs through all these methods. • CBT treatment of PTSD typically consists of some element of reprocessing the trauma story with appropriate emotions (Foa & Kozak (1986) on the ‘fear network’) plus other interventions to tackle other symptom areas such as avoidance and resultant phobias.

9. Steps in cognitive-emotional processing • Identify the negative emotion. • Encourage the client to hold the emotion in open awareness. • Allow the client to process the feeling and observe what new forms of feeling and meaning arise. • Reflect on the shift in feeling and meaning. • Stay with the shifts in feeling and meaning until they have fixed into a new meaning gestalt.

10. How trauma processing works (1) • Historical precedents with the work of Dr Rivers in the First World War (Barker, 1992). • There is always the possibility of a new and more benign meaning emerging – the war after all is over, the accident is in the past. • Has to be the right blend of new meaning and actual feeling – too intense emotion and/or post-accident pain can block processing and lead to ‘looping’ of the same trauma story/experience.

11. How trauma processing works (2) • Processing can ‘clear’ channels of negative meaning (similar to Freud’s and Breuer’s ‘chimney sweeping’ (Breuer et al., 1982)). • Trauma memories are typically hazy – processing may regain lost details that help to shift the meaning of the trauma. • There may be ‘layers of trauma’ – processing can help to feel them back – may uncover ‘nested’ previous traumas. (Can sometimes catch client and/or therapist unawares.)

12. Imagery reprocessing • Clients may retain sharp and disturbing images of early shameful experience that can re-emerge during periods of stress and trauma. • It can be helpful to revisit the scenes of earlier trauma using imagery re-scripting. • The client can be relaxed and taken back to the scene and encouraged to describe it in first-person, present-tense language (usually intensifies the memory and the feeling associated with it and thus allows some processing). • Re-scripting can be used to a greater or lesser extent (according to client preference). New outcomes can be scripted or new elements can be introduced – these frequently result in positive meaning shifts and defusing of negative emotion.

13. Self-soothing • Sometimes emotions can be simply too intense to work through, process or focus on. • We all at times need the capacity to soothe ourselves in the face of emotions that simply cannot be put aside or, for the moment, healed. • Some psychoanalytic theorists, such as Kohut (1977), have suggested that we learn to soothe ourselves by seeing how we could be soothed by our parents or other significant people. Some people, however, sadly lack a soothing model and have to learn how to do it from scratch.

14. Self-soothing and borderline personality • Clients with borderline symptoms often have backgrounds of abuse and therefore usually do lack internal models of appropriate self-soothing. • Self-soothing is a prime strategy, along with validation, in the treatment of borderline features using dialectic behaviour therapy (DBT, Linehan, 1993). • Self-soothing in DBT is heavily dependent on mobilizing comforting sensory soothing using a predetermined client list of appropriate and favourite sensory modes that have worked for the client in the past.