Emotion Dysregulation

1. Emotion Dysregulation Managing difficult emotions and behaviors

2. Presentation Objectives • Challenge perception of behavioral symptoms and diagnostics • Propose a new framework for working with problem behaviors resulting from dysregulation • Increase awareness of physiological changes and role in behavior • Introduce skills and approaches for client and worker to effectively manage problem behaviors

3. Foundational Principles • This presentation has been created out of basic Dialectical Behavior Therapy. We operate on several core ideas: • Individuals are doing the best they can AND must do better. When dysregulated, impairment in brain functioning makes behavioral change virtually impossible. • Emotion Dysregulation causes suffering and is not the result of a desire to manipulate or harm others. It is the result of a skills deficit in managing emotions and physiological responses that are resulting from stimulus such as threat, loss, fear of abandonment • Effective Intervention for change, occurs prior to problem behavior, when engaging problem behavior, looking to decrease reactivity through attunement and skills suggestions. • Our focus will be far more on process then content- tracking changes in emotional and arousal states rather then concerning ourselves with peoples narratives.

4. New lenses, New ideas • New ways of naming presenting symptoms can change not only how we approach our clients but can change our effectiveness and outcomes. • A common pejorative term used to describe a way of meeting needs is manipulation mostly because of the way we feel in the face of thebehavior. Terms like: played, manipulated, controlled, used….leave us feeling disempowered and angry. They also cast the individual in a negative light

5. Maladaptive behaviorsanother lens…… • Maladaptive behaviors inhibit a person’s ability to adjust healthily to particular situations. In essence, they prevent people from adapting or coping well with the demands and stresses of life. • Effective in short term for relief but not over long term • These behaviors are non-productive because they do nothing to alleviate the root of a person's problem and may, in fact, serve as reinforcers of the underlying problem.

6. Examples of maladaptive behaviors • Avoidance Talking over others • Withdrawal Attention seeking • Converting sadness or fear to anger, Addiction • Substance use Compulsions • Outbursts/ rages self injurious behaviors • Insistent demanding threats to achieve desired needs

7. Defining symptoms/ Diagnostics • DSM IV: Borderline Personality Disorder • A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:  • (1) frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.  • (2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation  • (3) identity disturbance: markedly and persistently unstable self-image or sense of self  • (4) impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, Substance Abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.  • (5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior  • (6) affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)  • (7) chronic feelings of emptiness  • (8) inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)  • (9) transient, stress-related paranoid ideation or severe dissociativesymptoms

8. DSM V Borderline Personality Disorder The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose borderline personality disorder, the following criteria must be met: A. Significant impairments in personality functioning manifest by: 1. Impairments in self functioning (a or b): a. Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress. b. Self-direction: Instability in goals, aspirations, values, or career plans. AND • 2. Impairments in interpersonal functioning (a or b): • a. Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities. • b. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over involvement and withdrawal.

9. New diagnostic lenses • Disruptive mood dysregulation disorder (DMDD) is a mental disorder in children and adolescents characterized by a persistently irritable or angry mood and frequent temper outbursts that are disproportionate to the situation and significantly more severe than the typical reaction of same-aged peers. The symptoms of DMDD resemble those of attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), anxiety disorders, and childhood bipolar disorder.[1]

10. The problem with calling this Borderline thinking is……

11. The lens is fed by our ideas about what’s happening: Perception

12. Handout 1: Bio Social Theory

13. Bio social theory provides a method for understanding behavior ( Lens changing) • Biological predisposition in emotional experiencing results in particular behaviors: • Fast reactions • Intense reactions • Slow return to baseline

14. Bio Social TheoryEmotional sensitivity/ Invalidating environment sets stage

15. Bio Social Theory • Describes the interplay between an individual with a biological predisposition to sensitivity raised in an invalidating environment. • Posits that individuals vary biologically in their experience of situations and life events. • Individuals are sensitive in varying degrees. • Individuals have different thresholds for conflict and pain. • Some people experience sensitivity to textures, sounds, sights, tastes and smells in higher intensities then others

16. Invalidating environments • Invalidating environments consist of: • Environments that are inconsistent or chaotic. • Environments that are perfectionistic. • Environments that oversimplify problems. • Environments that do not recognize or acknowledge each family member as a unique individual with specific needs and wants. • Environments in which caregivers are not sensitive and do not understand or realize the sensitivity of the individual • Environments in which caregivers are just as sensitive and struggle in regulating themselves and their emotions.

17. The result • Sensitive biology Invalidating environment

18. Emotion dysregulationand often maladaptive behavior

19. Emotion Dysregulation vs. Emotion Regulation • Emotion dysregulation: • Maladaptive pattern of regulating emotions. that may involve a failure of regulation or interference in adaptive functioning. • Operating at high intensities • Lack of executive function • Emotion regulation: • Ability to respond in a modulated full range of intensity • On a continuum and adaptive • Accessing executive function

20. Forms of Dysregulation Skill deficits and dis-integration typically exist for emotionally dysregulated clients: • Cognition • Interpersonal relationships • Emotions • Behaviors • Sense of self

21. New Science…. • Mental health approaches to behavioral problems are no longer solely a “soft” science. • Physiological changes have been documented and explain behaviors and behavioral patterns. • Plasticity of brain tells us that behavior can and does change AND provides us with guideposts for understanding and working effectively with others.

22. Benefits of Neurobiology:What's going on in the brain that might help us to understand the behavior? • When an individual experiences certain emotions, changes happen in the brainand body. • Powerful traumatic experiences or chronic traumatic experiences can result in sustained changes in how the brain operates and responds. • It is important to recognize that these responses in many instances are not intentional acts • AND these brain responses can be changed and interrupted over time

23. What is Trauma? • Trauma is not what happens to us, but what we hold inside in the absence of an empathetic witness.” ― Peter A. Levine • “Feelings of helplessness, immobility, and freezing. If hyperarousal is the nervous system’s accelerator, a sense of overwhelming helplessness is its brake. The helplessness that is experienced at such times is not the ordinary sense of helplessness that can affect anyone from time to time. It is the sense of being collapsed, immobilized, and utterly helpless. It is not a perception, belief, or a trick of the imagination. It is real.” ― Peter A. Levine, Healing Trauma: A Pioneering Program for Restoring the Wisdom of Your Body

24. Locations of behavioral response

25. Trauma and the Brain • https://www.youtube.com/watch?v=4-tcKYx24aA

26. PTSD Brain • What do we see here? • Case Study: PTSD • Sarah, 32-year-old married woman • 1/1 • Underside Active View • 1. High activity in the anterior cingulate gyrus2. High activity in the basal ganglia3. High activity in the deep limbic area (thalamus)

27. Homeostasis vs. chronic threat

28. Depressed/Non depressed brains

29. It’s a thin line between “response and RESPONSE”

31. A Simplified Model of Behavior Discomfort Threat Behavior

32. Emotional Needs Related to Threat Calm Safety Security Control Reassurance

33. Threat Executive Functions Executive Functions Threat Judgment • Memory • Attention Regulated Cognition • Language • Perception • Abstraction • Reasoning • Organization

34. States of mind • Emotion Mind: (highly aroused limbic system) • Wise Mind: neuro balance. Access prefrontal and limbic successfully • Reasonable Mind ( left brain activity devoid of emotion)

35. Wise Mind Hand Out #3

37. Strategies and Assumptions for effective Interventions We have been looking at variables that influence the development of maladaptive behavior. Other variables that may complicate or impact current behavior include: • Fear response./Threat • Medication on/off • Historical narratives ( victimization, abandonment, abuse, inadequate etc.) problem cognitions • Drug use • Expectations of environment

38. Nonjudgmental Stance is the key to attunement and mindful presence

39. What is a non-judgmental stance? • Staying present to what is occurring in the moment • Striving for objective observing and describing • Allowing information to be information and resisting the urge to judge, value or identify behaviors or words as anything other then what they are.

40. Facilitating Attunement 1 • Mindful awareness of internal and external states • Types of nonverbal communication that can be observed: • Whether the client is sustaining or avoiding eye contact • Noticing and following the client’s gaze • The client’s breath – a regulated nervous system is typically indicated by a longer exhalation and the breath moving like a wave through the belly to the chest. • A client who is riding the wave of their emotion will sigh or experience a longer exhalation when their nervous system is returning to baseline. • Movement that a client is engaging in such as rubbing the palms of the hands on the tops of the thighs. • Patterns of tension or gripping in the body – neck, shoulders, chest. • Tearfulness and any other expression of affect – frowning or smiling.

41. Facilitating Attunement 2 • Validating the client – acknowledging and indicating understanding of the client. • Radical genuineness – being honest with the client about yourself and in what you know or notice about them. • Attunement is about being willing to be with and ride the wave with the client regardless of whether or not they would like to attune to you or have you attune to them.

42. Activity: AttunementHigh Arousal/low arousal • Turning to person on your left. Taking turns observing/describing the other 2 minutes each partner. • Partner 1: think of distressing memory or thought- engage in fully developing your focus on remembering that moment or experience. • Partner 2: Observing the person in front of you for changes in presentation AND staying vigilant to changes taking place inside of you. ( changes in heart rate, breathing, comfort/discomfort etc.)

43. Lowering arousal statesDistress Tolerance Skills • People with a low tolerance for distress can become overwhelmed at relatively mild levels of stress, and may react with negative behaviors. • the tendency of some individuals to experience negative emotions as overwhelming and unbearable. • WHAT TO DO? Don’t jump to problem solving when the person is “high jacked” emotionally. Increasing resourcing insteadthrough the modeling and introduction of Distress Tolerance Skills to shift activated nervous systems.

44. Tip Skill T: Change Temperature I : Use intense exercise to decrease arousal P: Progressive Relaxation

45. STOP skill for the front line worker • Stop • Take a Step back • Observe • Proceed mindfully

46. Bottom up Processingvs. Top down Processing • A way of thinking about the processing of sensory and perceptual information. • Bottom Processing • Understanding is built from the smallest piece of sensory information as it is coming in to our brains. • What you see is built solely off of sensory information ( what you see, hear, touch and taste)

47. Top Down Processing • Perception that is driven by cognition and is therefore engaged in by the executors in the brain. • Your brain applies what it knows and what it expects to perceive and fills in the blanks, so to speak • With top-down processing, your brain adds meaning to what you perceive based on what it knows or expects.

48. What do you see?

49. Methods of processing provide keys to Intervention • If someone is in threat they are likely unable to process in a top down way because they are operating from their “ Alarm” system, which is committed to keeping one safe and alive. • In order to move an individual out of threat we need to appeal to sensory tools that communicate safety, calm and reason. • Interacting with their nervous system, may be more effective then interacting with their cognition, which is likely faulty if dysregulated.--

50. Managing Client Escalation • When an individual demonstrates high arousal that appears to be likely to intervene with effective interpersonal exchange: • Do NOT reinforce the individuals escalation by : • Engaging reactively or engaging in exchanges that increase reactivity ( whether yours or the clients) • Blocking and coaching individual on other options ( skills) they may have and helping them to use those skills as needed. • Important not to forget to reinforce the individual for their successful de escalation