Transcript Dia 1 - ESTSS

The European Network for Traumatic Stress
Training & Practice
www.tentsproject.eu
Emotional regulation and cognition
Barbara Juen
University of Innsbruck
Austrian Red Cross
IFRC Reference Centre for PS support
Learning outcomes
1.
To give participants some basic knowledge on emotional
regulation and the role of cognition
2.
To enable participants to understand the link between affect and
(dysfunctional) cognitions in trauma
3.
To give participants an insight into the importance of preventing
trauma survivors from becoming overwhelmed whilst at the same
time enabling a feeling of control and opportunities for
reinterpretation
What is an emotion?
• Emotion is defined as
– a reaction to an emotion-specific elicitor which has a
given form (Ekman, 1984, Izard and Malatesta, 1987,
Bänninger-Huber, 1996)
– a psychological function (motivation and action
readiness) in human action regulation (Campos et al,
1989, Frijda, 1986, Scherer, 1993)
Emotion as a self-regulating system
• Recent theories define emotion as a functional
system which consists of different subsystems
working together in a synchronised manner
(Scherer, 2000)
Sub-Systems of emotions
(Scherer, 2000)
•
•
•
•
Appraisal System
Motoric System
Body Regulation System
Feeling System
What is emotion regulation?
• Emotion regulation means the intentional or nonintentional influencing of emotions
• In order to regulate emotions, different levels of
regulation as well as different forms of regulation
strategies may be used
Levels of emotion regulation
(Leventhal & Scherer, 1987)
• Sensomotoric level (reflex)
• Schematic level (appraisal)
• Concept level (knowledge)
Classification of regulation strategies
(Bridges & Grolnik, 1995)
• Attention regulation (e.g. to divert oneself)
• Self soothing strategies (e.g. to suck one's
thumb)
• Interactive regulation (e.g. to seek comfort)
• Symbolic resp. verbal strategies (e.g. to
reinterpret)
Organic basis of the systems
(Damasio, 1994, Scherer, 2001)
• Appraisal System: cortex and subcortex
• Motoric System: motoric cortex and somatic
neurosystem
• Body Regulation System: autonomous neural
system and subcortical structures responsible
for endocrinological functions
• Feeling System: cortex and subcortex
Interaction of the sub-systems
(Holodynski, 2006, Damasio, 1994)
• Expression and body reactions elicit feelings
• Body and expression sensations are necessary
indicators for feeling
• The emotion eliciting cause is marked and
coloured by the body and expression sensation
(„somatic markers“, Damasio, 1994)
What if the relation between body sensation
and perceived cause is disturbed?
• Sometimes, the body and expression sensation
are present without a consciously perceived
cause (fear without perceiving an elicitor or
without perceiving an appropriate elicitor)
• Or the emotion eliciting cause is present without
the expected body and expression sensations (a
loved one dies and we feel nothing)
The disintegration of psychological
processes in the case of trauma
• In the case of trauma cognition, emotion,
memory, action and perception may „dissociate“
• For example a threat may be perceived without
experiencing an emotion (numbing) or without
being able to react (freezing, stupor)
Characteristics of trauma memory
• Mostly sensory impressions
• Experienced as if they where happening here and now
• Re-experience stays the same even if new information is
given
• Affect without recollection
• Some triggers without semantic relationship to trauma,
only temporarily associated
The role of concept based emotion
regulation in the course of trauma recovery
• A trauma threatens a persons´ belief system (JanoffBulman, 1992) and thus initiates a process of meaning
making.
Tedeschi and Calhoun talk of a „seismic“ event which
initiates a process of rumination (Tedeschi & Calhoun,
2004)
• Some of the cognitions in the course of searching for
new meanings may be functional, some may be
dysfunctional with regard to recovery
Integration and processing
• According to Horowitz (1997) persons remain in a state
of permanent arousal as long as the traumatic
experience is not fully processed
• Memories of the event are at the same time warded off
and relived obsessively until the processing comes to an
end, this oszillating process is seen as necessary for
trauma recovery
Contextualisation
• Trauma memory has to be contextualised (see
for example: Ehlers and Clark, 2003) which
means putting it into a chronological order,
distinguishing between now and then and
avoiding overgeneralization by going back to the
event and comparing subjective and objective
situation aspects (Fischer and Riedesser, 1989)
Appraisal and negative overgeneralization
• Ehlers and Clark assume that, unlike individuals who
recover naturally, individuals with persistent PTSD are
unable to see the trauma as a time-limited event that
does not have global negative implications for their
future.
Appraisal and negative overgeneralization
• Clients may overgeneralise
–
–
–
–
The event itself
Their reactions during the event
Their reactions after the event
Other persons reactions
Overgeneralising the event
• Persons who overgeneralise from the event perceive a range of
normal activities as more dangerous than they really are
• They may exaggerate the probability of further catastrophic events
in general or take the fact that the trauma happened to them, as
opposed to other people, as evidence for appraisals such as “I
attract disaster” or “bad things always happen to me”
Overgeneralising one's own reactions
• Appraisals of the way one felt or behaved during the
event also can have long-term threatening implications
• Also the negative appraisal of the sequelae of the
traumatic event can produce a sense of threat.
Negative appraisal of symptoms
• Symptoms like intrusions, irritability and mood swings,
lack of concentration and numbing are normal reactions
shortly after a traumatic event.
• If individuals do not see these symptoms as a normal
part of the recovery process, they may interpret them as
indications that they have permanently changed for the
worse or as indicators of a threat to their physical or
mental well being (see Ehlers and Clark, 2000)
Negative appraisal of others´ reactions
• Other people, including family and close friends, are
often uncertain about how they should respond to a
trauma victim and may avoid talking about the event in
order not to distress the victim.
Negative appraisals produce negative
emotions
• These appraisals maintain PTSD by producing negative
emotions (such as anxiety, depression or anger) and by
encouraging individuals to engage in dysfunctional
coping strategies that have the paradoxical effect of
enhancing PTSD symptoms (Ehlers and Clark, 2000).
The link between positive emotions and
recovery
• Experiencing positive emotions on the other hand seems
to have a positive effect on recovery after trauma. These
positive emotions may be pride, but also a feeling of
solidarity and group cohesion as well as other positive
emotions (e.g. Yehuda, 2006, Vasques, Hervas, & Sales,
2006)
How to use positive emotions in
interventions
•
Initiatives with the aim of channeling the diverse types of aid to the affected
people may promote growth, both of the individuals and of society as a
whole.
•
Creating spaces in which to communicate emotions can have a beneficial
effect on positive adaptation to the effects of the trauma.
•
Assess and provide feedback about the learnings experienced at the
individual and collective level to promote a more complete perspective of
the situation.
•
Shared rituals and Symbolic elements (i.e., flags, monuments,
demonstrations,…) seem to be very important to the way in which these
kinds of events are processed.
Early Interventions and their effects
• Single session debriefing has been one of the main
intervention strategies for a long time. It has been proved
to be not beneficial and sometimes may even cause
negative effects (see for example Rose et al, 2007,
Ehlers & Clark, 2003)
• Repeated sessions of individual CBT or EMDR given to
persons at risk have been proved to be more successful
(Ehlers & Clark, 2003)
Oscillating between withdrawal and
exposure
• According to Horowitz (1997), after traumatic events or
bereavement, people show a pattern of intermittent processing and
are continuously oscillating between phases of
withdrawal/numbness/ avoidance and intrusion/processing of the
event.
• Ehlers and Clark assume „that this intermittent processing in small
doses facilitates natural recovery and that very early exposure
instructions pushing people to talk and think about the trauma in its
aftermath may not be beneficial“ (Ehlers & Clark, 2003, p. 822)
Discrimination between past and present
• According to Ehlers and Clark (2003) a central element
of treatment is that the patient learns to discriminate
better between the “then” (the trauma and the stimuli that
accompanied it) and the “now” (the present situation and
the triggers of memories that have similarities and
differences to those present at the time of the event).
• In imaginal reliving a time code is put into the memory,
so that it can be experienced as a memory rather than
as something that is happening (again) in the present
Going through the event in a chronological
order
• Some patients may need active help in overcoming avoidance and
may not do self-exposure intensively and systematically enough.
• In CBT patients go through the event in chronological order. On their
own, patients may instead go over isolated moments of the event.
• In CBT the patient shall make progress in linking these moments in
memory with the final outcome of the situation or other moments
during the event that disconfirmed the patient’s expectations at the
time (“I though he would kill me” linked to “He let me go in the end”;
“I thought I was paralyzed” linked to “I could walk”) (Ehlers and
Clark, 2003)
Reappraisal of problematic meanings
• In the course of working through the experience it may
become important to reappraise problematic meanings
(such as feeling responsible for an accident although it
was not their fault, thinking that they actually died during
the event, thinking that the scars from an assault make
them look disfigured, or thinking that no one cared about
them when they waited for treatment in the hospital)
(Ehlers and Clark, 2003)
Comparing the objective and subjective
situation
• Fischer (1996) differentiates between objective and
subjective situation analysis
– Objective situation analysis: what has happened in the given
situation, what possibilities for action have been present in the
given situation?
– Subjective situation analysis: what subjective meaning is given
to the situation? Which of the given action possibilities have
been actually perceived and realised by the person?
Early rumination
• At the beginning traumatized persons often ruminate about the
event, thinking about questions such as why the event happened to
them, how their life has been ruined by the event, how the event
could have been prevented, or how they can punish the person who
caused the event
• Several prospective longitudinal studies have found that such
rumination about a traumatic event is among the best predictors of
chronic PTSD (Ehlers et al 1998; Murray et al 2002).
• Self-exposure instructions during this stage may run the risk of
increasing rather than decreasing one of the maintaining
mechanisms in persistent PTSD.
The experience of positive change after
trauma
• The appraisal of the traumatic events and its
consequences as something not entirely negative, which
also includes the subjective experience of positive
change in the domains of self, relationships and values
is an important effect of trauma (Tedeschi & Callhoun,
2004)
The experience of effective emotional regulation
as a prerequisite for recovery
• Znoij (2006) found that persons who lost a child showed
an improvement in the regulation of stressful emotions
compared to controls
• He assumed that due to the massive negative emotions
experienced by this group the cortical control for emotion
regulation might be stimulated and the ability for emotion
regulation be improved
Resumee
•
Cognitions and the emotions that result from negative appraisal play a very
important role in enhancing symptoms after trauma
•
Experiencing emotions as overwhelming, without chronological order, and
beyond control of reflexive processing may lead to an increase in
dysfunctional coping strategies after trauma
•
Especially in the early stages after trauma it may be of crucial importance
to assist persons in protecting themselves from too much trauma exposure
and arousal
•
The experience of effective emotion regulation and the appraisal that the
traumatic event does not only have negative outcomes are very important
factors in recovery
Resumee
• Talking about the event
– Be careful not to produce loss of control over
emotions
– Be careful about keeping the chronological order of
the events
– Help to reinterpret negative appraisals
– Be careful about distinguishing past and present
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