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Emotion Dysregulation Managing difficult emotions and behaviors Emotion Dysregulation Managing difficult emotions and behaviors

Emotion Dysregulation Managing difficult emotions and behaviors - PowerPoint Presentation

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Emotion Dysregulation Managing difficult emotions and behaviors - PPT Presentation

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 ID: 648085

behaviors behavior client brain behavior behaviors brain client problem change dysregulation individual emotion threat disorder environments skills processing high

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Slide1

Emotion Dysregulation

Managing difficult emotions and behaviorsSlide2

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 Slide3

Foundational Principles

This presentation has been created out of basic Dialectical Behavior

T

herapy. 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.Slide4

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 the

behavior.

Terms like: played, manipulated, controlled, used….leave us feeling disempowered and angry. They also cast the individual in a negative light

Slide5

Maladaptive behaviors

another 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.Slide6

Examples of maladaptive behaviors

Avoidance Talking over othersWithdrawal Attention seeking

C

onverting sadness or fear to anger, Addiction

S

ubstance use Compulsions

Outbursts

/

rages self injurious behaviorsInsistent demanding threats to achieve desired needsSlide7

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 

dissociative

 

symptomsSlide8

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.

DSM V

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.Slide9

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]Slide10

The problem with calling this Borderline thinking is……Slide11

The lens is fed by our ideas about what’s happening: PerceptionSlide12

Handout 1: Bio Social TheorySlide13

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 Slide14

Bio Social Theory

Emotional sensitivity/ Invalidating environment sets stageSlide15

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 othersSlide16

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.Slide17

The result

Sensitive biology Invalidating environment

Slide18

Emotion dysregulation

and often maladaptive behaviorSlide19

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 functionEmotion regulation:

Ability to respond in a modulated full range of intensityOn a continuum and adaptive

Accessing executive functionSlide20

Forms of Dysregulation

Skill deficits

and

dis-integration

typically exist for emotionally

dysregulated

c

lients

:Cognition Interpersonal relationshipsEmotionsBehaviors Sense of selfSlide21

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.Slide22

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 brain

and 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 timeSlide23

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 Slide24

Locations of behavioral responseSlide25

Trauma and the Brain

https://www.youtube.com/watch?v=4-tcKYx24aASlide26

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 gyrus

2. High activity in the basal ganglia

3. High activity in the deep limbic area (thalamus)Slide27

Homeostasis vs. chronic threatSlide28

Depressed/Non depressed brainsSlide29

It’s a thin line between

“response and RESPONSE”Slide30
Slide31

Threat

Discomfort

Behavior

A Simplified Model of BehaviorSlide32

Emotional Needs Related to

Threat

Calm

Safety

Security

Control

ReassuranceSlide33

Memory

Language

Abstraction

Organization

Judgment

Attention

Perception

Reasoning

Regulated

Cognition

Executive Functions

Executive Functions

Threat

ThreatSlide34

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)Slide35

Wise Mind Hand Out #3Slide36
Slide37

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.)

p

roblem cognitions

Drug use

Expectations of environmentSlide38

Nonjudgmental Stance is the key to attunement and mindful presenceSlide39

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.Slide40

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.Slide41

Facilitating A

ttunement 2Validating 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.Slide42

Activity: Attunement

High 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.)Slide43

Lowering arousal states

Distress 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

instead through the modeling and introduction of Distress Tolerance Skills to shift activated nervous systems.Slide44

Tip Skill

T: Change Temperature

I : Use intense exercise to decrease arousal

P: Progressive Relaxation Slide45

STOP skill for the front line worker

Stop Take a Step back

Observe

Proceed mindfullySlide46

Bottom up Processing

vs. 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)Slide47

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.Slide48

What do you see?Slide49

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.--Slide50

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 escalationSlide51

Behavioral Reinforcement

getting the behavior we desireSlide52

Dialectical balance is what creates change

Strategies that operate out of a DBT

framework do not base themselves out of a stagnant position (

eg

: neutrality at all costs)

Rather, effective engagement results from a dialectical balance that includes varying, intensity, speed movement and natural flow.

What is Dialectical balance?

The term "dialectical" means a synthesis or integration of opposites. The primary dialectic within DBT is between the seemingly opposite strategies of acceptance and change.

Dialectical balance is being able to move back and for the between acceptance and change in a pendulated

and strategic waySlide53

Remembering our Objectives……

Challenge perception of behavioral symptoms and diagnosticsPropose 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, lower arousal states and facilitate effective outcomes Slide54

Question/Answer

Thank you

for your time Today!!