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It’s all about the emotion
Hello,
These are exciting times in our field. There is increasing agreement from different areas of study, including developmental research, neuroscience and psychotherapy outcome studies, that we are emotional creatures, making most of our decisions on an emotional, rather than rational or logical basis. The cognitive revolution appears to be dead, now that our understanding of human functioning suggests that we are wired for emotion and for emotional connection with others. This emotional activation happens at lightening speed and is essentially an unconscious process. Not only have behavioral scientists come to understand this, but economists, market researchers, and the general public are now on to this new idea. David Brooks has just written a book for the general public called The Social Animal, which lays out the evidence for the public.
Within our field, there is also increasing agreement about the centrality of emotional awareness and regulation for both emotional and physical health and well being. Accumulating evidence suggests that the link between emotions and health is enormous. James Pennebaker has been researching this link for decades. The results clearly suggest that those who are aware of their emotions and allow themselves to experience and express them freely are happier, more productive, and healthier than their repressive cohorts. It seems that those who chronically repress their emotions simultaneously suppress their immune system, rendering them vulnerable to all kinds of illnesses. Conversely, those who focus on their feelings, especially regarding the most troubling and traumatic experiences of their lives, get a boost in immune functioning.
Even the pioneers of Cognitive Behavior Therapy, most notably, David Barlow, have come to conclude that we only need one therapy for all psychological disorders; namely a unified treatment that focuses on the awareness and regulation of emotion.In the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (2011), Barlow writes, “individuals with emotional disorders use maladaptive emotional regulation strategies – namely, attempts to avoid or dampen the intensity of uncomfortable emotions – which ultimately backfire and contribute to the maintenance of their symptoms” (pg.17). Given this, he suggests that our treatment efforts be designed to “help patients learn how to confront and experience uncomfortable emotions, and to respond to their emotions in more adaptive ways”. This is what psychodyanmic theory has always proposed, and what Intensive Short Term Dynamic Psychotherapy has been designed to facilitate.
Why re-invent the wheel? Those who have been educated in the study of unconscious processes and dynamic psychotherapy clearly have an advantage here. Studies by Allan Abbass substantiate the view that Intensive short term Dynamic Psychotherapy is both cost effective and clinically effective. The data indicate that physical health improves markedly, in alignment with emotional health and well being.
I look forward to a wide and spirited discussion about these issues.
Patricia Coughlin, Ph.D.
Kinderhook, NY
March 31, 2011
Dear Patricia,
First, congratulations with your inspiring redesigned website. I hope and wish lots of interesting material will be published on your site.
In response to ‘It is all about emotion’: Every major psychotherapeutic school or approach claimed- in a bout of pioneering enthusiasm ‘ it is all about…. emotion, cognition, behaviour, relationship, etc etc. But after the first wave of young enthusiasm always comes a sobering up when practice and research teaches us that different therapies, with different emphases on emotion, cognition, behaviour, relationship etc have different effects for different people with different problems in different circumstances. So without underestimating the role of emotion, let us remain modest enough to study what each aspect ( emotion, cognition, behaviour) can contribute to the rich mosaic of our being ‘ human’. Having said this, I have no doubt that your contribution to the therapeutic role of emotion in therapy is huge and for that, I want to thank you! Lots of success.
Joop,
Thanks for your incisive comments! Of course it’s not JUST about emotion. It is vital that we, as therapists, help patients tolerate anxiety in the moderate range and that we facilitate multiple modes of processing. In fact, neuroscientific research suggests that changing an adult brain (which is what we are trying to do in psychotherapy) requires the activation of cognitive, emotional, physiological and interpersonal modes of experience. Focus, intensity and repetition are also necessary. ISTDP incorporates all these variables, which may explain it’s effectiveness.
Aside from these specific factors, the person of the therapist appears to be the most potent, but understudied variable in psychotherapy outcome. I will write more about this in my next blog.
Thanks for contributing to the conversation.
Patricia
The Affordable Care Act embraces several themes related to mental health. It recognizes the correlation between high medical care costs and behavioral health problems, it institutionalizes the principle of parity for behavioral health services, and it speaks to the need for prevention and early intervention in health care problems. Yet, it continues the health insurance tradition of defining eligibility for mental health services around parameters of functional disability and symptoms instead of self actualization and character building. Discussions that I hear around the role of behavioral health services in the new health care system mostly revolve around linking primary care doctors with a psychiatric nurses or social workers so that they can provide medication and perhaps a couple of counseling sessions. For individuals with serious mental illness or substance abuse issues talk revolves around “health homes” that would provide an integrated package of care but are again built around primary care doctors with nurses and social workers. Having been on the patient side of dynamic psychotherapy and personally experiencing the benefits cited in this monograph, I wonder how the profession can bring the kind of psychodynamic service referred to above into the mainstream of the coming health care system.
Dear Barry,
Thanks for your comment, and for drawing our attention to the importance of getting effective behavioral interventions into the hands of primary care providers. Dr. Allan Abbass, at Dalhousie University in Nova Scotia, has probably done more work in this area than anyone. He has trained primary care docs to do emotion focused interviews with their patients who have chronic complaints but no medical findings, in order to assess whether psychotherapy is required. His studies also show that have a highly trained therapist in the ER to see repeat visitors who don’t have any signs of medical problems dramatically reduces symptoms, return visits and medical costs. If you google him, you will see all his research, which substantiate the cost, as well as clinical, savings from ISTDP. Now Dr. Monica Urru is training primary care physicians in Italy to do the same. It is a very fruitful area of study.
Dear Patricia
Thank you for your comments that- as always- stimulate me to further reflections on this important issue. A concept came to mind: ‘final common pathway’. As you may or may not remember from one of our discussions in Italy when we met, it was your book that was my original UCS or CS to begin the passage from CBT to EDT. After 30 years of CBT I knew and felt something was missing in CBT.
One core issue, I felt, not given enough emphasis in CBT , was how to use cognitive techniques in such a way that when the client was cognitively challenged , he could feel the real emotions and impulses that had to be there with the cognitions for change to take place. As CBT therapists we maybe knew – in theory- how to bend the iron, but we were not very proficient in making the iron hot so it could be bent in the first place. Your blue book (ISTDP) was an eye opener for me ( and we know that the visual system is more connected with the emotional system than – let us say- our ears). For the first time I felt there was a clear and effective way to direct the cognitive stream into the final common pathway of the emotional stream that- and here I absolutely agree with you- leads to the open sea of change.
There is a beautiful poem by Halil Gibran in his Prophet in which he compares the rudder of a sailing boat with the logical cognitions and the wind blowing into the sails with the ‘passions’ (emotions). The boat needs both, he says: without the rudder there is no clear direction but without the wind ( or maybe the motor) the boat will not move. We sail through life and need logic and passion. And yes, often our clients have more problems with ( denied, repressed) emotions than with their thinking. In those cases the therapy approach you have done so much to advance is no doubt of primary importance.
Thanks once more for your inspiring input.
Patricia, I’m sure you already know about this study, but I’m pasting in an article about it below. I work with people who have chronic pain, and there was a study done a last year that found when women feel anger or sadness they also experience more pain. Researchers say, “the occurrence of anger and sadness appears to be a general risk factor for pain amplification”. I’ve wondered about this since the study was published and assume this is because the subjects were using “maladaptive emotional regulation strategies”. But all of them? Really? Could that be? Do you have any thoughts on this one? Thanks. Bridget
Negative Emotions Increase Pain Sep 27 2010
By Michael Smith, North American Correspondent, MedPage Today
Published: September 27, 2010
Reviewed by Adam J. Carinci, MD; Instructor, Harvard Medical School and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner
Negative emotions such as sadness and anger increase pain in women — but the increase is similar in those with and without fibromyalgia, researchers reported.
In a cohort study among 121 women — 62 of whom were diagnosed with fibromyalgia — pain induced by an electrical stimulus was more keenly felt after the women recalled either a sadness- or anger-inducing event than after remembering a neutral event, according to Henriët van Middendorp, PhD, of Utrecht University in the Netherlands, and colleagues.
But there was “no convincing evidence for a larger pain response to anger or sadness in either study group,” van Middendorp and co-authors reported online in Arthritis Care & Research.Action Points
Discuss with patients that a recent study indicates that negative emotions such as sadness and anger may increase pain in women with and without fibromyalgia.
Also discuss that a second recent study indicates that tailored cognitive behavioral therapy and exercise training for patients with fibromyalgia are effective in improving short- and long-term psychological and physical functioning.
Instead, they argued, “the occurrence of anger and sadness appears to be a general risk factor for pain amplification” that might be attenuated by emotion regulation techniques.
Indeed, elsewhere in the journal, other Dutch researchers report that a combination of tailored cognitive behavioral therapy and exercise can significantly improve symptoms of fibromyalgia, including pain.
In a randomized controlled trial among more than 150 patients, those who received therapy had significantly reduced pain, fatigue, and functional disability (all atP<0.001) compared with patients placed on a waiting list, according to Saskia van Koulil, MSc, of Radboud University Nijmegen Medical Centre in Nijmegen, the Netherlands, and colleagues.
They also had significantly better psychological functioning and a lower impact of fibromyalgia on daily living, the researchers reported, again all at P<0.001.
Fibromyalgia is a chronic and widespread pain disorder whose causes are not known. However, in both healthy people and those with chronic pain, emotions have been shown to increase pain, van Middendorp and colleagues noted.
To test the idea that women with fibromyalgia might be more sensitive to such emotions the 121 women — 62 from three Dutch hospitals who had fibromyalgia, and 59 without the disease from the general population — were asked to recall a neutral situation, followed by recalling both an anger- and a sadness-inducing situation, in counterbalanced order.
The fibromyalgia patients were asked to report on their current pain levels after each session and — as expected — the researchers found that recalling sadness or anger increased current pain significantly (at P<0.001), compared with the neutral event.
In the induced pain experiments, women from both groups had electricity delivered to a forearm and pressed a button when they first felt the current, when it became painful, and when it became intolerable.
They found that the pain threshold of the women decreased after recalling both the anger- and sadness inducing events, compared with a neutral event. Pain tolerance fell in the same manner and all comparisons were significant at P<0.001.
But there were no differences:
Between the groups — P=0.06 for pain threshold and P=0.16 for pain tolerance
Between sadness and anger
Or between reactions to the first negative emotion and the second
In the other study, van Koulil and colleagues noted that people with fibromyalgia may react in different ways — some may restrict their activities to avoid pain, while some may attempt to keep going through pain. So they hypothesized that cognitive behavioral therapy combined with exercise tailored to those strategies might be beneficial.
To test the idea, the investigators enrolled 158 patients, of whom 84 were considered to be in the pain-avoidance group, while the remaining 74 tended to persist through pain. Within each group, patients were randomized to get immediate therapy — 16 sessions over 10 weeks — or to be put on a waiting list.
The primary outcome measures included pain, fatigue, functional disability, anxiety, negative mood, and overall impact of fibromyalgia, assessed at baseline, immediately post-treatment, and after six months.
The treatment effects were significant, suggesting that the tailored treatment "is effective in improving both short-and long-term physical and psychological outcomes," the researchers argued. "The effects were overall maintained at six months, suggesting that patients continued to benefit from the treatment."
Van Middendorp and co-authors cited a number of important limitations to their study. The use of emotion recall procedures and the attendant "difficulty of inducing a single unique emotion while minimizing the experience of other emotions … may have obfuscated the specific effects of anger versus sadness on pain."
As well, people likely vary in how intensively and accurately they experience and express a targeted emotion. "It is possible, therefore, that an autobiographical memory approach — asking people to recall, experience, and then verbally express angry and sad events — was most difficult and least successful for women with fibromyalgia," the investigators wrote.
They also noted that the controls (while free from fibromyalgia) also may have had physical and mental health symptoms or concerns and, as a result, may have been more like the fibromyalgia group.
Additionally, van Middendorp and colleagues acknowledged that findings from electrically-induced pain do not necessarily translate to other kinds of pain such as pressure pain or randomly occurring natural pain, and noted that participants were allowed to use pain and other medications before the experiment.
Van Koulil's group also cited some study limitations. The study was not blinded, they noted, and the small improvements seen in waiting list controls could have been due to the patients' expectations of treatment as well as "the intake procedure in which also patient education about the treatment was provided, they wrote.
The study was supported by the Dutch Arthritis Association. The researchers said they had no conflicts.
Primary source: Arthritis Care & Research
Source reference:
Van Middendorp H, et al "The effects of anger and sadness on clinical pain reports and experimentally-induced pain thresholds in women with and without fibromyalgia" Arthritis Care & Research 2010; DOI: 10.1002/acr.20230.
Additional source: Arthritis Care & Research
Source reference:
Van Koulil S, et al "Tailored cognitive-behavioral therapy and exercise training for high-risk fibromyalgia patients" Arthritis Care & Research 2010; DOI: 10.1002/acr.20268.
Dear Brigid,
Thanks for this information – how fabulous. There is also quite a lot of research on the relationship between expressed anger and reduction in pain in patients with arthritis. James Pennebaker has amassed a tremendous amount of research data on the link between emotion and immune functioning. His book, Opening Up, is a must have for anyone interesting in this fascinating topic. Many thanks for the detail you have provided. It is very valuable.
Dr. Allan Abbass has some data regarding the effectiveness of ISTDP with pain patients (everything from headaches, to back pain), all of which is very promising. This was done in a real life psychotherapy setting, where the focus was on the pain the patient was experiencing in the moment (as opposed to experimentally induced) and tracing it to the trigger – then facilitating the experience of the previously avoided emotional pain. Dr. Sarno has also done a great deal of work in the area of back pain and gotten excellent results. Somatization is one of the areas in which ISTDP seems to get better results than other therapies.
thanks again for your contribution.
Patricia Coughlin, Ph.D
Patricia, this isn’t a question about this post. I was actually wondering if you could address something I’ve been wondering about. It seems odd to me that a therapy like ISTDP, which puts so much attention on what’s happening in the client’s body, doesn’t utilize movement or touch in any way. Could you say something about that? I’m just thinking of the way people like Pat Ogden work. Clients will often ask to hold her hand or request that she touch them, and I wonder if being available to do that makes us more helpful or if it limits the client’s feeling in some way (“you can hold my hand, but you can’t slap me around or kiss me—so you better only want to hold my hand”). I know different things work for different people–and I have to work in a way that makes sense to me, but is there a reason why ISTDP practitioners choose not to touch or have clients get up and move around (particularly when experiencing rage—it seems like that might be helpful)? Is the thought that if they get up and actually move through what they are describing that they will discharge the feeling rather than fully experience it? Thank you!! Bridget
Dear Brigid,
I am glad you asked this question about movement and touch in psychotherapy. Our techniques flow from our theoretical understanding of psychopathology. In ISTDP, the patients symptoms and problems are understood as the inevitable consequence of defenses against the internal EXPERIENCE of complex, anxiety provoking feelings. Given this, we intervene in order to help the patient face, fee, and tolerate emotions without having to do anything about it – not repress it or discharge it. So, having a patient punch a pillow or stand up and push against me wouldn’t make sense in this model. That would be seen as a way to discharge or get rid of the feeling, rather than to tolerate the internal experience of it.
When it comes to the impulse or action tendency inherent in each emotion, we use visualization instead of action, to facilitate facing the impulse – again, with out DOING anything. This is because we want to get to the unconscious emotions and the memories associated with them. When a patient is mobilized and we ask them to just IMAGINE what their body wants to do, all the unconscious impulses can be faced and experienced without anyone getting hurt.
Not having trained in somatic experiencing, I can’t tell you how movement and touch facilitates their work, but I hope I have given you some sense of how ISTDP understands this.
Patricia
Dear Brigid,
I don’t think I answered your question – which was why these women would feel MORE pain when anger and sadness are evoked. According to the research on somatization, especially that by Allan Abbass, this makes some sense. Somatization is the result of a defense against the experience of anxiety provoking emotions. If the defense is interrupted, but he patient is not helped to face and experience the feelings directly, without resorting to symptoms, they can get worse. That is why patient with internalizing defenses like depression and physical pain need to experience a graded approach that increases their ability to feel emotion without resorting to pathological defenses or excessive anxiety. This requires a highly skilled therapist. In any case, they are still making the point that there is clear link between physical and emotional pain.
Patricia Coughlin