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
To enable participants to understand the link between affect and (dysfunctional) cognitions in trauma 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

2.

3.

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, Bnninger-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 patients 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

References (Trauma)
Antonovsky, A. (1993). The structure and properties of the Sense of Coherence Scale. Social Science and Medicine, 367, 725-733. Ehlers A, Mayou RA, Bryant B (1998): Psychological predictors of chronic PTSD after motor vehicle accidents. Journal of Abnormal Psychology 107:pp 508519. Ehlers, A, Clark, D. (2000) A cognitive model of posttraumatic stress disorder, Behaviour Research and Therapy, 38, pp. 319-345 Ehlers, A , Clark, D M (2003) Early psychological interventions for adult survivors of trauma, Journal of biological Pschiatry, 53, pp 817-82 Fischer, G., & Riedesser, P. (1998). Lehrbuch der Psychotraumatologie. Mnchen: Reinhardt Foa, E.B.,Rothbaum, B.O.,. Behavioural psychotherapy for post-traumatic stress disorder. (1989). The International Review Journal of Psychiatry vol. 1, 219-226 Horowitz MJ (1997): Stress Response Syndromes. PTSD, Grief and Adjustment Disorders. Northvale, NJ: Jason Aronson. Janoff-Bulman, R. (1992). Shattered assumptions. Towards a New Psychology of Trauma. New York: The Free press Juen, B., hler, U. & Thormar, S. (2009). Posttraumatisches Wachstum bei Einsatzkrften. Zeitschrift fr Psychotraumatologie, Psychotherapiewissenschaft und Psychologische Medizin, 7 (1), 9-19 Michael T (2000) The Nature of Trauma Memory and Intrusive Cognitions in Posttraumatic Stress Disorder [DPhil thesis]. Oxford, UK: University of Oxford. Neria, Y.; Solomon, Z.; Ginzburg, K. & Dekel, R. (2000). Sensation seeking, wartime performance and longterm adjustment among Israeli war veterans. Personality and Individual Differences, 29 (5), 921-932.

References (Trauma)
Ortlepp, K. & Friedman, M. (2002). Prevalence and correlates of secondary traumatic stress in Workplace Lay Trauma counselors. Journal of Traumatic Stress, 15 (3), 213-222. Rose S, Bisson J, Churchill R, Wessely S. (2007) Psychological debriefing for preventing post traumatic stress disorder (PTSD) (Review) In: The Cochrane Library, 2007, Issue 1 Shalev AY (1992): Posttraumatic stress disorder among injured survivors of a terrorist attack. Predictive value of early intrusion and avoidance symptoms. J Nerv Ment Dis 180:505509. Tedeschi, R S & Calhoun, L G (2004) Posttraumatic growth. Conceptual foundations and empirical evidence. Psychological Inquiry, 15, pp 1-18. Vzquez, C., Cervelln, P. Prez-Sales, P., Vidales, D., & Gaborit, M. (2005). Positive emotions in earthquake survivors in El Salvador (2001). Journal of Anxiety Disorders, 19, 313-328. Vzquez, C., Hervs, G., & Prez-Sales, P. (2006). The role of positive emotions on the psychological reactions following the Madrid March 11, 2004 terrorist attacks. Paper presented at the 3rd European Conference on Positive Psychology, Braga, Portugal. Vzquez, C., Prez-Sales, P., & Matt, G. (2006). Post-traumatic stress reactions following the Madrid March 11, 2004 terrorist attacks in a Madrid community sample: A cautionary note about the measurement of psychological trauma. The Spanish Journal of Psychology, 9, 61-74. Vasquez, C., Sales, P, Hervas, G. (2008 )Positive of terrorism and Posttraumatic growth,, In: Linley, A, & Joseph, S (eds) Positive Psychology in practice Vasquez and Hervas, Journal of Positive Psychology Yehuda, R. (2006) Biological aspects of fear, Paper presented at the conference: Citizens and resilience, De Hague, Nov 22-24

References (emotion)

Ekman, P. (1984) Expression and the Nature of Emotion, in: Scherer, K R, Ekman, P: (eds) Approaches to emotion . Erlbaum: Hillsdale, NJ, pp. 319-343 Izard, C E, Malatesta, C Z (1987) Perspectives on emotional developmentI: differential emotions theory of early emotional development. In: Osofsky, J D (ed) Handbook of Infant Development . Wiley, New York, pp 494-554 Bnninger-Huber, E, & Widmer, Ch (1996) A New Model of the Elicitation, Phenomenology, and Function of Emotions in Psychotherapy. Proceedings of the IXth Conference of the International Society for Research on Emotions, (pp. 251254), Toronto, August 13-17, 1996 Bridges, L J, Grolnik, W S (1995) The development of emotional self regulation in infancy and early childhood. In: Eisenberg N (ed) Social development, Sage; Thousand Oaks, CA, pp 185-211 Campos, JJ, Campos, R G, , Barrett K C (1989) Emergent themes in the study of emotional development and emotion regulation. Developmental Psychology, 25, pp. 394-402 Damasio, A R (1994) Descartes error. Emotion, reason and the human brain. Avon, New York Fonagy, P., Gergely, G., Jurist, E. & Target, M. (2002). Affect regulation, mentalization, and the development of the self. New York: Other Press

References (emotion)
Frijda, N H (1986) The emotions. Cambridge University Press., New York Holodynski, M (2006) Emotionen, Entwicklung und Regulation, Springer, Heidelberg Leventhal, H, Scheer, KR (1987) the relationship of emotion to cognition : a functional approach to a semantic controversy. Cognition and Emotion, 1, pp 3-28 Scherer, K R (1993) Studying the emotion antedecent appraisal process: an expert system approach. Cognition and Emotion 7: pp 325-355 Scherer, K R (2000) Emotions as episodes of subsystem synchronisation driven by nonlinear appraisal processes. In: Lewis, M, Granik,c, I (eds) Emotion, development and self organisation . Cambridge University Press, New York Scherer, K R (2001) Appraisal considered as a process of multilevel sequential checking. In: Scherer, K R, Schorr A, Johnstone, T (eds) Appraisal process in emotion. Theory, methods, research. Oxford University Press, Cambridge