Handbook of emotion regulation ( PDFDrive )

Emotion Regulation Therapy 481 as ways to help individuals gain awareness In other words, exposure in distress disor- of the availability of positive reinforcement, ders may be most fruitful when it involves engage in behaviors capable of obtaining contexts that have recurrent themes such as the positive reinforcement contingently, and threat (i.e., security motivation system) and ideally, effecting change in the environment encourage activation (i.e., reward motiva- so that access to positive reinforcers remain tion system). available when certain behavioral responses are provided (Ferster, 1973; Kanter et In support of this contention, recent al., 2010; Lewinsohn, 1974). In addition, work by Newman and Llera (2011) demon- recent innovative treatments for depression strates that worry is reinforced by creating have benefited from basic and translational a fixed, invariable, and predictive defensive findings (e.g., Bouton et al., 2001) about emotional state that inevitably precludes developing exposure-b­ased treatments for emotional processing. For individuals with depression that deliberately provoke and GAD, they argue, what they fear is a stark activate historical negative content, so that emotional contrast, such as moving from a this material can be explored alongside positive state to a negative state, which may information that is dissonant and serve to disincline these individuals to engage a posi- facilitate broad-based change in maladap- tive state if it means increased possibility for tive cognitive–a­ ffective–b­ ehavioral–­somatic a negative state. This conceptualization is patterns (e.g., Hayes et al., 2007). consistent with the emotion regulation model in which individuals with distress disorders Exposure therapy is most effective when resort to worry and rumination in response the fear stimulus is focal and difficult to to security motivations, which overshadow avoid (e.g., specific phobia). Traditional reward motivations. Furthermore, it is con- exposure therapy may be less efficacious in sistent with behavioral accounts of MDD distress disorders. Whereas individuals with that view depressed individuals as withdraw- uncomplicated presentations of anxiety have ing to protect themselves from the aversion relatively more discrete and circumscribed of loss, thus gaining no new rewards to help fears, individuals with distress disorders them counteract their depression. Taken as a have difficulties confronting emotional whole, these perspectives suggest that expo- arousal irrespective of what external cue sure to rewarding contexts with the possi- provokes it. That is, conducting exposure bility of high risk may be most ameliorative therapy in response to external fear cues for these individuals, since they simultane- does not effectively target the source of the ously engage both the security and reward difficulty for individuals with distress disor- systems. ders. Consistent with an emotion regulation framework, some approaches promote expo- In ERT, exposure to threat–­reward con- sure to emotional experiences themselves to trasts are accomplished by focusing clients’ increase acceptance of these experiences and attention on their personal values (i.e., their diminish the need to utilize strategies such highest priorities and most cherished princi- as worry or rumination in an attempt to ples; Hayes et al., 2012; Wilson & Murrell, escape aversively perceived emotional states 2004). Values-based exposure involves turn- (e.g., Barlow et al., 2011). However, this ing a problem on its head: Rather than being approach may not fully address dysfunction exposed to feared outcomes, one is exposed given that distress-­disordered individuals to the way he or she would like to be living, commonly resort to cognitively elaborative and the expected arrival of perceived fears, responses such as worry and rumination to disappointments, and judgments are treated help them escape emotional processing and as obstacles to being able to live a valued life to preclude new inhibitory learning. Fur- (Hayes et al., 2012). ERT expands values-­ thermore, a focus on negative emotional based exposure commonly utilized in ACT exposures may do less to expose individu- to address not only “top-down” decisions als to core idiographic and schematic themes about life goals but also “bottom–­up” influ- that certain emotions may convey. Also, this ences of security and reward motivational approach does not necessarily engage the pulls, as well as their interaction. During an reward system by directly encouraging pro- experiential exposure phase of ERT, clients active behavior toward desired outcomes. explore acting in accordance with their val- ues and confronting any accompanying per-

482 INTERVENTIONS addressed through the lens of “conflict ceived obstacles that arise both within and themes” and include primarily (1) a motiva- between sessions. Specifically, new learning tional conflict (e.g., security motivations are is targeted with three main exposure inter- blocking or interrupting efforts that engage ventions to promote valued living: (1) ima- the reward system) and (2) self-­critical reac- ginal exercises related to values-i­nformed tive responses to emotions (i.e., judgmen- goals; (2) experiential dialogue exercises tal negative beliefs about one’s emotional to explore perceived internal motivational responses and associated motivations are conflicts that impede engaging in valued interrupting self-­acceptance and engage- actions (Elliot et al., 2004); and (3) planned ment of reward). These conflict themes between-s­ession exercises wherein clients are addressed within the session using an engage valued actions outside of session. Cli- experiential dialogue exercise derived from ents also utilize regulatory capacity skills to emotion-f­ocused therapy (Elliot et al., help in engagement of in-­session experiential 2004). The motivational conflict is most tasks and to facilitate valued action outside central to interrupting valued action and is of session. addressed by encouraging clients to engage in a dialogue between the part of themselves Proactive Valued Action strongly motivated to obtain security, and the In ERT, therapists and clients collaborate part motivated toward self-a­ ctualization, to to identify cherished values in life domains arrive at a more unified motivational stance (e.g., family, friends, relationships, work, that is conducive to valued action. Resolution personal care), with clients reporting dis- comes when expressions from both sides of crepancies between the importance they the dialogue demonstrate acknowledgment place on this value and how consistently of the needs of the other and an agreement they have been living accordingly (Wilson & to commit to the valued action while allow- Murrell, 2004). Therapists then encourage ing a place for a softened obstacle voice to be clients to think about a salient value with a present without total control. The purpose large discrepancy and how they want their of these tasks is to reduce negative emotional actions to reflect this value today, even if responses that are activated when obstacles it involves only a small action step. Specifi- reflecting these conflicts are perceived (i.e., cally, imaginal exposure tasks that focus on exposure), to generate a new perspective engaging in specific valued actions are con- (i.e., new meaning) on these obstacles, and ducted to (1) provide clients with an experi- to engage more adaptive emotions that are entially rich rehearsal of the steps that might facilitative of valued action engagement. be necessary to live by their values and (2) confront the emotional challenges that are Engaging Proactive Valued Action likely to come up as clients imagine engage- Outside of Session ment of valued action. In this imagery expo- Valued action is also promoted between ses- sure task, therapists help clients imagine sions by building upon the in-s­ ession valued each step involved in engaging this action, action exploration and obstacles confronta- while noting changes in motivational lev- tion exposure tasks. Therapists encourage els and encouraging utilization of skills to clients to engage both planned (i.e., spe- address difficulties in awareness and bal- cific valued actions related to salient val- ancing of emotional responses. Utilizing ues explored in session and to which clients imagery to consolidate skills and promote commit in the presence of therapists) and functional action is also congruent with spontaneous (i.e., any other valued actions traditional interventions such as cognitive in which clients notice themselves engaging) rehearsal (Beck et al., 1979). valued actions outside of session (Hayes et al., 2012). Furthermore, clients are encour- Exploring Conflict Themes in Obstacles aged to utilize skills both proactively (in to Valued Living an antecedent-f­ocused manner) when they The second component of exposure work are planning to engage valued actions and in ERT involves addressing perceived obsta- counteractively (in a response-­focused man- cles to taking valued action. Obstacles are ner) when they notice themselves getting

Emotion Regulation Therapy 483 unexpectedly distressed and feel pulled to MAC clients, evidenced significantly greater respond reactively with worry, reassurance reductions in GAD severity, worry, trait seeking, self-c­riticism, or behavioral avoid- anxiousness, and depression symptoms, and ance. Finally, external barriers (i.e., obstacles corresponding improvements in functional- in the environment that are outside the cli- ity and quality of life, with between-­subjects ent’s control) that might have been deferred effect sizes in the medium to large range (d during exposure tasks can also be addressed = 0.50 to 2.0). These gains were maintained more actively in between-s­ession exercises. for 9 months following the end of treatment. Therapists can help clients problem-­solve In addition, these effect size estimates also these obstacles or utilize skills such as accep- take into account clients who dropped out tance to further facilitate valued action. of treatment. Research Findings Finally, a sizable subgroup of clients with To date, we have tested the efficacy and pur- GAD and comorbid MDD (N = 30) were ported mechanisms of ERT in a number of enrolled and treated. Within- subjects effect trials at various sites. These findings have sizes in both clinician-a­ssessed and self-­ been presented in greater detail at a number report measures of GAD severity, worry, of recent conference sessions (e.g., Mennin trait anxiousness, and depression symptoms, & Fresco, 2011; Mennin, Fresco, & Aldao, and corresponding improvements in func- 2012) and are the focus of submitted manu- tionality and quality of life, were comparable scripts currently under review. to overall trial findings—­thereby suggesting that MDD comorbidity did not interfere Preliminary Outcome Results with treatment efficacy (Cohen’s d’s = 1.5 to To date, ERT’s efficacy has been demon- 4.0). Furthermore, rumination and anhedo- strated in a recently concluded NIMH- nia also decreased (Cohen’s d’s = 1.5 to 2.0). funded project that comprises an open trial (N = 19) and a randomized control trial Preliminary Mechanisms Results (RCT; N = 60). In both trials, clients toler- We argue that efforts to demonstrate the ated ERT, as evidenced by high ratings of mechanisms by which one’s treatment pro- personal satisfaction and low rates of attri- duces clinical improvement are best tied tion in the course of treatment. For instance, to common target mechanisms such as 18 of 19 open-trial clients and 26 of 30 those that reflect the capacities described RCT clients completed treatment. In terms earlier (e.g., directed attention, emotional of clinical outcomes, open-trial clients evi- acceptance, cognitive distancing, cognitive denced reductions in both clinician-a­ ssessed change). Furthermore, target mechanism and self-­report measures of GAD severity, change should be demonstrated with biobe- worry, and trait-a­nxious and depression havioral marker assessments (e.g., behavioral symptoms, and corresponding improve- tasks, functional magnetic resonance imag- ments in quality of life, with within-­subjects ing [fMRI], psychophysiology) that have effect sizes well exceeding conventions for established reliability and validity in labora- large effects (Cohen’s d’s = 1.5 to 4.5). These tory and analogue studies. This approach is gains were maintained for 9 months follow- aligned with the growing multidisciplinary ing treatment. field of intervention science and with NIMH priorities (e.g., RDoC; Craske, 2012), which The RCT study compared ERT to a modi- seek to elucidate biobehavioral markers that fied attention control (MAC) condition, are reliably dissociable in patient subgroups which involved clients periodically speak- compared to healthy controls. Also, assess- ing via telephone to a clinician who pro- ing common target mechanisms in various vided supportive listening. Clients received approaches may help us better understand assessments at baseline, midtreatment, and patient characteristics that predict treatment postacute treatment. MAC clients were success and failure (e.g., treatment match- offered ERT in an open-label fashion follow- ing, treatment optimization/augmentation; ing the immediate RCT period. RCT find- NIMH Council’s treatment personalization ings revealed that ERT clients, compared to initiative; Kraemer, Wilson, Fairburn, & Agras, 2002).

484 INTERVENTIONS Commensurate with this viewpoint, ERT normalizes emotional response patterns, and that this normalization plays a role in has been designed to target mechanisms of the therapeutic effects of ERT. However, it affective dysfunction that we have argued is unclear how clients were able to improve are central to refractory distress disorders. their response to the film, because spontane- Thus, we have been interested in examining ous utilization of ERT-related or other strate- whether these treatment outcomes are the gies was not assessed. It will be important in result of changes in purported motivational, future research to determine whether these regulatory, and contextual learning mecha- improvements are indeed due to implementa- nisms. One promising preliminary finding tion of the skills learned in ERT. is related to emotional conflict adaptation (Etkin & Schatzberg, 2011). A subset of our Conclusions and Future Directions ERT clients (N = 15) completed the Etkin Individuals with distress disorders (i.e., emotional conflict task (described earlier) GAD, MDD) are commonly comorbid and at pretreatment and at the midpoint of ERT. appear to be characterized by higher order Findings indicate that by midtreatment, cli- negative emotional factors (e.g., Krueger & ents improved in ability to shift their atten- Markon, 2006; Watson, 2005) that reflect tion in the face of emotional conflict (pre- to activation of underlying motivational sys- midtreatment d = 0.74) to levels comparable tems related to threat–­safety and reward–­ to healthy controls (Etkin et al., 2010). Fur- loss (Campbell-S­ills et al., 2004; Klenk thermore, clients who showed the greatest et al., 2011; Woody & Rachman, 1994). gains in conflict adaptation by midtreat- Furthermore, they tend to perseverate (i.e., ment, showed the greatest pre- to posttreat- worry, ruminate) as a way to manage this ment response in anxiety, anhedonic depres- motivationally relevant distress (Borkovec sion, and worry. These preliminary data are et al., 2004; Nolen-H­ oeksema et al., 2008) supportive of our hypotheses that ERT may, and often utilize these self-c­onscious pro- in part, exert its therapeutic impact through cesses to the detriment of engaging new normalization of less elaborative emotion learning repertoires. ERT (Mennin & regulatory mechanisms such as ability to Fresco, 2009) integrates principles from tra- shift attention by adapting to conflict. ditional and contemporary CBT (e.g., skills training and exposure) with basic and trans- Although we have not yet tested changes in lational findings from affect science to offer more elaborative regulatory mechanisms, we a blueprint for improving intervention by have examined responses to more complex focusing on the motivational responses and emotional stimuli, which likely require more corresponding regulatory characteristics effort and elaboration to manage. Specifi- of individuals with distress disorders. This cally, we assessed HRV during a fearful film emphasis on affect science permits identifi- paradigm at pre- and midtreatment. Eigh- cation of mechanisms of treatment in terms teen clients were assessed during the neutral of core disruptions of normative cognitive, film, the fearful film, and, a recovery period. emotional, and motivational systems, which At pretreatment, these clients displayed a in turn helps generate more targeted solu- flattened response throughout the experi- tions to help clients utilize adaptive ways to mental period—s­uggesting reduced flex- cope or compensate for these core deficits. ibility. At midtreatment, clients displayed a In essence, contrasting a client’s difficulties quadratic pattern of vagal withdrawal (i.e., with what we understand as normative func- r0e.a8c1t)ivrietfyl)ecatnindgvaagmalorreebnoournmda(tdivpere troemspido-tnxs=e tioning allows us to generate theory-d­ riven to these changing emotional contexts. hypotheses that form that basis of our case Period-­averaged HRV levels at midtreatment conceptualization and treatment planning also increased to within 1 SD of levels in a (e.g., Craske, 2012). healthy control sample. Furthermore, clients who showed the greatest increases in para- A summary of the conceptual model of sympathetic flexibility from pre- to midtreat- ERT as presented in this chapter appears in ment showed the greatest pre to posttreat- Figure 28.1. However, ERT continues to be ment gains in diagnostic severity, anxiety, developed and tested. For up-to-date infor- worry, anhedonic depression, impairment, and life quality. These data suggest that ERT

485 Target Mechanisms Motivation Regulation Contextual Learning security system; reward system Less Elaborative → More Elaborative flexible responding to simultaneous risk and reward context (i.e., approach–avoidance conflict) Change Principles and Awareness Skills Training Regulation Skills Training Experiential Exposure Therapeutic Processes psychoeducation of motivations/emotions; mindfulness of sensations, body, and emotions; values delineation; experiential imagery and conflict improved detection of and attendance to allowance metaphors and practices; distancing in dialogue exercises; valued action homework motivational cues time and space; courageous and compassionate self-statements FIGURE 28.1.╇ Conceptual model of target mechanisms, change principles, and therapeutic processes in emotion regulation therapy.

486 INTERVENTIONS mation about ERT, please visit www.emo- Barlow, D. H. (2002). Anxiety and its disorders tionregulationtherapy.com. Our emotion (2nd ed.). New York: Guilford Press. regulation model is based on current find- ings in affect science and the psychopathol- Barlow, D. H., Farchione, T. J., Fairholme, C. ogy of distress disorders. However, many P., Ellard, K. K., Boisseau, C. L., Allen, L. B., of the central tenets of our model await et al. (2011). The unified protocol for trans- further careful experimental inquiry using diagnostic treatment of emotional disorders: multimethod biobehavioral approaches. Therapist guide. New York: Oxford Univer- Nonetheless, preliminary data are support- sity Press. ive of our hypotheses that ERT may exert its therapeutic impact in part through normal- Barlow, D. H., Gorman, J. M., Shear, M. K., & ization of emotional processes, and there- Woods, S. W. (2000). Cognitive-­behavioral fore be most effective for individuals with therapy, imipramine, or their combination for distress disorders in whom this system is panic disorder. Journal of the American Medi- most impaired. Building on these pilot find- cal Association, 283, 2529–2536. ings on biobehavioral mechanisms of ERT, we are currently examining neural changes Beck, A. T., Rush, J., Shaw, B. F., & Emery, G. related to ERT utilizing fMRI procedures (1979). Cognitive therapy of depression: A while administering paradigms examining treatment manual. New York: Guilford Press. motivational engagement and regulatory responses at less and more elaborate levels. Berridge, K. C., Robinson, T. E., & Aldridge, Furthermore, we are currently developing a J. W. (2009). Dissecting components of reward: portable, computer-b­ ased “emotion regula- “Liking,” “wanting,” and learning. Current tion training” to target mechanisms of ERT Opinion in Pharmacology, 9(1), 65–73. in a briefer, more rapid, and cost-e­ffective method of intervention, which may be par- Bogdan, R., & Pizzagalli, D. A. (2006). Acute ticularly useful for certain populations and stress reduces reward responsiveness: Impli- geographical locations in which standard cations for depression. Biological Psychiatry, treatment efforts are less feasible (Kazdin 60, 1147–1154. & Blase, 2011). Through this work, we are eager to continue testing motivational and Borkovec, T. D., Alcaine, O., & Behar, E. (2004). regulatory mechanisms in the distress dis- Avoidance theory of worry and generalized orders and to demonstrate their role in tar- anxiety disorder. In R. G. Heimberg, C. L. geted treatments such as ERT. Turk, & D. S. Mennin (Eds.), Generalized anxiety disorder: Advances in research and References practice (pp. 77–108). New York: Guilford Press. Aldao, A., & Mennin, D. S. (2012). Paradoxical cardiovascular effects of implementing adap- Borkovec, T. D., & Ruscio, A. M. (2001). Psy- tive emotion regulation strategies in general- chotherapy for generalized anxiety disorder. ized anxiety disorder. Behaviour Research Journal of Clinical Psychiatry, 62(Suppl. 11), and Therapy, 50, 122–130. 37– 42. Aupperle, R. L., & Paulus, M. P. (2010). Neural Botvinick, M., Braver, T., Barch, D., Carter, C., systems underlying approach and avoidance in & Cohen, J. (2001). Conflict monitoring and anxiety disorders. Dialogues in Clinical Neu- cognitive control. Psychological Review, 108, roscience, 12, 517–531. 624 – 652 . Badre, D., & D’Esposito, M. (2007). Functional Bouton, M. E., Mineka, S., & Barlow, D. H. magnetic resonance imaging evidence for a (2001). A modern learning theory perspective hierarchical organization of the prefrontal on the etiology of panic disorder. Psychologi- cortex. Journal of Cognitive Neuroscience, cal Review, 108, 4–32. 19, 2082–2099. Brown, T. A. (2007). Temporal course and struc- Bar, M. (2009). A cognitive neuroscience hypoth- tural relationships among dimensions of tem- esis of mood and depression. Trends in Cogni- perament and DSM-IV anxiety and mood tive Sciences, 13, 456–463. disorder constructs. Journal of Abnormal Psychology, 116(2), 313–328. Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-­behavioral therapy: A review of meta-­analyses. Clinical Psychology Review, 26, 17–31. Campbell-S­ills, L., Liverant, G. I., & Brown, T. A. (2004). Psychometric evaluation of the

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Chapter 29 Dialectical Behavior Therapy: An Intervention for Emotion Dysregulation Andrada D. Neacsiu Martin Bohus Marsha M. Linehan Our aim in this chapter is to describe a set of emotion regulation that we teach in DBT. emotion regulation skills developed within We argue that BPD is a disorder of perva- the context of dialectical behavior therapy sive emotion dysregulation, and also provide (DBT; Linehan, 1993a, 1993b) and their examples of how this model is relevant to potential to serve as a transdiagnostic inter- people without BPD who have difficulties vention. DBT is a comprehensive cognitive-­ managing emotions. We then present how behavioral treatment originally developed the DBT skills map onto the model of emo- for suicidal individuals and later expanded tion regulation, and how they can be used to suicidal individuals meeting criteria for systematically to change dysregulation. We borderline personality disorder (BPD). DBT conclude by describing the research needed has since been adapted to treat BPD with to evaluate the model proposed. several comorbidities and other psychologi- cal disorders in which problems in emotion Emotion and Emotion Dysregulation regulation lead to psychopathology. Data for The DBT Model of Emotion Regulation the efficacy of DBT are extensive, including Similar to many others (e.g., Ekman & David- 43 clinical trials conducted across 21 inde- son, 1994), in DBT we consider emotions to pendent research teams (for a review, see be complex, brief, involuntary, patterned, Neacsiu & Linehan, in press). full-­system responses to internal and exter- nal stimuli. DBT emphasizes the importance DBT conceptualizes difficulties with emo- of the evolutionary adaptive value of emo- tion regulation as a consequence of biosocial tions (Tooby & Cosmides, 1990). Although transactions: A biological sensitivity to emo- emotional responses are viewed as systemic, tions interacts with aversive or invalidating we present them to clients as comprising six experiences during childhood and adoles- transacting subsystems that are practical in cence, and leads to neurobiological malfunc- both understanding and learning to regu- tion and to insufficient skills to manage the late emotions: (1) emotion vulnerability fac- emotional system (Linehan, 1993a; Crowell, tors; (2) internal and/or external events that Beauchaine, & Linehan, 2009). Therefore, a serve as emotional cues; (3) interpretations primary focus in DBT is to teach clients how to regulate emotional responses actively. In this chapter we present a model of 491

492 INTERVENTIONS of cues; (4) emotional response tendencies, tial and expressive responses. Research sup- including physiological responses, cogni- porting the importance of this distinction tive processing, experiential responses, and for clinical populations suggests that pro- action urges; (5) nonverbal–­verbal expres- cesses occurring after the emotional firing sive responses and actions; and (6) afteref- are key for psychopathology (Aldao, Nolen-­ fects of the initial emotion, including sec- Hoeksema, & Schweizer, 2010). ondary emotions (see Linehan, 1993a). An additional difference is the inclusion Although the DBT emotion model was of emotion vulnerability factors. The con- developed to serve a clinical population, it struct of emotion vulnerability refers to the is interesting to note the similarities it has to effects of distal and proximal prior events the modal model of emotions that evolved on the initiation, course, and intensity of in basic science (Gross & Thompson, 2007). emotional responses. For example, individu- Briefly, in the modal model, emotions origi- als diagnosed with BPD who meet diagnos- nate from person–s­ ituation transactions that tic criteria for co-­occurring posttraumatic are relevant to one’s goals and values. Such stress disorder (PTSD; a distal vulnerability a situation acts as a cue and draws the indi- factor) report significantly higher emotion vidual’s attention, gives rise to an appraisal dysregulation (Harned, Rizvi, & Linehan, of the event, and leads to an emotional 2010). Similarly, sufficient sleep (a proximal response. This response is associated with vulnerability factor) leads to less emotional behavioral displays and action tendencies, intensity when compared to lack of sleep and is malleable, in that the course of the (Gujar, Yoo, Hu, & Walker, 2011). emotion is not fixed when it starts (Gross & Thompson, 2007). In this chapter, we reorganize Linehan’s original model (1993a) to be applicable to a Both the DBT and the modal model wider range of disorders and to use termi- include the importance of attending to a nology consistent with basic research mod- cue within a relevant context, highlight els (Figure 29.1; Table 29.1). Briefly, in this appraisals as potentially influencing the model, emotions start within the context of course of the emotion and present how a situation, where a cue grabs the individu- emotions directly affect context. Never- al’s attention. The cue is appraised or inter- theless, DBT places more emphasis on dif- preted, which triggers an emotional response ficulties regulating the emotional response that comprises biological–­experiential after it has already been initiated, espe- changes (including urges or response ten- cially when it is past the point at which it dencies) and expressions–­actions changes could be suppressed. Therefore, one differ- (including body language, facial expression, ence between the models is that in DBT the and actions). All components are affected by emotional response is broken into experien- proximal and distal emotion vulnerability FIGURE 29.1.  DBT extended model of emotion regulation. Adapted to be consistent with Gross and Thompson (2007).

Dialectical Behavior Therapy 493 TABLE 29.1.  Emotion Regulation Tasks and Corresponding DBT Skills Emotion components Regulation strategies DBT skills A. Emotion Vulnerability Factors Managing Vulnerability Factors Change Biological Sensitivity (Biological and Contextual) (PLEASE skills) Accumulate Positives Build Mastery Cope Ahead by Covert Rehearsal [Mindfulness Skills] B. Situation (emotional cue) Situation Selection Problem Solving Situation Modification Interpersonal Effectiveness Skills [Mindfulness Skills] C. Attention Attention Deployment Distract Crisis Survival Skills [Mindfulness Skills] D. Appraisal Cognitive Change Check the Facts Reality Acceptance [Mindfulness Skills] E. Biological/ Experiential Biological Change Change Physiology (TIP skills) Response Self-Soothe Half-Smile/Willing Hands [Mindfulness Skills] F. Expression/ Action Response Expression and Action Change Opposite Action [Mindfulness Skills] G. Emotional After-Effects Emotional Processing Identify and Label Emotions (including emotional awareness) [Mindfulness Skills] Note.  See text for explanation of acronyms. factors. The emotional response is followed [action response] and subsequently becomes by aftereffects, including secondary emo- angry with herself [secondary emotion]. tions. Figure 29.1 and Table 29.1 present types To give an example: A depressed woman of strategies that can be used to change each has a fight with her partner over house emotion component. Like Davidson (1998) chores, followed by a night of poor sleep. we contend that emotion regulation can be Within the context of these emotion vulner- both automatic and effortful, and that regu- ability factors, she walks into the kitchen latory processes are an integral part of emo- and a pile of dirty dishes [situation] in the tional responding. sink captures her attention. She appraises the situation by thinking “The dishes are Pervasive Emotion Dysregulation dirty”; “I should have washed them”; and “I Emotion dysregulation is the inability, didn’t so I’m a terrible wife.” The emotion even when one’s best efforts are applied, continues, with her heart beating faster, her to change in a desired way emotional cues, body slumping lower; she has the urge to go experiences, actions, verbal responses, and/ to bed and hide under the covers [biological or nonverbal expressions under norma- response–a­ ction urge] and she starts crying tive conditions. Characteristics of emotion [expression–­action response]. Her atten- dysregulation include an excess of aversive tion narrows [aftereffect] and, as she walks emotional experiences, an inability to regu- around the house, she sees the clothes [situ- late intense physiological arousal, problems ation] she did not iron [appraisal], which turning attention away from stimuli, cogni- refires her emotion of shame. She goes to tive distortions and failures in information bed and covers her head with the blanket

494 INTERVENTIONS and consequently develops biological and processing, insufficient control of impulsive psychological alterations of the emotion behaviors related to strong emotions, diffi- regulation system (Linehan, 1993a; Distel culties organizing and coordinating activi- et al., 2011). The neurobiological alterations ties to achieve non-mood-­dependent goals in the emotion circuitry manifest in adult- when emotionally aroused, and a tendency hood as heightened emotional sensitivity to “freeze” or dissociate under very high (low threshold for recognition of/response stress (Ray et al., 2006). Pervasive emo- to emotional stimuli), heightened reactivity tion dysregulation refers to an inability to (high amplitude of emotional responses), regulate emotions that occurs across a wide and a slow return to baseline after emotion range of emotions and situational contexts. induction (Linehan, 1993a; Crowell et al., 2009). The psychological alterations involve BPD: A Disorder of Pervasive maladaptive or insufficient learning in how Emotion Dysregulation to understand, label, regulate, or tolerate The Disorder emotional responses effectively. A BPD diag- BPD is a severe mental disorder with a seri- nosis is hypothesized to emerge from such ous dysregulation of the emotion system at biological alterations, coupled with insuffi- its core. Clients show a characteristic pat- cient knowledge about emotion regulation. tern of instability in emotion regulation, impulse control, interpersonal relationship, Existing evidence provides emerging and self-image. The often severe functional support for this theory. First, 60% of cli- impairment leads to substantial treatment ents with BPD report sexual abuse and utilization and a mortality rate by suicide severe interpersonal violence during child- of almost 10%, which is 50% higher than hood (Hernandez, Arntz, Gaviria, Labad, the rate in the general population (American & Gutiérrez-Zotes, 2012; Bornovalova Psychiatric Association, 2001). BPD affects et al., 2013), which leads to significantly approximately 3% of the general popula- higher suicidality and emotion dysregula- tion, up to 10% of outpatients treated for tion (Harned et al., 2010). Second, animal mental disorders, and up to 20% of inpa- research shows that traumatization during tients (Trull, Jahng, Tomko, Wood, & Sher, early life stages leads to morphological alter- 2010). Because of the severity of the distur- ations of the central frontolimbic system and bance and the intensive treatment use, cli- to behavioral and epigenetic modifications ents with BPD constitute a disproportion- (Pryce & Feldon, 2003; Cirulli et al., 2009). ately large subset of psychiatric patients, Third, preliminary data connect genetic fac- consuming considerably more mental health tors with the development of borderline fea- resources than most other psychiatric groups tures (Distel et al., 2009). (Soeteman, Hakkaart-v­an Roijen, Verheul, & Busschbach, 2008). Neurobiological Dysfunction in BPD Numerous studies have tested biological BPD as a Disorder alterations in the emotion circuitry in BPD, of Emotion Regulation with the majority of studies assessing reac- Based on clinical experience, Linehan tivity and return to baseline. Findings are (1993a) proposed that pervasive emo- extensive and somewhat mixed; next, we tion dysregulation in BPD is caused by an present some highlights of this body of lit- interplay between biological (e.g., genetic, erature. intrauterine factors; trauma to the biologi- cal system) vulnerability and aversive socio- Functional and structural data support biographical experiences. According to this enhanced reactivity and slow return to biosocial theory, a child born with height- baseline in BPD. In this population, volume ened biological sensitivity to emotional reduction of the amygdala (Nunes et al., cues encounters emotionally aversive expe- 2009) was correlated with amygdala hyper- riences (e.g., interpersonal violence, social reactivity to emotional stimuli (e.g., Her- rejection, emotional neglect, invalidation) pertz et al., 2001; Niedtfeld et al., 2012). This heightened amygdala activation was more prominent in BPD and took longer to return to baseline when compared to clini-

Dialectical Behavior Therapy 495 cal and nonclinical controls (Hazlett et al., Emotion Dysregulation in BPD 2012). In addition to amygdala dysfunction, It is important to highlight that the con- volume reductions in brain areas hypoth- struct of emotion dysregulation is indepen- esized to serve emotion regulation func- dent from neurobiological alterations in tions were also found (Tebartz van Elst et the emotion circuitry that are thought to al., 2003; Minzenberg, Fan, New, Tang, underlie BPD. Having increased sensitiv- & Siever, 2008). Recent studies also report ity, reactivity and a slow return to baseline reduced neural connectivity between such may make it more difficult for individuals brain areas and the amygdala at baseline to regulate emotions. At the same time, (New et al., 2007) or during emotional dis- persistent use of dysfunctional regulation tress (Niedtfeld et al., 2012). Furthermore, strategies may lead to continued biological research indicates a reduced activation of alteration. Whether neurobiological altera- prefrontal areas after emotional induction tions precede dysregulation, or vice versa, (Minzenberg, Fan, New, Tang, & Siever, remains an empirical question. Neverthe- 2007; Schulze et al., 2011). These findings less, both constructs are crucial for under- suggest that in BPD amygdala hyperactivity standing difficulties with emotions as pre- in the presence of emotional stimuli takes sented in DBT. longer to return to baseline, partly because of insufficient modulation from brain cen- We propose that individuals with BPD ters responsible for emotion regulation. have pervasive emotion dysregulation. In support, below we summarize evidence Self-­report and psychophysiological find- suggesting that individuals diagnosed with ings are less clear with regard to heightened BPD have problems with each set of emotion reactivity in individuals diagnosed with BPD regulation strategies described in the DBT (for a detailed review, see Rosenthal et al., model. Difficulties with reducing emotion 2008). Across several samples, people diag- vulnerability are highlighted by findings nosed with BPD self-r­ eport being more reac- suggesting dysregulated sleep patterns in tive, having more negative emotions, and BPD individuals (Schredl et al., 2012), high experiencing more emotional instability than prevalence of abuse history and substance non-BPD controls (Rosenthal et al., 2008; use disorders (Trull et al., 2010; Distel et al., Lobbestael & Arntz, 2010). Additional stud- 2012), as well as chronic health problems ies using heart rate as a psychophysiologi- and poor lifestyle choices (Frankenburg & cal measures of distress (Gratz, Rosenthal, Zanarini, 2004). Tull, Lejuez, & Gunderson, 2010; Reitz et al., 2012), or electrophysiological recordings Self-­inflicted injuries (including suicide (Marissen, Meuleman, & Franken, 2010) attempts) and most other dysfunctional also found greater emotional reactivity for behaviors (i.e., suicide threats, impulsive participants with BPD. Nevertheless, studies behaviors, dissociation) are hypothesized using different psychophysiological indices to be maladaptive problem-­solving strate- of distress (i.e., skin conductance response) gies (Reitz et al., 2012), an escape mecha- failed to show enhanced reactivity (e.g., Kuo nism (Chapman, Gratz, & Brown, 2006), or & Linehan, 2009; Rosenthal et al., 2008). a way to communicate distress (Koerner & Thus, additional research is needed to better Linehan, 1997). These behaviors may sug- understand the mixed findings on reactivity. gest problems with regulating the biological and expressive components of the emotion, Self-r­eport and psychophysiological data or with selecting effective situation modifi- support a prolonged return to baseline. cation strategies. Problems with emotion-­ Applying ambulatory assessments under daily induced dissociation have also consistently life conditions, Stiglmayr, Shapiro, Stieglitz, been shown and suggest impairments in Limberger, and Bohus (2001) reported signif- the attention regulation component (Ebner-­ icantly longer intervals of activated aversive Priemer et al., 2009). In addition, research emotions but no nonspecific arousal for peo- has documented problems with cognitive ple with BPD compared to healthy controls. flexibility (Ruocco, 2005), cognitive change In addition, in a laboratory study participants (Selby & Joiner, 2009), emotional aware- diagnosed with BPD evidenced prolonged ness (Levine, Marzialli, & Hood, 1997), return to baseline after induced anger (Jacob and aftereffects (Korfine & Hooley, 2000), et al., 2008) and stress (Reitz et al., 2012).

496 INTERVENTIONS suggesting difficulties with regulation of all the remaining emotion components. pretations (e.g., catastrophizing) that lead to dysregulated emotions, and use maladaptive The DBT Model and Other Disorders situation selection and situation modifica- Emotional dysregulation has been reported tion strategies (e.g., avoidance, use of safety to underlie etiological and maintenance cues; Kring & Werner, 2004; Aldao et al., mechanisms for a large number of mental 2010). Experimental evidence also makes health problems (Kring & Sloan, 2010). a strong link between depression and anxi- Literature reviews have demonstrated that ety, and difficulties regulating attention in mood disorders, anxiety disorders, sub- emotional contexts. For example, depressed stance use disorders (SUDs), eating disor- individuals have a reduced capacity to sus- ders, schizophrenia, and even psychotic tain positive emotions (Heller et al., 2009) disorders are directly linked to emotion and more difficulties finding attentional dysregulation (Cisler, Olatunji, Feldner, & distracters in the context of a distressing Forsyth, 2010; Harrison, Sullivan, Tchan- emotion (Koole, 2009) when compared with turia, & Treasure, 2009; Kring & Werner, controls. Similarly, when presented with 2004; Thorberg, Young, Sullivan, & Lyvers, social threat stimuli, participants with SAD 2009). report more negative emotions than do con- trols, suggesting attention deployment and/ Individuals diagnosed with a variety of or cognitive change dysregulation (Goldin, Axis I disorders also appear to reveal emo- Manber, Hakimi, Canli, & Gross, 2009). tion dysregulation patterns. Increased reac- tivity when compared to controls has been Finally, difficulties with emotion pro- connected to generalized anxiety disorder cessing have been linked to PTSD (Frewen, (GAD; Mennin, Heimberg, Turk, & Fresco, Dozois, Neufeld, & Lanius, 2012). 2005), substance dependence (Thorberg et al., 2009), social anxiety disorder (SAD), DBT Emotion Regulation Skills and specific phobias (Etkin & Wager, 2007). Rationale Furthermore, the transaction between neu- Linehan (1993a) included in DBT a set of robiological dysfunction (e.g., anxiety sen- concrete skills translated from behavioral sitivity) and lack of skills to manage it is research and other evidence-­based treat- similar to the etiological theories presented ments, aimed to address emotion dysregula- in panic disorder (Barlow, Allen, & Choate, tion in BPD. It was therefore hypothesized 2004), GAD (Mennin et al., 2005), and some that increases in skills use led to improve- specific phobias (Cisler et al., 2010). It can ments in emotion regulation, which in turn therefore be hypothesized that in cases where led to positive outcomes in treated popula- emotion dysregulation is involved, reactivity tions. Empirical findings indeed suggest that to emotional cues coupled with insufficient use of DBT skills explains changes in depres- regulation strategies may result in psychopa- sion, anger regulation, and suicidal behavior thology. Thus, emotion dysregulation may across BPD treatments (Neacsiu, Rizvi, & be a transdiagnostic phenomenon. Linehan, 2010). Therefore, behavioral skills are likely a potent mechanism of change for People diagnosed with BPD have difficul- emotion dysregulation. ties with regulating all of the emotion sub- systems described in the DBT model. Similar In addition to the five sets of regulatory difficulties can be found in many additional processes proposed by Gross and Thomp- Axis I disorders, as described in the fifth edi- son (2007), DBT targets five additional tion of the Diagnostic and Statistical Man- processes: managing emotion vulnerability ual of Mental Disorders (DSM-5). Difficul- factors, biological change, expression and ties managing emotion vulnerability factors action change, and emotional processing (at are common in mood and anxiety disorders the point of emotional aftereffects). We next and in SUDs (e.g., Monti & Monti, 2000; present the skills that directly map onto the Wong, Brower, Fitzgerald, & Zucker, 2004). DBT model of emotions, organizing them Individuals diagnosed with anxiety and according to regulation process to which mood disorders also make negative inter- they primarily relate, although the functions

Dialectical Behavior Therapy 497 of each set of skills can be applied across likely to increase peoples’ appraisal of their many of the regulation processes (see Table own ability to cope with an emotional event, 29.1). This is particularly the case for mind- effectively increasing a sense of mastery and fulness skills, which can be viewed as criti- self-e­ fficacy. cal at every juncture in the emotion regula- tion process. Situation Selection– Modification Strategies Strategies for Managing Emotion Situation selection and modification are Vulnerability Factors two classes of emotion regulation strategies DBT teaches clients to decrease emotion through which emotions are modulated via vulnerability factors by increasing happi- stimulus control (i.e., avoiding or modify- ness and resilience (“building a life worth ing situations that generate unwanted emo- living”) through a set of skills that target tions). To promote effective situation selec- biological homeostasis and influence emo- tion skills, DBT teaches how to generate a tional reactivity. The PLEASE skills target list of pros and cons to guide a course of treating Physical iLlness (Anderson, Hack- action. To improve situation modification, ett, & House, 2004), balancing nutrition DBT teaches a simple set of problem-­solving and Eating (Smith, Williamson, Bray, & skills (Linehan, in press) aimed at chang- Ryan, 1999), staying off nonprescribed ing or developing strategies for eliminating, mood-Altering drugs, getting sufficient but reducing, or avoiding emotionally problem- not excessive Sleep (Gujar et al., 2011), and atic situations. The focus here is on defining getting adequate Exercise (Cox, Thomas, those situations that cue unwanted emotions, Hinton, & Donahue, 2004). then applying standard problem-­solving steps, such as those outline by D’Zurilla and In addition, DBT promotes resilience by Nezu (1999) and others. teaching skills for accumulating positive life events and for building a sense of general- Because many problems are interpersonal ized mastery. Increasing the number of plea- (and even if they are not may require inter- surable events in one’s life is one approach personal interactions to solve), DBT also to increasing positive emotions. In the short includes a set of interpersonal effectiveness term, this involves increasing daily posi- skills. These skills focus on how to obtain tive experiences. In the long term, it means a wanted objective without hurting the working on goals related to important life interpersonal relationship or one’s own self-­ values, so that pleasant events will occur respect. Coping ahead as a way to practice more often. Building mastery is achieved by these skills and to manage intense emotional engaging in activities that increase a sense arousal before it happens is often a helpful of competence and self-e­ fficacy. The focus is addition to problem solving. very similar to activity and mastery schedul- ing in psychotherapy for depression (Martell, DBT also includes a set of mindfulness Addis, & Jacobson, 2001). Both skills have skills that emphasize observing, describing, been shown to predict decreased vulner- and participating in the present moment ability to negative emotional states (Joiner, effectively and without judgment. These Lewinsohn, & Seeley, 2002; de Beurs et al., skills may also promote adaptive situation 2005). selection by nonjudgmentally expanding awareness regarding situations that in the Coping ahead (Linehan, in press) is an past have evoked emotional experience. additional skill that promotes contextual This awareness is hypothesized to increase resiliency. Individuals learn to use imaginal sensitivity to the current contingencies in exposure and rehearsal to cope successfully the environment, allowing the opportunity with a difficult situation ahead of time. For for new learning. Thus, by seeing reality people who are prone to dysregulation, cop- “as it is” (i.e., being in the present moment ing ahead via covert rehearsal can be help- without historical filters), mindfulness may ful in building the coping skills necessary enhance the ability of an individual to decide for problem solving (see Fourkas, Avenanti, what situations to avoid, when to attempt to Urgesi, & Aglioti, 2006). Thus, this skill is problem-­solve, or when to cope ahead.

498 INTERVENTIONS Attentional Deployment Strategies to emotions, DBT reality acceptance skills Mindfulness skills are often used in DBT (“turning the mind” toward acceptance, to promote attentional control, which can radical acceptance, and willingness over reduce problems with attentional deploy- willfulness) focus on radical (meaning full ment. Mindfulness involves learning to con- and complete) acceptance of the current trol the focus of attention, not the object to emotion and willingness to experience even which one attends (e.g., observing a thought aversive emotions. as a thought or emotion as emotion, with- out attempting to change the thought or Mindfulness skills may also alter situa- emotion). Being able to disengage from tion appraisal by reducing literal belief in emotional stimuli may reduce the tendency emotional appraisals. Mindfulness teaches to experience negative affect (Ellenbogen, individuals to observe appraisals as only Schwartzman, Stewart, & Walker, 2002), thoughts that are not necessarily literally and redeploying attention has been postu- true. This is hypothesized to increase sen- lated to lead to a “flexibility of attention” sitivity to the current contingencies in the (Teasdale, Segal, & Williams, 1995) needed environment, allowing the opportunity for for successful attention modulation in emo- new learning. In this context, mindfulness tional contexts. Thus, mindfulness may help in DBT would not be predicted to reduce the modulate emotional experience by enhanc- frequency of distressing thoughts but instead ing the practioner’s ability to turn his or her to decrease the influence these thoughts have attention away from that which is not useful on subsequent behavior and emotions. (or effective) and attend to what is (Lynch, Rosenthal, et al., 2006). Biological–Experiential Change Strategies Cognitive Change Strategies In DBT, an important part of the biologi- DBT focuses on analyzing and correcting cal component of an emotion is the action situation appraisals by checking the facts tendency, or urge, to act in a specific man- (Linehan, in press). These skills focus on ner. DBT provides a range of distress toler- discriminating assumptions, interpretations, ance skills whose aim is to inhibit acting on ruminative thoughts, and worries from the maladaptive urges that interfere with long- actual observed facts of situations. Support term emotion regulation. These skills are for this set of skills comes from a number also designed to down-­regulate the extreme of studies comparing different reappraisal physiological arousal that often accompa- strategies, including nonappraisal control nies intense emotions. The function of these conditions, following presentation of emo- skills is to impact high arousal quickly, with- tional cues (e.g., Lazarus & Abramovitz, out requiring a high level of cognitive pro- 1962). cessing to complete. Grouped under the term TIP skills (Linehan, in press) these skills tar- An additional set of strategies (reality get activation of the parasympathetic ner- acceptance) targets changing one’s appraisal vous system. of emotions as experiences that cannot be tolerated or experienced willingly. Emo- The first skill (Temperature change with tion acceptance, when compared to emotion ice water) has to do with using cold, icy suppression, or a control, has been shown water on the face to trigger the human dive to result in less subjective anxiety or avoid- reflex (which is typically elicited to aid sur- ance in clients diagnosed with panic disor- vival when falling into a frozen lake). This der undergoing a carbon dioxide challenge reflex can be triggered by a combination of (Levitt, Brown, Orsillo, & Barlow, 2004). In breath holding and face immersion in cold addition, coaching in an acceptance mind- water. The physiological response that fol- set, compared to coaching in a control-­your-­ lows involves both branches of the auto- emotions mindset or a placebo condition, nomic nervous system and reduces emotional significantly increased the amount of time a arousal for a short period of time (Hurwitz subject was willing to spend in a cold pres- & Furedy, 1986). sor task (Hayes et al., 1999). With respect Intense exercise is also recommended if arousal is very high. Most important here is the intensity of the exercise. Cox and col-

Dialectical Behavior Therapy 499 leagues (2004) compared intensity of bouts the individual galvanize him- or herself to of exercise and found that while intensity engage in activities that result in a sense of of exercise conditions did not differ in state mastery or pleasure. This engagement runs anxiety immediately after exercise, a sig- counter to the depression urge to withdraw nificant difference favoring the most intense and shut down. exercise condition over the control condition emerged at 30 minutes postexercise. Opposite action “all the way” (Linehan, in press) targets changing the entire range of Additional distress tolerance strategies are physical responses that accompany action, Paced breathing and Progressive relaxation, including visceral responses, body postures, soothing one of the five senses, adopting an facial expressions, and movements. A large opened posture with palms facing the ceiling literature has demonstrated that the activa- (willing hands), or adopting a serene facial tion of specific physical states activates the expression (half smile). other facets of the corresponding emotion responses, whether via the face (e.g., Duclos Expression and Action & Laird, 2001), posture (Stepper & Strack, Change Strategies 1993) or respiration. To the contrary, there Changing expression and action components is ample empirical evidence that modulat- of emotions implies preventing emotional ing one’s physical state alters one’s emo- actions, or acting in a way that opposes or tional state (Philippot, Baeyenes, Douilliez, is inconsistent with the emotion. The DBT & Francart, 2004). Also implied by “all the skill of opposite action is based on the idea way” are emotion-l­inked thought patterns that not only is changing action tendencies and verbal responses. The idea here is to act essential for reducing emotional disorders, contrary to an emotion, not to mask or hide but also that deliberate actions opposite to emotions. those associated with unwanted emotions can effectively change emotions as well as In part, opposite action is hypothesized to action tendencies. Others have made this work by influencing classically conditioned same point (e.g., Barlow, 1988, p. 313). Izard emotional responses (Lynch, Chapman, (1977) stated that treatment for anxiety dis- Rosenthal, Kuo, & Linehan, 2006). Oppo- orders involves “the individual learn[ing] to site action may also create sensory feedback act his way into a new feeling” (cited in Bar- from facial muscles and skin that can be low, 1988, p. 410). transformed directly into emotional expe- rience without cognitive mediation (Izard, Opposite action in DBT applies principles 1977). Finally, self-­perception of expressive of exposure-b­ased treatments for anxiety behavior, action, and appraisals regarding disorders across the entire domain of emo- proprioceptive sensations has been proposed tions. All exposure-b­ased interventions to influence subjective emotional experience include this one common element: Individu- (Laird, 1974). Opposite action may influence als have to approach the object/situation emotion by changing the perception of the that is fearful, thus acting counter to (and emotional event. Thus, behavior that is the inhibiting) their prominent urges to avoid. opposite of the automatic response or action Effective treatments for anger also require urge of an emotion is intended to alter the individuals to act counter to the urges asso- meaning of the emotional event automati- ciated with anger (attack physically or ver- cally and without conscious effort (Lynch, bally) by leaving the situation. Anger inter- Rosenthal, et al., 2006). In essence, people ventions also focus on taking the opposite conclude that they feel safe because they are perspective, and shifting from aggression “acting as if” all is safe. and blame to gentleness and forgiveness (e.g., Tafrate, Kassinove, & Dundin, 2002). Strategies for Changing A number of researchers have observed that Emotional Aftereffects effective therapies for depression also share Aftereffects of emotions, which include a common thread: They activate behavior. changes in attention, memory, and reason- For example cognitive therapy (Beck, Rush, ing, are fairly well established (see Dolan, Shaw, & Emery, 1979) and behavioral acti- 2002, for a review). These aftereffects can vation (BA; Martell et al., 2001) require that increase the probability that the emotion

500 INTERVENTIONS will reoccur. Interrupting the cycle can be enhanced if the individual notices and iden- to target each of the types of emotion dys- tifies a current, ongoing emotion, which can regulation our model presented. Therefore, then guide application of relevant change DBT skills training is a promising candidate strategies. for treating emotion dysregulation in BPD and other Axis I disorders. Therefore, DBT included a skill (Observe and Describe Emotions) through which Treatment trials, albeit fraught with increased awareness of the emotional expe- methodological flaws, offer some support rience is promoted. This skill is supported that DBT skills training is effective in reduc- by research showing that processing emo- ing emotion dysregulation in various clinical tional experience with greater specificity has presentations. A DBT skills training inter- advantages for improved emotion regulation vention improved pre- to posttreatment rat- over emotional processing that is overgen- ings of depression in abuse victims (Iverson, eral or nonspecific (e.g., Williams, Stiles, & Shenk, & Fruzzetti, 2009), and depression Shapiro, 1999). Indeed, recent research has and anger in vocational rehabilitation cli- demonstrated that priming individuals with ents (Koons et al., 2006). When compared overgeneral emotional memories results in to treatment as usual (TAU) or a wait-list more intense emotional experience com- condition, DBT skills training decreased pared to priming specific emotional memo- depression in treatment-­resistant depressed ries or a control condition (Schaefer et al., individuals (Harley, Sprich, Safren, Jacobo, 2003). In addition, experimentally manipu- & Fava, 2008) and self-r­eported anger in a lated social anxiety has been shown to be forensic sample (Evershed et al., 2003). DBT reduced by observing and describing spe- skills training was also superior to standard cifically the fear producing cues, in contrast group therapy in improving depression, to general impressions regarding cues that anger and affect instability in a BPD sample resulted in higher fear (Philippot, Burgos, (Soler et al., 2009). Verhasselt, & Baeyens, 2002). Therefore, although originally developed Drawing from the work of many, includ- to be part of a comprehensive intervention, ing both Shaver (e.g., Shaver, Schwartz, Kir- skills training by itself may be the mecha- son, & O’Connor, 1987) and Hupka (e.g., nism through which change occurs in a vari- Hupka, Lenton, & Hutchinson, 1999), Line- ety of populations with emotion regulation han (in press) expanded the original list of difficulties. Indeed, skills training has been six emotions to a taxonomy of 10 basic emo- linked to the reduction of emotion dysreg- tions: anger, disgust, envy, fear, jealousy, ulation indices (Neacsiu et al., 2010) and joy, love, sadness, shame, and guilt. For emotion dysregulation has, in turn, been each emotion the following characteristics related to a variety of mental health prob- are listed: (1) family of emotion names asso- lems (Kring & Sloan, 2010). Although this ciated with the basic emotion, (2) typical research area is in its infancy and more find- prompting events (cues), (3) interpretations ings are needed, the evidence suggests that or appraisals, (4) biological changes and DBT skills are a promising intervention for experiences, (5) expressions and actions, emotion dysregulation across psychopathol- (6) aftereffects, and (7) secondary emotions ogy. associated with each family of emotions. Using the taxonomy, clients are coached in Directions for Future Research learning to observe and describe their emo- Psychopathology Research tions relative to various events. Construct Validity of Emotion Regulation We have refined the construct of emotion Evidence for DBT Skills as a regulation as applicable to psychopathology Treatment for Emotion Dysregulation and presented a testable model. Although we Problems with regulating each component of have defined dysregulation as dysfunction the emotion system can be connected with at either level in the emotion generation–­ BPD and with other disorders. As we argued regulation process, we do not know whether in the previous section, there are DBT skills one or more “tipping” points differentiate

Dialectical Behavior Therapy 501 normative difficulties regulating extreme the frontolimbic circuits of clients with BPD. emotional arousal versus non-n­ormative However, it remains unclear whether these difficulties that predict serious emotional findings are specific to clients with BPD or disturbance. In addition, how difficulties characteristic of individuals with emotion as emphasized by this model vary with each regulation difficulties in general. It is also mental disorder is also not yet clear. unclear how neurobiological alterations interact with pervasive emotion dysregula- Construct Validity of Pervasive tion, especially in the case of social emo- Emotion Dysregulation tions such as shame or guilt. There is only We have proposed the construct of pervasive beginning research on restitution of these emotion dysregulation and conceptualized it neurobiological alterations after successful as a combination of a tendency to high emo- treatment. tionality across a wide array of both posi- tive and negative emotions, together with an Emotion Dysregulation inability to regulate intense emotion-l­inked as a Transdiagnostic Phenomenon responses. The validity of this construct As we have highlighted, emotion dysregula- has not been evaluated, nor are there mea- tion and alterations of the biological archi- sures of the construct. The high incidence tecture of the emotion system are issues not of comorbidity across emotional disorders entirely unique to BPD. Therefore, future suggests that the construct may be a useful research should further examine the rela- one. Research is needed both to validate and tionship between problems with emotions identify the parameters of the construct. We and other disorders. Furthermore, much of further have proposed BPD as a model of the research assessing emotion dysregula- pervasive emotion dysregulation. Research tion in BPD has compared people with BPD designed specifically to evaluate this conten- to healthy controls (for a review, see Rosen- tion, particularly research comparing BPD thal et al., 2008). There is a great need for to other emotional disorders, is needed. research examining the specificity of emo- Research on BPD and emotions outside of tion dysregulation in BPD, by comparing anxiety, depression, and anger is also needed people with BPD to those with other mental to support or refute the pervasiveness of disorders. This could help refine nuances emotion dysregulation in this disorder. of how emotion dysregulation manifests in psychopathology and how it can be more Neurobiological Dysfunction effectively targeted. of the Emotion Circuitry in BPD We have defined neurobiological dysfunc- Intervention Research tion of the emotion system in BPD as sensi- As noted previously, emerging data indicate tivity to emotional stimuli; intense reactions that the skills training component of DBT to such stimuli; and a slow, delayed return to is a successful stand-alone intervention for an emotional baseline. First, more research emotion dysregulation in a variety of clini- is needed to assess whether individuals with cal samples. What we do not know yet is BPD do have a heightened sensitivity to emo- whether we can use DBT skills training as a tional stimuli. Second, although it appears transdiagnostic treatment for emotion dys- evident that the intensity of all emotions is regulation. enhanced in BPD, the empirical evidence that clients with BPD are reactive to emotion-­ In addition, we do not know whether some eliciting cues is mixed. Additional research DBT skills are more useful than others, nor clarifying the inconsistent findings on emo- are there data regarding the role of compe- tional reactivity in BPD is sorely needed. tence of skills application (i.e., whether appli- Furthermore, it is unclear whether mode of cation of the “right skill at the right time” is stimulation (visual, auditory, somatic, etc.) important). It is also not clear which skills makes a difference. are the right skills for various situations. Given the propensity for emotional avoid- We have highlighted clear evidence for ance in many emotionally disturbed indi- both structural and functional alterations in viduals, it is extremely important to find out

502 INTERVENTIONS when to teach clients to distract themselves from unwanted emotions and cues and when tion dysregulation is prevalent beyond BPD to expose themselves to emotions and emo- and invite research to support our model tional stimuli. In DBT we make a distinction in other disorders in which problems with between moderate and extreme emotional emotions have been identified. Furthermore, responses. Extreme emotional responses are we offer a set of skills aimed at addressing defined as those accompanied by cognitive directly common components of dysregu- processing that is so compromised that skills lation and illustrate how such skills have requiring high use of cognitive resources been used with individuals diagnosed with (e.g., problem solving, checking the facts) BPD. We propose additional ways in which are unlikely to be successful. With extreme intervention research, as directly relevant responses, skills that more directly impact to emotion dysregulation, can advance our somatic arousal (e.g., deep breathing, using knowledge and help make treatments for ice water) or attention (e.g., distraction) are this problem more effective. recommended. Data verifying the wisdom of these recommendations are sorely lacking. Acknowledgment This is particularly important in light of the increasing use of mindfulness-b­ased treat- The authors would like to thank Thomas R. ment interventions, which teach individu- Lynch, PhD, for his contribution to the previous als to notice and accept ongoing emotional version of this chapter. responses. The question might be reframed as follows: When is mindfulness of current References emotions (a DBT skill) more or less impor- tant? Aldao, A., Nolen-H­ oeksema, S., & Schweizer, S. (2010). Emotion-­regulation strategies across Although there is a fair amount of basic psychopathology: A meta-a­nalytic review. research supporting the specific skills taught Clinical Psychology Review, 30, 217–237. in DBT, there is little evidence on their indi- vidual effectiveness as treatment interven- American Psychiatric Association. (2001). Prac- tions in clinical populations. The systematic tice guideline for the treatment of patients examination of the DBT skills, both indi- with borderline personality disorder. Ameri- vidually and in combination, is an essen- can Journal of Psychiatry, 158(Suppl. 10), tial first step in improving treatment for 1–52. deregulated individuals. This is particularly important for the skill of opposite action. Anderson, C. S., Hackett, M. L., & House, A. O. Linehan (1993a) has suggested that opposite (2004). Interventions for preventing depres- action will be effective across a wide range sion after stroke. Cochrane Database Systems of both dysfunctional positive (e.g., loving Review, 2, CD003689. the wrong person) and negative emotions. One study found promising results for oppo- Barlow, D. H. (1988). Anxiety and its disorders: site action with shame (Rizvi & Linehan, The nature and treatment of anxiety and 2006), but other emotions have not been panic. New York: Guilford Press. studied explicitly. Thus, although DBT has been thoroughly evaluated in efficacy stud- Barlow, D. H., Allen, L. B., & Choate, M. L. ies, there has been substantially less empha- (2004). Toward a unified treatment for emo- sis on the treatment mechanisms of change, tional disorders. Behavior Therapy, 35, 205– and future research must work to narrow 230. this gap. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. Conclusion (1979). Cognitive therapy of depression. New To sum up, we propose a framework for York: Guilford Press. emotion dysregulation that is applicable to BPD and in theory can be extended to other Bornovalova, M. A., Huibregtse, B. M., Hicks, psychological disorders. We argue that emo- B. M., Keyes, M., McGue, M., & Iacono, W. (2013). Tests of a direct effect of childhood abuse on adult borderline personality disorder traits: A longitudinal discordant twin design. Journal of Abnormal Psychology, 122(1), 180 –194. Chapman, A. L., Gratz, K. L., & Brown, M.

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Chapter 30 Regulation of Emotion through Modification of Attention Colin MacLeod Ben Grafton Emotions tend to be triggered by situations to maladaptive emotional regulation (Moses and generally operate to facilitate adaptive & Barlow, 2006). Such accounts carry the functioning (Werner & Gross, 2010). How- implication that a better understanding of ever, the nature and intensity of emotional the specific processes that functionally con- experience is not determined by situational tribute to emotion regulation, coupled with factors alone. As clearly evidenced by the the ability to systematically influence these extensive work reviewed in this handbook, a processes, could potentially enhance such range of psychological operations can mod- regulation in ways that ameliorate emo- erate emotional responses to environmental tional vulnerability and dysfunction. circumstances. Collectively these have been termed emotion regulation processes. Gross Since variation in emotion regulation gives and others have emphasized that emotion rise to individual differences in emotional regulation results from a heterogeneous disposition, it follows that information-­ array of processes exerting their influence processing biases theoretically implicated at differing points in the emotion generation in the determination of emotional disposi- continuum (Gross, 1998; Gross & Thomp- tion represent plausible emotion regulation son, 2007). Antecedent-f­ocused components mechanisms. Numerous influential mod- operate prior to the generation of emotion, els have proposed that biased attentional and response-f­ocused components operate selectivity contributes both to dispositional subsequent to emotion generation, while emotional vulnerability and emotional other emotion regulation processes exert pathology (cf. Mathews & MacLeod, 2005). a direct influence on emotion generation Hence, it is unsurprising that selective atten- itself. The combined impact of these emo- tion has been widely implicated in models of tion regulation processes shapes the nature emotion regulation (Gross & Barrett, 2011). of emotional experience, with individual dif- Kring and Werner (2004) contend that ferences in emotional regulation giving rise selective attentional deployment is a criti- to variation in emotional disposition. Thus, cal emotion regulation process that causally emotional resilience has been attributed to contributes both to variability in normal the effective use of adaptive emotion regu- emotional experience and to emotional dys- lation (Troy & Mauss, 2011), while height- function. Thompson and Goodman (2010) ened vulnerability to negative emotions and echo this view, arguing that certain types to emotional pathology have been attributed of attentional selectivity contribute to good 508 emotional regulation and therefore to emo-

Regulation of Emotion through Modification of Attention 509 tional resilience, while other patterns of researchers investigating whether individ- attentional deployment compromise emo- ual differences in emotion regulation are tional regulation in ways that give rise to systematically associated with variation in emotional pathology. Many other theorists selective attentional responding to negative have similarly proposed that attentional bias information have drawn upon cognitive–­ to negative information makes a maladap- experimental methodologies, to appraise tive contribution to emotion regulation that more objectively the attentional processes of elevates emotional vulnerability and the risk interest (Mathews & MacLeod, 2005). The of emotional pathology (White, Helfinstein, resulting assessment procedures infer atten- Reeb-S­utherland, Degnan, & Fox, 2009), tional selectivity not from self-r­eport mea- while attentional avoidance of negative sures but from performance measures, such information serves to enhance emotional as response latencies to make particular resilience (Troy & Mauss, 2011). decisions, that necessarily will be influenced in particular ways by underlying patterns of This idea that selective attentional attentional selectivity. Several such atten- response to negative information makes a tional assessment tasks have been widely causal contribution to emotional regula- used in studies designed to establish whether tion, and therefore functionally influences biased attention to negative information is emotional vulnerability and dysfunction, is characteristic of people who display evi- our focus in this chapter. Here we examine dence of poor emotion regulation. We now how use of cognitive technologies that have briefly describe these assessment techniques proven capable of systematically training and illustrate how each has lent support to attentional change has served to illumi- the veracity of this hypothesis. nate the causal role of selective attentional deployment in the regulation of emotion. We One of the earliest methodologies devel- also review evidence that the enhancement oped to objectively assess the association of emotion regulation, through the applica- between selective attentional responding to tion of such attentional bias modification negative information and emotional vulner- procedures, can yield tangible benefits for ability is the emotional Stroop task. In this people experiencing emotional difficulties. assessment approach, the participant must Before describing the attentional bias modi- rapidly name the color of emotionally toned fication approach, we first briefly summa- words displayed in differing ink colors, while rize the evidence that attentional preference ignoring their semantic content. The degree for negative information represents a reli- to which color naming is disproportionately able characteristic of emotional vulnerabil- slow on negative words compared to neutral ity and dysfunction. This also enables us to words is taken as a measure of attentional communicate how the types of cognitive–­ bias to negative information, as it suggests experimental tasks previously employed to particular difficulty ignoring the negative assess attentional bias recently have been content of these words. Individuals who adapted to create attentional bias modifica- display heightened emotional vulnerabil- tion procedures. ity, or who suffer from emotional dysfunc- tion, commonly show this pattern of emo- Assessing the Association tional Stroop performance (e.g., Williams, between Attentional Bias Mathews, & MacLeod, 1996), leading to and Emotion Regulation the conclusion that variation in the capac- Some investigators have sought to assess ity to regulate emotion is indeed related to attention simply by asking people to intro- differential attentional responding to nega- spectively reflect upon and self-r­eport the tive information (Ashley & Swick, 2009). manner in which their attention operates Another technique commonly used to assess (e.g., Derryberry & Reed, 2002). However, the association between selective attentional the limitations of relying on verbal reports response to negative information and indi- to assess cognitive processes have been well vidual difference in emotion regulation is documented (cf. Nisbett & Wilson, 1977). the visual search task. In this approach, par- In response to these limitations, many ticipants are exposed to an array of stimuli and are required to locate a specified target stimulus as quickly as possible. An index of

510 INTERVENTIONS attentional bias to negative information is tion, this does not permit the conclusion that provided by their relative speeding to detect such attentional deployment makes a direct emotionally negative targets compared to functional contribution to emotion regula- neutral or positive targets. It has repeatedly tion. This association could instead reflect been found that participants with height- the influence of emotion regulation on ened emotional vulnerability or dysfunction attentional selectivity. Alternatively, it could display greater evidence of such speeding be that attentional selectivity and emotion (c.f. Cisler & Koster, 2010). Investigators regulation represent the independent conse- employing this visual search approach have quence of some third individual-d­ ifference concluded that variation in attentional variable. To determine whether selective responding to emotional information is sys- attention exerts a causal influence on emo- tematically related to variation in the ability tion regulation, it is necessary to system- to regulate emotion effectively (Leclerc & atically alter attentional selectivity. Adop- Kensinger, 2008). tion of the attentional bias modification approach has served both to confirm, and to Probably the most widely used method capitalize on, the contribution of attentional of assessing biased attention to negative selectivity to emotion regulation. information is the attentional probe task (MacLeod, Mathews, & Tata, 1986). In The Attentional Bias this task, the participant is briefly exposed Modification Approach to stimulus pairs whose members differ in The most powerful way to evaluate the emotional valence. These stimuli can be hypothesis that patterns of selective atten- words or images, and most commonly one tional response to emotional information member of each pair is emotionally nega- make a functional contribution to individ- tive, while the other is neutral in emotional ual differences in emotion regulation is to tone. Immediately following stimulus offset, systematically manipulate such attentional a small visual probe is presented in the locus selectivity, in order to test the prediction of one the previously displayed stimuli, and that the modification of attentional bias the participant is required to rapidly execute will alter emotion regulation, as revealed by a discriminatory response to this probe. It changes in emotional reactivity and dysfunc- is assumed that the probe will be processed tion. Confirmation of this prediction would fastest when it appears in the locus where lend powerful support to the contention that participants already are attending. Hence, attentional bias is causally involved in emo- the degree to which this discrimination tion regulation. It also would introduce the response is speeded when the probe appears possibility that dysfunctional patterns of in the locus of the negative information, emotional symptomatology, resulting from rather than the locus of neutral informa- deficiencies in emotion regulation, might be tion, provides a measure of attentional bias therapeutically attenuated by clinical inter- toward negative information. A reliable ventions that appropriately exploit such finding from studies using this task is that attentional bias modification procedures. emotionally vulnerable individuals, and those suffering from emotional pathology, A number of early studies designed to display an attentional bias to negative infor- appraise the possibility that emotion regu- mation (c.f. Bar-Haim, Lamy, Pergamin, lation may be influenced by altering atten- Bakermans-K­ ranenburg, & van IJzendoorn, tional selectivity have employed only ver- 2007). Once again, this has led theorists to bal instruction as the intended method conclude that an attentional bias to nega- of attentional manipulation. Participants tive information is characteristic of deficient instructed to alter their attentional style not emotion regulation (e.g., Bradley, Mogg, uncommonly report that this alters their White, Groom, & de Bono, 1999). emotional experience (Richards & Gross, 2006). However, while such findings are While the weight of evidence leaves little certainly encouraging, reliance on verbal room for doubt that impaired emotion regu- instruction to modify attentional selectiv- lation, as evidenced by heightened emotional ity has a number of significant limitations vulnerability or the presence of emotional pathology, is reliably characterized by an attentional bias favoring negative informa-

Regulation of Emotion through Modification of Attention 511 (MacLeod & Bucks, 2011). For one thing, sented. In their ABM version of the task, such an approach at best could only influ- however, MacLeod et al. either presented all ence attentional processes amenable to voli- probes in the loci where the negative words tional control, and it is well established that appeared, in order to induce attentional the patterns of attentional bias that char- vigilance for negative information (attend-Â

512 INTERVENTIONS Harmer (2010) have demonstrated that the tial attentional response to negative verbal attentional change elicited by ABM proce- stimuli in students who obtained midrange dures is mediated by altered patterns of acti- scores on a measure of emotional vulnera- vation in the lateral frontal cortex. bility. These participants were subsequently exposed to a stressful anagram task, and This powerful new capacity to directly their emotion regulation capability was modify selective attentional responding to determined by assessing the degree to which emotional information has enabled research- this elicited anxious and depressed mood. ers not only to evaluate the hypothesis that While the anagram stressor increased levels such attentional bias causally contributes to of anxiety and depression across all partici- emotion regulation but also to exploit thera- pants, the magnitude of this dysphoric emo- peutically the capacity of these ABM pro- tional response was significantly attenuated cedures to enhance emotion regulation (cf. for the participants who had just completed Bar-Haim, 2010; Hertel & Mathews, 2011; ABM in the avoid-­negative rather than the MacLeod & Mathews, 2012). In reviewing attend-­negative training condition. Further- this work, we focus first on laboratory-b­ ased more, the degree to which the ABM proce- research that has employed single-­session dure influenced the emotional impact of this ABM, with the principal aim of illuminat- stressor was a direct function of the degree ing the functional nature of the associa- to which it influenced selective attentional tion between attentional bias and emotion responding to negative stimuli. These find- regulation. We next consider work that has ings confirm that selective attentional avoid- delivered extended ABM, with the aim of ance of negative information can enhance enhancing emotion regulation in ways that down-r­egulation of dysphoric responses to can reduce emotional vulnerability and dys- stressful experiences, which is a characteris- function in real-world settings. tic of good emotion regulation. Single‑Session ABM Studies: Using a single session of their visual search Determining the Causal ABM variant, Dandeneau and Baldwin Contribution of Attentional Bias (2009) have provided further support for to Emotion Regulation the idea that attentional selectivity causally Studies employing single-s­ession ABM influences emotion regulation. Unselected procedures have examined the impact of workers at an adult education center com- transiently induced change in attentional pleted a single session of this ABM task responding to emotional information on either in a condition designed to induce emotional experience within controlled lab- attentional vigilance for socially positive oratory settings. In some cases, investigators information (smiling faces) and avoidance have studied the effect of such ABM proce- of socially negative information (frowning dures on normal emotional reactions to con- faces), or in a control condition designed to trived stress. In others, the focus has been leave attentional selectivity unaltered. A sub- on the capacity of ABM to attenuate dys- sequent attentional probe assessment task functional emotional symptoms in partici- confirmed that participants given the ABM pants selected because of their disposition to training, but not those receiving the control experience particular types of emotional dif- condition, came to display attentional avoid- ficulties, such as worry, obsessive concerns, ance of information related to social rejec- or social anxiety. The following sections tion. The former participants also evidenced review the outcomes of these investigations. enhanced emotion regulation when exposed to a variety of stressor tasks. For example, Impact of Single‑Session they felt less subjective rejection than did ABM on Affective Reactivity control participants following a simulated to Laboratory‑Based Mood Induction interaction in which they were treated coldly, In two early studies, MacLeod et al. (2002) and this was particularly evident in partici- employed a single session of the probe-based pants who initially had scored low in self-­ ABM task to successfully induce a differen- esteem. Participants who had received the ABM training also reported less rejection-­ related thoughts when attempting to com- plete a subsequent insoluble anagram task.

Regulation of Emotion through Modification of Attention 513 Furthermore, failure on this task exerted a In an extension of this work, using wor- less negative impact on self-e­ steem in partici- riers selected in the same manner, Hirsch et pants who received the ABM than was the al. (2011) compared the impact of two vari- case for those in the control condition. Dan- ants of ABM. Both employed verbal stimuli, deneau and Baldwin reasonably concluded but one was designed to modify the degree from these findings that selective attentional to which attention is captured by negative responding to emotional information makes information, while the other was designed a direct functional contribution to the self-­ to instead modify the degree to which atten- regulation of emotional experience. tion is held by negative information. These two procedures altered attentional selectiv- These aforementioned studies indicate ity to an equivalent degree, but only the for- that attentional bias can causally influence mer ABM variant influenced subsequently emotion regulation in participants whose assessed negative thought intrusions. On the emotional experiences fall within the nor- basis of these findings, Hirsch et al. argue mal range. Researchers have gone on to that heightened attentional engagement with investigate whether a single session of ABM negative information may contribute more can transiently ameliorate dysfunctional than impaired attentional disengagement emotion in participants selected on the basis from such information to the evocation of of preexisting emotional problems. worry-r­elated negative thought intrusion. This study illustrates the capacity for care- Impact of Single‑Session ABM fully designed implementations of the ABM on Negative Thought Intrusions approach to illuminate which aspects of in Worriers attentional bias make the greatest contribu- Hayes, Hirsch, and Mathews (2010) tions to dysfunctional symptoms reflecting recruited volunteers who defined themselves impaired emotion regulation. as high worriers, and who scored high on a conventional worry questionnaire. Half of Impact of Single‑Session ABM on these participants were given an ABM proce- Behavioral Avoidance in Subclinical dure that delivered the probe ABM task and Obsessive–Compulsive Disorder a novel dichotic ABM task, both configured The studies reported so far have assessed to induce attentional avoidance of negative the impact of ABM only on self-­report mea- information. The remaining participants sures of emotion. However, the modification were given control versions of these tasks of attentional bias to negative information without any training contingency. When also has been shown to influence behavioral attentional bias was subsequently measured, indices of dysfunctional emotion. Najmi it was found that participants receiving and Amir (2010) recruited individuals who ABM differed significantly from the control reported excessive concern about germs, dirt, participants in terms of attentional bias, and or contamination, and scored high on a con- now demonstrated the intended avoidance of ventional measure of obsessive–c­ompulsive negative information. A thought-­sampling symptomatology. Half these participants procedure was then employed to assess neg- received a single session of probe-based ative thought intrusions before and after a ABM, delivered in the avoid-n­ egative train- final worry induction. Although there was ing condition, while the other half received no significant difference between the groups this task in a control condition that did not in terms of negative thought intrusions include any training contingencies. The before the worry induction, the control par- emotionally negative information presented ticipants, but not the experimental partici- in these tasks was words chosen on the basis pants, evidenced an increase in such intru- of their relevance to contamination-­related sions following this worry manipulation. concerns. As intended, the former group, but The finding that participants who received not the latter, came to exhibit attentional avoid-n­ egative ABM experienced less nega- avoidance of this contamination-r­ elated neg- tive thought intrusions than did those who ative information. A behavioral approach received the no-t­raining control procedure task was then given, which required par- verifies that attentional bias can make a ticipants to take as many steps as possible casual contribution to worry.

514 INTERVENTIONS toward a contamination-­related stimulus with beneficial behavioral consequences for (e.g., potting soil mixed with cat hair and speech performance. dead crickets). Those who had received the avoid-­negative ABM training exhib- Using a somewhat more complex design, ited greater levels of behavioral approach which involved having participants engage in than did those who instead received the physical exercise during the ABM sessions, control condition. Moreover, Najmi and Julian, Beard, Schmidt, Powers, and Smits Amir were able to show that the degree to (2012) recently failed to replicate Amir et al.’s which this ABM training increased behav- (2008) finding that ABM designed to reduce ioral approach was mediated by the degree attention to negative information served to to which it reduced attentional bias to the attenuate emotional reactivity to a subse- negative information. Thus, selective atten- quent speech stressor. However, it should be tional responding to negative information emphasized that Julian et al.’s (2012) ABM makes a contribution to not only the regula- procedure actually failed to modify selective tion of emotion itself but also the regulation attentional responding to negative infor- of emotionally relevant patterns of behavior. mation. Hence, the results of this study do not challenge the hypothesis that selective Impact of Single‑Session ABM on attentional deployment influences emotion Affective, Somatic, and Behavioral regulation. Other investigators who have Symptoms of Social Anxiety succeeded in modifying this attentional bias Amir, Weber, Beard, Bomyea, and Taylor have been able to verify Amir et al.’s (2008) (2008) have shown that ABM also influ- original conclusion that such attentional ences emotionally relevant patterns of bias modification influences both subjective behavior in socially anxious people with and behavioral measures of socially anx- a fear of public speaking. Included in the ious participants’ stress response to a speech study were individuals who responded to an task. Heeren, Lievens, and Philippot et al. advertisement seeking volunteers who had (2011) delivered a range of attentional train- difficulty giving speeches, and who scored ing variants to socially anxious participants high on a questionnaire measure of social and found that an ABM procedure designed anxiety. They were exposed to a single-­ specifically to increase attentional disen- session attentional probe procedure that gagement from faces displaying negative presented faces displaying either negative expressions was most effective in enhancing emotion (disgust) or neutral expressions, independently rated speech performance, delivered in either the avoid-­negative ABM while also reducing self-­reported anxiety. condition or a no-­training control condi- Thus, the pattern of attentional selectivity tion. As intended, the former participants that most contributes to the adaptive regula- alone displayed a significant reduction in tion of social anxiety may involve the ready attention to the socially relevant negative disengagement of attention from socially rel- information, coming to show less atten- evant negative information. tion to such negative information than did control participants. When subsequently The weight of evidence from single-­session required to give a short speech, the partici- ABM studies firmly favors the conclusion pants who had received avoid-n­ egative ABM that selective attentional responding to emo- were rated as performing better than con- tional information can make a causal contri- trol participants. They also reported lower bution to emotion regulation. Single sessions levels of anxiety during speech presentation of ABM can moderate the intensity of nor- than did control participants. The superior mal affective reactions to laboratory stress- speech performance exhibited by the par- ors, and attenuate dysfunctional emotional ticipants who received avoid-n­ egative ABM symptoms such as excessive worry, elevated was statistically mediated by the emotional social anxiety, and undue concerns over impact of this ABM procedure. This sug- contamination within the laboratory set- gests that the induced attentional avoidance ting. Such findings offer empirical support of negative information adaptively regulated to the hypothesis that attentional selectiv- emotional response to the speech stressor, ity contributes to the regulation of emotion. They also raise the prospect that appropri- ately designed extensions of single-­session ABM procedures may be capable of enhanc-

Regulation of Emotion through Modification of Attention 515 ing emotion regulation within real-world emotional reaction was attenuated in partic- settings in ways that may deliver practical ipants who had received the avoid-­negative therapeutic benefits. In the next section, ABM, compared to control participants. we consider ABM studies that have directly Furthermore, a measure of trait anxiety, evaluated this exciting possibility. reflecting general disposition to experience anxiety symptoms, also was attenuated by Extended‑Delivery ABM Studies: the ABM procedure. The degree to which The Therapeutic Enhancement ABM reduced attention to negative infor- of Emotion Regulation mation statistically mediated the degree to in Real‑World Settings which it reduced trait anxiety, which in turn While the results of single-­session ABM mediated its impact on emotional reactivity studies have confirmed that selective atten- to the stressful transition event. Thus, the tional responding to emotional information reduction of attention to negative informa- can influence emotion regulation within the tion through extended exposure to ABM laboratory, this does not mean that atten- served to enhance the regulation of emotion tional bias necessarily contributes to real- within the naturalistic setting in ways that world emotion regulation. Nor do these decreased negative emotional reactivity to a finding permit the conclusion that ABM has real-world stressor. the capacity to enhance emotion regulation in ways that can reduce dysfunctional emo- Similar conclusions are invited by the find- tional experience outside the experimen- ings of Dandeneau et al. (2007), who exam- tal setting. Both of these issues have been ined the impact of 5 consecutive days of their addressed, however, by studies designed to visual search ABM task on self-­report and evaluate whether repeated exposure to ABM physiological indices of negative emotional procedures can enhance regulation of emo- experience in participants who experienced tional reactions to naturalistic stressors, and stressful real-world situations. Compared can improve emotion regulation to an extent to those who received a no-t­raining con- that ameliorates the clinical symptoms of trol procedure, students who completed this emotional pathology in the real-world. extended ABM in the condition designed to inhibit attention to negative and increase Impact of Extended ABM on Affective attention to positive information reacted to Reactivity to Real‑Life Stressors a subsequent school examination with lower See, MacLeod, and Bridle (2009) employed levels of subjective stress and anxiety. When an online procedure to deliver 10-minute telemarketers, employed within a stress- sessions of a probe-based ABM task on each ful work environment, received this 5-day of 15 consecutive days, to high school grad- ABM procedure, they reported an increase uates approaching the stressor of migrating in self-­esteem and decrease in subjective overseas to commence tertiary education. stress, compared to colleagues given a no-­ Half received this task in the avoid-n­ egative training control procedure. They also evi- training condition, while the other half denced a reduction in physiological signs of received it in a control condition containing stress, were rated as more confident by their no attentional training contingency. The for- supervisors, and even showed higher levels mer participants, unlike the latter, displayed of sales performance. Such findings strongly a reduction in attention to negative informa- support the involvement of attentional selec- tion across the duration of the study. Emo- tivity in real-world emotion regulation and tional measures taken immediately after par- demonstrate that attentional bias modifica- ticipants subsequently experienced the stress tion procedures can enhance the regulation of migration were compared with measures of normal emotional experience in ways that taken prior to the commencement of the benefit people in stressful real-world situa- study. As anticipated, this real-world stress tions. event substantially increased state anxiety. However, the magnitude of this negative Impact of Extended ABM on Pathological Worry The extended delivery of ABM also has been shown to attenuate dysfunctional emo-

516 INTERVENTIONS tional symptoms experienced outside the was such that, after this 4-week period, only laboratory by people who report worry- 50% of the participants who had received ing excessively. Hazen, Vasey, and Schmidt avoid-n­egative ABM continued to meet (2009) recruited participants who exhibited diagnostic criteria for GAD, compared extreme levels of worry, and across a 2-week with 87% of those in the control condition. period completed five sessions, each lasting Amir et al. concluded that biased attentional for 30 minutes, of either probe-based ABM responding to negative information func- in the avoid-­negative condition or a control tionally contributes to the emotional pathol- task that contained no training contingency. ogy observed in GAD. Moreover, on the The attentional vigilance for negative infor- basis of their findings, they advocate the use mation initially shown by these worriers was of ABM as a clinical tool in the treatment of reversed by the avoid-­negative ABM. Partici- this emotional disorder. pants who received this ABM, unlike con- trol participants, also displayed a significant Impact of Extended ABM on Social reduction in worry, anxiety, and depression. Anxiety Dysfunction Hazen et al. contend, on the basis of their There is compelling evidence that extended findings, that the enhancement of emotion exposure to ABM can enhance emotional regulation using attentional training may functioning in people experiencing problem- make a therapeutic contribution to the treat- atic levels of social anxiety. After recruiting ment of generalized anxiety disorder (GAD), participants who scored high on a question- in which pathological worry is the hallmark naire measure of social anxiety, Li, Tan, symptom. Qian, and Liu (2008) gave them seven con- secutive daily sessions that presented either Subsequent research has lent empiri- probe-based ABM in the avoid-n­ egative con- cal weight to this contention. Amir, Beard, dition, or a control version of this procedure Burns, and Bomyea (2009) directly assessed that contained no training condition. Only whether ABM produced clinically significant those who received the avoid-n­ egative ABM benefits when given to treatment-­seeking came to display reduced attention to nega- individuals meeting diagnostic criteria for tive information, and only they evidenced GAD. All patients completed an attentional a significant reduction in Social Interaction probe task twice weekly across a 4-week Anxiety Scale (SIAS) scores. Li et al.’s find- period. For one group, this task was given ings suggest that the regulation of real-world in the avoid-­negative ABM condition, con- social anxiety can be improved by the modi- figured to induce attentional avoidance of fication of attentional bias in nonclinical negative information, while another group participants. Later work carried out with received a control condition that contained clinical samples indicates that such ABM no training contingency. Clinical symp- procedures also can therapeutically alleviate tomatology was assessed before and after the clinical symptoms of patients with psy- this 4-week period, using both question- chological disorders that involve excessive naire measures and diagnostic interview. levels of social anxiety. Patients who received avoid-­negative ABM procedure displayed the expected decrease Amir, Beard, Taylor, et al. (2009) exam- in attention to negative information, which ined whether ABM could enhance emo- was not shown by patients in the control tional functioning in patients meeting diag- condition, resulting, as intended, in a post- nostic criteria for generalized social phobia training group difference in selective atten- (GSP). Patients who received eight sessions tional responding to negative information. of avoid-­negative ABM across a 4-week Across the 4 weeks of the study, patients in period evidenced reduced levels of attention the control condition evidenced no decline in to socially relevant negative facial expres- either questionnaire measures or interview-­ sions, which was not the case for those who based measures of symptomatology that instead received a no-­training control ver- assessed worry, anxiety, and depression. In sion of the procedure. Over these 4 weeks, contrast, patients who received the avoid-­ the former patients, relative to the latter, negative ABM procedure demonstrated reli- also exhibited disproportionate reductions able reductions in all these symptom mea- across all measures of social anxiety, which sures. The clinical significance of the change

Regulation of Emotion through Modification of Attention 517 included the Liebowitz Social Anxiety Scale tic environments and enhances their capacity (LSAS), the Social Phobia and Anxiety to regulate their emotional reaction to exper- Inventory (SPAI) and the Sheehan Disability imentally delivered social stress. Patients Scale (SDS). At the end of this period, only diagnosed with GSAD were given four daily 50% of the individuals who had received the sessions of ABM training in either the avoid-­ avoid-­negative ABM training continued to negative condition or a no-t­raining control meet diagnostic criteria, compared to 86% version of the task. Attentional bias to nega- of those who received the control condition. tive information was significantly attenu- This improvement in social anxiety symp- ated at a posttraining assessment point for toms experienced by the patients given ABM the former participants relative to the latter. was maintained at 4-month follow-u­ p. Participants receiving ABM also exhibited a disproportionate decline in social anxi- Carlbring et al. (2012) recently failed to ety, as assessed by the LSAS and the Fear of replicate Amir, Beard, Taylor, et al. (2009) Negative Evaluation Scale (FNE). Prior to, findings when delivering ABM online to and after, the 4 days of attentional training Internet-­recruited volunteers who met diag- participants were exposed to a speech task, nostic criteria for social anxiety disorder in which they delivered a 2-minute oral pre- (SAD). However, it is important to note sentation, and the impact of this stressor on that this intended ABM procedure failed to self-r­eport, behavioral, and physiological induce any reduction in selective attention measures of emotion was assessed. Partici- to negative information. Hence, while Carl- pants who received the avoid-­negative ABM bring et al.’s study raises questions concern- displayed a disproportionate reduction, rela- ing the most effective methods of bringing tive to control participants, in the degree to about attentional change, its negative find- which this stressor evoked negative emotion ings do not challenge Amir, Beard, Taylor, at the posttraining assessment point. Those et al.’s (2009) conclusion that attentional who had received ABM reported experienc- bias causally contributes to impaired emo- ing less distress than did control participants tion regulation in SAD. Moreover, converg- during the speech task. They also performed ing support for the conclusion that ABM can the task with less evidence of negative emo- alleviate such clinical dysfunction has been tion, as assessed by behavioral ratings and independently obtained by other investiga- galvanic skin response (GSR). tors. For example, Schmidt, Richey, Buck- ner, and Timpano (2009) evaluated the Impact of Extended ABM impact of avoid-­negative ABM on the clini- on Depression cal symptoms of patients diagnosed with An attentional bias to negative information generalized social anxiety disorder (GSAD), is generally considered a more robust char- using the same experimental design as Amir, acteristic of anxiety than depression, raising Beard, Taylor, et al. (2009). Patients who uncertainty concerning whether such atten- received eight such ABM sessions across a tional selectivity contributes to the regula- 4-week period demonstrated reduced levels tion of depression. Nevertheless, a few ABM of emotional dysfunction compared to par- studies suggest that this is the case, at least ticipants who received the no-­training con- when depression is not severe. For example, trol condition on all measures of social anxi- Wells and Beevers (2010) recruited under- ety, which included the SPAI, the LSAS, and graduate students whose questionnaire the Brief Social Phobia Scale. At the end of scores indicated mild to moderate levels of this 4-week period only 28% of those who depression. Across a 2-week period they received the avoid-­negative ABM continued received four sessions of either probe-based to meet diagnostic criteria for GSAD, com- ABM in the avoid-n­ egative training condi- pared to 75% of participants in the control tion or a control probe task that contained condition. Again, these gains were largely no training contingency. Across this period, maintained at 4-month follow-­up. the former participants alone displayed a reduction in attention to negative informa- Heeren, Reese, McNally, and Philippot tion, and by the end of the 2 weeks they (2012) have shown that extended exposure were displaying significantly lower levels to avoid-n­ egative ABM reduces the negative emotional symptoms experienced by patients with social anxiety dysfunction in naturalis-

518 INTERVENTIONS of attention to negative information than adolescence has led researchers to recognize was the case for control participants. Like- the importance of better understanding the wise, only the participants who received the factors that contribute to emotion regula- avoid-­negative ABM showed a reduction in tion in young people and identifying ways depressive symptoms across these 2 weeks, of enhancing this. ABM studies suggest that and at the end of the period their depression selective attentional responding to negative scores were significantly lower than those information causally influences emotion of control participants. This ABM-induced regulation in children as well as adults, and difference in depression levels remained evi- provide grounds for optimism that ABM dent at a follow-­up assessment 2 weeks later. procedures can be used to enhance emotion The influence of the training procedure on regulation in younger populations. Early depressive symptomatology was statistically support for the hypothesis that attentional mediated by its impact on attentional bias. selectivity contributes to emotion regulation in children was provided by Eldar, Ricon, These findings suggest that attentional and Bar-Haim (2008). These researchers’ selectivity causally contributes to the regula- recruited children ages 7–12 years, whose tion of depression, as well as anxiety, rais- questionnaire scores placed them midrange ing the possibility that ABM may potentially in terms of emotional vulnerability. Across yield benefits in the treatment of depressive two sessions, these children completed a dysfunction. It would be premature, how- probe-based ABM procedure in either an ever, to draw conclusions concerning the avoid-­negative or an attend-n­egative train- responsiveness of clinical depression to this ing condition. Following this, they were type of attentional manipulation. Baert, De exposed to a stressor, which involved their Raedt, Schacht, and Koster (2010) reported being videotaped while trying to solve a dif- finding no therapeutic impact of a novel ficult puzzle. Children who had been given probe-based ABM procedure they deliv- the differing ABM procedures exhibited dis- ered, across 10 daily sessions, to students crepant emotional reactivity to this stressor. reporting severe depression, and to patients Those who had received the attend-­negative receiving concurrent conventional treatment ABM experienced a pronounced elevation for clinical depression. It must be noted, of negative emotion following exposure to however, that the probe-based procedure the stressor, relative to a prestressor base- employed by these researchers not only dif- line mood measure. In contrast, children fered in significant ways from the ABM task who had received the avoid-­negative ABM adopted by most other researchers (e.g., showed no elevation of negative emotion presenting only single stimuli rather than in response to the stressor. Thus, altering stimulus pairs) but also prove ineffective in attentional responding to negative informa- altering selective attentional responding to tion influenced the regulation of the emo- negative emotional information. We concur tional reactions to stress exhibited by the with the authors that their failure to induce children. In addition to confirming the role differential attentional selectivity using this of attentional selectivity in childhood emo- intended bias modification procedure begs tion regulation, these findings highlight the a cautious interpretation of the accompany- potential value of ABM as a technique for ing failure to influence emotional symptom- enhancing such regulation in children with atology in severely depressed students and dysfunctional emotional symptomatology. clinically depressed patients. It remains to be seen whether the successful reduction of More recently, two published randomized attention to negative information can serve controlled trials further strengthen the con- to therapeutically attenuate clinically signif- clusion that improving emotion regulation icant depression. through direct modification of attentional selectivity can therapeutically alleviate dys- Impact of Extended ABM functional emotional experience in anxious on Dysfunctional Affect in Children children. The first of these was carried out and Adolescents by Bar-Haim, Morag, and Glickman (2011) Across recent years, growing concern over on a sample of 10-year-old children who emotional dysfunction in childhood and scored high on a questionnaire instrument screening for childhood emotional disor-

Regulation of Emotion through Modification of Attention 519 ders. These children were randomly assigned Well over twice as many of children who to receive either a probe-based ABM avoid-­ received avoid-n­ egative ABM, as those who threat training, or a control version of the received the control condition, showed full task containing no training contingency, on remission. Specifically, 33.3% no longer met two occasions separated by 4–6 days. Pre- diagnostic criteria for any anxiety disorder training attentional bias was assessed prior after receiving the 4 weeks of avoid-n­ egative to the first ABM session, while posttrain- ABM, compared to only 13.3% of those in ing attentional bias was assessed 5–8 days the control condition. Hence, for children after the second ABM session. At this latter who suffer from emotional dysfunction, assessment point, participants were exposed as for adults, modification of attentional to the puzzle stressor employed by Eldar et selectivity to increase avoidance of negative al. (2008) to ascertain whether ABM influ- information serves to improve emotion regu- enced regulation of their emotional reactivity lation, as evidenced by the significant reduc- to stress. The avoid-n­ egative ABM training tion of dysfunctional emotional experience. changed attentional selectivity as intended, with the children who received this train- Future Directions for ABM ing displaying reduced attention to negative Approaches to Emotion Regulation information compared to control children. The studies reviewed in this chapter have It also enhanced emotion regulation dur- demonstrated that ABM procedures can ing performance of the stressor task. While serve to attenuate dysfunctional emotional children in the control condition displayed a symptoms. It may seem paradoxical that significant elevation of negative emotion in ABM-induced attentional avoidance of response to the final stressor, no elevation of negative information can be therapeutically negative affect was elicited by this stressor in beneficial given that many models implicate children who had undergone avoid-n­ egative avoidance in the etiology of psychopathol- ABM training. Hence, despite their initially ogy. However, such accounts often pertain high levels of emotional vulnerability, these to behavioral rather than to cognitive avoid- children became more resilient to stress ance (see Barlow, 2002). Furthermore, with when they acquired the ability to attention- respect to cognitive avoidance, it is impor- ally avoid-­negative information, indicat- tant to distinguish effortful attempts to ing that this style of attentional selectivity suppress negative thoughts from the type improves emotion regulation in younger of attentional avoidance induced by ABM. populations also. The former appears to be emotionally coun- terproductive, probably because effortful Eldar et al. (2012) recently conducted thought suppression commonly fails to pro- the first randomized controlled trial evalu- duce the intended pattern of cognitive avoid- ating the impact of ABM on children with ance and can instead paradoxically increase formally diagnosed pediatric emotional dis- the very thoughts one tries to suppress (Weg- orders. Their sample comprised treatment-­ ner, Schneider, Carter, & White, 1987). seeking children, ages 8–14 years, recruited In contrast, ABM procedures designed to from a hospital-b­ ased child anxiety clinic. reduce attention to negative information All met diagnostic criteria for at least one without effort or intention have proven suc- anxiety disorder (i.e., separation anxiety cessful in inducing attentional avoidance disorder, social phobia, specific phobia, or of such information, with consequent emo- GAD), with 75% meeting diagnostic criteria tional benefits. for more than one such disorder. These clini- cally anxious children received four weekly The conclusion that ABM procedures sessions of either probe-based ABM in the can effectively modify attentional response avoid-­negative condition or a control ver- to negative information and therapeutically sion of the task containing no training con- alleviate dysfunctional emotion has been tingency. Children who received the avoid-­ bolstered by the outcomes of recent meta-­ negative ABM, but not those who received analyses. One such meta-a­nalysis by Hal- the control condition, demonstrated a sig- lion and Ruscio (2011), which did not distin- nificant decline in both the number of anxi- guish between bias modification procedures ety symptoms recorded at clinical interview and the rated severity of these symptoms.

520 INTERVENTIONS designed to alter attentional vs. interpretive procedures, in ways guided by deeper under- selectivity, revealed that cognitive bias mod- standing of the mechanisms through which ification exerts a medium-s­ ize effect on both existing ABM tasks exert their influence. cognitive bias (g = 0.49) and clinical symp- Additionally, the capacity of existing ABM tomatology (g = 0.39). Other meta-a­ nalyses tasks to modify attentional selectivity effec- that have focused specifically on the modifi- tively may be further enhanced by refining cation of attentional bias (Hakamata et al., the manner in which they are delivered. We 2010; Beard, Sawyer, & Hofmann, 2012) briefly consider, in turn, each of these poten- have concluded that ABM exerts a large tial approaches to the future improvement of effect on attention bias (g = 1.06–1.15), and ABM techniques. a medium-­to-large effect on clinical symp- tomatology (g = 0.48–0.77). Meta-­analysis One important issue will be to establish also has identified some clinically relevant whether ABM tasks exert a highly specific variables that may moderate the magni- effect on attentional bias alone, or whether tude of both effects. For example, Beard et their emotional benefits reflect change in al. report that ABM alters attentional bias more general cognitive control systems, such to the greatest degree in participants who as working memory. Consistent with this lat- show highest initial levels of negative emo- ter possibility, Hirsch, Hayes, and Mathews tional symptomatology. Bias modification (2009) reported that their cognitive bias appears to influence anxiety more than modification procedure not only reduced the depression (Hallion & Ruscio, 2011). Haka- selective process of negative information but mata et al. (2010) found that ABM has a also improved working memory. Klumpp greater impact on anxious disposition than and Amir (2010) argued, on the basis of on anxious mood state per se, and that this their findings, that the impact of ABM tasks emotional impact is nominally greater in on attentional bias may be mediated by a anxiety patients than in nonclinical partici- general improvement in cognitive control. pants. This overall pattern lends weight to Whether any such training induces improve- the potential value of ABM in the treatment ment in working memory, directly influences of emotional dysfunction, particularly in the emotion regulation, or instead facilitates case of anxiety disorders. adaptive change in attentional bias, must be determined by future research. However, Having established that attentional avoid- such considerations suggest that develop- ance of negative information can success- ing ABM tasks in ways that maximize their fully be induced by ABM procedures, and capacity to improve working memory, or serves to increase emotional resilience and perhaps supplementing the delivery of ABM alleviate dysfunction emotional experience, tasks with training procedures designed to future research can now build on this firm directly improve working memory (Owens, foundation in a number of important ways. Koster, & Derakshan, 2013), may augment We close this chapter by considering several their capacity to enhance emotion regula- directions that we believe will prove to be tion. particularly profitable. The refinement of ABM procedures also Improving ABM Techniques to Better will likely benefit from better understanding Enhance Emotion Regulation of the particular juncture(s) in the emotion The degree to which emotion is influenced regulation continuum where ABM exerts by ABM procedures is largely determined its effect(s). Gross and Thompson (2007) by the extent of change in negative atten- propose that the influence of selective atten- tional bias that they induce (Hakamata tional deployment on emotion regulation et al., 2010). Therefore, an obvious way occurs at the emotion generation stage. The potentially to increase the beneficial impact finding that ABM influences emotional of ABM techniques on emotion regulation reactivity to stressors is consistent with the will be to improve their capacity to modify possibility that it affects the generation of selective attentional responding to nega- negative emotion. However, ABM also may tive information. This endeavor will likely exert an influence subsequent to initial emo- involve the future development of new CBM tion generation, at the response-­focused stage of emotional regulation, by operat- ing to prolong or curtail negative emotional

Regulation of Emotion through Modification of Attention 521 experience. This, too, could contribute to ing contingency, or to identify the training its observed impact on emotional reactiv- condition to which they have been exposed ity measures, which typically involve the (Beard, 2011). However, this represents only assessment of emotional experience at least weak evidence that ABM influences atten- several minutes after commencing exposure tional selectivity implicitly. Furthermore, to an emotion-­generating stressor. Indeed, even if attentional change is trained implic- it may be that modifying certain aspects of itly by existing ABM approaches, the pos- attentional selectivity, such as initial atten- sibility remains that explicit training may tional engagement with negative informa- more effectively induce therapeutic change tion, could influence the emotion-­generation in attentional bias. Hence, we suggest that stage, while modifying other aspects of future investigators should empirically con- attentional selectivity, such as the degree trast the impact of implicit and explicit ver- to which negative information holds atten- sions of ABM, which differ with respect tion over time, instead could influence the to whether they provide participants train- longevity of generated emotions (Hirsch ing contingency information and directly et al., 2011). Determining where alterna- instruct practice in the target pattern of tive ABM variants exert their influence on attentional selectivity. Future research of emotion regulation will require fine-­grained this type will identify which approach yields assessment of the temporal dynamics of the the greatest emotional benefit, and in doing resulting change in emotional experience, so will also illuminate whether implicit or and physiological measures such as GSR explicit attentional change more strongly and heart rate variability may prove useful governs the impact of ABM on emotional in this regard. Future research of this type regulation. could potentially lead to the development of new ABM batteries designed either to exert Enhancing the power of ABM procedures a broader influence across multiple stages of must involve not only increasing the size emotion regulation or selectively target par- and longevity of the attentional effects they ticular stages of emotional regulation, per- evoke but also ensuring good generalization haps in an individually tailored manner. of this training. Generalization is revealed by the transfer of training effects beyond While the creation of new of attentional the original training task. A distinction has training procedures, guided by better under- been drawn between “far-­transfer” and standing of the mechanisms through which “near-t­ransfer” where, respectively, train- ABM influences emotion regulation, will ing effects are observed under conditions likely contribute to future progress, it also that differ either greatly, or only slightly, seems probable that the efficacy of existing from the initial training experience (Her- ABM tasks could be improved by identify- tel & Mathews, 2011). Most ABM studies ing the most effective delivery formats. Most have confirmed near-t­ransfer of training by obviously, increasing the number and length showing that the attentional impact of ABM of ABM sessions may amplify the resulting can be detected on new stimulus materi- attentional change, and it has been suggested als not employed in the training task (e.g., that such change may be more enduring if MacLeod et al., 2002; Hirsch et al., 2011). ABM sessions are widely distributed across However, the practical value of ABM clearly time rather than grouped in close tempo- depends on also ensuring the far-­transfer of ral proximity (Hertel & Mathews, 2011). training. Given that the effect of ABM can be Another interesting possibility is that the detected on emotional assessment tasks very impact of ABM procedures on attentional different in nature from the original training bias may be affected by nature of instruc- procedures, it seems clear such far-t­ransfer tions given to participants. Researchers can occur (MacLeod & Mathews, 2012). commonly have assumed that ABM alters Further evidence of far-t­ransfer comes from attention implicitly, and so typically have studies demonstrating that ABM-induced not explicitly communicated either the train- training effects can be detected across quite ing contingency or intention to participants different measures of attentional selectivity (MacLeod & Mathews, 2012). Consistent (e.g., Dandeneau & Baldwin, 2004), and with this assumption, participants often also on measures of interpretive selectivity are unable to subsequently report the train- (e.g., White, Suway, Pine, Bar-Haim, & Fox,

522 INTERVENTIONS 2011). Nevertheless, occasional transfer fail- specifically to modify attentional response ures (e.g., Bockstaele, Koster, Verschuere, to negative information. However, the ABM Crombez, & De Houwer, 2012) underscore approach could potentially be employed to the importance of identifying how best to enhance other forms of self-­regulation that optimize far-­transfer. It has been proposed plausibly are affected by attentional selec- that the prospect of ABM training generaliz- tivity. For example, the hypothesis that ing to new contexts and to new tasks might heightened positive affectivity reflects an best be ensured by delivering ABM training attentional bias toward positive information sessions across a variety of differing con- (Taylor, Bomyea, & Amir, 2011), suggests texts, and varying the task procedures and that ABM designed to modify attentional parameters employed within them to induce responding to positive information could attentional change (MacLeod, Koster, & influence positive emotional reactivity to Fox, 2009). As yet, this proposal has not happy events. Grafton, Ang, and MacLeod been formally tested, so it remains to be seen (2012) recently confirmed this by demon- whether these innovations would indeed strating that participants exposed to an increase such generalization. ABM procedure that increased attention to positive words, compared to those given an While the purpose of ABM in clinical ABM procedure that reduced attention to studies conducted to date has been to induce such words, displayed disproportionately general attentional avoidance of negative intense positive emotional reactions to a information, such a pattern of selectivity subsequent success experience. may not be optimal across all contexts. For example, there will likely be advantages The potential therapeutic benefits of associated with attending to threat cues in ABM need not be restricted to the regula- situations where the risk of genuine danger tion of emotional experience. In many types is high. Maximal well-being may result from of psychological dysfunction that involve attentional vigilance to negative informa- biased patterns of attentional selectivity, the tion in high-risk contexts, and attentional primary symptom that could benefit from avoidance of such information in low-risk better regulation is not emotion. There is contexts. It would therefore be appropriate growing evidence that ABM procedures may for future researchers to investigate whether prove beneficial in enhancing these other ABM can be delivered in ways that induce clinically relevant aspects of self-­regulation. situation-­specific patterns of attentional For example, people with chronic pain syn- selectivity, such that the optimal attentional drome display an attentional bias toward response to negative information becomes pain-­related information, and theorists con- operational within each of these differing tend that this pattern of attentional selectiv- types of context. While undoubtedly ambi- ity makes a functional contribution to their tious, the viability of this objective is sup- heightened perceptions of pain (Eccleston ported by recent demonstrations that when & Crombez, 1999). A long-­standing aim alternative patterns of implicit processing of psychological interventions for this con- each are trained within a differing situa- dition has been to enhance self-­regulation tional context, reinstatement of either train- of pain sensation. Recent work examining ing context favors expression of the spe- whether ABM can contribute to the regula- cific pattern of cognition originally trained tion of pain experience has yielded promis- within that same context (e.g., D’Angelo, ing outcomes. For example, Sharpe et al. Milliken, Jimenez, & Lupianez, 2013). (2010) gave participants either a conven- tional relaxation manipulation or a probe- Extending the Application of ABM based ABM procedure designed to induce to Other Forms of Self‑Regulation attentional avoidance of pain-r­elated infor- Because this review describes research moti- mation, before exposing them to a cold vated by the hypothesis that attentional bias pressor task designed to induce painful sen- to negative information underpins emo- sation. Those who received the attentional tional vulnerability and dysfunction, the training reported later onset of pain than did focus has been on ABM procedures designed those given the relaxation procedure. Such findings should encourage future research-

Regulation of Emotion through Modification of Attention 523 ers to investigate whether the use of ABM Refining the Clinical Utility of ABM to directly manipulate selective attentional in the Remediation of Dysfunctional responding to pain-r­ elevant information can Emotion Regulation enhance the regulation of pain sensation in Given the wealth of evidence that supports ways that yield therapeutic benefits for peo- the capacity of ABM approaches to influ- ple who suffer from this clinical condition. ence emotion regulation beneficially, it is no surprise that investigators now are seek- Another clinical disorder that involves ing to exploit its therapeutic potential in impaired self-r­egulation, but in which nega- the treatment of emotional dysfunction and tive emotional experience is incidental to the other psychological disorders that involve symptoms of primary concern, is substance deficient self-­regulation. This approach now dependency. Addictions are characterized has passed the proof-of-­concept stage as a by biased patterns of attentional selectivity viable means of therapeutically attenuating that favor information related to the abused clinically relevant symptoms, warranting substance, and theorists contend that this its further development as a practical tool bias contributes to associated craving and that can be employed in the clinical setting. consumption (Wiers et al., 2007). This has Already, several small-scale studies have led some investigators to examine whether confirmed that ABM configured to induce ABM variants designed to reduce attention attentional avoidance of negative informa- to such information can serve to attenu- tion can be employed effectively within con- ate craving and/or regulate consumption, ventional psychology clinics to treat patients and positive findings have been reported suffering from anxiety disorders and/or clin- for both tobacco dependency and alcohol ical depression (Brosan, Hoppitt, Shelfer, abuse. After exposure to a single-­session Sillence, & Mackintosh, 2011; Beard, Weis- of probe-based ABM, configured to either berg, & Amir, 2011). increase or decrease attention to smoking cues, Attwood, O’Sullivan, Leonards, Mack- The more widespread adoption of ABM intosh, and Munafo (2008) found that male within the clinical setting will partly depend smokers in the latter group reported reduced upon patients’ perceived acceptability of the craving for tobacco, and this reduction in approach. Hence, it is reassuring that patient craving was predicted by the magnitude of feedback has generally been favorable. Fol- the induced attention change. Fadardi and lowing delivery of their 12-session ABM Cox (2009) gave a sample of problem drink- program to socially anxious 10- to 17-year- ers four weekly sessions of ABM, configured olds, Rozenman, Weersing, and Amir (2011) to reduce attention to alcohol-r­elated infor- had recipients and their parents rate the mation. This successfully modified atten- acceptability of this intervention procedure. tional selectivity as intended and led also to Responses ranged from acceptable to excel- a significant decline in alcohol consumption, lent, with mean participant and parent rat- which was maintained at 3-month follow-u­ p. ings of 4.2 and 4.5, respectively, on a 5-point scale. Beard (2011) likewise reported that Thus, it would appear that the modifica- primary care patients receiving ABM were tion of attentional bias carries the potential generally quite satisfied with the procedure to enhance other forms of self-r­egulation, on average, rating its acceptability at level 3 beyond the direct regulation of emotional on 4-point scale. Beard also noted that drop- experience, so future research could prof- out rates from treatment trials delivering itably seek to extend the application of the such bias modification have typically been ABM approach across a wider range of such low, ranging from 0 to 8%, suggesting that conditions. Of course, given that distressing recipients find the procedures acceptable. conditions such as chronic pain and sub- Nevertheless, qualitative interviews car- stance dependency contribute to negative ried out by Beard and her colleagues (2011) emotional experience, ABM procedures that revealed that some recipients experience increase the capacity to regulate pain, addic- ABM as overly repetitive. Hence, one type tive symptomatology, and other maladaptive of refinement to ABM that may increase aspects of experience and behavior also will patient acceptability could involve the intro- likely indirectly benefit emotion regulation itself.

524 INTERVENTIONS duction of features that sustain interest and lor that the incorporation of ABM into com- motivation. For example, this might involve puterized, home-based treatments for emo- delivering ABM in shorter blocks and pro- tional dysfunction, represents a promising viding performance feedback, so that par- future method of effectively exploiting its ticipants can strive to improve across blocks. demonstrated capacity to enhance emotion Beard (2011) also reports that some patients regulation. express a desire to better understand how ABM could help with their emotional dif- Closing Comments ficulties. Therefore, another refinement that The use of ABM procedures to test hypoth- might enhance patient acceptance would be eses concerning the contributions of atten- provision of a rationale that communicates tional selectivity to emotion regulation and how this procedure can contribute to the therapeutically enhance such regulation in regulation of negative emotion. people experiencing emotional dysfunction is still a young area of research. Well over One feature of ABM that Beard’s inter- 70% of all the research published in this view data (2011) identified as being partic- field has appeared only within the past 3 or ularly highly valued by patients is the flex- 4 years (MacLeod & Mathews, 2012). Nev- ibility and convenience with which it can be ertheless, this early work already has clearly accessed by recipients, due to its computer-­ established that biased attentional respond- based method of delivery. Recent years have ing to negative information does causally witnessed the growing use of computer tech- contribute to emotion regulation, affecting nology to facilitate the transport of conven- emotional reactivity to stress and influenc- tional psychological interventions into the ing the symptoms of emotional dysfunction. community (Marks & Cavanagh, 2009). The research reviewed in this chapter also Given its amenability to Internet delivery has convincingly demonstrated that the use (e.g., See et al., 2009), ABM could readily be of ABM procedures to reduce attention to integrated into such forms of intervention. negative information can improve emotion Remotely accessed computerized treatments regulation. Inducing such attention change that include ABM components already are serves to attenuate the degree to which beginning emerge. For example, Amir and stress elicits dysphoric emotional responses Taylor (2012) recently evaluated the effi- and also to alleviate the negative emo- cacy of a home-based treatment that pro- tional symptoms associated with subclini- vided treatment-s­eeking GAD patients with cal or clinical manifestations of emotional both ABM and computerized cognitive-­ pathology. By drawing upon increasingly behavioral therapy (CBT), accessed online sophisticated contemporary approaches to as often as desired across a 6-week period. attentional bias assessment, designed to Patients who completed this intervention assess progressively more precise dimen- evidenced reduced attention to negative sions of attention, it should be possible to information and displayed significant reduc- develop novel training variants that target tions in both self-r­eported and clinician-­ highly specific aspects of selective attention rated symptoms of anxiety, worry, and for modification. Hence, we anticipate that depression. Symptom change was related future ABM research will illuminate the to the magnitude of the observed reduction ways in which particular facets of attention in attentional bias. At completion of the selectivity functionally contribute to differ- 6-week intervention, 79% of participants no ent features of emotion regulation. Further- longer met diagnostic criteria for GAD. This more, if these evolving ABM technologies study was not designed to distinguish the become more widely embedded in the types contributions made by the CBT and ABM of computerized treatment programs now components of the online package. It will be being used to deliver psychological inter- important for future investigators to directly ventions, we also can expect that they will compare the efficacy of CBT and ABM pro- make a growing future contribution to the cedures, and also to determine whether the effective remediation of emotional dysfunc- combination of these two types of cognitive tion. intervention can deliver greater therapeutic benefit than does either approach alone. Nevertheless, we agree with Amir and Tay-

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Chapter 31 Affect Regulation Training Matthias Berking Jeanine Schwarz Deficits in emotion regulation skills are pointments (because hope is an antecedent a putative risk and maintaining factor in of disappointment). In a situation in which various forms of psychopathology (Berking an individual is under high pressure to solve & Wupperman, 2012; Hofmann, Sawyer, numerous problems but neither feels able to Fang, & Asnaani, 2012; Werner & Gross, do so nor to bear another disappointment, a 2010). The defining criteria for many disor- depressogenic type of thinking that reduces ders listed in the Diagnostic and Statistical the pressure associated with unsolved prob- Manual of Mental Disorders (DSM-5; Amer- lems and/or the pain associated with unful- ican Psychiatric Association, 2013) include filled hopes may become an irresistible temp- undesired emotions, such as sadness, anxi- tation. Giving in to this type of thinking may ety, or anger, that exceed the intensity and/ result in a small and short-lived reduction of or duration of what is considered adaptive. negative affect. In turn, this type of thinking For other disorders, core symptoms can be is reinforced and more likely to occur again conceptualized as dysfunctional attempts to in similar situations in the future. Eventu- avoid or down-­regulate undesired emotions. ally, this process may lead into a clinically For example, bingeing in eating disorders significant depression. Adaptive affect reg- and substance use in alcohol dependence are ulation skills present an alternative way of often seen as dysfunctional attempts to cope coping with undesired affective states that with states of sadness, anger, boredom, or may prevent such depressogenic cognitive other forms of emotional anguish (Berking processes or facilitate disengagement from et al., 2011; Dingemans, Martijn, Jansen, & such processes (Berking & Whitley, 2013). Furth, 2009). Given the increasing amount of evidence In a similar fashion, the development and favoring such theories across various men- maintenance of depressive thinking can be tal disorders, enhancing emotion regulation conceptualized as dysfunctional emotion skills can be considered a promising transdi- regulation. Appraising a situation as aver- agnostic treatment target (Berking, Wupper- sive, uncontrollable, and unlikely to change man, et al., 2008; Mennin & Fresco, 2009; over time (Teasdale & Barnard, 1993) may Moses & Barlow, 2006). Others have also help to reduce the pressure actively to solve argued that undifferentiated stress responses personal problems (because working on (Bogdan & Pizzagalli, 2006), negative mood unattainable goals would be pointless) and states (Van Rijsbergen, Bockting, Berk- provide protection against hurtful disap- ing, Koeter, & Schene, 2012), motivational 529

530 INTERVENTIONS impulses (Grawe, 2006), and even appraisal anger, dysphoric mood, and/or hopelessness processes, which are defined through a significantly reduce the client’s motivation strong intrinsic affective component (e.g., and capacity to confront feared stimuli and/ “feelings” of hopelessness; Gibb, Beevers, or to draw helpful conclusions from such Andover, & Holleran, 2006; Teasdale & exercises or habituate to feared stimuli; e.g., Barnard, 1993), constitute a serious health Foa, Riggs, Massie, & Yarczower, 1995), a risk when the individual is unable to cope systematic focus on general affect regulation successfully with these phenomena. Based skills might be warranted. on the feasibility of applying “emotion” reg- ulation skills to these other affective states, Moreover, many patients suffer from more we propose that the same arguments that than one mental disorder (Kessler, Chiu, indicate the importance of emotion regu- Demler, & Walters, 2005). Particularly in lation skills also apply to undesired affec- highly comorbid patients, “transaffective” tive states in general (i.e., emotions, stress deficits in adaptive coping skills (e.g., the responses, moods, and urges; Gross, this inability to accept various undesired affec- volume). Thus, the potential of targeting tive states if they cannot be modified) might emotion regulation skills in treatment can be be at the core of many of their problems. For hypothesized to generalize to affect regula- these patients, a systematic focus on affect tion skills in general. regulation skills in general might be a more efficient way of treatment than a compila- Almost all psychotherapeutic treat- tion of various disorder-­specific manuals. ments implicitly or explicitly work to Minimally, an additional focus on strength- improve affect regulation skills in one way ening affect regulation skills in addition or another. However, in some treatments to providing disorder-­specific treatments (e.g., person-­centered psychotherapy, psy- should be considered when there is evidence chodynamic treatments) general emotion that general affect regulation deficits have regulation skills are not explicitly addressed contributed to various psychopathological and directly targeted but are assumed to be symptoms. Thus, there is a need for inter- enhanced through the application of strat- ventions focusing on general affect regula- egies considered to stimulate the healing tion skills that may complement disorder-­ process in general (e.g., personal growth, focused interventions. self-­understanding, insight into uncon- scious motives). In other treatments, such as Treatments such as emotion regulation cognitive-­behavioral therapy (CBT), these therapy (ERT; Mennin & Fresco, this vol- efforts often focus on affective states that ume), the emotion regulation module used are thought to be strongly related to the cli- in dialectic behavior therapy (DBT; Neacsiu, ent’s symptoms. For example, clients suffer- Bohus, & Linehan, this volume), and some ing from anxiety are primarily taught skills mindfulness-b­ ased treatments (Farb, Ander- to cope successfully with anxiety. Although son, Irving, & Segal, this volume; Wup- patients are usually encouraged to apply the perman et al., 2012) are based on a similar acquired skills to other emotions, specific conceptualization of mental disorders as attempts to (1) systematically train patients affect regulation training (ART) and, conse- to apply acquired coping skills in the context quently, also address affect regulation skills of other challenging affective states or (2) to in a more general fashion. The main differ- teach and practice additional skills that are ence between these treatments and ART is not relevant in the context of anxiety but that ART has from its beginning focused on are relevant for successful coping with other communalities across various mental disor- undesired affective states (e.g., distraction ders with regard to deficits in general emo- as a strategy to reduce anger; engagement in tion regulation skills. To improve such skills, positive activities to reduce dysphoric mood ART systematically integrates techniques and feelings of hopelessness) are rare. If these from various psychotherapeutic approaches, additional undesired affective states are rel- such as CBT (e.g., Beck, 1995), compassion-­ evant for the maintenance of the anxiety dis- based therapy (Gilbert, 2011; Weissman & order, focusing only on anxiety-­managing Weissman, 1996), DBT (Neacsiu et al., this skills may not be sufficient to solve the prob- volume), emotion-f­ocused therapy (EFT; lem effectively. On such occasions (e.g., if Greenberg, 2004), ERT (Mennin & Fresco, this volume), mindfulness-­based interven-