Mental Health

This mental health series thus far has focused on specific coping tools to assist our clients in working through emotional impasses in rehabilitation sessions. But sometimes the emotional challenges our patients face are prolonged; for example, when awaiting test results, coping with relapses, or experiencing exacerbations in pain (see the mental health center at www.advanceweb.com/OT).

Emotional regulation is a holistic skill set taught in cognitive behavioral therapy counseling approaches, offering guidance on how to better manage emotional upsets, contain emotions or pace ourselves when we are emotionally distressed for extended periods. Whether or not an individual has a pre-existing psychological condition such as depression or anxiety, emoting is a daily human occurrence, and not only a mental health/illness issue. Anyone can be emotionally dysregulated (upset) at any time, and the reasons why can range from everyday events (being late to work) to serious life issues (recent diagnosis of cancer).

When we don't have the skills to get back our emotional balance, we can be vulnerable to repetitive mood ruts (low motivation, irritability) or mind-body habits, which prolong our distress (overeating, not asking for help, ruminating etc).

Dr. Kristene Doyle, director of clinical services at the Albert Ellis Institute, specializes in rational emotive behavior therapy (REBT), a skills counseling model that instructs clients on how to improve their coping when upset. "There is the problem, and then [there is] the emotional reaction to the problem. it's often what's in between - the way in which we are looking at the event," she stated.

Doyle explains that regulating our emotions is not invalidating pain or anger we may feel in the moment, but rather, when we suffer, how can we best support ourselves? To help our patients with this task, it can be helpful to listen for the common self-statements patients may be expressing in session:

Examples: "I'm off balance"; "I don't know what's bothering me"; "I am feeling tense"; "I am just stressed out"; "I can't think right now." In this perspective, emotional dysregulation is often likened to an ocean wave - there is usually a trigger that starts a cycle of distress, a point of peak escalation and then a de-escalation period.

Different types of distressing moments will require different coping choices. Sometimes patients need help de-escalating; other times patients need to know how to contain difficult feelings. Some patients may need help with getting perspectives on a mood. Others need guidance on how to self-soothe during a distressing affect.

The coping options in learning how to emotionally regulate is a skill set with several parts - prevention, regulation, building resilience, and recovery.

"The strategies for regulating emotions vary and have different therapeutic effects. For one client, mindfulness may help manage emotions; while for another, challenging the thinking underneath the emotions may help him de-escalate. It is important to attend to individual client needs," says Doyle.

Prevention

The basic skill in regulating our emotions is recognizing when we may anticipate being upset - for clients, strenuous rehab sessions, upcoming medical procedures, or impending discharge can bring up distressing feelings. We need to map out a coping strategy for an upcoming stressor.

For example, a college student with special needs who is planning to live away from home for the first time may have many anxieties about establishing a new routine in a new environment. How can this student tolerate the anxiety of the unknown and tolerate the distress of a new learning curve to advocate for herself?

Regulation

When an individual is in the heart of a distressing emotion - anger, fear, confusion, sadness - "regulating" that emotion at this juncture would be to find ways to constructively tolerate the distress, cope with the feeling in the moment, and not amplify the distress further.

"If you are dealing with something unexpected, what is the most constructive emotion you can have when facing a new medical challenge?" asks Doyle. It is common to experience the distress (anxiety or any other feeling) and have a secondary thought, which causes more stress (panic). Some common thinking styles noted in the REBT counseling model include:

• demands - "I must not be upset"

• "awfulizing" beliefs - "It would be terrible if I were upset"

• low frustration tolerance - "I can't stand it if I were upset"

• deprecating beliefs - "If I am upset, I am no good; life is no good"

"Most often people struggle not only with the core feeling, but also with a secondary disturbance," says Doyle. In other words, a secondary belief is often driving the belief behind the mood.

In 2006, when Doyle's husband was diagnosed with a severe form of brain cancer, she unexpectedly had to face an intense mix of emotions that endured throughout the treatment journey. "Even though the odds were 99 percent against us, I realized I had two options - have 16-18 months of hell and being miserable, or 16-18 months of good memories. You don't have to stay stuck in emotions that are not constructive. There are healthier emotions, and we do have the ability to control our level of reactivity. I learned how to be mindful and be in the moment."

Building Resilience

Emotional dysregulation is so distressing because it is a mind-body phenomenon. When we feel upset it can also not feel right in our bodies, so what's needed are skills to calm the mind and the body.

If a patient is already prone to physical or emotional distress due to a medical condition, the additional upsets of daily life can tip her emotional equilibrium beyond the coping point. It is important to teach clients to re-charge each day in an integrated way. Employing stress management techniques - taking a deep breath, releasing feelings, relying on faith practice, and/or pacing - builds the immune system and buffers the effects of stressful emotions. A great question to ask patients who need help with this phase of emotional regulation is: "What are the health habits that keep you emotionally balanced?"

Recovery

Skill in knowing how to emotionally regulate does not mean that sometimes your emotions won't get the best of you. When recovering from periods of emotional distress, patients can be guided to learn from their suffering and decide what they would need help with next time, or what they would want to be different. Also, this is a critical time to identify new skills that would aid in coping in the future. Advise patients to allow for meaningful recovery time - an afternoon or week etc, and not to push on to the next stressor.

Two years after his initial diagnosis, Doyle's husband passed away. "It is a deep loss on so many levels," she said. "I do struggle with a feeling of being lost, and it's OK. I allow this feeling. The first days after my loss, I had no idea what to feel, what to do with each day. I would tell patients to honor wherever they are [at the moment]. To respect their feelings. What we want to do is let those normal human emotions be part of our experience and take away the secondary disturbance, like 'I should not be feeling this way.' The heart of emotional regulation is to teach our patients acceptance, self-acceptance, other acceptance and life acceptance," says Doyle.

Dr. Reji Mathew is a psychotherapist/clinical instructor at New York University. She is a disability advocate and freelance writer. The main focus of her work is to promote coping skills education for persons with chronic illness and disability. Her clinical expertise is in integrative psychotherapy, particularly cognitive behavioral skills training. Reach her via e-mail at her website: rejimathewwriter.com.