Emotion Regulation Treatment of Alcohol Use Disorders

Helping Clients Manage Negative Thoughts and Feelings

Paul R. Stasiewicz, Clara M. Bradizza, Kim S. Slosman

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781315406008
• Edition: 1
• Topic: Psychologie
• Subtopic: Émotions en psychologie

Emotion Regulation Treatment of Alcohol Use Disorders provides step-by-step, detailed procedures for assessing and treating emotion regulation difficulties in individuals diagnosed with an alcohol use disorder (AUD). The Emotion Regulation Treatment (ERT) program, consisting of 12 weekly sessions, combines an empirically supported cognitive-behavioral treatment with emotion regulation strategies to help clients manage negative emotions and cravings for alcohol. This therapist guide contains all the materials needed for the clinician to implement the program, including session outlines, detailed session content with suggestions for therapist dialogue, and client assignment for between-session skill practice. It is also designed to be used with the accompanying client workbook Managing Negative Emotions Without Drinking, which includes educational materials, handouts, worksheets, and between-session skill practice.

Chapter 1

Introduction and Information for Therapists

Rationale for Emotion Regulation Treatment

In this chapter, we describe the role of emotions in alcohol use disorder (AUD) and define several key terms including affect regulation and emotion regulation. Next, we review research that supports the development of an Emotion Regulation Treatment (ERT) approach for individuals with AUD and provide evidence of its initial efficacy. Finally, we provide an outline of ERT, its session structure, who should administer ERT, and discuss the use of the companion ERT client workbook (Managing Negative Emotions Without Drinking: A Workbook of Effective Strategies).

Role of Emotions in Alcohol Use Disorder

A number of theories relevant to the development and maintenance of AUD suggest that the desire to regulate one’s emotional experience is an important motive underlying alcohol use. Social learning theory views alcohol use as a coping behavior that is learned as a response to unpleasant or aversive emotional states (Bandura, 1986; Maisto, Carey, & Bradizza, 1999). According to this theory, an individual’s pattern of use may become problematic if alcohol is used frequently to cope with stress or other unpleasant emotions, which is most likely to happen when the individual does not possess adequate social or emotion regulation skills to manage the situation effectively. Social learning theory also emphasizes the role of cognitions to explain the role of emotional states in the maintenance of alcohol use behavior. These include self-efficacy expectations (belief that one can enact a given behavior to achieve desired outcomes) and outcome expectancies (belief about the likelihood of a behavior leading to a particular outcome). With regard to a high-risk drinking situation involving an unpleasant or negative emotion, drinking is more likely to occur if an individual has low self-efficacy for maintaining abstinence in this situation coupled with outcome expectancies that drinking will reduce or alleviate the unpleasant emotion.

Both positive and negative emotions can motivate alcohol consumption. An individual experiencing a positive emotion (e.g., joy, contentment) may drink to extend or enhance the positive emotional state. In this case, alcohol provides a source of positive reinforcement or enjoyment and this increases the likelihood that the drinking behavior will be repeated in future, similar situations. An individual experiencing a negative emotion (e.g., sadness, anxiety, irritability) may drink to reduce or get rid of the unpleasant feeling. In this case, alcohol provides a source of negative reinforcement (i.e., removal or reduction of an unpleasant or aversive stimulus) and increases the likelihood that the drinking behavior will be repeated in future, similar situations. As an individual moves along the continuum from nonproblem to problem use of alcohol, a shift occurs over time from positive reinforcement sustaining the behavior of alcohol consumption to negative reinforcement sustaining the behavior; that is, individuals who initially began drinking in order to increase enjoyment or celebrate, now are more likely to drink when feeling distressed. As part of this shift from nonproblem to problem alcohol use, when access to alcohol is prevented, a motivational withdrawal syndrome emerges that is characterized by negative emotional states (e.g., frustration, anger, irritability) (Baker, Piper, McCarthy, Majeskie, & Fiore, 2004; Koob & Volkow, 2010).

Affect Regulation and Emotion Regulation

An individual’s effort to influence positive and negative affect fall under the broad heading of affect regulation and include the following subprocesses: (1) emotion regulation, (2) coping, and (3) distress tolerance (Gross, 2014). These three second-level regulatory subprocesses share similar functions (e.g., to reduce negative emotional responses), but can be distinguished from one another by the type of response they are meant to target. Emotion regulation targets characteristics of the emotional response itself (e.g., latency, intensity, duration), coping targets cognitive and situational antecedents of the emotional response (e.g., thoughts about the event or attempts to leave the situation), and distress tolerance targets behavioral reactivity (e.g., impulsive or harmful acts) to emotional responses (Linehan, 2015). ERT approaches often combine two or more of these second-level regulatory processes. While the broader term affect regulation may better reflect the use of these multiple, diverse strategies within a given intervention, the term emotion regulation has taken hold in the field as evidenced by the tremendous growth in the number of new publications over the past two decades on the topic (Gross, 2013). As a result, we have chosen the name “Emotion Regulation Treatment” for our intervention. However, given that the intervention combines emotion regulation, coping, and distress tolerance components, it could be more accurately termed an “affect regulation treatment.”

What Is Emotion Regulation?

Gross (2014) describes the regulation of emotions as “shaping which emotions one has, when one has them, and how one experiences or expresses these emotions” (p. 6). Emotion regulation includes efforts to down-regulate negative emotions (i.e., reduce or eliminate the intensity and duration) or up-regulate positive emotions (i.e., increase intensity or duration). Further, the strategies that people use to regulate their emotions can either be adaptive or maladaptive, depending on the way they affect an individual’s physical and psychological well-being (Carmody, 1989; Aldao, Nolen-Hoeksema, & Schweizer, 2010). The goals of an emotion regulation intervention would be to increase adaptive responses to the environment and reduce maladaptive responses to specific emotions. For example, substance use in response to experiencing an aversive or unpleasant emotion is a maladaptive response for a person diagnosed with AUD. In this case, treatment would aim to provide the individual with an adaptive alternative response for regulating the unpleasant emotion (e.g., Mindful Breathing, Cognitive Reappraisal, Urge Surfing). Finally, Gross’ (1998, 2014) process model of emotion identifies specific points during the emotion-generative process (i.e., the point at which an emotion begins) where individuals can regulate their emotions. This model draws a distinction between antecedent-focused and response-focused strategies. Antecedent-focused strategies occur earlier in the emotion-generative process (e.g., using cognitive reappraisal before entering a stressful situation) while response-focused strategies occur later in the emotion-generative process, after the emotion is fully formed (e.g., inhibiting or suppressing the expression of an ongoing emotional response). This account acknowledges that certain emotion regulation strategies are better suited to varying intensities and developmental stage of an emotional response than others. For example, clients may derive greater benefit from applying cognitive reappraisal before entering a negative-affect drinking situation rather than waiting until they are in the situation and their negative emotional intensity is at or near its peak.

Theory and Research Supporting an Emotion Regulation Treatment Approach

Both theory and research support the notion that individuals who are less skilled at emotion regulation often resort to a range of unhealthy behaviors, including excessive alcohol use, in an attempt to regulate both positive and negative affect (e.g., Baker et al., 2004; Cooper, Frone, Russell, & Mudar, 1995; Cooper, Russell, Skinner, Frone, & Mudar, 1992; Koob & LeMoal, 2001; Stasiewicz & Maisto, 1993). Self-reported emotion regulation skills are lower among individuals with an AUD relative to nonclinical samples, and are comparable to other clinical samples with mental health disorders (e.g., generalized anxiety disorder, cocaine use disorders; see Stasiewicz et al., 2013). Empirical evidence indicates that poor emotion regulation skills increase risk for alcohol relapse in situations involving negative affect (Berking et al., 2011). Additionally, clinical and high-risk samples demonstrate that emotion regulation difficulties are positively associated with alcohol- related negative consequences (Dvorak, Wray, Kuvaas, & Kilwein, 2013). When coupled with deficits in emotion regulation skills, the use of alcohol to regulate emotion may be adaptive in the short term, but in the long term, drinking to regulate emotion often proves to be a maladaptive response (see Holahan, Moos, Holahan, Cronkite, & Randall, 2001; Holahan, Moos, Holahan, Cronkite, & Randall, 2003). An emotion regulation intervention proposes adding treatment components to existing cognitive-behavioral interventions for AUDs with the goal of assisting clients in becoming more comfortable with arousing emotional experiences, better able to access and utilize emotional information to engage in adaptive problem solving, and developing better skills for modulating and expressing emotions in an adaptive manner (Stasiewicz et al., 2013).

Emotion Regulation as a Mechanism Underlying Successful Treatment of Alcohol Use Disorder

Although a number of theories propose that emotion regulation is a primary motive for alcohol use (e.g., Baker et al., 2004; Conger, 1956; Cooper et al., 1995, 1992; Khantzian, 1997; Koob, 2003; Stasiewicz & Maisto, 1993), to our knowledge, there are no studies that have investigated change in emotion regulation skills as a potential mechanism of alcohol treatment effects. To date, one observational study has demonstrated that pretreatment adaptive affect regulation skills predicted less alcohol use at follow-up among patients in treatment for alcohol dependence (Berking et al., 2011). A second study has shown that abstinent alcoholics report more difficulty effectively regulating their emotions than do social drinkers (Fox, Hong, & Sinha, 2008). More encouraging, in the past decade an increasing number of studies have investigated emotion regulation processes as mediators of treatment effects for a range of mental health disorders, including borderline personality disorder (e.g., Neacsiu, Eberle, Kramer, Wiesmann, & Linehan, 2014), deliberate self-harm (e.g., Gratz, Bardeen, Levy, Dixon-Gordon, & Tull, 2015), depression and anxiety disorders (e.g., Desrosiers, Vine, Klemanski, & Nolen-Hoeksema, 2013), and social anxiety disorder (e.g., Goldin et al., 2014). While the methods employed by these studies differ (e.g., cross-sectional vs. longitudinal design, type of control group, single-group design), a common pattern of results is beginning to emerge providing broad support for the importance of adaptive emotion regulation strategies as a unifying mechanism of change underlying efficacious and effective treatments for a number of different mental health disorders.

The ERT described in this therapist guide directly targets emotion regulation as one component of a more comprehensive treatment for individuals diagnosed with an AUD. In our initial treatment development study (Stasiewicz et al., 2013), individuals who received ERT reported significant within-group decreases in negative affect, increases in cognitive reappraisal (an adaptive coping skill), and increases in observing and describing, which are both facets of mindfulness. These treatment process variables are theoretically related to ERT’s two primary treatment strategies: (1) direct experiencing of emotion and (2) mindfulness. Both mindfulness and the direct experiencing of emotion (via imaginal exposure) involve similar procedures in that they both encourage contact with avoided/aversive thoughts, emotions, and sensations (Treanor, 2011). In this way, mindfulness and the direct experiencing of emotion may have a synergistic effect. For example, being mindful may enhance the direct experiencing of emotion by increasing awareness of negative affect and alcohol cues. Mindfulness may also enhance the client’s ability to maintain attention on a given cue, or set of cues, during the direct experiencing of emotion. Conversely, procedures involved with direct experiencing of emotion may enhance a person’s ability to observe and describe emotions, thoughts, and physical sensations. Thus, what has become clear across theoretical orientations is that exposure to avoided material, emotional arousal, and emotional acceptance and/or tolerance, are important components in the process of change in therapy (Hayes & Feldman, 2004). Future research in this area would benefit from further examination of mechanisms of change in alcohol interventions generally, and those that target emotion regulation difficulties specifically.

Identifying Emotion Regulation Difficulties in Alcohol Use Disorder

Assessment of Emotion Regulation Difficulties

Self-report continues to be the primary method by which clinicians and researchers assess difficulties with emotion regulation. The two questionnaires used most often are the Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004) and the Emotion Regulation Questionnaire (ERQ; Gross & John, 2003). The DERS is a 37-item measure that assesses self-reported emotion regulation difficulties. The DERS has six subscales that assess the following characteristics: nonacceptance of emotions, difficulties engaging in goal-directed behavior when distressed, impulse control difficulties, lack of emotional awareness, limited access to emotion regulation strategies, and lack of emotional clarity. The ERQ is a 10-item questionnaire with two subscales assessing emotion reappraisal and expressive suppression of emotion.

The Inventory of Drug Taking Situations–Alcohol version (IDTS-A; Annis, Turner, & Sklar, 1997) is administered to determine if the client reports drinking in response to negative emotions. The IDTS-A provides a profile of situations in which an individual reports drinking heavily over the past year. Heavy drinking is measured across eight subscales including Unpleasant Emotions, Physical Discomfort, Pleasant Emotions, Testing Personal Control, Urges and Temptations to Drink, Conflict with Others, Social Pressure to Drink, and Pleasant Times with Others. Participants who score above the midpoint on the Unpleasant Emotions subscale (e.g., “When I felt anxious or tense about something”; “If I was depressed about things in general”) are considered to be good candidates for ERT.

Negative and Positive Emotions and Relationship to Drinking

Negative and positive emotions are the two most often-cited reasons for drinking. As noted earlier, people may drink to obtain or enhance pleasant emotion or to eliminate or reduce unpleasant emotion. Although a main focus of ERT is helping people become more accepting or tolerant of unpleasant emotions, it does not rule out the inclusion of positive or pleasant emotional drinking situations during the direct experiencing of emotion sessions (Sessions 7–10). Both theory and research provide a compelling rationale for expanding ERT to include positive affect drinking situations. First, positive and negative affect drinking situations involve appetitive responses such as craving, a highly relevant treatment target for ERT considering that craving is conceptualized as a form of affect (e.g., Baker, Morse, & Sherman, 1987; Baker et al., 2004; Tiffany, 2010). Second, despite being labeled as “positive” or “pleasant,” there are several sources of negative affect in “positive affect,” high-risk drinking situations that render them excellent treatment targets for ERT. For example, the experience of craving for someone trying to abstain is unpleasant and negatively valenced (e.g., Stasiewicz & Maisto, 1993; Tiffany, 1990; Sinha et al., 2009; Oliver, MacQueen, & Drobes, 2013). Often, attempts to reduce or abstain from drinking in positively valenced situations result in unpleasant feelings of loss and frustration. Attempts to abstain in these situations can also expose individuals to negative affect that may have been previously escaped or avoided by drinking (e.g., drinking at a social event to reduce social anxiety). In summary, all of these negative emotional experiences have been observed and reported by treatment-seeking individuals attempting to abstain from drinking in situations reported as “positive affect” drinking situations. Thus, although the focus of ERT is on helping individuals down-regulate negative emotions, it is uniquely suited to address the full range of drinking situations.

The Importance of Secondary Emotions

Primary emotions are innate and universal: anger, fear, sadness, happiness, disgust. Secondary emotions are emotional responses to the experience of other emotions. For example, a person may learn to feel shame in response to feeling sad or angry. In this case, sadness or anger is the primary emotion and shame is the secondary emotion. Secondary emotions are the result of a learning process. For example, a child who is belittled in the presence of others for being tearful and sad may learn to feel shame when feeling sad in the presence of others. Alternatively, a man who was punished for expressions of anger as a child may experience feelings of guilt when expressing his anger as an adult. Finally, a child who was yelled at and punished for being full of energy and laughing may become anxious when feeling excessively cheerful or happy around others. For people with an AUD, drinking may occur in response to primary emotions but it also occurs in response to secondary emotions. In our experience conducting imaginal exposure with AUD clients, secondary emotions are usually experienced as more aversive than primary emotions. Secondary, or conditioned emotional responses, are often the emotions the person is seeking to escape from or avoid by drinking. In real life, clients often report drinking prior to the emergence of secondary emotions. During the direct experiencing of emotion sessions, therapists are taught to follow the emotion as their clients’ high-risk drinking situations unfold over time. Therapists are trained to identify the emergence of secondary emotions and to monitor the subsequent effect of any secondary emotion on clients’ self-reported levels of craving and distress.

Development of This Treatment Program and Initial Efficacy

In a behavioral therapies development study completed by the authors, we developed and evaluated ERT (referred to as “Affect Regulation Treatment” or “ART” at that time) for alcohol dependence (Stasiewicz et al., 2013, 2014). Because ERT places greater emphasis on developing emotion regulation strategies and relatively less emphasis on specific strategies for changing drinking behavior, ERT was developed as a treatment supplement that could be used to supplement or enhance standard cognitive-behavioral therapy (CBT) for alcohol dependence. Based upon the literature linking negative affect and drinking, including the associations between deficits in emotion regulation and problematic use, ERT was designed to include cognitive and behavioral strategies addressing (1) direct experiencing of emotion (utilizing imaginal exposure), (2) mindfulness skills, and (3) several other emotion regulation skills. These emotion regulation strategies were derived from interventions that address a range of mental health disorders (e.g., panic disorder, posttraumatic stress disorder [PTSD], depression, borderline personality disorder) including substance use disorders, and differ from traditional coping skills interventions by placing greater emphasis on increasing the patient’s ability to experience and regulate the subjective, physiological, and behavioral components of emotion, and less emphasis on teaching the patient how to “change” the emotion or the situational and cognitive antecedents or precursors of the emotion. Specifically, during the mindfulness and direct experiencing of emotion sessions, the therapist instruc...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Acknowledgments
• About the Authors
• 1 Introduction and Information for Therapists
• 2 Basic Principles Underlying Emotion Regulation Treatment
• 3 Overview of General Treatment Format and Procedures
• 4 Session 1: Introduction to Emotion Regulation Treatment
• 5 Session 2: Enhancing Motivation and Mindfulness
• 6 Session 3: High-Risk Situations and Mindful Coping
• 7 Session 4: Drinking-Related Thoughts, Coping With Urges and Cravings, and Cognitive Reappraisal
• 8 Session 5: Drink Refusal Skills and Managing Emotions With Actions
• 9 Session 6: Skill and Treatment Progress Review and Preparing for Direct Experiencing of Emotion
• 10 Session 7: Coping With a Lapse or Relapse and Direct Experiencing of Emotion
• 11 Session 8: Enhancing Social Support Networks and Direct Experiencing of Emotion
• 12 Session 9: Seemingly Irrelevant Decisions and Direct Experiencing of Emotion
• 13 Session 10: Progress Review, Stimulus Control Strategies, and Direct Experiencing of Emotion
• 14 Session 11: Relapse Prevention and Lifestyle Balance
• 15 Session 12: Accomplishments and Future Directions
• Appendix A: Common Barriers to Mindfulness Practice
• Appendix B: Scene Development Worksheet
• Appendix C: Individual Distress Scale
• Appendix D: Direct Experiencing of Emotion Recording Form
• Appendix E: Relapse Prevention Plan
• References
• Index