The 3 Building Blocks

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First, let's learn about an important principle which is at the core of the Fount model. Based on this model, there are 3 building blocks that constitute our psychological existence: thoughts, emotions, and awareness. Although in principle we are all well familiar with these 3 building blocks, but you may be surprised to find that in practice, most of us can struggle to differentiate between them. And I’d like to suggest that learning to differentiate between them is at the core of successful clinical practice. Let's take a closer look at each.

1. Thoughts

Let's begin with the first building block: thoughts or cognitive elements. Picture this - thoughts are like an internal conversation, a cinema screen in our minds, or even a sports commentator providing commentary on everything as we go about our day. They are formed from words, images, or ideas. From analyzing and judging things to planning and coming up with new ideas, thoughts are the general activities of the mind. And when I say the word ‘activity’, I need to highlight that word. Thoughts are about doing. They are the act of using logic, rationality, and imagination, naming, comparing, categorising, judging and so on. I would like to invite you to take a moment to watch your thoughts, or listen to your internal dialogue. It may help to close your eyes, bring your attention inward and pay attention. See if you can get to know your own thoughts for a minute. I suggest you pause the audio and try it now.

2. Emotions

Now, let's move on to the second building block: emotions. Unlike thoughts, emotions are not based on language. Instead, they are pure experiences, much like the taste of an apple - something that's hard to put into words. You could try to describe how an apple tastes to someone who’s never had an apple before, but they could never quite understand the taste of an apple until they’ve tried it for themselves, right? Because experiences are not language based. They need to be felt and experienced. Language can’t communicate them effectively.

We often feel emotions somewhere in our bodies, like a racing heart or trembling knees when scared, butterflies in the belly when anxious or excited, heaviness in the head or eyes when feeling down, or the heat of anger. At times emotions are still. At other times they are restless and chaotic, moving, pulsating, or appearing and disappearing. We don’t always know that we are feeling an emotion, or what kind of emotion we are feeling. At times, the emotion can feel purely physical and somatic.

Try to take note of your emotions for a minute. It may help to close your eyes. See if you can scan your body for a minute and notice any emotions that you may be feeling right now. You may like to pause the audio to give yourself as much time as you need.

Another feature of emotions is that they can be pleasant or unpleasant, but thoughts, on their own, do not carry such inherent qualities. For example, you can have a thought ‘I’m not good at playing the piano’ without any emotional attachment. It’s just a thought, an understanding that I’m not good at playing the piano. But the same thought could have an emotional attachment for someone else. They could feel sad or upset about not being able to play the piano well. In that case, the thought and the emotion may happen concurrently, but still they can be seen as qualitatively different. The Fount model emphasizes the importance of recognizing the fusion of thoughts and emotions and yet recognise their qualitative distinction.

3. Awareness

Lastly, let's explore the third building block: awareness. Often confused with thinking or emotions, awareness is entirely different. Similar to emotions, awareness is not composed of words and sentences. It is the simple act of noticing things, like looking, listening, tasting, smelling, and feeling.

As humans, we tend to quickly start thinking about whatever we notice. Imagine seeing a pink flower; initially, you simply notice its shape, color, and smell. But then your thoughts may soon follow, like, ‘I like this flower, but I like red flowers better,’ or ‘I wish my partner would surprise me with flowers.’ Again, although thoughts and emotions may arise soon after noticing, they are qualitatively different and it is helpful to be able to differentiate between them. The act of noticing and becoming aware is also what we call mindfulness.

Let’s do an exercise to help with noticing awareness. The following section is an excerpt from my book Mind Wellbeing.

“Pick up an object and hold it in your hand. It can be a pen, a book, a spoon, a flower etc. First spend some time thinking about this object. Notice that your thoughts are made up of words. They may look like this:

'This is a nice looking pen. I like the shape. But it doesn't write so well. My other pen writes better. I wonder where it was made. Is it cheap or expensive? I should write with the other one though, it's nicer to write with.' And so on.

Notice your thoughts as they take place.

Now spend a bit of time just looking at the object. No thoughts. No commentary. Just look at it. And feel how it feels in your hand. Maybe smell it. Notice the object, with all its little details, with all of your attention.

This is called awareness, or the act of mindfulness.”

Therapeutic Implications of the Building Blocks

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First, let's take a look at the relationship between mental health and thoughts. As mental health declines, a combination of changes occurs to our thought patterns. Research has shown that many mental health conditions, such as anxiety and depression, lead to an increase in the frequency and intensity of thoughts. These conditions can result in heightened rumination and overthinking, leading to a continuous stream of repetitive and intrusive thoughts. During manic episodes in Bipolar Disorder, thought activity can significantly escalate, with racing thoughts and difficulty in focusing on one idea. Many conditions, such as schizophrenia or other psychosis can result in disorganized and fragmented thinking.

Next, let's look at what changes we could expect to our emotions as mental health declines. When experiencing mental health challenges, emotions tend to intensify. We know that individuals facing mental health challenges often experience heightened emotional responses to various situations. Emotions like anxiety, sadness, or anger, may become more frequent and intense, making it challenging to regulate emotions effectively. Feelings of overwhelm, vulnerability, and emotional exhaustion are common as individuals navigate the complexities of mental health difficulties.

While the rate and intensity of thoughts and emotions can increase during mental health crisis, the impact of mental illness on mindful awareness can be the reverse. As mental health declines, our ability to engage in mindful awareness may reduce or diminish. This is particularly evident in individuals with severe mental health conditions, as these individuals may have very little awareness of their surroundings or ability to be rooted in the present moment. A decrease in mindful awareness might lead to a higher prevalence of autopilot thinking, where our minds habitually wander, dwelling on past regrets or future anxieties, without truly being present in the moment.

The following graph is a rough illustrative demonstration of the relationship between mental health conditions and the 3 building blocks:

In contrast, a mentally healthy individual can enjoy periods of rest from cognitive activities through increased mindfulness and emotional calm. Their existing thoughts are more likely to be balanced with mindful awareness, reducing the tendency for autopilot thinking, rumination, or worry. As a result, their emotions become interspersed with periods of calmness, where they can experience a sense of emotional balance and equanimity.

In he following slides, we'll explore strategies and practices that can assist clients on the level of each of these building blocks.

Addressing the Building Blocks in Therapy

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During therapy, it's essential to address these 3 building blocks using distinct therapeutic tools and with a level of discernment and purposefulness. Addressing each area requires a thoughtful and tailored approach. Below are the specific tools and techniques that I recommend for addressing each of these areas:

Thoughts: To modify thoughts effectively, we employ cognitive reappraisal. In my practice, I like to combine traditional cognitive reappraisal techniques with imagery work.

Emotions: When working with emotions, body-oriented therapies have shown great promise. Specifically, I find that emotion or interoceptive exposure are ground breaking techniques that deserve a lot of attention in the clinical field.

Awareness: Using mindfulness strategies, including present-moment focus, can assist us in cultivating awareness. I often find that as thoughts and emotions become better managed, mindful awareness naturally increases. At other times, I need to purposefully incorporate mindfulness strategies in the therapeutic process.

In the following slides, we will explore each of these strategies in more detail, discussing their benefits and practical applications.

Thoughts: Cognitive Restructuring and Reappraisal

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Although, as therapists, we come from various therapeutic backgrounds and use different methods and modalities in our work, it's safe to say that we all use cognitive restructuring or reappraisal to one degree or another. As you are no doubt aware, cognitive restructuring or reappraisal are the act of reevaluating and reconsidering one's thoughts, beliefs, and perspectives. These techniques are a fundamental aspect of most therapeutic approaches and whether we realise it or not, most of us incorporate some form of it, in our therapy sessions.

Delving into all the nitty-gritties of how to apply cognitive restructuring or reappraisal is outside the scope of this course, but we will discuss a few key aspects related to its use and explore how we could use it most effectively.

Substituting vs re-evaluating

When it comes to methods of reappraisal, there are two main schools of thought:

1. Traditional Cognitive Restructuring: This approach involves challenging "thinking errors" by replacing them with more rational or accurate thoughts. The focus is on substituting or replacing thoughts with healthier alternatives.

2. Evidence-Based Cognitive Reappraisal: This approach places emphasis on evaluating thoughts against available evidence and considering alternative perspectives. Therapists help clients develop critical thinking skills by examining the accuracy and validity of their thoughts. Instead of solely prescribing alternative thoughts, this approach encourages clients to engage in a process of evidence-based evaluation. Furthermore, instead of replacing or substituting thoughts, clients organically arrive at alternative conclusions through this process of re-evaluation.

Traditional cognitive restructuring techniques have faced certain criticisms over time. Some of these criticisms include:

• Superficial Treatment: Critics argue that traditional cognitive restructuring techniques can focus solely on changing surface-level thoughts without addressing deeper underlying beliefs or core schemas that contribute to cognitive distortions.

• Overemphasis on Positive Thinking: This is one that I personally feel quite passionate about. Research consistently highlights that experiential avoidance, which is the act of suppressing or avoiding distressing thoughts, emotions, or sensations, can lead to increased psychological distress, reduced well-being, and hinder personal growth. Studies underscore the importance of facing and accepting challenging experiences, as avoidance tends to prolong emotional suffering and contribute to the persistence of mental health difficulties. Naturally, this means that we need to approach with caution any therapeutic approach that pushes us away from our real feelings and encourages avoidance. Critics suggest that the emphasis on replacing negative thoughts with positive ones might oversimplify complex emotional experiences and potentially lead to a pressure to always think positively. This approach could downplay the importance of fully experiencing and validating one's emotions. The term 'toxic positivity' has emerged to describe this phenomenon, shedding light on the potential drawbacks of excessive emphasis on positivity.

• Focus on Control: Encouraging excessive control over one's thoughts might inadvertently discourage the valuable practice of accepting thoughts as they naturally arise. It could steer individuals towards avoidance strategies, encouraging them to distance themselves from uncomfortable or distressing thoughts rather than developing a healthy relationship with them.

  Critics of traditional cognitive restructuring have pointed out that an overemphasis on thought control may inadvertently lead to avoidance of uncomfortable or distressing thoughts. This avoidance can hinder the process of fully engaging with one's thoughts and emotions, which is essential for meaningful personal growth and psychological well-being. Instead, approaches that focus on acknowledging, accepting, and mindfully observing thoughts without immediate attempts to control them have gained prominence as more holistic and effective strategies in therapeutic practices.

  In addition, some critics highlight that the emphasis on control over thoughts might inadvertently reinforce a sense of inadequacy or self-blame when individuals struggle to completely control their cognitive processes. My personal observation is that these approaches can contribute to mental exhaustion over time, as people feel a constant need to wrestle with, control, shape or replace negative thoughts.

A seasoned therapist takes a more nuanced and thoughtful approach to cognitive restructuring. Rather than simply prescribing alternative thoughts, a skilled therapist guides clients through a process of evidence evaluation. When we encourage clients to critically assess their thoughts against any available evidence, clients arrive at more helpful and realistic conclusions on their own. This approach promotes deeper insight and equips clients with tools to identify, evaluate and modify their thought patterns independently.

I should clarify that a skilled and experienced therapist can apply Traditional Cognitive Restructuring in a manner that involves guiding clients to evaluate their thoughts against evidence and encouraging deeper exploration, similar to the principles of Evidence-Based Cognitive Reappraisal. The main point of differentiation is that Evidence-Based Cognitive Reappraisal places a particular emphasis on evidence evaluation, which is not always as explicitly highlighted in all applications of Traditional Cognitive Restructuring.

Present and Past Thoughts

While we might not always realise it, the use of cognitive reappraisal or restructuring extends beyond our current thoughts. This transformative process is harnessed by various therapeutic approaches, such as CBT, Schema Therapy, Narrative Therapy, EMDR, Internal Family Systems (IFS) Therapy, Hypnotherapy, and Gestalt Therapy, often integrating imagery work to facilitate healing around past memories and traumas.

And here are a couple of practical examples to illustrate these concepts:

Example 1: Rewriting Childhood Memories

When practicing cognitive restructuring, imagery becomes a potent tool that assists with the exploration of our past experiences. Imagine a client who, as a child, experienced a significant event that left a lasting negative impression. Using imagery, the client is guided to revisit this memory, engaging their inner child. Through compassionate dialogue and reframing, the client's adult self can provide understanding, reassurance, and new interpretations. This process not only reshapes the memory's emotional charge but also fosters a sense of healing and integration.

Example 2: Addressing Traumatic Experiences

Various therapeutic modalities, including EMDR, trauma-focused CBT, and narrative therapy, harness the potential of imagery work to address deeply rooted traumas. Narrative therapy, for instance, encourages individuals to reconstruct and retell their life stories, often incorporating imagery to create a new narrative that empowers them and reframes their experiences. Similarly, in EMDR and trauma-focused CBT, imagery work plays a crucial role in facilitating cognitive shifts and emotional healing by allowing clients to view their traumas from different angles.

Imagination as a Source of Healing and Harm

Imagination can be seen as a double-edged sword, capable of both psychological harm and benefit. Often, we may not fully realise the immense power that our imagination holds in shaping our emotional experiences and psychological landscape. So, let's take a closer look at this.

Imagination and Psychological Harm: In our formative years, imagination plays a significant role in shaping our beliefs about ourselves and the world. According to Karen Horney's theory, “the idealised self” is born when a child uses their imagination to create a perfect idea of who they should be. However, this imagination can turn into an unrealistic expectation, leading to feelings of inadequacy, anxiety, and self-criticism later in life. Such maladaptive use of imagination can create a host of future issues that impact mental well-being.

Additionally, scholarly research has shed light on the potential risks of excessive or maladaptive fantasising, which involves the creation of intricate mental scenarios often for the purpose of escaping reality or wishful thinking. Studies have indicated that chronic fantasising may correlate with increased levels of anxiety, decreased psychological well-being, and difficulty in managing negative emotions (Smith et al., 2018; Soffer-Dudek, 2018). This highlights the delicate balance between the creative potential of imagination and its potential to contribute to psychological harm.

Positive Use of Imagination in Therapy: On the other hand, when we purposefully engage in imagination during therapy, we unlock its potential as a powerful tool for positive change. Imagery work allows us to tap into the creative depths of the mind, encouraging clients to explore alternative perspectives and cultivate more balanced and rational thoughts.

While there are many techniques for the use of imagination in therapy, our main goal is usually this: to travel with the client to a specific time in the past or future and then to help them see events or their understanding of the events in a new light. A good practice is to inform the client that although we can't change the past, that what's done is done, through this exercise can change how those events affect them now. In other words, by imagining the past differently, we might feel different emotions, and that can extend to how we feel today.

Stay tuned as we have some practical examples and case studies lined up in the next section, to help you develop a real grasp of how to apply cognitive appraisal and imagery exercises for various mental health conditions.

Cognitive Reappraisal and Self Image

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In the next few pages we will circle back to our old friend, Maslow's hierarchy of needs and explore how we can utilise cognitive reappraisal strategies for the treatment of deficits in each tier of the triangle. First, let’s take a look at the self image tier of the triangle:

If you've identified that the Self Image and self-esteem tier of the hierarchy of needs is your client's primary concern, there are two critical areas that require attention:

1. Current Thought Errors:

The types of thought errors that you are likely to encounter with a client experiencing self-image issues revolve around comparisons between oneself and others, manifesting in the following thoughts or core belief patterns:

1. I am LESS than others due to one or several weaknesses, failures or deficits. For example, I am less than others because I don't know how to suceed in life, I don't know how to fit in, I am physically unattractive, I am financially or educationally behind, I am weak or emotional and so on.

2. Other people view me as less favourable, less significant, less desirable, less interesting, less admirable than others due to one or several weaknesses, failures or deficits.

3. I am MORE than others due to one or several strengths, features or abilities. For example, I am more worthy, more exceptional, more unique, more admirable, more virtuous and so on.

Or a combination of these.

Please note: we are not talking about a client's constructive assessment of their abilities, stenghts or weaknesses. In fact, the ability to be self critical and be able to rationally assess one's challenges along with strenghts is indicative of a healthy self-image. The type of thoughts and core beliefs that we are referring to here are excessively negative, emotion ridden (e.g. feelings of inferiority, shame, anger, self blame, competetiveness, over excitement or euphoria associated with accessive pride) often accompanied by thinking errors such as emotional reasoning, catasrophising, over-generalising, magnification/minimisation etc.

The process of therapy involves carefully examining these thoughts with clients and exploring their accuracy against evidence, as the client is ready to engage in such exploration.

One more point to remember is, in keeping with the principles of emotion regulation and to avoid inadvertently encouraging experiential avoidance and toxic positivity, we also need to inform clients that once their thoughts are shifted, their emotions may or may not match their thoughts yet. This means that they could have a more rational and balanced view towards the situation, but underneath those thoughts, they may still feel shame, embarrassment, a sense of failure, inferiority, or a sense of defeat and helplessness. In other words, the process of cognitive shift isn't a magical wand that immediately erases underlying emotions. In fact, it's entirely normal for the emotions to lag behind the cognitive shifts. The purpose of cognitive reappraisal is not to diminish these emotions. Other techniques that we will explore in future sections can assist with alleviating emotions. So clients can stay true to their existing emotions, accept these emotions, and not try to fight or control them. While simultaneously, they can review their thoughts and adjust them to a more rational view.

Let's look at an example to illustrate these principles in action. Imagine working with Alex, a capable individual who tends to downplays his achievements in his career or personal life. Your conversation might unfold like this:

Therapist: Alex, you've mentioned feeling hesitant about your recent accomplishment. Can you share more about that?

Alex: Well, I kind of feel like I got lucky with it. Maybe it wasn't a big deal. Or maybe I'm a fraud and people will soon see that I'm really not very capable.

Therapist: Can you remember another time when you tackled a similar challenge and received positive feedback from your colleagues?

Alex gives several examples of his past accomplishments.

Therapist: That's a great. It seems like your skills often do come through when you face various challenges. Could it be that your recent accomplishment wasn’t just luck? What if we looked at your recent achievement through that lens?

Alex: I guess I could see it as a reflection of my skills.

If, as seen in this example, our client shows a willingness to embrace new perspectives and adjust their views with a level of ease, focusing on the present moment could be enough to achieve our goals. However, if the client's fundamental convictions seem to be deeply ingrained and resistant to change, or if we notice that the client consistently disregards current realities and evidence, it may be helpful to delve into client's past memories, particularly those from his middle childhood.

2. Past Memories:

An essential first step is to determine key events that may have contributed to an unhealthy self-image. As we learned in the previous module, by working together with your client to delve into their history, you can pinpoint specific moments that hold emotional weight. For instance, let's go back to the case of Alex. Through exploring his history, you may come to realise that he first experienced feelings of inadequacy in primary school (middle childhood) due to a yet to be diagnosed case of dyslexia, which made him feel like he wasn't adequate, as well as a schoolyard bully that made him feel like he didn't fit in with his peers.

Therapist: Can we take a minute and explore something? It's a technique called imagery work. I'll guide you to use your imagination to travel back in time to specific moments from your past and then, by imagining things a bit differently, you can gain new insights and perspectives. Of course the past is the past and we can't really change it, but through imagining it differently, we can change the way that we are impacted by it today. Close your eyes if you're comfortable, and imagine you're traveling back in time to your childhood. Can you remember a time when your carefree childhood feelings were replaced by the ideas of self doubt and feeling not good enough? Do you remember any memory like that?

Alex: I remember struggling a lot with reading and writing at school. All the other kids seemed to get it, but I kept struggling. I had dyslexia, and it made me feel like I wasn't as smart as the other kids in my class.

Therapist: I'm sorry to hear you experienced that. Can we try something now? Imagine if your adult self, or some else you trust, was to step into the story and support your younger self through this experience? What do you think he needed to hear? What would you like to do for him?

Alex: I'm not sure. Maybe somehow making his dyslexia disappear?

[Note: Often clients opt for imagery solutions that involve changing external circumstances in their past. The issue with this type of strategy is that, in reality the client has still experienced what they have experienced, and the imagery work has not addressed the need for the experience to be reframed. Hence, usually, the best use of these imagery exercises is to assist the client to still go through the experience, but try to make sense of the experience or reshape their thoughts around it.]

Therapist: We can try that. But in reality, this child will still have a memory of what it felt like to have dyslexia and feel inadequate in class. So maybe instead of making the dyslexia disappear, we could help him understand that his dyslexia doesn't make him less worthy than other kids. We could tell him that his dyslexia is just a specific challenge in a specific area, and that all people will experience their own challenges in life. Having challenges doesn't make you less worthy. You could practice the things that are a little hard, like your spelling, and eventually become better at them. Or you could shine even brighter in the things that you're already good at, like sports or science. It's all about having fun and learning new things! Every kid's journey will be different, so you don't have to compare yourself to the other kids around you.

[Note: The purpose of this dialogue with Alex is partly to convince adult Alex why his child self wasn't inferior than his classmates. Once he is convinced of this, he can use imagery to convince the child in his imagination as well. For some clients this step may take a bit more time as their self worth is so deeply scarred, that they can’t even accept that as a child they were worthy or deserved better. For such clients, you may need to focus on broader cognitive restructuring aimed at improving their self work a bit longer before they are ready to delve into childhood imagery work. A good strategy would be to try to detect any maladaptive core beliefs that may cause them to have such poor self image.]

Alex: I guess I can see your point. The dyslexia was just a challenge. I didn't need to form such a negative self image around it.

Therapist: Exactly, can you imagine if someone had told little Alex about all of this back then? Can you close your eyes again and talk to him about it?

Alex: I would tell myself that dyslexia doesn't define my worth. I'd say that I have strengths and abilities that go beyond just reading and writing.

Therapist: That's great! How does your younger self feel after hearing these words?

Alex: He feels a bit lighter, like there's more to him than just his struggles. But he's still worried about the schoolyard bully. He still feels like there is something wrong with him if the bully picks on him.

Therapist: Shall we use the same technique to support him through the bullying as well? What did the bully say or do that was hurtful?

Alex: He kept telling me that I was annoying and no one wanted to play with me.

Therapist: And you believed him?

Alex: I'm not sure. I mean, there were times when I was alone during breaks and no one was playing with me. So yes, I did believe him.

Therapist: What about at other times? Were there times when things were different?

Alex: I do remember playing and having fun with the other kids at times.

Therapist: So what do you think caused you to fit in one day, and not fit in another day?

Alex: I remember standing on the side of the schoolyard and keeping to myself a lot. Not really mixing with the other kids. I was too shy or anxious to mix with them.

Therapist: Do you remember why you were shy or anxious?

Alex: Because I kept remembering the words of the bully kid. I thought I was annoying and no one wanted to play with me. So I pulled myself away.

Therapist: And while you were pulling yourself away, naturally the other kids left you alone. And in your mind, that must have confirmed what the bully was telling you.

Alex: Exactly. It kept firming up the belief that no kid wanted to play with me.

Therapist: Sadly bullies often tell us that there's something wrong with us and it's understandable that you believed what the bully was telling you. But it's good to remember that the purpose of a bully is to make you feel bad about yourself. If their purpose was to tell you the truth, they could have done it in more gentle ways. So it's wise to not believe all the negative things that a bully tells you about yourself. Do you think we could tell the younger you to not believe the bully?

Alex: Yes, he now realises that if he just went back into the playground, other kids would play with him. He feels like he fits in.

The Domino Effect of Memories

One thing to keep in mind here is a principle referred to as the cascading effect or the domino effect of memories. As we know, early memories act as a foundation for interpreting later events in life. During the process of therapy, if we change a client’s perception of an earlier memory, a cascading shift can ripple through time, influencing how they perceive subsequent experiences. In Alex's case, for example, the core belief "I'm not good enough and I don't fit in" was maintained as part of his identity and once he hit adolescence, a combination of challenges like puberty, increased peer pressures and highschool bullying caused this belief to exacerbate even more. Later, adulthood experiences such as employment challenges or searching for a partner further cemented this belief in. As you can imagine, once the belief “I’m not good enough” or “I don’t fit in” is there, life would create a myriad of scenarios to confirm this existing belief.

Once therapy had helped Alex develop a new understanding of his middle childhood experiences, not only was his self-perception in the present moment transformed, but a ripple effect was initiated whereby he began reframing his memories of adolescence and adulthood too. At times you may find that this ripple effect happens automatically, as your client starts pondering all the subsequent memories and developing a new view of them. At other times, you may need to manually help your client apply their new understanding to the subsequent events of their life.

In contrast, you may find that if you first attempted to shift Alex’s view of his adolescence and adulthood, his views would be more resistant to change as he would still remember the events of his adolescence and adulthood through the lens of a child who was less than his peers as he couldn’t spell or fit in. That earlier belief needed to have been shifted first. After addressing the earlier memories, the intense emotional charge connected to later events, such as high school difficulties, also began to diminish. Transforming the core, foundational memories can gradually reshape the entire narrative of Alex’s sense of self-worth.

Another way to view this principle is that early memories can serve as templates or reference points for how we interpret and respond to later life events. Thus, modifying our perspective on these foundational memories can potentially have a positive influence on how we view and process more recent experiences.

So from a practical standpoint, we are suggesting that a rule of thumb is to commence the exploration with the event that occurred at the youngest age and progressively work through to more recent memories. However, therapists may encounter situations where clients display resistance to revisiting earlier memories and instead prefer to focus on later-life events. This inclination can be attributed to the escalating intensity of negative emotions as clients navigate through life's challenges. For instance, a memory from age 7 might seem less emotionally charged than one from age 18, as years of challenging experiences would have eroded client’s self-worth even further. Clients often express that while the origin of their self-esteem issues dates back to middle childhood, these issues didn't gain prominence until later stages of life. This is where psychoeducation comes into play. It's crucial for therapists to help clients comprehend the significance of revisiting earlier memories, even if the associated emotions appear less intense, as it lays the groundwork for untangling the web of self-perception. Below is an analogy that I like to provide to clients about this principle, to help them understand the logic:

"Just like a big tree starts as a small seed, our feelings about ourselves also begin when we are very young. Even though those early feelings might not seem as big as the ones we have now, they are like the roots that grow into the big tree. To understand the big tree, we need to look at how it started as a little seed and grew. In the same way, to understand how you feel about yourself today, we need to go back and see how it all began when you were younger."

Cognitive Reappraisal and Attachment

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In this section we will explore how cognitive reappraisal techniques can be applied if you have identified that the attachment and connection tier of the hierarchy of needs is your client's primary concern.

The types of thought errors that you are likely to encounter with a client experiencing attachment related issues revolve around the belief that they are not loved or cared for by others, hyper-sensitivity to abandonment, maladaptive beliefs around others being trustworthy or well-intentioned and a tendency to feel alone. Clients justify these beliefs by adhering to evidence from both past and present experiences.

1. Past Memories:

Childhood memories which create the belief that the child is not loved or cared for by adult caregivers are the primary foundation for attachment-related challenges. Attachment theory, initially focused on infancy, extends its influence beyond that period, encompassing toddlerhood and early childhood. While the foundations of attachment are primarily formed during infancy, they continue to evolve and interact with a child's growing cognitive and emotional capacities beyond that age.

In my experience, when engaging in imagery work with clients who have encountered environments marked by inadequate attachment, a common pattern emerges: these individuals frequently recollect their earliest memories of abandonment, feeling alone or not cared for, from the age group of 3 to 6 years. This observation aligns well with the principle of cascading memories, as well as Erikson's psychosocial theory. Erikson's theory highlights the significance of the 'Initiative vs. Guilt' stage during these formative years, where children develop a sense of control and initiative over their environment. Poor attachment experiences during this phase can leave a lasting impact on a child's sense of security and control. Additionally, memories from this stage hold a unique blend of accessibility and richness due to the emergence of language skills, cognitive abilities, and moral awareness. This combination of factors makes memories from this time particularly poignant for clients. As a result, addressing memories within this age range through cognitive reappraisal allows for targeted and effective interventions, enhancing the potential for meaningful transformation. By revisiting memories from this age range and applying cognitive reappraisal techniques, we can help clients reframe early experiences and foster more secure attachment patterns that can cascade through a client's life. Let’s take a look at an imagery exercise to illustrate these principles in action.

Therapist: It sounds like you've been through a lot during your early years. I've noticed that there's a recurring theme of loneliness and not feeling cared for whenever we have talked about your past. Would you be open to exploring these feelings a bit today through an imagery exercise?

Sarah: Yes, sure, let's try it.

Therapist: Let's start by focusing on a particular memory. What's the earliest memory that stands out to you from your childhood?

Sarah: There's this memory from when I was around 5 years old. My mom was always distant, lost in her own world, and my dad wasn't in the picture. My siblings were dealing with their own stuff, and I often felt like a burden. I remember wanting to play with them or talk to them, but they would push me away and tell me to leave them alone. It felt like my presence was a burden to everyone. I was just not lovable.

Therapist: Now, imagine that you, the present-day grown-up Sarah, could travel to the past and be with the child Sarah as her mum is mentally absent and she's experiencing being pushed away by her siblings. But you're not there to push her away; you're there to show her the love and care she needed. Can you do that?

Sarah: No, I can't do it. I'm not sure why. It's like there's a wall between me and that little girl.

Therapist: Look deep within your heart. How do you feel towards that child? Do you feel love and compassion towards her?

Sarah: No, I feel angry towards her. I feel horrible saying this, because I normally love children. But I can't feel love for this child. I have such negative feelings towards her. I feel like if she was a bit less pathetic, her mum and siblings wouldn't push her away.

[Please note: during imagery work, when you come across clients who, like Sarah, struggle to extend love and compassion towards their younger selves, this should be considered as a sign of the severity of their self worth and attachment issues. With these clients, your first goal becomes to help them grow compassion towards their child self.]

Therapist: Sarah, please don't blame yourself for struggling to love that child. Your struggle to connect with your younger self is completely understandable, given the experiences you've had. Growing up, you didn't receive the modeling from the adults around you that this child version of yourself was deserving of love and care. This is exactly why we're engaging in this exercise – to bring healing and change to those deep-rooted beliefs. You could say that as you gradually grow love and compassion towards that child, you will also be growing love and compassion towards yourself. This may take some time, so don't feel like you have to achieve it overnight. And you're not doing this alone – I'm here to support you through it.

[Please note: It's common for clients to feel guilt when they struggle to love and care for their inner child. The purpose of the above statement from the therapist is to set the client's mind at ease that they are not judged and that they can let go of their guilt so that these thoughts could be explored freely.]

Sarah: Thank you. It's good to hear that.

Therapist: Do you feel ready to continue?

Sarah: Yes, let's continue.

Therapist: You know, it's quite common for children to view adults as having everything figured out, almost as if they're perfect. But the truth is, adults have their own struggles and challenges too. Your mom might have been dealing with her own issues, maybe mental health concerns, that made it difficult for her to be as present as she should have been. And your siblings, they were also navigating their own difficulties. It's possible that they never learned how to be fully present and caring because of the family's difficult circumstances. The family was struggling as a whole. You interpreted their actions as a reflection of your own worth, but that's not accurate. The 5-year-old Sarah wasn't responsible for the actions or behaviors of the adults and siblings around her. You were just a child, seeking the love, care, and validation that any child needs.

I wanted to also tell you about a cycle that can form where the more a child feels pushed away, the more desperate they become to receive love and attention. As a result the child may start to act either overly reserved or overly clingy. The child's clingy or reserved behavior can then lead to the adult caregivers responding negatively, causing the child to feel even more unloved and rejected. Unfortunately this is a common cycle that can happen with neglected children. It is a possibility that these dynamics impacted you as a child as well.

So with all of this in mind, can you logically agree that there was nothing inherently wrong with little Sarah? That she was simply a child in a challenging environment, doing her best to navigate the circumstances around her?

Even if you find it challenging to emotionally love little Sarah right now, could you at least acknowledge, from a rational perspective, that she did deserve love and care, just like any other child?

Sarah: You have given me so much to think about. Logically, I can see your point. I wasn't bad or broken. I was just a normal child within an unhealthy environment.

Therapist: And how do you feel now, with all this new perspective?

Sarah: I feel sad for her. I mean, I still struggle to fully accept and love her. But I'm a bit more open to it. I feel like I'm not so angry with her anymore.

Therapist: That's a step in the right direction. It may take some time for your emotions to fully shift. That's totally okay. Emotions can take time to catch up with our thoughts and realisations.

2. Current Thought Errors:

When working with clients who are grappling with attachment issues, you'll often come across thought errors that revolve around their connections with others and the security they feel within relationships. These thought patterns might involve doubts about the authenticity and dependability of other people's care and affection for them. Or they may hold the belief that they are intrinsically unworthy of love and care.

The biggest "here and now" issue with this group of clients is a need for them to realise that although earlier in their life, their social connection issues came from outside sources (i.e. neglectful or abusive caregivers), their current struggles with relationships mostly stem from their own maladaptive beliefs, habits and behaviour. As a therapist hearing story after story where your client with attachment problems was treated terribly, ending up feeling abandoned, rejected or betrayed, you may start wondering: what is going on here? Is this person incredibly unlucky? How come they keep experiencing such a dark side of the society on a consistent basis? This line of questioning may continue for you until a point where you find yourself surprised that your own innocent behaviour was interpreted by your client as a sign of abandonment or abuse. Or where the client communicated with you in highly ineffective ways, leading to a myriads of misunderstandings within the therapeutic setting. This, usually, is the point where therapists stop and wonder: am I dealing with a personality disorder here??

The consistent patterns of abandonment, rejection and mistreatment experienced by clients with poor attachment are a result of three main mechamisms:

1) Scarring their realtionships through hyper-sensitivity and poor communication: Clients with attachment issues often grapple with poor emotion regulation, maladaptive coping strategies, and intense emotions like anger, clinginess and tendency to take offense easily. Moreover, they are often challenged with poor communication, an issues that likely stems from lacking positive communication models in their family of origin. These challenges can contribute to increased likelihood of experiencing rejection and abandonment by those around them due to frequent relationship breakdowns.

Cognitive reappraisal: One of the goals of the therapeutic journey is to explore with the client these problematic communication patterns with due sensitivity to their emotional landscape. Through cognitive reappraisal, the therapist delicately guides the client to a deeper understanding that certain communication patterns, might inadvertently distance others or harm their relationships. This realisation is not about making the client feel blamed or holding them accountable for their past actions; instead, it is to help them gain insight into the root causes of their relational challenges. If these therapeutic processes are done with due sensitivity and care, clients often find relief and renewed hope in uncovering the origins of the patterns they have found perplexing their whole lives.

Balancing Care and Honesty, therapists must navigate the fine line between gentleness and transparency. If we manage to communicate with sensitivity and honesty, clients can find their renewed understanding liberating, as it fosters a sense of agency and the potential for healthier connections.

An important element of this is educating clients with attachment problems about healthier communication styles. The exploration of healthier communication strategies is a large topic that extends beyond the scope of this module. We will be exploring communication strategies in upcoming modules or you may like to refer to the chapters on communication within the Mind Wellbeing Workbook. These resources provide practical tools to help clients with attachment issues cultivate and sustain healthier communication habits.

2) Not perceiving or detecting genuine love/care: Individuals with attachment issues often struggle to perceive genuine love and care when they receive these. The idea that individuals with attachment issues might struggle to perceive or fully accept genuine love and care is well-established in the literature on attachment theory. This concept ties into their tendency to interpret situations through the lens of their past experiences and attachment patterns. People with attachment difficulties might have developed defensive mechanisms that make it hard for them to trust or believe in positive interactions. As a result, they might be more attuned to cues of rejection or mistrust and they may find it challenging to embrace positive feelings or connections. For example, when interacting with others, they may dismiss or not notice any signs that the other person cares for them or wants their company, but only notice the times when the other person is preoccupied with other things or fails to respond favorably.

3) Attraction to Abusive or Uncaring Partners: An additional element is that individuals with attachment issues often do become vulnerable to real abuse or mistreatment. This is due to the fact that they tend to get attracted to abusive or uncaring relationships, while rejecting genuinely kind or caring people. This further increases the likelihood of broken relationships or hurt and a reinforcement of their beliefs in relationships being insecure.

The phenomenon of individuals with attachment issues being attracted to abusive or uncaring partners is well-documented within psychology and relationship research. This pattern likely stems from the fact that these individuals are attracted to relationships that feel familiar and "normal" as they replicate the unhealthy dynamics of their early attachment experiences. Moreover, relationships with partners who treat them poorly might validate their negative beliefs about themselves, as they may feel they deserve such treatment.

So, here we can observe a paradoxical situation where people with attachment problems often find it easier to see love and care in abusive or uncaring people rather than in those who genuinely care about them. It's important to note that these patterns do not imply that individuals with attachment issues intentionally seek out harm. Rather, it often reflects deeply ingrained emotional patterns and a lack of healthy relationship models.

Cognitive reappraisal: An important task for cognitive reappraisal is to help these clients re-evaluate their relationships and their inner "detectors", so that they can understand:

a) which instances of relationship breakdown were due to their own hypersensitivity and poor communication;

b) which instances were due to not noticing or detecting genuine love; and

c) which instances were due to them simply choosing an uncaring or abusive partner.

A task of therapy, then, is to go through a journey of discovery with these clients, to assist them to find these distinctions.

Understanding the Paradox

The phenomenon of perceiving care in abusive or uncaring individuals while struggling to recognise it in genuinely kind ones is rooted in a complex interplay of psychological factors. Below are a few factors explored in the literature which may help us understand this perplexing dynamic, along with suggested intervention strategies using cognitive appraisal:

1. Attachment Blueprint: As we explored earlier, early attachment experiences serve as the foundation for understanding relationships throughout life, and a blueprint for how relationships should look like. Their early attachment experiences might have been characterised by inconsistency, neglect, or even abuse. These negative experiences, while painful, become ingrained in their understanding of relationships. As a result, they may be more comfortable or accustomed to relationships that mirror their past.

Cognitive reappraisal: When therapists observe these tendencies in their clients, it presents an opportunity to bring this pattern to the client's attention. By gently exploring their past attachment experiences and their influence on present relationship choices, therapists can help clients assess and challenge these deeply ingrained patterns. This process can shed light on the origins of their preferences and offer them the chance to redefine healthy relationship dynamics.

2. Low Self-Worth: Deep-seated feelings of unworthiness often plague individuals with attachment problems. As a result, they might struggle to believe that someone genuinely caring and kind would be interested in them. This disbelief can push them towards relationships that align with their self-perception and poor self image.

As we delve into the self worth aspect of attachment problems, it might be worth revisiting an idea that we previously discussed. You may remember that in Module 1 we suggested that while everyone with attachment issues tends to grapple with self-image problems, the inverse is not necessarily true. Meaning that it is possible for individuals with secure and healthy attachment styles to grapple with self image issues. Here it may be worth spending a bit of time exploring the distinctions and nuanced differences between the self worth/self image issues experienced by people with attachment problems and those without attachment problems. These differences can be summarised as follows:

• Developmental Origins: Attachment-related self-image issues are likely onset earlier in life, influenced by the quality of attachment experienced with primary caregivers during infancy and childhood. Self-image issues not related to attachment, on the other hand, are likely to be created later in life. As explored in the previous module, they are frequently rooted in middle childhood experiences. At other times, they can be developed as a result of pressures or traumas experienced in adolescence or adulthood.

• Depth and Scope of Impact: The depth of self-image and self-worth problems can differ significantly between individuals with attachment-related issues and those with self-image problems unrelated to attachment. For individuals with attachment problems, the self-worth issues can be deeply ingrained, pervasive and profound, often affecting their overall sense of identity and ability to form healthy relationships. On the other hand, self-image issues not tied to attachment may be more context-specific, potentially leading to fluctuating feelings of self-worth based on different situations. They are often centered around aspects of oneself that are not directly linked to their bonds with close connections and loved ones, but are related to external factors, societal influences, or personal attributes and capabilities.

Cognitive reappraisal: An effective approach to cognitive reappraisal here involves guiding the client to realise that the way their self-worth was defined within their family of origin is not a testament to their genuine worth as a person. Instead, the neglect, lack of empathy, or abuse that they experienced while growing up was a result of the dysfunction or stressful factors present within their family dynamics. As a result, these clients can begin developing an alternative explanation for the patterns of harsh criticism, disapproval, neglect or maltreatment they experienced, leading to a paradigm shift within their sense of self-worth.

3. Loss of Trust in Kindness: Perhaps the most powerful testament to the depth of these individuals' low self-worth and self-resentment is that, if attachment problems are severe enough, when the individual experiences genuine care and kindness, they are more inclined to perceive the caring person as flawed or insincere than to entertain the idea that they themselves might be deserving of such care. At times this tendency can result in them perceiving the caring person as having something inherently wrong with them. For example, they may believe that the kind person must be too lonely or unpopular to be able to find other company. Or they may perceive their kindness as a vulnerability or weakness. At other times, they may lose trust in the kind person, thinking that they must be insincere or manipulative. Within the therapeutic setting, they may believe that the therapist is only displaying kindness because they are getting paid for the sessions or because they are professionally obligated to do so. As you can imagine, navigating this tendency can be a significant challenge for the therapeutic alliance and this can account for much of the difficulties therapists face when trying to assist individuals with borderline personality or other personality disorders.

Cognitive reappraisal: Cultivating cognitive reappraisal around this issue entails several objectives aimed at dismantling the patterns of mistrust and negative labeling that individuals with attachment problems might exhibit:

• Awareness Raising: As therapists, it's crucial to recognise when clients consistently label individuals who have shown them care or kindness in negative ways. By gently pinpointing this inclination, or bringing it to the client’s awareness, therapists can prompt clients to reflect on their own cognitive biases and how these biases might affect their perceptions of relationships.

• Questioning Patterns: At times a deliberate line of inquiry may be necessary for the therapist to understand unhelpful patterns that may be impacting the client. When clients with attachment problems complain about consistent pattern of abuse, mistrust or hurt in their lives, therapists can quiz the client to see if there have been any exception to the rule, where the client experienced being treated well or with kindness? If so, how did the client perceive the individuals who treated them well? Did they trust or respect the kind individual? Did they enjoy their company? This line of inquiry can help detect any negativity that the client may have felt in relation with the kind or caring individuals that have crossed their path. The therapist can then help challenge any cognitive biases.

• Exploring the Intentions of Others: People with attachment problems may face difficulties in accurately interpreting the intentions and behaviors of others due to potential challenges in emotional and social intelligence. Therapists can play a crucial role in gently probing clients' negative interpretations, helping them confront and reevaluate their perceptions. By highlighting instances where their assumptions might not align with the actual intentions of both caring and non-caring individuals, therapists guide clients to distinguish between past triggers and present reality. This process can empowers clients with a sense of confidence and control as they become more skilled at predicting the behavior of others.

• Engaging in Therapeutic Dialogue: If the therapeutic relationship encounters moments of strain or disconnection due to clients’ tendency to replicate their attachment-related dynamics, such as miscommunication or mistrust, therapists can use these moments as opportunities for open and honest dialogue. Conversations centered on the client's feelings of doubt can be pivotal in building faith in the sincerity of the therapeutic connection. This open dialogue can potentially salvage the therapeutic bond during difficult moments and contribute to the healing process. These discussions also serve as a reflection of the therapist's commitment to maintaining a safe and open environment for communication, fostering a sense of trust that might have been absent in the client's earlier experiences.

• Proactive Communication: It is beneficial to be proactive with clients with attachment issues, recognising the potential for them to distance themselves due to past dynamics, and establishing a foundation of open communication from the outset. This means that early on in the therapeutic relationship, it is beneficial to explicitly invite clients to voice their concerns and feelings of hurt, if these ever arise in the therapeutic relationship. By emphasising that the therapeutic relationship can be transparent and open around such matters, we can address these challenges head-on and mitigate potential misunderstandings. We can also demonstrate a departure from the negative relational patterns clients might have experienced in the past.

4. Repetition Compulsion: Some theories suggest that individuals unconsciously seek out relationships that replicate their past in an attempt to "rewrite" or heal their early attachment wounds. In the case of individuals with attachment problems, this often results in a tendency to engage in relationships with uncaring or abusive individuals in an emotionally driven attempt to finally receive the approval and affection of individuals who are reminiscent of their early caregivers. In some ways, individuals with attachment problems feel a compulsion towards receiving the care and affection of uncaring or callus people, as these are the types of individuals who made them feel unworthy in the first place. At times, I have found that this compulsion is so strong that even after they have become aware of its futility during the process of therapy, they still find it difficult to give up on this life long desire. In these cases, assisting clients to overcome this compulsive desire becomes a gradual and consistent goal of therapy for an extended period of time.

Cognitive reappraisal: The cognitive reappraisal process in this context aims to help clients recognise the futility of seeking care and affection from uncaring or callous individuals. An analogy that can be beneficial is to compare this situation to expecting apples from an orange tree. Just as you wouldn't get apples from an orange tree, seeking genuine care and affection from individuals who are emotionally disconnected and callous is unlikely to yield the desired results.

Psychoeducation about the mindset of uncaring and callous individuals can shed light on why their actions and behavior may not align with the client's expectations. It's important to emphasise that their lack of care is not a personal rejection but a reflection of their own emotional state and limitations at that given time. Clients can benefit from understanding that these individuals are often disconnected from their own emotions and empathy for various reasons, making it challenging for them to provide the care and affection the client seeks.

The goal of this cognitive reappraisal task is to help clients let go of the compulsion to seek care from those who cannot provide it and redirect their focus toward healthier, more fulfilling relationships. By understanding the limitations of these uncaring individuals, clients can work toward building relationships that genuinely meet their emotional needs and move beyond the repetition compulsion.

5. Need for Exaggerated Claims of Affection: Individuals with attachment problems can experience a heightened sensitivity to cues of rejection, and a reduced ability to perceive affection or praise. This tendency may mean that they require more pronounced or exaggerated claims of affection or praise to register in their awareness. Abusive or manipulative individuals can exploit this vulnerability by displaying intense and overstated claims of affection or praise as a means of control or manipulation. These exaggerated expressions can stand out more to those with attachment issues, and capture their attention more readily than the subtle yet genuine expressions of care found in healthier relationships.

Cognitive reappraisal: When therapists observe these tendencies in their clients, it presents an opportunity to bring this pattern to the client's attention.

6. Fear of Intimacy: Individuals with attachment issues might have an underlying fear of intimacy due to their early attachment experiences. Forming genuine connections can feel threatening to them, as it opens them up to the possibility of rejection and abandonment. As a result, they might gravitate toward relationships where intimacy is superficial, artificial, limited or absent.

Cognitive reappraisal: When therapists observe these tendencies in their clients, it presents an opportunity to bring this pattern to the client's attention.

7. Distraction Mechanism: Poor emotion regulation can result in distraction seeking behavior as individuals with attachment issues attempt to sooth their unresolved emotional pain and attachment wounds. Being with abusive or uncaring partners can often present much drama and chaos which can feel attractive to individuals with attachment issues, as it can momentarily divert their attention from emotional pain.

Cognitive reappraisal: When therapists observe these tendencies in their clients, it presents an opportunity to bring this pattern to the client's attention.

As you can imagine, the intricacies of treatment for people with attachment related issues are multilayered and there are many complexities. However, with a systematic approach that takes into consideration communication strategies and increased awareness of maladaptive attachment dynamics, we can increase the chances of success in therapeutic outcomes. A further element that is necessary in the treatment of these clients is the establishment of emotion regulation and mindfulness techniques. These will be covered in later sections.

Cognitive Reappraisal and Safety/Basic Needs

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In this section we will delve into the lower two tiers of the hierarchy of needs, which share similarities with the challenges often associated with trauma. We'll explore the essential cognitive therapy steps required to address and heal these foundational aspects of well-being.

There are many exciting therapies emerging in the field of trauma. In this course, we won't extensively cover the field of trauma-informed therapies, given the wide range of approaches and ongoing developments. Instead, our focus will be on providing essential insights into our goals and methods when providing treatment to this client group, so that we can have a foundational understanding of our objectives and strategies.

When addressing trauma, we encounter a distinctive set of challenges that set it apart from other forms of psychological distress. Trauma often engages our primal fight or flight mechanisms and can have profound physiological and neurological effects. Therefore, navigating trauma therapy necessitates a comprehensive approach that considers the intricate interplay between mind and body. So before we delve into the cognitive reappraisal steps for these lower-tier needs, we'll need to touch upon several other elements of trauma therapy that must be holistically considered.

Some Thoughts on the Stabilisation Phase of Trauma Therapy

Stabilisation in the context of trauma therapy refers to the initial phase of treatment which focuses on enhancing the client's sense of safety, emotional regulation, and coping skills. It aims to prepare clients for the challenging work of processing traumatic memories and experiences. While the components of stabilisation can vary widely among different approaches or therapists, some typical elements of stabilization include:

Safety Planning: Collaboratively developing a safety plan to help the client feel safe about any overwhelming emotions that may arise during trauma processing. For example, you and your client could write down emotion processing strategies, emergency or support contacts, and other coping strategies to use if needed.

Grounding Techniques: Introducing grounding exercises that anchor clients in the present moment and prevent them from becoming overwhelmed by traumatic memories. Examples of grounding techniques include simple mindfulness strategies like focusing on the five senses, such as noticing or describing what they see, hear, touch, taste, or smell in their immediate environment. Additionally, clients can engage in rhythmic activities like deep breathing or tapping specific parts of their body to foster a sense of safety and connection to the here and now.

Relaxation techniques: Introducing deep breathing and relaxation exercises to help clients manage physiological arousal related to trauma triggers. For example, progressive muscle relaxation can be taught, where clients systematically tense and then release different muscle groups to promote physical relaxation. Additionally, diaphragmatic breathing techniques can be employed, encouraging slow, deep breaths to calm the nervous system and reduce anxiety associated with traumatic memories.

A common misconception is that effective treatment needs to follow an exact, step-by-step process, involving a stabilisation phase, followed by a trauma processing phase, and finally reintegration into daily living. The necessity of a stabilisation phase before trauma work has been a topic of debate within the field of trauma therapy. The concept of stabilisation often stems from models like Herman's phased approach for complex PTSD, suggesting that a stabilisation phase should happen before trauma processing. It's important to note that Herman herself emphasised the oscillating and dialectical nature of these phases (Herman, 1992b). In practice, the stages of healing from trauma don't always happen in a strictly sequential manner. They can overlap or be repeated at different points during treatment. Also, there isn't strong evidence to suggest that a phased approach, where stablisation has to take place before trauma processing, always works better than just focusing directly on dealing with the trauma itself. Critics argue that stabilisation can be an unnecessary use of clinical time without significantly improving outcomes or reducing dropout rates (Baekkalund et al., 2021; de Jongh et al., 2016; Oprel et al., 2021).

An additional concern raised is that overly emphasising a stabilisation phase in trauma therapy can inadvertently encourage avoidance behavior in clients. The idea behind this concern is that if therapy overly prioritises or prolongs the period dedicated to helping clients feel safe and stable, without addressing traumatic memories and their associated distress, it can reinforce the idea that avoiding those memories is the safest option. Clients may interpret this focus as confirmation that their fear of confronting the trauma is justified and that avoidance is an acceptable strategy.

Over emphasising or prolonging the stablisation phase can stem from several factors, including therapists' empathetic and compassionate tendencies leading to the concern that they may upset the client, therapists’ feeling under-confident, or a misconception that addressing trauma memories may cause harm or retraumatisation (Murray et al., 2022). However, it's crucial to stress that substantial evidence supports the idea that actively engaging with trauma memories, rather than avoiding them, is the most effective approach to treating trauma patients.

Avoiding Overactivation:

Although we do not wish to encourage avoidance of trauma memories, we should simultaneously be vigilant to only activate trauma memories at a pace that is tolerable to the client and can be processed effectively within the time limits of the session. We must avoid overwhelming clients by uncovering too many facets of the trauma memory at once. Instead, we should focus on one aspect or part of the memory during a session before considering addressing other aspects, preventing potential retraumatisation.

There are moments when we, as therapists, need to act as a brake during the session. Sometimes, clients struggle with regulating their emotions, and they might start recounting multiple layers of trauma. This can lead to unresolved issues when they leave the session, as there isn't enough time to address them comprehensively. In other cases, clients may share more about their trauma than they're emotionally prepared to handle at once, often because they believe it's what we expect from them.

Unfortunately, I've seen instances where such situations caused clients with PTSD to disconnect from treatment. They return home to flashbacks, distress, nightmares, and develop the belief that therapy is too intimidating or unhelpful. In some instances, this has occurred despite my best efforts to prevent it, as I may have underestimated the painfulness of certain memories for the client. Therefore, while our goal is to bring these memories to the surface and facilitate a reframing process, it must be done carefully and thoughtfully, ensuring that we only delve into the amount that the client can update and heal during a specific session.

Here are a few strategies that may prove helpful in this regard:

1. Notice Client Discomfort: If a client expresses that recalling certain memories is uncomfortable, emotional, triggers nightmares, or causes other psychological distress, or if they mention that they tend to avoid talking about or remembering a particular memory, take these remarks as cues to exercise extra caution with these memories. It's important to emphasise that this cautious approach isn't about avoidance but rather a means to assist the client in confronting their trauma memories in a supportive and considerate environment.

2. Attentive History Taking: During the client's history-taking phase, be attentive to any memories that appear trauma-related or trigger distress or discomfort. Ask the client questions such as, "How do you typically feel after revisiting or discussing this memory?" If a client indicates that recalling or discussing a memory induces significant distress or mentions avoidance, treat these memories with care.

3. Act as a Gentle Gatekeeper: In such cases, inform your client that while you're eager to hear their story, you are also aware that this memory may be overwhelming to them, and you would like to make sure that at this stage of assessment or treatment, you don’t uncover memories that they are not ready to process. An effective strategy is to ask clients to flag with you the existence of trauma memories but not delve into too many details during that stage. Encourage them to communicate the existence of these memories but to provide only the level of detail that feels comfortable at this stage. Explain that you do need to know if they've experienced certain traumas for a more accurate assessment, but that you don't require all the details immediately. This proactive approach can be crucial, as many clients mistakenly believe they must divulge all the details of their trauma to the therapist at once, which can put them at risk of retraumatisation or disconnection from treatment.

Keeping these considerations in mind, here are some guidelines regarding when and how to employ stabilisation techniques:

Assessing Current Needs: At the start of each trauma-focused session, begin by assessing your client's current emotional state and their readiness to engage with traumatic memories. Ask about their anxiety levels, emotional regulation, and any immediate distress.

External Circumstances: Some clients may be experiencing external life circumstances that contribute to instability, such as house moves, financial difficulties, or ongoing medical or legal issues. It is important to adopt a client-centered approach here, maintaining open communication with the client about their priorities and their capacity to engage in trauma work. An initial goal in therapy could be to focus on supporting them through handling the external circumstances. While some clients prefer to arrive at greater stability around their external circumstances before commencing trauma work, others are happy to get to trauma work straight away. External difficulties shouldn't always be a reason to delay trauma-focused treatment, especially if the client is willing and able to engage in therapy. Additionally, therapists should remain vigilant in cases where clients use a prolonged focus on external circumstances as a way to avoid addressing their trauma.

Gradual Exposure: When the time comes to address traumatic memories, therapists often use a gradual and systematic approach. This involves breaking down the traumatic material into manageable pieces and addressing it step by step, ensuring that the client is well-prepared and has effective coping strategies in place.

Monitoring Emotional Threshold: Continuously monitor your client's emotional threshold during the trauma processing phase. Be vigilant for signs of distress or overwhelm, and be ready to pause or shift back to stabilisation techniques if needed.

Post-Processing Stabilisation: After a trauma-focused segment, reintroduce stabilisation techniques to help your client re-center and manage any emotions that may have been stirred up by the processing.

Clients with a Higher Need for Stabilisation: Finally, there are clients who would benefit from a greater focus on stablisation prior to trauma work. Clients who have engaged in long-term avoidance of their traumatic memories may have a heightened fear or anxiety related to these memories. This fear can be so intense that attempting to address the trauma directly and immediately without adequate preparation can lead to retraumatisation and a breakdown of trust in the therapeutic process. Establishing a sense of safety and trust in the therapeutic relationship is a foundational step in trauma therapy. Clients need to feel confident that the therapy space is a safe and supportive environment in which they can gradually approach their traumatic material. So for clients with a high degree of trauma-related avoidance and fear, a period of psychoeducation and stabilisation work can help the client to become open to the idea of facing their traumas, knowing that they have the necessary tools to manage any symptoms that may arise post-trauma work.

Psychoeducation

One important element of cognitive reappraisal is psychoeducation. Psychoeducation is a powerful tool that can assist clients to understand and depersonalise the changes that they have experienced following their traumatic experiences, as well as instilling hope in the possibility of healing and recovery. Psychoeducation is helpful in the beginning stages of trauma work, although it is helpful to circle back to psychoeducation at subsequent points of treatment work, as the need arises.

Trauma can significantly alter the brain's structure and functioning, leading to a range of emotional and physiological responses. Below are several factors that clients may benefit from learning about during psychoeducation stages of treatment:

a) Neurological Impacts of Trauma:

Trauma significantly alters brain structure and functioning. The amygdala becomes hypersensitive, triggering intense emotional reactions, while the prefrontal cortex, responsible for decision-making and emotional regulation, is affected. These changes lead to heightened stress responses and emotional reactions, making traumatic memories vivid and emotionally charged.

Clients can understand these neurological impacts through psychoeducation. Knowing that these changes are adaptive responses to a traumatic environment, not personal failings, helps alleviate self-blame. Therapists can explain that the brain is capable of change (neuroplasticity), offering hope for healing.

b) Memory Processes:

Trauma often leads to fragmented and emotionally charged memories. During trauma, the brain prioritizes survival over orderly memory encoding. This results in isolated sensory fragments and emotional reactions rather than a coherent narrative. The hyperactivity of the amygdala reinforces emotional intensity.

Clients can grasp these memory processes through psychoeducation. This knowledge helps them understand why traumatic memories resurface with great intensity when triggered, leading to flashbacks, nightmares, or overwhelming emotions.

c) Neuroplasticity and Hope:

Neuroplasticity, the brain's ability to reorganize and form new neural connections, offers hope for healing the neurological and memory aspects of trauma. Through specific therapeutic approaches, clients can experience significant improvements.

d) Healthy and Unhealthy Processing:

Experiential avoidance, the avoidance of distressing thoughts, emotions, or memories related to trauma, can provide temporary relief but hinder long-term healing. Clients need to understand that facing and processing traumatic experiences with therapeutic techniques like cognitive reappraisal is essential for recovery.

Bodily Sensations

Understanding the strong connection between the mind and body is paramount in trauma treatment. Traumatic experiences often manifest as bodily sensations, such as tension, pain, or numbness, which can serve as triggers for distressing memories. Recognising and addressing these sensations are essential for trauma survivors. Emerging research highlights the effectiveness of interoceptive exposure techniques in trauma therapy, emphasising the importance of integrating interoception into trauma treatment strategies. In upcoming sections of this eCourse, we will delve into the practice of these techniques and their application in the therapeutic setting.

Cognitive Reappraisal

Cognitive reappraisal for individuals recovering from trauma involves identifying and challenging negative beliefs and thought patterns associated with the sense of threat stemming from the traumatic event or its aftermath. This perceived threat can manifest as external danger (i.e., the belief that the world is more dangerous than previously realized) or internal vulnerability (i.e. the belief that one is vulnerable, weak or at risk). Furthermore, trauma frequently generates feelings of guilt (commonly known as survivor guilt), remorse, self-blame, and hopelessness.

It’s worth mentioning that trauma does not necessarily only create issues in two bottom tiers of the triangle (sense of safety and deprivation from basic physiological needs). Often perpetrators of trauma also target the individuals’ sense of self worth and their connection to other people. For example, an abusive partner may be physically abusive, creating a sense of fear and threat, but could also be emotionally abusive, making their partner feel worthless, incapable, alone and abandoned. They may even instill in their partner the idea that their family, friends or public look down upon them or ridicule them. Similarly, trauma sustained from persecution, torture or many other forms of abuse and bullying can be multilayered and multifaceted. The purpose of understanding these experiences in light of the hierarchy of needs is not to simplify trauma or deny its many facets. Rather, the purpose is to be able to categorise the different types of harm which our clients can be suffering from at any one moment, and understanding what treatments are most effective for each type of harm. In this section, our focus will be on the aspects of trauma that impact the individual on the level of safety, security and basic needs.

So, to address those aspects of trauma that threaten the individual’s sense of physical safety, security and access to basic needs, I would like to bring our focus to two exciting methods of reappraisal that are used in cognitive therapy for PTSD (CT-PTSD). These are:

1- Updating Trauma Memories:

This three-step procedure involves:

(i) Accessing memories of the most distressing moments during the traumatic events, often referred to as 'hotspots,' and exploring their associated meanings.

(ii) Identifying information that updates these meanings, drawing from the course of events during the trauma or cognitive restructuring and testing of predictions.

(iii) Linking the new meanings to the worst moments in the memory, essentially 'updating' the memory.

Scenario: Imagine a combat veteran who experiences vivid and distressing flashbacks related to an ambush they survived during their deployment. These flashbacks lead to intense anxiety and hyperarousal.

Therapeutic Process: In therapy, the veteran recalls the traumatic event in detail, openly expressing their emotions, thoughts, and beliefs connected to the memory. As therapy progresses, the therapist guides the veteran in adding new information to the memory. This could involve focusing on moments of resilience, camaraderie with fellow soldiers, or the realization of their survival skills.

Purpose: Revisiting and updating the traumatic memory helps the veteran gradually reduce the emotional intensity associated with it. Over time, the memory becomes less distressing, resulting in decreased flashbacks and anxiety.

2- Stimulus Discrimination Training with Triggers of Reexperiencing:

This technique involves systematically identifying idiosyncratic triggers, often subtle sensory cues, and learning to differentiate between THEN (cue in the traumatic event) and NOW (similar cue in a new safe context).

Scenario: Picture a survivor of a serious car accident who experiences strong emotional reactions whenever they hear the sound of screeching tires, triggering vivid memories of the crash.

Therapeutic Process: The therapist collaborates with the survivor to identify various triggers associated with the accident, creating a comprehensive list that includes triggers like the sound of screeching tires, specific road signs, and images of the accident scene. These triggers are categorized based on their intensity, with the screeching tires sound identified as one of the most distressing.

Purpose: Recognizing and categorizing triggers provides clarity on what specifically prompts distressing reactions. This clarity empowers the survivor to develop strategies for managing these triggers effectively. For instance, they might use relaxation techniques when exposed to the sound of screeching tires.

This comprehensive approach to cognitive reappraisal and the described treatment procedures are valuable tools in helping individuals recover from trauma by challenging and updating the negative thought patterns and beliefs that often arise from these experiences.

Mindfulness and Reappraisal

As we will learn in future sections, an important principle of mindfulness is that staying rooted in the present moment holds the key to peace and wellbeing. This principle also plays a crucial role in successful trauma treatment. Trauma survivors often struggle to distinguish the past from the present. Despite the traumatic event being in the past and no longer occurring in the present moment, they frequently find themselves re-experiencing the trauma through flashbacks, regrets, and distressing emotions.

Assisting clients in reaching a deep realisation that the past trauma is over and no longer happening in the present moment is a vital therapeutic goal. This can be achieved through mindfulness strategies, grounding techniques, and cognitive reappraisal. Let's imagine a conversation between a therapist and a trauma client as an example of using mindfulness principles during cognitive reappraisal:

Therapist: "I understand that reminders of the accident, like the sound of car engines or certain weather conditions, can trigger distressing flashbacks. It's as if the accident is happening all over again. But I want you to consider something. As you hear those sounds, as you experience those moments, can you recognize that, in this current moment, you are safe? The accident is not happening now. You've survived."

Client: "Survived? I don't feel like I've survived. I'm physically and emotionally scarred by what happened. It's not over for me."

Therapist: "I understand. It's true that you've been deeply affected by the accident, both physically and emotionally. But here's a different perspective to consider. If you stay grounded in the present moment and stop comparing it to how things were before the accident, you might find a path to reduced suffering. Yes, your body and emotions have changed, but by accepting your current reality without constantly measuring it against the past, you can find a way to better cope with your current condition. For example, when you experience physical pain, instead of dwelling on how your body used to be comfortable, you can focus on what your body feels like now. It's about being present with your sensations and feelings as they are in this moment, without resistance, and without comparison."

Client: "I hear what you're saying about being in the present, but honestly, I don't want to accept that the accident happened. I wish it never did. I guess I'm still in denial in some ways."

Therapist: "This is very insightful. Let's talk about acceptance a bit. Acceptance doesn't mean you're okay with what happened or that you're giving up. It's about acknowledging that this event is a part of your life story, whether you like it or not. If we resist what's here to stay and is unchangeable, we don't change the reality. We suffer. The past is something that has happened and can't be changed. It's like a page in a book; you can't erase it, but you can decide how you want to write the next chapters. So, let's try something. Take a moment to imagine what it would feel like if you allowed yourself to accept that the accident did happen. Picture this acceptance as a small, safe step. What thoughts and feelings come up? If you feel an emotional resistence in your body, feel it until it passes."

Client: (After a pause) "I guess it feels like a weight off my shoulders. Maybe I could stop fighting against it so hard. It's been exhausting fighting against it."

Therapist: "So, coming back to our previous point, can you see that you have indeed survived the accident? The accident is in the past, and all that exists right now is what you're feeling and experiencing in this moment. It's about being present with your reality and finding a way to heal from here. How does this perspective feel to you?"

Client: "I can see that perhaps life goes on. I can enjoy things without letting the accident define every moment."

Self-Compassion and Reappraisal

Self-compassion is a vital aspect of trauma recovery, often underestimated in its significance. When individuals have experienced trauma, they often carry profound feelings of shame, guilt, and self-blame. These emotions can impede the healing process. Self-compassion involves treating oneself with the same kindness, understanding, and forgiveness that one would offer to a close friend facing similar challenges. It enables trauma survivors to reframe their internal narrative, fostering a sense of self-worth and acceptance. Integrating self-compassion into cognitive reappraisal for trauma encourages individuals to navigate their trauma with greater resilience and self-care. It helps them let go of self-criticism and embrace a path to healing that acknowledges their inherent worthiness.

Exposure

Exposure therapy is a well-established and effective approach in trauma treatment. It involves gradually and systematically confronting distressing memories, situations, or thoughts related to the traumatic event in a safe and controlled environment. This process allows individuals to process and eventually reduce the emotional charge associated with their trauma. Imagery work plays a significant role in exposure therapy for trauma. Through guided imagery exercises, clients can vividly explore their traumatic memories or triggers while in a secure therapeutic setting. This controlled exposure not only desensitizes them to the distressing content but also provides a valuable opportunity for cognitive reappraisal. Clients can reevaluate their traumatic experiences from a more empowered perspective, leading to a shift in their emotional response and beliefs about the trauma. This dual functionality of imagery work, both as a tool for exposure and cognitive reappraisal, makes it a valuable component of trauma therapy, aiding clients in their journey toward recovery and resilience.

Trauma and The Domino Effect of Memories

Although we have previously discussed the principle that ..., it's important to consider the principle of cascading effect or the domino effect of memories. Meaning that if a person whom had a healthy attachment or healthy self image growing up, but encountered a traumatic event during adulthood, is likely to maintain their healthy self image or attachment patterns, despite developing symptoms of posttraumatic stress disorder or other acute anxiety or mood conditions as an adult. This person is likely to have increased resilience better prognosis as a result of their healthier upbringing as compared to someone who may have experienced a trauma of similar severity but also suffered a background of poor attachment, poor self image or other childhood traumas. Therefore, when treating trauma related conditions, it's important to assess both the implications of the recent trauma and the type and severity of childhood traumas or deficits. Treatment then needs to balance addressing core beliefs from earlier in life, and the way that these core beliefs may have impacted clients' processing of their more recent trauma experiences. To do so, we need to remember the principle of the cascading effect or the domino effect of memories. A good approach is to first address any burning or pressing matters on the client's mind that may prevent them from wishing to address deeper emotional matters, as well as establishing a foundation of relaxation, grounding and psychoeducation. Once these foundational steps are taken, client can be educated about the principle of cascading effect or the domino effect of memories and guided to travel to potential earlier points in their life where foundational core beliefs formed, as well as exploring how these foundational core beliefs impact their understanding of their most recent trauma.

Cognitive Reappraisal and Self Actualisation

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In Maslow's hierarchy of needs, self-realization stands at the pinnacle, representing the highest form of human flourishing. While we briefly touch upon this tier in our course, it's not because it lacks importance; rather, it is the ultimate goal achieved when the lower tiers are adequately addressed. Self-realization encompasses a deep sense of purpose, creativity, authenticity, and fulfillment. It's about becoming the best version of oneself and realizing one's full potential. At this stage, individuals experience profound happiness, peace, and a profound connection with the world around them.

Characteristics of self-realization include a strong sense of self-awareness, a capacity for personal growth, and the ability to form meaningful and genuine relationships. It involves pursuing passions, interests, and goals that align with one's authentic self. However, despite its significance, achieving self-realization can be a challenge for many individuals due to various barriers.

One common barrier to self-realization is rooted in childhood experiences, where children may be overcontrolled to the extent that they lose their sense of autonomy and agency. This can hinder the development of a strong, authentic self. Additionally, the demands of modern life can create short-term barriers to self-realization. Adults often find themselves overwhelmed with busyness and preoccupied by life's responsibilities, leaving little time for self-exploration and pursuing what truly matters to them. In therapy, our ultimate aim is not only to address the lower tiers of needs but also to create a path towards self-realization, enabling clients to experience the highest form of happiness and fulfillment in their lives.

**Self-Realization: The Pinnacle of Human Flourishing**

In Maslow's Hierarchy of Needs, self-realization stands at the apex, representing the highest tier of human development and well-being. While this tier is briefly touched upon in this course, it holds immense significance. Self-realization is not only the ultimate goal but also the ultimate source of happiness, peace, and fulfillment.

At this tier, individuals move beyond fulfilling basic physiological, safety, love and belonging, and esteem needs. They enter a realm of profound self-discovery, personal growth, and actualization. Characteristics of self-realization include a deep sense of purpose and meaning in life, a strong connection with one's inner values, a heightened awareness of the world around them, and the ability to live authentically and in alignment with their true selves.

However, various barriers can obstruct individuals from reaching this pinnacle of self-realization. Chronic barriers may stem from childhood experiences where children were overcontrolled to the point of losing their sense of autonomy and agency. In such cases, therapy must work to address these past traumas and restore a sense of personal agency. Additionally, more immediate barriers can emerge from the demands of modern life, leaving adults feeling perpetually busy and preoccupied, with little time to explore their interests or pursue what genuinely matters to them.

Therapy, at its core, should aim to heal the lower tiers of needs while keeping self-realization as the ultimate objective. Only when these foundational needs are addressed can individuals fully embark on the journey towards self-realization, where they can truly flourish, find happiness, and experience peace in their lives.

Self-realization represents the highest form of human flourishing, where individuals achieve their full potential, leading to profound happiness and inner peace.

Characterized by qualities such as creativity, spontaneity, problem-solving, and a deep sense of purpose, self-realization is a state where individuals are not only in tune with their inner selves but also in harmony with the world around them. It's the realization of one's talents, pursuits, and passions, leading to a life rich with meaning and fulfillment.

However, various barriers can impede the satisfaction of this tier in individuals' lives. Chronic issues, such as childhood experiences marked by overcontrol and a lack of autonomy, can leave lasting scars, inhibiting one's ability to pursue self-realization. Additionally, the busyness and preoccupations of adult life can also stand in the way. Many find themselves caught in a relentless cycle of obligations, leaving them with little time or energy to explore their interests or what genuinely matters to them. Nevertheless, the highest aspiration of therapy is not merely to address the lower tiers of needs but to ultimately empower individuals to embark on their journey towards self-realization, where true happiness and fulfillment await.

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One important principle to remember here is that if the lower sections of the triangle are in deficit, our clients can struggle to attend to this tier. This is a principle we have explored before. This doesn't mean that we have to wait until all client issues are resolved before we can attend to this tier. It simply means that we need to address the lower needs to the degree necessary for our client to begin having the internal space necessary to give importance to self-actualization needs. I often see that therapists try to address self-actualization needs prematurely, and before the client has the capacity or interest to focus on these. Although this may be necessary to some degree while we engage in behavioral activation, too much focus on self-actualization needs before the client's deeper emotional pains are resolved can result in one of the two following scenarios:

• Disengagement from therapy because the client feels that therapy is pushing them in a direction where they are not ready to go. Or that therapy only has to offer tools that are not relevant to their main concerns.

• Encouraging avoidance as clients may feel that therapy is encouraging them to engage in feel-good techniques and toxic positivity, rather than dealing with deeper emotional pains.

The way we use cognitive reappraisal to pave the way for self-actualization depends on the specific barriers a person faces in achieving this tier. For instance, if a client struggles with time management or undervalues their genuine wishes and interests, cognitive reappraisal can help them reframe these issues. If childhood experiences are a barrier, imagery work can assist the client in reframing their earlier learnings. By tailoring our therapeutic strategies to address these barriers and aligning them with the client's readiness and capacity, we can foster an environment where self-realization becomes not just a lofty goal, but an achievable reality.

Emotions: Body-Oriented Therapies

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Let's take a step back and revisit the 3 building blocks which we have discussed in previous sections. We have already delved into the first building block, thoughts, and how cognitive reappraisal plays a significant role in reshaping them. In this section we will focus on the next building block: emotions. We will explore how we can work with emotions within the context of therapy. We will learn about the techniques of interoceptive or emotion exposure, which are incredibly promising and exciting areas of therapy and research. The two therapies are very similar in goals and approach and for the purpose of our eCourse, I will be using the terms interchangeably.*

Interoceptive and emotion exposure techniques aim to facilitate the processing of emotions by encouraging individuals to fully experience their emotions and the related bodily sensations in a controlled and supportive environment. They involve systematic and gradual exposure to specific emotional or interoceptive cues, such as increased heart rate, shortness of breath, or muscle tension. The aim is to reduce avoidance and facilitate emotional processing, desensitization, and habituation, as well as the development of adaptive coping strategies and better emotion regulation.

Case Example

A long-term client of mine, let's call her Kelly, attended my practice one day with a return of old symptoms: after a catch up with her brother she had found herself feeling down, unmotivated and struggling to get out of bed for a few days. She couldn't understand why she was feeling this way. It was all very puzzling. Yes, there was a time when her brother's harsh criticisms used to impact her self-esteem. But she thought that was all behind her. Therapy and self-reflection had helped her understand that her brother's criticisms were really not justified. She knew, with no trace of doubt, for instance, that she was a good aunt to her little nephew. Her brother's criticisms following each time she babysat her nephew were, in fact, due to his intense anxiety around parenting his child. She knew that this was not personal. That it was not a sign of her being faulty or not good enough. Cognitive behavioral therapy (CBT) had helped her reassess her thoughts and this had helped relieve her depressive symptoms.

So what could explain this sudden rush of old emotions, which used to be so characteristic of her past self-loathing? She didn't see a logical basis for feeling what she felt.

In the days leading to her therapy session she kept recapping all of her CBT knowledge. Reassessing her negative thoughts wasn't possible. She didn't have any. Well, none that she truly believed in anyway. Reassuring herself with all the rational facts wasn't helping. She still felt just as down and unmotivated.

What Kelly was experiencing was an emotion memory, an automatic response to an old conditioned stimulus. What she was missing was that her current emotion wasn't triggered by a thought or belief. She had already changed those thoughts and beliefs months ago. So there was little point in continuing to meddle with them. Her emotion was being triggered by an external stimulus: her brother, his critical tone of voice and body language, and his specific choice of words (e.g. "I'm disappointed in you"). Kelly's brain had learned to trigger an automatic emotional response every time she was around her brother's criticisms. What did that emotion response feel like to Kelly? Initially, her heart raced faster and she felt a lump in her throat. Then gradually she began feeling tired all over her body, and a heaviness in her chest. These feelings were all too familiar to Kelly as she had felt them many times before. At one stage she used to feel them while having self-loathing thoughts. Now, even though the self-loathing thoughts were gone, she still felt them in her body.

What’s more, Kelly would feel the above emotional response in situations that had nothing to do with her brother. For example, if a friend had a similar body language. Or if she even thought of a memory of her brother being critical towards her or someone else.

Kelly's story is by no means unique. I am all too familiar with new clients complaining of having seen several therapists in the past, with months or years of cognitive based treatment that have not resulted in the emotional relief that they had hoped for. Or if it has, maintaining a 'good feeling' seems to be constant work: keeping on top of those negative thoughts, challenging them on a daily basis, relaxation exercises, breathing and so on.

Of course, when Kelly first attended therapy, changing those negative thoughts and beliefs was crucial. Kelly needed to learn, on a logical, rational level, why she was a worthy human being. She needed to challenge those unhelpful thoughts that had formed the basis of her self-perception. This was the job of cognitive therapy. A job that we have learned, through mountains of research, cognitive therapy does well. Cognitive therapy is necessary. But Kelly's story suggests that on its own, it is not enough.

Fortunately, Kelly only needed a brief recap of her skills in emotion exposure, which she had learned in therapy before. Practicing emotion exposure lifted that emotion and Kelly began feeling her normal vitality, energy and sense of humor.

The Practice of Interoceptive or Emotion Exposure

The following section is…

Please note: the following is an excerpt from the Fount Mental Wellbeing Course.

Copyright © Sahba Saberi 2012

All rights reserved.

Most of us are familiar with the experiences of our emotions, which we normally feel in the body. Let's take a look at a few common emotions and consider how they feel to you. First up, anger. How does anger feel to you?

If your answer was along the lines of 'anger feels like everything is unfair', 'it feels like no one respects you' and so on, you are actually using your thoughts to describe the feeling of anger. The kind of answer that we are looking for is a lot simpler than that. Just pay attention to your body. We are looking for answers like 'it feels like my face is getting hot', or 'I feel a pressure in my throat and chest' and so on. Try one more time. How does anger make your body feel?

And what about the following emotions? Don't forget, you are not describing your thoughts here. You are only paying attention to your body and trying to describe how the emotion makes your body feel:

Fear

Sadness

Shame

Worry

Excitement

Nervousness

Boredom

Disgust

As you can imagine, these emotions could feel different for different people. For example, a person may feel sadness, anger, and anxiety all as sensations in their chest. Another person may call a sensation in their chest 'sadness', but also naming another sensation in their head and a third one in their belly different shades of sadness. They may be felt in different parts of the body, but this person recognises them all as the same emotion. You may have also experienced those times when you feel an emotion, but don't quite know what to call it. What is important to notice here is what the body is feeling, and not so much what we may decide to call that emotion or how we use our thoughts to describe it. To understand our emotions better, it's important to develop a closer connection with the sensations in our bodies, just like the way you became familiar with the taste of an apple in that earlier exercise.

It's also worth mentioning that not all emotions behave the same way. Some emotions are still and stay in one part of the body. Others may feel like a sensation that moves around or pulsates in the body. Some may feel identical to a physical experience. Others are experienced as partly physical, but not entirely!

Some of you may be wondering: what about the advice that you often get, that it's best to not pay too much attention to your emotions? Wouldn't giving them too much attention make us more emotional? Well, if you are sitting in a corner and passively thinking about emotional matters, then yes, you are right. Passively obsessing over issues will not be helpful. Awareness is a different matter. And awareness of the body will help improve your coping with the issues you are facing, not reduce it.

Quality Attention

Some of you may be wondering 'What does it mean to pay attention to an emotion? How do I know if I'm doing it right?' We will try to answer these questions in this section. It is helpful to improve the quality of our attention. So we'll dedicate a bit of time to mastering this seemingly simple skill. First, let's place a little dot on the page…

.

What we will get you to do now is very simple. Just stare at the dot for a while and keep your attention on it. That's it. You don't need to do anything else. Just fix your gaze on the dot for a little while.

How did you go? Were you able to keep your attention there?

Let's try that exercise one more time. If thoughts distract you, gently bring your attention back to the dot and keep staring at it. The longer you can maintain your attention there, the better. And if you can't go very long, that's okay! Practice makes perfect. Let's try again.

.

This is what we mean when we say, 'Keep your attention on the emotion in the body'. It's just like keeping your attention on the dot, except you would be keeping your attention on the part of the body where you feel the emotion. Of course, when it comes to emotions, you won't be using your physical eyes, just your internal awareness.

So, notice what emotion you are feeling in the body, then fix your attention on that part of the body and keep it there as if you are staring right at it and cannot take your eyes off it. Do this even if the emotion is uncomfortable. The discomfort is likely to pass soon. Keep your attention there until the emotion eases. Don't fight the emotion or try to make it go away. You just need to keep your attention on it.

But what about emotions that move around in the body, pulsate, or appear and disappear? How do you keep your attention on moving sensations within the body?

To help you develop the skill of keeping your attention on moving emotions, please view the following video:

What you practised here is similar to what you would do if you are keeping your attention on a moving emotion within your body. Keep your mind’s eye, or your internal awareness, on the moving sensations within your body. It’s best to try and keep your eyes still even if the emotion is moving around in your body.

Perhaps the biggest challenge for your attention is emotions that appear and disappear. This type of emotion is often hard to pay attention to, because as soon as it disappears, we tend to lose focus and get distracted. But then it comes back and surprises us again. But with a little bit of practice we can learn to keep our attention on these types of emotions just as we did with the other emotions. It takes time and patience, but the general rule is, first, give your attention to the emotion. When it disappears, you don't need to do anything special. Just stay focused and ready to look at it again once it returns.

Essentially, what we are saying is that at times it would be helpful to shift your attention away from your chattering and analysing thoughts, and place it on your body. Resist the temptation to stay focused on your thoughts. Keep your attention on your body until it reaches a calmer state. Then you can go back to thinking and see if you still see the problems in front of you in the same way, or whether the new calm body has changed your view of the issues in front of you. Give it a go and see for yourself!

The Science

By now some of you may be thinking, 'Well, it seems to work. But why does it work?' or more precisely 'How does it work?' In this section we will journey into the science of emotion exposure. Although research shows that emotion exposure is effective, there are still a lot of unknowns around exactly how it works. But there are a few theories that try to explain the reasons behind its effectiveness. The first theory relates to a concept called habituation. Habituation is what happens when something is repeated over and over again, and with repetition it gradually loses its impact on you. For example, say you just moved to a new house next to a noisy street. At first the noise feels loud and overwhelming. You can't hear yourself think! But as the hours and days go by, you start noticing it less and less. At some point you barely notice it, unless you pay attention.

Another example is when you wear a new watch for the first time. For some time, you can feel it clearly on your wrist. You notice its temperature, its weight and every other sensation about it. But gradually you stop noticing it altogether. Once in a while, when you think of your watch, you may feel it on your wrist again. But then it goes on to join the many other 'normal' things that you rarely pay attention to.

Most people have heard the story of the boy who cried wolf. It can be said that by repeatedly crying 'wolf', the boy in the story would have habituated the people in the village so that they were no longer alarmed by it.

Usually when we talk about 'getting used to' something, what is really happening is that our brain has developed habituation towards that thing. When habituation takes place, the brain changes at a cellular and chemical level, causing it to become less sensitive to what it has become habituated to. So every time you are habituated, your brain actually changes a little. That's right, there are actual changes to the structure of your brain or its chemicals, that allow your brain to no longer show sensitivity to that thing.

This theory suggests that when we concentrate on our emotions long enough, we get to a point of habituation and that's why we no longer feel that emotion to the same intensity. So, by closing your eyes and keeping your attention on the emotion, what's happening within your brain is very similar to what happened after a few hours or days in that new house in the noisy street. We often don't let this process happen in our brain because we try to distract ourselves from uncomfortable emotions before the brain has had a chance to reach habituation. When you close your eyes and concentrate on an emotion instead of avoiding it, your brain structures and chemicals may be changing and, in turn, what you experience is reduced sensitivity to that emotional experience.

The second theory is that emotion exposure works in a similar way to normal exposure therapy. Remember, classical conditioning means that our brain makes a connection between two unrelated things. And when we perform exposure therapy, we teach the brain that the two things aren't really connected anymore. We do that by facing the things that we fear or dislike and letting our body do the rest! Exposure is an automatic process. We don't need to deliberately teach our body anything.

Similarly, our bodies can be conditioned to react to certain situations, giving us the experience of an emotion. So a date, like the anniversary of a sad event, or a smell, a place, a person or any other reminders might bring back the memory of an emotion for you. Like a heavy heart, a lump in the throat, a funny feeling in the belly and so on. So that smell, that place, that person or the date of that anniversary are now acting like conditioned triggers that bring back an emotional memory.

Sometimes we don't even know what emotion has been triggered. Here's an example. Imagine that today you are feeling upset because you just had an argument with a friend. You go shopping to get it off your mind. You see a perfume bottle, have a smell and spray a little bit on your wrist. As you smell it for the rest of the day, you are conditioning the smell of that perfume to act as a trigger for the emotion that you're feeling. Months later, you walk past a complete stranger that's wearing the same perfume. You might suddenly feel a heavy emotion and have no idea where it came from. You see how confusing the world of our conditioned emotions can get?

As you can see, not all emotions are new and fresh. Many of our emotions are conditioned responses from things that have happened to us in the past. Our bodies react in similar ways in similar situations, creating similar emotional experiences, over and over again. Emotion exposure means that we can clear up the fingerprints of an emotion that belongs to the past. The memory can then be just a memory, rather than a trigger for an old emotion.

It's also worth noting that some of the conditioned emotional memories that we have, go all the way back to our childhood. Pleasant or unpleasant childhood environments can create all kinds of emotional memories. When parents and other caregivers punish or reward children, for example, some powerful conditioned responses can be created. So for example, if a parent used to snap at you or tell you off every time you were having playful fun, chances are that as an adult, every time you are having a good time, you also feel a negative emotion deep down. You then use your thinking to make sense of this and say to yourself 'I'm feeling guilty because I'm wasting time'. Or at times, when people are sensitive to criticism, they could very well be reacting to a conditioned response that was created earlier in their life, when they were in trouble with their parents for making mistakes.

The final theory that tries to explain the effectiveness of emotion exposure is that it facilitates acceptance. As you may recall, acceptance is letting go of our internal resistance and war against the reality of this moment. Emotion exposure and acceptance have a few things in common. Emotion exposure relies on the principle of not expecting ourselves to change, control, resist or fight our emotions. In other words, it increases our acceptance of our emotions, just as they are in this moment. And acceptance can help us cope better with unwanted and uncomfortable realities. In turn we may feel a general state of calmness and peace. You may have experienced this during your practice of acceptance in previous chapters.

Thinking vs. Emotion Exposure

Perhaps the real answer to the question of emotion exposure's effectiveness lies in a combination of these 3 principles: habituation, conditioning and acceptance. Considering these principles can help us make sense of those ingredients that seem to make emotion exposure work most effectively! For most of us, emotions are often there, running amok within the body, day after day. And we are often busy thinking about our problems and the emotions attached to them. So you may say that every day you think about your emotions and wonder why emotion exposure would do anything different or new for you. The answer is that emotion exposure is not the same as thinking about your emotions. There are three main ingredients that distinguish emotion exposure from the way that we normally relate to our emotions.

1. Awareness, not thinking - emotion exposure is all about bringing our attention to the body, or to the experience of our emotions. It is a mindfulness practice. The focus is not on analysing the emotions or thinking about them - thoughts like 'What is this emotion?', 'Where does it come from?', 'I’m tired of always feeling down’, 'What if something bad happens?', and so on. When practising emotion exposure we take a break from thinking and instead notice what the body is doing. Or what the experience of that emotion feels like.

2. Sustained attention - we normally only give quick short-lived attention to our emotions, and our attention is weak and divided as we go about our day or are distracted by a million racing thoughts in our head. Focusing your attention on the emotion and keeping it there a bit longer than usual may be what is needed to allow habituation to be achieved, or to make exposure therapy most effective.

3. Acceptance - in other words, giving up the temptation to change the emotion. This is very important. When practising emotion exposure, you are only a passive watcher. You are not trying to change, soothe or escape. The more you give up the temptation to control your emotion, the more quickly it will pass. Imagine getting on a roller coaster. Once you are on the ride, it is not your job to control it or stop it. And you could not do that even if you tried! You just need to sit back and let the ride take you wherever it takes you. Trying to control it is pointless. When practising emotion exposure, we need to treat our emotions in exactly the same way. We cannot control or get rid of emotions using will power. That only results in more internal anguish and distress. So we might as well sit back and experience the ride.

Remember, this is not a process that you can speed up using your will power. So as you have your eyes closed and are feeling the emotion, be mindful of thoughts like: 'When is it going to go away?', 'How can I get rid of it?', 'This is pointless', 'It's not working' and so on. These thoughts are an indication that you are placing your focus on trying to get rid of the emotion, rather than on feeling the emotion and experiencing it fully.

An Onion

At times, our emotions are like an onion. If you peel off a layer of the onion, there will be another one underneath it. And another one. And another one. After some time, the layers will stop and you will end up with no more onion. Similarly, at times during emotion exposure you will find that, as an emotion leaves, there is another one underneath it. And another one underneath that one. It may feel like the layers of emotion will never end, and that all you are doing is replacing one layer with the next one. But continuing to practise emotion exposure means that at some point the layers may end, allowing you to experience a calm, peaceful space of no emotion.

It may help you to remember a rule:

— Thinking often brings up emotions (new emotions or old ones)

— Emotion exposure allows the emotions to be alleviated

So you may find that at times when you begin thinking, you begin feeling more emotions. If this happens, practise emotion exposure on the new emotions that are activated. Remember to get into the habit of pausing your thinking and focusing on the body instead, because getting lost in thoughts may result in more and more emotions coming to surface. However, as each emotion lifts up, feel free to allow your thoughts back in again. So allow the thoughts in, and once you feel an emotion, stop thinking and focus on the body. Repeat this process until you feel lighter and more at peace.

Note: don't forget to check for any errors in your thinking as well. If a thought error keeps creating an emotion for you, it's important to first realise the thought error and change your thinking.

Challenges with the Practice of Emotion Exposure

The challenge of practicing emotion exposure is not going to be the same for everyone or for every emotion. You might find that certain emotions are more challenging to work through or concentrate on. Others are a lot easier. At times, practicing it will result in quick relief to your emotions. At other times it might not work so quickly or smoothly. What is important is to not give up when you face a challenge, but to keep trying. Check that you are correctly applying all the principles that you have learned in this session. Here are 7 common challenges that people report when practicing emotion exposure, and tips on how to deal with them:

1.   'I feel an emotion, but I can't find it in my body' - If this applies to you (and it's one of the things that most people experience from time to time), then don't try so hard to pin the emotion down in your body. Just concentrate on the general experience of the emotion. The overall feel of it. The feeling that the emotion gives you. Sit with that experience and keep your attention still. At some point, you may start noticing it within the body as well. If that happens, start keeping your attention on that part of the body.

2.   'I'm feeling a few different sensations, in different parts of my body all at the same time' - it's best to focus on one part of the body at a time. Maybe start with the one that you're feeling most strongly, or the one that keeps grabbing your attention. Once that sensation lifts off, move on to the next. The reason that we suggest this is that the more intensely you focus, the quicker you will get results. So, if your attention is jumping between different parts of your body, it might at times reduce its effectiveness. But, if focusing on only one part proves difficult, then try staying aware of all the different sensations appearing and disappearing within your body, as if you are watching a show. Keep your attention on the show until the feeling calms down.

3.   'I am feeling a sensation in my body, but I'm not sure if it's an emotion or just physical?' - It is not always easy to tell emotions apart from purely physical sensations. That's one reason why, when our bodies are unhappy, (e.g. when we are hungry, tired, coming down with a cold and so on) we are more likely to feel intense emotions. The key here is to stop getting bogged down with the question 'is it an emotion or just the body?' and instead practise emotion exposure on it anyway. If what you are feeling in the body has an emotional component, you should experience relief after some time. But that said, if you are certain that there is a physical component, attend to that as well. If you are hungry, eat something. If you are tired, make sure you get some rest. If you are sick or in pain, speak to a doctor. The bottom line is that the body and emotions are so intertwined, that they regularly impact each other. For example, pain can intensify your emotions, but emotions can also intensify your pain. So it is best to work on both.

4.   'I'm feeling bored, restless or tired. What do I do?' - Boredom and restlessness are also emotions. Notice how they make your body feel and practise emotion exposure around them. Tiredness can be physical or emotional. If you believe it may be emotional, try practising emotion exposure on the parts of the body where you feel it.

5.   'What happens if emotions come up in situations where I can't close my eyes and focus? How do I deal with that?' - With continued practice, you can start noticing your emotions even as you go about your day and with your eyes open. Notice how in social situations, as painful emotions arise within your body, you actively try to push them away and ignore them. Instead, stay with the pain in the body and place your attention on it, until it subsides. If, at times, you need to focus more, find a quiet corner (e.g. take a toilet break!) and practise emotion exposure. Alternatively, work on any left-over feelings from the emotion at the end of the day, when you get home or when you find some alone time. As you work through these emotions, you may notice that they return with less and less intensity over time, or that some emotions never return again.

6.   'The emotion that I'm feeling is too uncomfortable. I find it too painful to pay attention to. What do I do?' - It is unfortunate that some emotions can be so uncomfortable. It often feels easier to put them in a box and forget about them, like Jasmine did with her monster. But with a bit of determination you may be able to reduce the discomfort of these emotions as well. Here are a few things you can try:

—   Use your imagination to picture yourself yelling, screaming or expressing the emotion however you would like to express it. Or consider expressing yourself while writing or creating art. Now feel the emotion in the body as you express yourself.
—   Imgine a scenario where the emotion is changed. Picture your life situation improved. Or if the emotion is from the past, imagine a scenario with a happier ending. As you imagine these things, keep your attention on the body and feel all the sensations that are happening. Feel the relief as well as any left over emotions.
—   Talk to someone. Seek therapy from a trained professional, or find a friend who will not rush you to get rid of the emotion using logic, and ask them to allow you to express what you're feeling. It may be helpful to let them know that the purpose of speaking to them is just so you can express your emotions. Now, just talk it out as you feel the body at the same time.
—   Focus on one sensation at a time, as we discussed in the 2nd point above. Once you find a painful sensation in your body, don't get distracted by other sensations or thoughts. Just fix all of your attention on it and keep your attention firmly on that part of the body until the sensation is relieved. Now look for other sensations.
—   Chip away at it - look at the emotion a few seconds at a time, and then if it's too painful let it go. Do the same again next time. Gradually, by repeating this, the monster will feel less and less scary and you will be able to keep your attention on it for longer.

7.   'My attention is wandering and I am too distracted. How do I concentrate on the emotion?' - It may be a good idea for you to place your focus on mindfulness of thoughts to begin with. As you practise sitting there and watching your thoughts, remaining aware of their movements, it may help to consider this analogy, which we've touched on before:

Imagine you're standing in a river with waves of water washing against your legs. Imagine your thoughts and emotions to be like the water. Your job is to stay aware of the water (i.e. thoughts and emotions) as they come and go. Do not think, analyse, try to create the current or stop the current. Just stay aware and let it flow. Practise this as often as you can. You may find that this practice gradually helps your thoughts to slow down and for you to become more mindful of your thoughts and emotions.

Finally, please remember that emotion exposure can be a boring practice! Mindfulness in general may feel boring. That is okay. Being bored is not something to be afraid of. In fact, we suggest that you expose yourself to 'boring' and push through it. So if you are feeling bored focusing on a boring sensation within the body, just tolerate it and keep your attention there anyway. At some point you may find that boredom gives rise to a sense of peace and calm. So this will be worth the effort!

Therapeutic Decisions: When to Address Thoughts and When to Practice Emotion Exposure?

In the realm of therapy, a common dilemma often arises when determining the most effective approach to address a client's concerns: should one focus on reshaping thoughts through cognitive reappraisal or delve into the underlying emotions through emotion exposure? The decision hinges on a variety of factors, including the client's unique presentation and the nature of their distress.

**Starting with Cognitive Reappraisal:**

As a general guideline, when cognitive distortions or unhelpful thinking patterns are apparent, it's often beneficial to begin by addressing these cognitions through cognitive reappraisal techniques. This approach involves identifying and challenging irrational or negative thoughts and replacing them with more balanced and realistic perspectives.

However, it's vital to emphasize to clients that the cognitive strategy, while powerful, might not instantaneously eliminate all associated emotions. It's not a magic wand that makes all distress disappear. Setting realistic expectations in this regard helps clients understand the limitations of cognitive work, preventing potential disappointment and reducing the pressure to 'feel better' immediately.

**Transitioning to Emotion Exposure:**

Once cognitive errors have been identified and addressed, the therapist can then pivot towards exploring and processing the underlying emotions through emotion exposure techniques. However, there are situations where it's more appropriate to initiate therapy with emotion exposure:

1. **Client Struggles to Identify Triggers or Cognitive Causes:** In some cases, clients might find it challenging to pinpoint specific triggers or cognitive reasons for their emotional distress. This could be due to a lack of self-awareness or a deeply rooted emotional issue that resists easy categorization. In such instances, it's often more practical to commence with emotion exposure to access and work through these complex emotions directly.

2. **Prior Cognitive Work:** If previous therapy sessions have effectively tackled cognitive barriers, and the client still presents with persistent and overwhelming emotions linked to a particular issue, shifting the focus to emotion exposure is advisable. This transition ensures that therapy continues to progress and evolve to meet the client's evolving needs.

In essence, the choice between cognitive reappraisal and emotion exposure isn't rigid but rather adaptable to the client's circumstances. Therapists must remain flexible and attuned to the client's unique situation, selecting the approach that aligns most effectively with their current needs and the underlying complexities of their emotional experience. By navigating this therapeutic dilemma thoughtfully, therapists can offer tailored interventions that promote emotional healing and growth.

Incorporating Imagery Work

Imagery exercises offer a powerful and versatile tool in therapy, especially when combined with emotion exposure techniques. These methods can be applied in two key ways to facilitate clients' emotional processing and healing.

1. Practicing Emotional Exposure in Challenging Scenarios:

• Scenario Visualisation: In situations where clients grapple with specific emotional challenges like social anxiety, imagery exercises can be employed to help them imagine scenarios that typically trigger distressing emotions. For instance, a client dealing with social anxiety may envision themselves in various uncomfortable social situations, such as public speaking or attending a social gathering.

• Emotion Exposure: Following the scenario visualization, clients can then practice emotion exposure techniques centered on the sensations within their bodies. Encourage clients to fully immerse themselves in these imagined situations, paying close attention to the physical and emotional responses that arise. This could include observing racing heartbeats, sweaty palms, or feelings of dread.

• Gradual Desensitization: The goal is to gradually desensitize clients to these emotional triggers through repeated exposure. Over time, as clients continue to imagine and engage with these emotionally charged scenarios while practicing emotion exposure, they can begin to build tolerance and find the imagery of the situation more tolerable. This process can help reduce the intensity of their emotional reactions in real-life situations.

2. Childhood Work and Emotion Exposure:

• Revisiting Childhood Memories: Another valuable application of imagery exercises combined with emotion exposure is in childhood work. Clients are encouraged to revisit memories from their early years, particularly those marked by emotional turmoil or distressing experiences.

• Cognitive Reappraisal: Initially, imagery exercises can be employed to facilitate cognitive reappraisal. Clients are guided to reimagine these childhood scenarios and engage in cognitive work that helps them reframe and make sense of their childhood experiences from a more adult perspective. This step aims to provide insight and understanding.

• Emotion Exposure in Childhood Scenarios: Subsequently, clients can revisit these same childhood memories but now focus on the emotional aspect. They are encouraged to immerse themselves in the memory, paying close attention to the physical sensations and emotions that emerge. This process allows clients to practice emotion exposure, where they embrace and process the emotions associated with these past events.

This combination of cognitive reappraisal followed by emotion exposure within the framework of imagery exercises can be remarkably transformative. It enables clients to gain deeper insights into their emotional responses, providing a pathway for healing and growth. Moreover, it empowers clients to develop healthier coping mechanisms and navigate challenging emotions with increased resilience.

As with any therapeutic technique, it's essential to tailor these approaches to each client's unique needs and progression. Encourage open communication throughout the process to ensure that clients feel safe, supported, and empowered on their journey toward emotional well-being and healing.

Therapist Anxieties

Therapists often approach interoceptive exposure (IE) with caution, employing relaxation, breathing, or appraisal exercises to alleviate its perceived discomfort. However, emerging research challenges these preconceptions and suggests that IE, when used in isolation, is not only tolerable but also effective in diminishing anxiety sensitivity (Deacon et al., 2012). Therefore, therapists are encouraged to embrace emotion and interoceptive exposure techniques without reservation. By integrating these approaches into their practice, therapists can offer targeted interventions that directly engage with the fundamental mechanisms of emotions, promoting more efficient and focused therapy.

The Therapist's Practice of Emotion Exposure and its Benefits

The practice of emotion exposure offers therapists substantial advantages when integrated into their professional routines. While it serves as a valuable self-care tool, it also has the potential to achieve the additional objectives of mitigating countertransference, addressing emotional contagion, and enhancing therapists' comprehension of their clients.

Emotional contagion, the phenomenon where one person's emotions and related behaviors can trigger similar emotions and behaviors in others, is a recognised aspect of human interaction. In the context of therapy, emotional contagion can result in countertransference, where a therapist unconsciously takes on the emotions and reactions of their clients, potentially interfering with the therapeutic process. As therapists, it's crucial to be aware of our emotional responses to clients and to use this awareness as a tool for growth and understanding.

There have been instances when certain clients triggered specific emotional reactions in me. Mindfully exploring and working through these emotions not only assisted me in gaining new insights about the client but also deepened my understanding of how to best support them. Allow me to share a couple of illustrative examples:

Example 1:

On several occasions, I found myself feeling perplexed when working with particular clients. Despite having well-thought-out treatment plans, I would enter sessions only to be overtaken by confusion, forgetting my intended strategies or the starting point for our discussions. This pattern persisted consistently with these clients, prompting me to inquire into its origins. As I engaged in emotion exposure centered around the emotions tied to my confusion, a remarkable revelation emerged: my clients frequently exhibited parallel patterns of confusion and mental disorganization. Attending to my vicarious emotional response not only provided valuable insights into my client's psychological state but also enabled me to regain my focus and composure within these sessions.

Example 2:

Certain clients with histories of childhood abuse often reported ongoing mistreatment in their daily lives. During interactions with these clients, I occasionally experienced heightened emotions, including anger, frustration, or an inclination to react harshly to various behaviors. While some of these behaviors might have appeared reasonable grounds for such emotional responses, the intensity of my reactions stood out. Furthermore, similar behaviors displayed by others did not consistently trigger the same emotional responses within me. Recognizing this divergence led me to explore my emotional reactions through emotion exposure. What I uncovered were patterns of abuse that had given rise to unhelpful emotional responses in these clients, including anger, a sense of victimhood, and an overcompensatory entitlement. By attentively exploring my own emotional reactions, I not only gained a deeper understanding of my clients but also managed to circumvent the customary angry reactions they often faced from society. Instead, we could collaboratively address their unhelpful behavior and help them comprehend why they seemed to attract mistreatment.

In cases where clients were ready, I shared with them my emotional reactions in response to their behavior, using a specific analogy to facilitate their understanding. I likened the emotional residue of past abuse and unhelpful environments to the lingering smell of smoke on clothes after exiting a smoke-filled room. In the same way, individuals who have been surrounded by abuse or bullying tend to carry emotional remnants from those environments, which others can subconsciously pick up on and react to. This, I emphasize, is not the client's fault but may help them make sense of their recurring experiences with people.

By engaging in emotion exposure personally, therapists can gain a deeper understanding of their clients' emotional experiences and cultivate greater empathy, which ultimately enhances the therapeutic process.

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* Disclaimer: I use the terms emotion exposure and interoceptive exposure interchangeably. Although there are small differences between the two therapeutic techniques, there is significant overlap between these therapies and I have elsewhere argued that the two should be considered synonomous. Additionally, you may notice that I preference the term emotion exposure over interoceptive exposure because when speaking to the public, I think there’s value in keeping the language simple and accessible. Especially if we want to be accessible to kids and adolescents. Everyone has an idea of what emotions are, but a term like interoception needs definitions and a level of academic interest from our audience.

Awareness: Mindfulness Strategies

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In our exploration of the three fundamental building blocks of therapy - thoughts, emotions, and awareness - we now turn our attention to the critical element of awareness. Awareness, particularly as cultivated through mindfulness techniques, is a powerful tool in therapeutic practice.

Awareness, often cultivated through mindfulness techniques, is a cornerstone of effective therapeutic work. Mindfulness involves the practice of intentionally paying attention to the present moment without judgment. This heightened awareness can help individuals gain insight into their thoughts, emotions, and behaviors. In the context of therapy, it serves as a valuable tool to address a wide range of concerns.

Mindfulness techniques encompass a variety of practices, including mindfulness meditation, deep breathing exercises, body scans, and more. These techniques encourage individuals to observe their thoughts and feelings as they arise, allowing for a non-reactive and accepting stance towards their inner experiences.

Avoiding Experiential Avoidance

While mindfulness techniques are powerful, it's essential to use them judiciously in therapy. Mindfulness should not be employed in a way that facilitates experiential avoidance or gives clients the impression that their concerns are being sidestepped. Instead, it should be utilized to encourage clients to confront and accept their experiences, no matter how distressing, in a non-judgmental and compassionate manner.

**Living in the Present: Mindfulness for Worry and Acceptance**

Mindfulness, coupled with here and now strategies, can be particularly effective in helping clients break free from patterns of worry and anxiety. These techniques enable clients to embrace the present moment fully. Rather than dwelling on past regrets or fearing an uncertain future, clients learn to engage with the here and now.

Living in the present moment allows clients to accept the uncertainty of the future and learn to navigate life's challenges more skillfully. By staying present, clients can develop the resilience to face life's ups and downs with greater equanimity and clarity. These skills are invaluable in promoting emotional well-being and reducing the grip of anxiety and rumination.

The Practice of Interoceptive or Emotion Exposure

The following section is…

Please note: the following is an excerpt from the Fount Mental Wellbeing Course.

Copyright © Sahba Saberi 2012

All rights reserved.

Most of us are familiar with the experiences of our emotions, which we normally feel in the body. Let's take a look at a few common emotions and consider how they feel to you. First up, anger. How does anger feel to you?

If your answer was along the lines of 'anger feels like everything is unfair', 'it feels like no one respects you' and so on, you are actually using your thoughts to describe the feeling of anger. The kind of answer that we are looking for is a lot simpler than that. Just pay attention to your body. We are looking for answers like 'it feels like my face is getting hot', or 'I feel a pressure in my throat and chest' and so on. Try one more time. How does anger make your body feel?

And what about the following emotions? Don't forget, you are not describing your thoughts here. You are only paying attention to your body and trying to describe how the emotion makes your body feel:

Fear

Sadness

Shame

Worry

Excitement

Nervousness

Boredom

Disgust

As you can imagine, these emotions could feel different for different people. For example, a person may feel sadness, anger, and anxiety all as sensations in their chest. Another person may call a sensation in their chest 'sadness', but also naming another sensation in their head and a third one in their belly different shades of sadness. They may be felt in different parts of the body, but this person recognises them all as the same emotion. You may have also experienced those times when you feel an emotion, but don't quite know what to call it. What is important to notice here is what the body is feeling, and not so much what we may decide to call that emotion or how we use our thoughts to describe it. To understand our emotions better, it's important to develop a closer connection with the sensations in our bodies, just like the way you became familiar with the taste of an apple in that earlier exercise.

It's also worth mentioning that not all emotions behave the same way. Some emotions are still and stay in one part of the body. Others may feel like a sensation that moves around or pulsates in the body. Some may feel identical to a physical experience. Others are experienced as partly physical, but not entirely!

Some of you may be wondering: what about the advice that you often get, that it's best to not pay too much attention to your emotions? Wouldn't giving them too much attention make us more emotional? Well, if you are sitting in a corner and passively thinking about emotional matters, then yes, you are right. Passively obsessing over issues will not be helpful. Awareness is a different matter. And awareness of the body will help improve your coping with the issues you are facing, not reduce it.

Quality Attention

Some of you may be wondering 'What does it mean to pay attention to an emotion? How do I know if I'm doing it right?' We will try to answer these questions in this section. It is helpful to improve the quality of our attention. So we'll dedicate a bit of time to mastering this seemingly simple skill. First, let's place a little dot on the page…

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What we will get you to do now is very simple. Just stare at the dot for a while and keep your attention on it. That's it. You don't need to do anything else. Just fix your gaze on the dot for a little while.

How did you go? Were you able to keep your attention there?

Let's try that exercise one more time. If thoughts distract you, gently bring your attention back to the dot and keep staring at it. The longer you can maintain your attention there, the better. And if you can't go very long, that's okay! Practice makes perfect. Let's try again.

.

This is what we mean when we say, 'Keep your attention on the emotion in the body'. It's just like keeping your attention on the dot, except you would be keeping your attention on the part of the body where you feel the emotion. Of course, when it comes to emotions, you won't be using your physical eyes, just your internal awareness.

So, notice what emotion you are feeling in the body, then fix your attention on that part of the body and keep it there as if you are staring right at it and cannot take your eyes off it. Do this even if the emotion is uncomfortable. The discomfort is likely to pass soon. Keep your attention there until the emotion eases. Don't fight the emotion or try to make it go away. You just need to keep your attention on it.

But what about emotions that move around in the body, pulsate, or appear and disappear? How do you keep your attention on moving sensations within the body?

To help you develop the skill of keeping your attention on moving emotions, please view the following video:

What you practised here is similar to what you would do if you are keeping your attention on a moving emotion within your body. Keep your mind’s eye, or your internal awareness, on the moving sensations within your body. It’s best to try and keep your eyes still even if the emotion is moving around in your body.

Perhaps the biggest challenge for your attention is emotions that appear and disappear. This type of emotion is often hard to pay attention to, because as soon as it disappears, we tend to lose focus and get distracted. But then it comes back and surprises us again. But with a little bit of practice we can learn to keep our attention on these types of emotions just as we did with the other emotions. It takes time and patience, but the general rule is, first, give your attention to the emotion. When it disappears, you don't need to do anything special. Just stay focused and ready to look at it again once it returns.

Essentially, what we are saying is that at times it would be helpful to shift your attention away from your chattering and analysing thoughts, and place it on your body. Resist the temptation to stay focused on your thoughts. Keep your attention on your body until it reaches a calmer state. Then you can go back to thinking and see if you still see the problems in front of you in the same way, or whether the new calm body has changed your view of the issues in front of you. Give it a go and see for yourself!

The Science

By now some of you may be thinking, 'Well, it seems to work. But why does it work?' or more precisely 'How does it work?' In this section we will journey into the science of emotion exposure. Although research shows that emotion exposure is effective, there are still a lot of unknowns around exactly how it works. But there are a few theories that try to explain the reasons behind its effectiveness. The first theory relates to a concept called habituation. Habituation is what happens when something is repeated over and over again, and with repetition it gradually loses its impact on you. For example, say you just moved to a new house next to a noisy street. At first the noise feels loud and overwhelming. You can't hear yourself think! But as the hours and days go by, you start noticing it less and less. At some point you barely notice it, unless you pay attention.

Another example is when you wear a new watch for the first time. For some time, you can feel it clearly on your wrist. You notice its temperature, its weight and every other sensation about it. But gradually you stop noticing it altogether. Once in a while, when you think of your watch, you may feel it on your wrist again. But then it goes on to join the many other 'normal' things that you rarely pay attention to.

Most people have heard the story of the boy who cried wolf. It can be said that by repeatedly crying 'wolf', the boy in the story would have habituated the people in the village so that they were no longer alarmed by it.

Usually when we talk about 'getting used to' something, what is really happening is that our brain has developed habituation towards that thing. When habituation takes place, the brain changes at a cellular and chemical level, causing it to become less sensitive to what it has become habituated to. So every time you are habituated, your brain actually changes a little. That's right, there are actual changes to the structure of your brain or its chemicals, that allow your brain to no longer show sensitivity to that thing.

This theory suggests that when we concentrate on our emotions long enough, we get to a point of habituation and that's why we no longer feel that emotion to the same intensity. So, by closing your eyes and keeping your attention on the emotion, what's happening within your brain is very similar to what happened after a few hours or days in that new house in the noisy street. We often don't let this process happen in our brain because we try to distract ourselves from uncomfortable emotions before the brain has had a chance to reach habituation. When you close your eyes and concentrate on an emotion instead of avoiding it, your brain structures and chemicals may be changing and, in turn, what you experience is reduced sensitivity to that emotional experience.

The second theory is that emotion exposure works in a similar way to normal exposure therapy. Remember, classical conditioning means that our brain makes a connection between two unrelated things. And when we perform exposure therapy, we teach the brain that the two things aren't really connected anymore. We do that by facing the things that we fear or dislike and letting our body do the rest! Exposure is an automatic process. We don't need to deliberately teach our body anything.

Similarly, our bodies can be conditioned to react to certain situations, giving us the experience of an emotion. So a date, like the anniversary of a sad event, or a smell, a place, a person or any other reminders might bring back the memory of an emotion for you. Like a heavy heart, a lump in the throat, a funny feeling in the belly and so on. So that smell, that place, that person or the date of that anniversary are now acting like conditioned triggers that bring back an emotional memory.

Sometimes we don't even know what emotion has been triggered. Here's an example. Imagine that today you are feeling upset because you just had an argument with a friend. You go shopping to get it off your mind. You see a perfume bottle, have a smell and spray a little bit on your wrist. As you smell it for the rest of the day, you are conditioning the smell of that perfume to act as a trigger for the emotion that you're feeling. Months later, you walk past a complete stranger that's wearing the same perfume. You might suddenly feel a heavy emotion and have no idea where it came from. You see how confusing the world of our conditioned emotions can get?

As you can see, not all emotions are new and fresh. Many of our emotions are conditioned responses from things that have happened to us in the past. Our bodies react in similar ways in similar situations, creating similar emotional experiences, over and over again. Emotion exposure means that we can clear up the fingerprints of an emotion that belongs to the past. The memory can then be just a memory, rather than a trigger for an old emotion.

It's also worth noting that some of the conditioned emotional memories that we have, go all the way back to our childhood. Pleasant or unpleasant childhood environments can create all kinds of emotional memories. When parents and other caregivers punish or reward children, for example, some powerful conditioned responses can be created. So for example, if a parent used to snap at you or tell you off every time you were having playful fun, chances are that as an adult, every time you are having a good time, you also feel a negative emotion deep down. You then use your thinking to make sense of this and say to yourself 'I'm feeling guilty because I'm wasting time'. Or at times, when people are sensitive to criticism, they could very well be reacting to a conditioned response that was created earlier in their life, when they were in trouble with their parents for making mistakes.

The final theory that tries to explain the effectiveness of emotion exposure is that it facilitates acceptance. As you may recall, acceptance is letting go of our internal resistance and war against the reality of this moment. Emotion exposure and acceptance have a few things in common. Emotion exposure relies on the principle of not expecting ourselves to change, control, resist or fight our emotions. In other words, it increases our acceptance of our emotions, just as they are in this moment. And acceptance can help us cope better with unwanted and uncomfortable realities. In turn we may feel a general state of calmness and peace. You may have experienced this during your practice of acceptance in previous chapters.

Thinking vs. Emotion Exposure

Perhaps the real answer to the question of emotion exposure's effectiveness lies in a combination of these 3 principles: habituation, conditioning and acceptance. Considering these principles can help us make sense of those ingredients that seem to make emotion exposure work most effectively! For most of us, emotions are often there, running amok within the body, day after day. And we are often busy thinking about our problems and the emotions attached to them. So you may say that every day you think about your emotions and wonder why emotion exposure would do anything different or new for you. The answer is that emotion exposure is not the same as thinking about your emotions. There are three main ingredients that distinguish emotion exposure from the way that we normally relate to our emotions.

1. Awareness, not thinking - emotion exposure is all about bringing our attention to the body, or to the experience of our emotions. It is a mindfulness practice. The focus is not on analysing the emotions or thinking about them - thoughts like 'What is this emotion?', 'Where does it come from?', 'I’m tired of always feeling down’, 'What if something bad happens?', and so on. When practising emotion exposure we take a break from thinking and instead notice what the body is doing. Or what the experience of that emotion feels like.

2. Sustained attention - we normally only give quick short-lived attention to our emotions, and our attention is weak and divided as we go about our day or are distracted by a million racing thoughts in our head. Focusing your attention on the emotion and keeping it there a bit longer than usual may be what is needed to allow habituation to be achieved, or to make exposure therapy most effective.

3. Acceptance - in other words, giving up the temptation to change the emotion. This is very important. When practising emotion exposure, you are only a passive watcher. You are not trying to change, soothe or escape. The more you give up the temptation to control your emotion, the more quickly it will pass. Imagine getting on a roller coaster. Once you are on the ride, it is not your job to control it or stop it. And you could not do that even if you tried! You just need to sit back and let the ride take you wherever it takes you. Trying to control it is pointless. When practising emotion exposure, we need to treat our emotions in exactly the same way. We cannot control or get rid of emotions using will power. That only results in more internal anguish and distress. So we might as well sit back and experience the ride.

Remember, this is not a process that you can speed up using your will power. So as you have your eyes closed and are feeling the emotion, be mindful of thoughts like: 'When is it going to go away?', 'How can I get rid of it?', 'This is pointless', 'It's not working' and so on. These thoughts are an indication that you are placing your focus on trying to get rid of the emotion, rather than on feeling the emotion and experiencing it fully.

An Onion

At times, our emotions are like an onion. If you peel off a layer of the onion, there will be another one underneath it. And another one. And another one. After some time, the layers will stop and you will end up with no more onion. Similarly, at times during emotion exposure you will find that, as an emotion leaves, there is another one underneath it. And another one underneath that one. It may feel like the layers of emotion will never end, and that all you are doing is replacing one layer with the next one. But continuing to practise emotion exposure means that at some point the layers may end, allowing you to experience a calm, peaceful space of no emotion.

It may help you to remember a rule:

— Thinking often brings up emotions (new emotions or old ones)

— Emotion exposure allows the emotions to be alleviated

So you may find that at times when you begin thinking, you begin feeling more emotions. If this happens, practise emotion exposure on the new emotions that are activated. Remember to get into the habit of pausing your thinking and focusing on the body instead, because getting lost in thoughts may result in more and more emotions coming to surface. However, as each emotion lifts up, feel free to allow your thoughts back in again. So allow the thoughts in, and once you feel an emotion, stop thinking and focus on the body. Repeat this process until you feel lighter and more at peace.

Note: don't forget to check for any errors in your thinking as well. If a thought error keeps creating an emotion for you, it's important to first realise the thought error and change your thinking.

Challenges with the Practice of Emotion Exposure

The challenge of practicing emotion exposure is not going to be the same for everyone or for every emotion. You might find that certain emotions are more challenging to work through or concentrate on. Others are a lot easier. At times, practicing it will result in quick relief to your emotions. At other times it might not work so quickly or smoothly. What is important is to not give up when you face a challenge, but to keep trying. Check that you are correctly applying all the principles that you have learned in this session. Here are 7 common challenges that people report when practicing emotion exposure, and tips on how to deal with them:

1.   'I feel an emotion, but I can't find it in my body' - If this applies to you (and it's one of the things that most people experience from time to time), then don't try so hard to pin the emotion down in your body. Just concentrate on the general experience of the emotion. The overall feel of it. The feeling that the emotion gives you. Sit with that experience and keep your attention still. At some point, you may start noticing it within the body as well. If that happens, start keeping your attention on that part of the body.

2.   'I'm feeling a few different sensations, in different parts of my body all at the same time' - it's best to focus on one part of the body at a time. Maybe start with the one that you're feeling most strongly, or the one that keeps grabbing your attention. Once that sensation lifts off, move on to the next. The reason that we suggest this is that the more intensely you focus, the quicker you will get results. So, if your attention is jumping between different parts of your body, it might at times reduce its effectiveness. But, if focusing on only one part proves difficult, then try staying aware of all the different sensations appearing and disappearing within your body, as if you are watching a show. Keep your attention on the show until the feeling calms down.

3.   'I am feeling a sensation in my body, but I'm not sure if it's an emotion or just physical?' - It is not always easy to tell emotions apart from purely physical sensations. That's one reason why, when our bodies are unhappy, (e.g. when we are hungry, tired, coming down with a cold and so on) we are more likely to feel intense emotions. The key here is to stop getting bogged down with the question 'is it an emotion or just the body?' and instead practise emotion exposure on it anyway. If what you are feeling in the body has an emotional component, you should experience relief after some time. But that said, if you are certain that there is a physical component, attend to that as well. If you are hungry, eat something. If you are tired, make sure you get some rest. If you are sick or in pain, speak to a doctor. The bottom line is that the body and emotions are so intertwined, that they regularly impact each other. For example, pain can intensify your emotions, but emotions can also intensify your pain. So it is best to work on both.

4.   'I'm feeling bored, restless or tired. What do I do?' - Boredom and restlessness are also emotions. Notice how they make your body feel and practise emotion exposure around them. Tiredness can be physical or emotional. If you believe it may be emotional, try practising emotion exposure on the parts of the body where you feel it.

5.   'What happens if emotions come up in situations where I can't close my eyes and focus? How do I deal with that?' - With continued practice, you can start noticing your emotions even as you go about your day and with your eyes open. Notice how in social situations, as painful emotions arise within your body, you actively try to push them away and ignore them. Instead, stay with the pain in the body and place your attention on it, until it subsides. If, at times, you need to focus more, find a quiet corner (e.g. take a toilet break!) and practise emotion exposure. Alternatively, work on any left-over feelings from the emotion at the end of the day, when you get home or when you find some alone time. As you work through these emotions, you may notice that they return with less and less intensity over time, or that some emotions never return again.

6.   'The emotion that I'm feeling is too uncomfortable. I find it too painful to pay attention to. What do I do?' - It is unfortunate that some emotions can be so uncomfortable. It often feels easier to put them in a box and forget about them, like Jasmine did with her monster. But with a bit of determination you may be able to reduce the discomfort of these emotions as well. Here are a few things you can try:

—   Use your imagination to picture yourself yelling, screaming or expressing the emotion however you would like to express it. Or consider expressing yourself while writing or creating art. Now feel the emotion in the body as you express yourself.
—   Imgine a scenario where the emotion is changed. Picture your life situation improved. Or if the emotion is from the past, imagine a scenario with a happier ending. As you imagine these things, keep your attention on the body and feel all the sensations that are happening. Feel the relief as well as any left over emotions.
—   Talk to someone. Seek therapy from a trained professional, or find a friend who will not rush you to get rid of the emotion using logic, and ask them to allow you to express what you're feeling. It may be helpful to let them know that the purpose of speaking to them is just so you can express your emotions. Now, just talk it out as you feel the body at the same time.
—   Focus on one sensation at a time, as we discussed in the 2nd point above. Once you find a painful sensation in your body, don't get distracted by other sensations or thoughts. Just fix all of your attention on it and keep your attention firmly on that part of the body until the sensation is relieved. Now look for other sensations.
—   Chip away at it - look at the emotion a few seconds at a time, and then if it's too painful let it go. Do the same again next time. Gradually, by repeating this, the monster will feel less and less scary and you will be able to keep your attention on it for longer.

7.   'My attention is wandering and I am too distracted. How do I concentrate on the emotion?' - It may be a good idea for you to place your focus on mindfulness of thoughts to begin with. As you practise sitting there and watching your thoughts, remaining aware of their movements, it may help to consider this analogy, which we've touched on before:

Imagine you're standing in a river with waves of water washing against your legs. Imagine your thoughts and emotions to be like the water. Your job is to stay aware of the water (i.e. thoughts and emotions) as they come and go. Do not think, analyse, try to create the current or stop the current. Just stay aware and let it flow. Practise this as often as you can. You may find that this practice gradually helps your thoughts to slow down and for you to become more mindful of your thoughts and emotions.

Finally, please remember that emotion exposure can be a boring practice! Mindfulness in general may feel boring. That is okay. Being bored is not something to be afraid of. In fact, we suggest that you expose yourself to 'boring' and push through it. So if you are feeling bored focusing on a boring sensation within the body, just tolerate it and keep your attention there anyway. At some point you may find that boredom gives rise to a sense of peace and calm. So this will be worth the effort!

Therapist Anxieties

Therapists often approach interoceptive exposure (IE) with caution, employing relaxation, breathing, or appraisal exercises to alleviate its perceived discomfort. However, emerging research challenges these preconceptions and suggests that IE, when used in isolation, is not only tolerable but also effective in diminishing anxiety sensitivity (Deacon et al., 2012). Therefore, therapists are encouraged to embrace emotion and interoceptive exposure techniques without reservation. By integrating these approaches into their practice, therapists can offer targeted interventions that directly engage with the fundamental mechanisms of emotions, promoting more efficient and focused therapy.

The Therapist's Practice of Emotion Exposure and its Benefits

The practice of emotion exposure offers therapists substantial advantages when integrated into their professional routines. While it serves as a valuable self-care tool, it also has the potential to achieve the additional objectives of mitigating countertransference, addressing emotional contagion, and enhancing therapists' comprehension of their clients.

Emotional contagion, the phenomenon where one person's emotions and related behaviors can trigger similar emotions and behaviors in others, is a recognised aspect of human interaction. In the context of therapy, emotional contagion can result in countertransference, where a therapist unconsciously takes on the emotions and reactions of their clients, potentially interfering with the therapeutic process. As therapists, it's crucial to be aware of our emotional responses to clients and to use this awareness as a tool for growth and understanding.

There have been instances when certain clients triggered specific emotional reactions in me. Mindfully exploring and working through these emotions not only assisted me in gaining new insights about the client but also deepened my understanding of how to best support them. Allow me to share a couple of illustrative examples:

Example 1:

On several occasions, I found myself feeling perplexed when working with particular clients. Despite having well-thought-out treatment plans, I would enter sessions only to be overtaken by confusion, forgetting my intended strategies or the starting point for our discussions. This pattern persisted consistently with these clients, prompting me to inquire into its origins. As I engaged in emotion exposure centered around the emotions tied to my confusion, a remarkable revelation emerged: my clients frequently exhibited parallel patterns of confusion and mental disorganization. Attending to my vicarious emotional response not only provided valuable insights into my client's psychological state but also enabled me to regain my focus and composure within these sessions.

Example 2:

Certain clients with histories of childhood abuse often reported ongoing mistreatment in their daily lives. During interactions with these clients, I occasionally experienced heightened emotions, including anger, frustration, or an inclination to react harshly to various behaviors. While some of these behaviors might have appeared reasonable grounds for such emotional responses, the intensity of my reactions stood out. Furthermore, similar behaviors displayed by others did not consistently trigger the same emotional responses within me. Recognizing this divergence led me to explore my emotional reactions through emotion exposure. What I uncovered were patterns of abuse that had given rise to unhelpful emotional responses in these clients, including anger, a sense of victimhood, and an overcompensatory entitlement. By attentively exploring my own emotional reactions, I not only gained a deeper understanding of my clients but also managed to circumvent the customary angry reactions they often faced from society. Instead, we could collaboratively address their unhelpful behavior and help them comprehend why they seemed to attract mistreatment.

In cases where clients were ready, I shared with them my emotional reactions in response to their behavior, using a specific analogy to facilitate their understanding. I likened the emotional residue of past abuse and unhelpful environments to the lingering smell of smoke on clothes after exiting a smoke-filled room. In the same way, individuals who have been surrounded by abuse or bullying tend to carry emotional remnants from those environments, which others can subconsciously pick up on and react to. This, I emphasize, is not the client's fault but may help them make sense of their recurring experiences with people.

By engaging in emotion exposure personally, therapists can gain a deeper understanding of their clients' emotional experiences and cultivate greater empathy, which ultimately enhances the therapeutic process.

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* Disclaimer: I use the terms emotion exposure and interoceptive exposure interchangeably. Although there are small differences between the two therapeutic techniques, there is significant overlap between these therapies and I have elsewhere argued that the two should be considered synonomous. Additionally, you may notice that I preference the term emotion exposure over interoceptive exposure because when speaking to the public, I think there’s value in keeping the language simple and accessible. Especially if we want to be accessible to kids and adolescents. Everyone has an idea of what emotions are, but a term like interoception needs definitions and a level of academic interest from our audience.

Session Planning and Goal Setting

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Effective therapy sessions begin with a clear understanding of the goals to be achieved during that particular session. Creating session goals is like charting a map for therapy, and this map can change as we go along. The formation of session goals can occur at various points in the therapeutic journey, including:

1. At the end of a Session: A good time to reflect on what you achieved with the client and what you plan to work on next is at the end of a session, particularly while you are doing your case notes. Always include 'plans' in your session notes, as this is when your memory is the most fresh on what happened during the session and what would be beneficial to achieve next. However, there are times when your plan for the next session hinges on the client's reports during that session. For example, you may need to wait to hear about the outcome of their homework practice. Or you may need to hear their reports about the impact of the session you just had, which can determine if you have successfully addressed the current goals and any subsequent goals which may emerge. In such cases, your plans for the upcoming session can be left open to be decided upon at the session's commencement.

2. Before the Next Session: Before you meet with the client for the next session, it's a good practice to take a moment to study your notes and reflect. Review the plans you made at the end of the previous session. This review ensures that each session builds upon the progress and intentions established earlier and helps maintain continuity and a clear sense of direction in the therapeutic process.

3. During the Session: Understanding the client’s dominant thoughts and emotions during the time between therapy sessions holds much valuable insights. At the start of each session, it's imperative to explore the dominant thoughts, emotions, and dreams since the previous meeting. This information can help you form goals for the session, or readjust your previous goals. Below are a few factors to consider:

Thoughts and Emotions: Start by inquiring about the client's prevalent thoughts and emotions during this interval. Ask if they've noticed what occupied their minds most since the last session. If the client is uncertain, prompt them to recollect their mental and emotional states during moments of solitude or mundane activities, such as bedtime or routine tasks like sweeping or brushing teeth. These moments often unveil unfiltered thoughts and emotions.

Dreams: Additionally, inquire about any dreams the client remembers from this period. Dreams can serve as gateways to the unconscious, providing glimpses of underlying emotions, concerns, or questions that may not surface during regular conversations. Explore the dream's content, the emotions it aroused, and any thoughts or insights that emerged during or after the dream.

• Exploring Dominant Thoughts and Emotions: The period between therapy sessions is crucial, offering insights into the client's mental landscape. Start by asking the client about their dominant thoughts and emotions since the last session. Inquire about the content of their inner world and any recurring themes or concerns that have occupied their mind. Encourage them to recall moments when they were alone or engaged in less mentally engaging activities, as these moments often reveal unfiltered thoughts and emotions.

- **Uncovering Dreams:** Dreams can serve as windows into the unconscious, offering glimpses of underlying emotions, concerns, or questions that might not come up in everyday conversation. Ask the client about any dreams they recall since the previous session. Dive into the dream's content, the emotions it stirred, and any thoughts or insights that emerged during or after the dream."

Psychological Trends and Goal Setting:

As you delve into these discussions, you may notice trends in your client's thoughts, emotions, and dreams. These trends typically fall into three categories:

1. Consistent Dominance: In some cases, a particular trend may have consistently dominated the client's thoughts, emotions, and dreams, persisting over multiple sessions. If this trend appears unyielding and resists change, it's crucial to conduct a "case conference" with yourself. Reevaluate whether you've correctly identified and targeted core beliefs or emotions. Sometimes, minor adjustments to your approach may be sufficient. In other instances, a more substantial redirection in treatment goals may be necessary. External circumstances may also influence the client's reluctance to engage in inner healing processes, lengthening the therapy process. In such cases, your role involves patient education and encouragement, demonstrating how inner shifts can enhance their coping in challenging external environments.

2. Emerging Trends: Clients may experience shifts in the dominant trends of their thoughts, emotions, and dreams. Unless these shifts align with significant external changes in their circumstances, they often indicate the need to address new layers of trauma or unresolved issues. This transformation can occur because previous sessions successfully shifted a dominant core belief or emotion, allowing secondary concerns to surface. Think of psychological healing like peeling an onion—one layer at a time. However, when a new trend emerges, it may not necessarily result from successfully healing the previous layer. It could signify that you've inadvertently brought another layer to the surface prematurely. This could overwhelm the client, leading to heightened agitation, restlessness, and inattention, and a constant oscillation between the new dominant trend and the unresolved issues. When this occurs, it's essential to help the client understand the dynamics at play, prioritize what to address first, and potentially explore both trends simultaneously if they inform each other.

3. Chaotic Trends: Some clients present with a complex web of emotions and thoughts, lacking a clear point of focus. Sessions with these clients may feel like navigating a labyrinth, as their thoughts constantly shift from one topic to another. If your client struggles to concentrate on any specific activity or therapeutic goal, this trend may be present. Addressing any area may prove challenging, as the client's attention easily wanders, and staying focused can be a struggle. When confronted with such complexity, it's vital to maintain patience and flexibility in your approach.

As you navigate these client trends, remember that therapy isn't always linear. It's a dynamic process that adapts to the client's evolving needs and experiences. By acknowledging and understanding these trends, you can tailor your therapeutic interventions to best serve your client's progress and well-being.