Chapter Seven – Distress Reduction and Affect Regulation Training

Adolescents with complex trauma exposure often experience chronic and intense distress as well as posttraumatic symptomatology.

Many also describe extremely negative emotional responses to trauma-related stimuli and memories – feeling states that are easily triggered by later relationships and dangerous environments. When faced with overwhelming negative emotions and trauma memories, the youth is often forced to rely on avoidance strategies such as substance abuse, tension-reduction activities, or dissociation (Briere, Hodges, & Godbout, 2010). Unfortunately, high levels of avoidance, in turn, appear to interfere with psychological recovery from the effects of trauma (Briere, Scott, & Weathers, 2005; Polusny, Rosenthal, Aban, & Follette, 2004). In the worst case, the need to avoid additional posttraumatic distress may lead the hyperaroused or emotionally overwhelmed client to avoid threatening or destabilizing material during therapy, or to drop out of treatment altogether. This scenario is exemplified by the psychosocially challenged youth who either is so involved in avoidance behaviors that his or her participation in treatment is minimal, or who attends therapy for one or two sessions, then disappears.

The interventions in this chapter have two foci: the reduction of acute, destabilizing emotions and symptoms (distress reduction), and an increase in the client’s more general capacity to regulate negative emotional states (the development of affect regulation skills). This material is presented before the chapters on cognitive and exposure-based processing because, in some cases, low affect regulation capacity must be addressed before more classic trauma therapy (e.g., therapeutic exposure) can occur (Cloitre et al., 2010, Pearlman & Courtois, 2005).

Acute Distress Reduction

Acute stress reduction involves techniques that reduce triggered, overwhelming states that may emerge during therapy, such as panic, flashbacks, intrusive emotional states (e.g., terror or rage), dissociative states, or even transient psychotic symptoms. These internal processes can be frightening – if not destabilizing – to the adolescent survivor, and can diminish his or her moment-to-moment psychological contact with the therapist. At such times, it may be necessary to refocus the survivor’s attention onto the immediate therapeutic environment (with its implicit safety and predictability) and the therapist-client connection.

These interventions also may be of use to the adolescent trauma survivor outside of the therapy session. For example, learning to “ground” oneself or induce a more relaxed state may be helpful when the youth encounters potentially threatening or destabilizing experiences in his or her life, such as in conflicts with others, exposure to trauma triggers, at school, or even when applying for a job or going on a first date.

Grounding

Grounding involves focusing the client’s attention away from potentially overwhelming negative thoughts, feelings, and memories. The ability to disengage from intrusive, escalating internal states can be learned, and then applied when necessary. As noted above, the therapist may teach the adolescent how to ground himself or herself during treatment sessions, when triggered memories produce potentially overwhelming emotional states. This skill can then be used by the client to address destabilizing states outside of treatment.

Grounding typically involves the following steps:

1. Ask the client to briefly describe the nature of his or her internal experience. For example, “Susan, is something going on/upsetting you/happening right now?” If the adolescent is clearly frightened or responding to distressing internal stimuli, but can’t or won’t describe them, go to Step #2 below. If he or she is able to talk about the internal experience, however, it is often helpful for him or her to label it in some fashion. This does not mean the survivor should go into extensive detail – a highly specific description of the flashback or dissociative state may increase its intensity, thereby reinforcing the response rather than lessening it. Instead, the client is encouraged to focus on the experiential process he or she is undergoing, rather than describing the content of the thoughts. The therapist can facilitate this labeling procedure by saying something like “Can you tell me what’s going on, inside, right now?” or “Just tell me what your thoughts are like right now; you don’t have to get into them.” In this regard, a client’s process response would be, “my thoughts are bouncing around inside my head and it feels like I’m going crazy,” rather than a content statement such as, “I see her face and hear her voice screaming at me that it was all my fault.”
2. Orient the adolescent to the immediate, external environment. This often involves two, related messages: (a) that the client is safe and not, in fact, in danger, and (b) he or she is here (i.e., in the room, in the session, with the therapist) and now (i.e., not in the past, being re-exposed to the trauma). In some cases, the client can be oriented by reassuring statements, typically using the client’s name as an additional orienting device (e.g., “Susan, you’re ok. You’re here in the room with me. You’re safe.”). In others, grounding may involve asking the client to describe the room or other aspects of the immediate environment (e.g., “Susan, let’s try to bring you back to the room, OK? Where are we? What time is it? Can you describe the room?”). He or she might be asked to focus his or her attention on physical sensations, such as the feeling of the chair or couch underneath him or her, or of his or her feet on the floor. The client may also find it helpful to shift attention from internal experiences to external sensory perceptions. For example, the adolescent might be invited to look carefully at the details of an object in the room (e.g., a painting on the wall), listen intently to nearby sounds, or explore a small object by touch. Some clinicians place a hand on the client’s shoulder or arm, so that the sensation of physical touch can both reassure and “bring him/her out” of an escalating internal state. This is generally not recommended, however, unless the clinician knows how touch will be interpreted by the client. For some victims of sexual or physical assault, for example, touch may trigger memories of the assault, and increase, rather than decrease, negative internal states. However accomplished, the client’s re-orientation to the here and now may occur relatively quickly (e.g., in a few seconds), or may take substantially longer (e.g., a number of minutes).
3. If indicated, focus on breathing or other methods of relaxation (described later in this chapter). Take the adolescent through the relaxation/breathing exercise for as long as is necessary (typically for several minutes or longer), reminding the client of his or her safety and presence in the here-and-now.
4. Repeat Step #1, and assess the client’s ability and willingness to return to the therapeutic process. Repeat Steps #2 and #3 as needed.

If it is possible for therapy to return to its earlier focus, the clinician should normalize the traumatic intrusion (e.g., as a not-unexpected part of trauma processing) and the grounding activity (e.g., as a simple procedure for focusing attention away from intrusive events), and continue trauma treatment, albeit at a temporarily reduced level of intensity. It is important that the adolescent’s temporary reexperiencing or symptom exacerbation be neither stigmatized nor given greater meaning than appropriate. The overall message should be that trauma processing sometimes involves the intrusion of potentially upsetting memories, thoughts, and/or feelings, but that such events are part of the healing process.

Relaxation

One of the most basic forms of arousal reduction during therapy is learned relaxation. Strategically induced relaxation can facilitate the processing of traumatic material during the therapy session by reducing the adolescent’s overall level of anxiety. Reduced anxiety during trauma processing lessens the likelihood that the client will feel overwhelmed by trauma-related distress, and probably serves to counter-condition traumatic material, as described in Chapter 10. In addition, relaxation can be used by the survivor outside of treatment as a way to reduce the effects of triggered traumatic memories. It is likely, however, that relaxation training alone is insufficient for trauma treatment (Taylor, 2003). Its primary function in ITCT-A is to augment the other components outlined in this guide.

Progressive relaxation

This technique involves clenching and then releasing muscles, sequentially, from head to toe, until the entire body reaches a relaxed state (Rimm & Masters, 1979). As clients practice progressive relaxation on a regular basis, most are eventually able to enter a relaxed state relatively quickly. Some practitioners begin each session with a relaxation exercise; others teach it initially in treatment, and then utilize it only when specifically indicated, for example, when discussion of traumatic material results in a high state of anxiety. It should be noted that, in a small number of cases, the client may experience increased anxiety during relaxation training (e.g., Young, Ruzek, & Ford, 1999). In most instances, this anxiety passes relatively quickly, especially with reassurance. When it does not, the clinician may choose to discontinue this approach, or use the breath training method described below.

Breath training

When stressed, many individuals breathe in a more shallow manner, hyperventilate, or, in some cases, temporarily stop breathing altogether. Teaching the adolescent “how to breathe” during stress can help restore more normal respiration, and thus adequate oxygenation of the brain. Equally important, as the client learns to breathe in ways that are more efficient and more aligned with normal, non-stressed inhalation and exhalation, there is usually a calming effect on the body and the autonomic nervous system.

Breath training generally involves guided exercises that teach the client to be more aware of his or her breathing – especially the ways in which it is inadvertently constrained by tension and adaptation to trauma – and to adjust his or her musculature, posture, and thinking so that more effective and calming respiration can occur. Below is one approach to breath training, adapted from Briere and Scott (2012).

First:

1. Explain to the client that learning to pay attention to breathing, and learning to breathe deeply, can both help with relaxation and be useful for managing anxiety. Note that when we get anxious or have a panic attack, one thing that happens is that our breathing becomes shallow and rapid. When we slow down fearful breathing, fear, itself, may slowly decrease.
2. Explain that, initially, some people become dizzy when they start to breathe more slowly and deeply – this is a normal reaction. For this reason, they should not try breathing exercises while standing until they have become experienced and comfortable with them.
3. Note that the exercises may feel strange at first because the client will be asked to breathe into his or her belly.

Then:

1. Have the client sit in a comfortable position
2. Go through the sequence below with the client – the whole process should take about 10 to 15 minutes. After each step, “check in” as appropriate to see how the client is feeling, and ascertain if there are any problems or questions.a. If the adolescent is comfortable with closing his or her eyes, ask him or her to do so. Some trauma survivors will feel more anxious with their eyes closed, and will want to keep them open. This is entirely acceptable. If they prefer to keep their eyes open, the client can be invited to take a “soft gaze” — unfocusing the eyes while looking slightly downward at the floor about three feet ahead.b. Ask the client to try to “just pay attention to your breathing, noting else” while doing the exercise. If his or her mind wanders (e.g., thinking about school, or about an argument with someone), he or she should gently try to bring it back to the immediate experience of breathing.c. Ask the client to begin breathing through the nose, paying attention to the breath coming in and going out. Ask him or her to pay attention to how long each inhale and exhale lasts. Do this for 5 or 6 breaths.d. It is usually helpful for the clinician to breathe along with the adolescent at the beginning of the exercise. You can guide him or her for each inhalation and exhalation, saying “in” and “out” to help him or her along.e. Instruct the client to start breathing more into his or her abdomen. This means that the belly should visibly rise and fall with each breath. This sort of breathing should feel different from normal breathing, and the client should notice that each breath is deeper than normal. Do this for another 5 or 6 breaths.

   f. Ask the adolescent to imagine that each time he or she breathes in, air is flowing in to fill up the abdomen and lungs. It goes into the belly first, and then rises up to fill in the top of the chest cavity. In the same way, when breathing out, the breath first leaves the abdomen, and then the chest. Some people find it helpful to imagine the breath coming in and out like a wave. Do this for another 5 or 6 breaths.

   g. Explain that once the client is breathing more deeply and fully into the belly and chest, the next step is to slow the breath down. Ask the client to slowly count to three with each inhalation and exhalation – in for three counts, out for three counts. Tell him or her that there is no specific amount of time necessary for each inhalation and exhalation, only that he or she try to slow his or her breathing. Do this for 5 or 6 breaths.

3. Ask the client to practice this type of breathing at home for 5 to 10 minutes a day. He or she should choose a specific time of day (e.g., in the morning, before work or school, before going to sleep), and make this exercise a regular part of his or her daily routine.²

Eventually, the youth may be able to extend this exercise to other times in the day as well, especially when relaxation would be a good idea, e.g., in stressful social situations or whenever he or she feels especially anxious. Remind the client to internally count during each inhalation and exhalation, since counting, itself, often serves to trigger the relaxation response.

Visualization

A third approach to relaxation does not involve learning to breathe or relax, per se, but rather how to imagine a peaceful or pleasant scene in sufficient detail that relaxation naturally follows. The adolescent may be encouraged to sit with eyes closed and visualize a day at the beach, a mountain lake, or walking in a forest. Often, the therapist verbalizes this scene while the youth attends to it, and then the client continues to imagine it for several minutes while the therapist is silent. Later, at moments of stress, the adolescent can “go back” to the scene, if only for a few seconds or minutes. Some clinicians refer to this as the client going to their “special place,” although some older adolescents may not value this terminology. Importantly, this skill is not useful in a crisis or emergency where the client must be vigilant and react quickly, but rather when the stress is expected, and the youth has a chance to do this exercise beforehand . Some clients also find this approach helpful as a sleep technique at night.

Mindfulness and Meditation

This last approach is in some ways more ambitious than the others described in this chapter, because it takes more effort and practice. On the other hand, the actual technique is relatively simple. Meditation accomplishes more than relaxation alone; also learned is the ability to observe one’s internal experience with less judgment; to “let go” of upsetting thoughts, feeling and memories; and, with practice, to enter a state of relative calm (Germer, Siegel, & Fulton, 2012; Semple & Lee, 2011) – all skills that can be helpful for traumatized youth (Goodman, 2005). Nevertheless, not all adolescents will want to meditate, now will all therapists feel comfortable or qualified in teaching it. When reduced to a simple activity, however, meditation can be easily practiced and often is quite helpful. Because meditation training is an optional component of ITCT-A, it is presented separately in Chapter 8.

Increasing General Affect Regulation Capacity

In addition to immediate methods of distress reduction, such as grounding, relaxation, and meditation, there are a number of suggestions in the literature for increasing the general affect regulation abilities of trauma clients. All are focused on increasing the survivor’s overall capacity to tolerate and down-regulate negative feeling states, thereby reducing the likelihood that he or she will be overwhelmed by activated emotions. In some cases, such affect regulation work may be necessary before any significant memory processing can be accomplished (Blaustein & Kinniburgh, 2010; Cloitre, Cohen, & Koenen, 2006; Pearlman & Courtois, 2005).

Identifying and discriminating emotions

An important aspect of successful affect regulation is the ability to correctly perceive and label emotions as they are experienced (Cloitre, et al., 2006; Linehan, 1993). Many adolescent survivors of complex trauma have trouble knowing exactly what they feel when triggered into an emotional state, beyond, perhaps, a sense of feeling “bad” or “upset.” In a similar vein, some may not be able to accurately discriminate feelings of anger, for example, from anxiety or sadness. Although this sometimes reflects dissociative disconnection from emotion, in other cases it represents a basic inability to “know about” one’s emotions. As a result, the youth may perceive his or her internal state as consisting of chaotic, intense, but undifferentiated emotionality that is not logical or predictable. For example, the adolescent triggered into a seemingly undifferentiated negative emotional state will not be able to say, “I am anxious,” let alone infer that “I am anxious because I feel threatened.” Instead, the experience may be of overwhelming and unexplainable negative emotion that comes out of nowhere. Not only may the unknown quality of these states foster a sense of helplessness, it often prevents the adolescent from making connections between current emotional distress and the environmental or historical conditions that produced it. Without such insight, the youth is unlikely to be able to intervene in the causes of his or her distress or improve his or her situation.

The clinician may be helpful in this area by regularly facilitating exploration and discussion of the client’s emotional experience. In fact, “checking in” with the client multiple times per session is a regular part of ITCT-A. Often, the young survivor will become more able to identify feelings just by being asked about them on a regular basis. On other occasions, the therapist can encourage the client to do “emotional detective work,” involving attempts to hypothesize an emotional state based on the events surrounding it, or the bodily states associated with it. For example, the client may guess that a feeling is anxiety because it follows a frightening stimulus, or anger because it is associated with resentful cognitions or aggressive behaviors. Affect identification and discrimination also may occasionally be fostered by the therapist’s direct feedback, such as “it looks like you’re feeling angry. Are you?” or “you look scared.” This last option should be approached with caution, however. There is a risk of labeling a client’s affect as feeling A when, in fact, the client is experiencing feeling B – thereby increasing confusion rather than fostering emotional identification. For this reason, it is recommended that, in most instances, the therapist facilitate the client’s exploration and hypothesis testing of his or her feeling state, rather than telling the client what he or she is feeling. The critical issue here is not usually whether the client (or therapist) correctly identifies a particular emotional state, but rather that the client explores and attempts to label his or her feelings on a regular basis. Typically, the more this is done as a general part of therapy, the more skillful the adolescent survivor may become at accurate feeling identification and discrimination.

Identifying and countering thoughts that underlie negative emotional states

Not only should the client’s feelings be monitored and identified, the same is true for his or her thoughts. This is most relevant in situations when thoughts trigger a strong emotional reaction, but the thought is somehow unknown to the survivor. Affect regulation capacities often can be improved by encouraging the client to identify and counter the cognitions that exacerbate or trigger trauma-related emotions (Linehan, 1993). Beyond the more general cognitive interventions described in Chapter 9, this involves the survivor learning how to identify whatever thoughts mediate between a triggered traumatic memory and a subsequent negative emotional reaction. For example, an adolescent survivor of sexual abuse might think, “she wants to have sex with me” when interacting with an older woman, and then experience revulsion, rage, or terror. In such cases, although the memory itself is likely to produce negative emotionality, the associated cognitions often exacerbate this response to produce more extreme emotional states. In other instances, thoughts may be less directly trauma-related, yet still increase the intensity of the client’s emotional response. For example, in a stressful situation the client may have thoughts such as “I’m out of control,” or “I’m making a fool of myself” that produce panic or fears of being overwhelmed or inundated.

Because triggered thoughts may be out of superficial awareness, their role in subsequent emotionality may not always be clear to the survivor. As the client is made more aware of the cognitive antecedents to overwhelming emotionality, he or she can learn to lessen the impact of such thoughts. In many cases, this is done by the client explicitly disagreeing with the cognition (e.g., “nobody’s out to get me” or “I can handle this”), or by repeatedly labeling such cognitions as “old movies” rather than accurate perceptions. In this regard, one of the benefits of what is referred to as insight in psychodynamic therapy is often the self-developed realization that one is acting in a certain way by virtue of erroneous, “old” (e.g., trauma- or abuse-related) beliefs or perceptions. This understanding may reduce the power of those cognitions to produce distress or motivate problematic behavior in the present.

When the thoughts that underlie extremely powerful and overwhelming emotional states are triggered by trauma-related memories, the therapist can focus on these intermediate responses by asking questions such as “what happened just before you got