This is the fifth in a series of posts about David Barlow & colleagues' new unified protocol for treatment of anxiety, depression & related emotional disorders.  The fourth post was on "Emotional awareness training & cognitive reappraisal" and this one is on the fifth & sixth modules in the eight module training - "Emotional avoidance & emotion driven behaviours (EDB's)" (typically taking one to three treatment sessions) and "Awareness & tolerance of physical sensations" (typically taking just one treatment session).

In the unified protocol "Therapist guide", they state "Emotion avoidance refers to any strategies someone might use to avoid feeling strong emotions, or to prevent emotions from becoming more intense" and then go on to say "Although emotion avoidance strategies may be useful in some situations, they rarely work well in the long term" and "In addition to more 'obvious' avoidance, such as when someone refuses to enter a situation that is likely to produce emotional distress, avoidance strategies can be broken down into three main types: subtle behavioral avoidance, cognitive avoidance, and the use of 'safety signals'".  There's a developing research literature here that therapists would do well to be aware of.  For example, five studies (all published last year) show emotional avoidance's relevance for generalised anxiety disorder, depression, social anxiety disorder, and grief respectively, as well as for anxiety disorders generally: "Fear and perceived uncontrollability of emotion: Evaluating the unique contribution of emotion appraisal variables to prediction of worry and generalised anxiety disorder"; "Let it be: Accepting negative emotional experiences predicts decreased negative affect and depressive symptoms"; "Experiential avoidance in idiographic, autobiographical memories: construct validity and links to social anxiety, depressive, and anger symptoms"; "Mediating processes in bereavement: The role of rumination, threatening grief interpretations, and deliberate grief avoidance" and "Tolerate or eliminate? A systematic review on the effects of safety behavior across anxiety disorders".  This is not a new understanding - e.g. see the 2003 book "Treating affect phobia" - but I think what is new is such a clear focus on this area in a short-term, manualized, cognitive-behavioural psychotherapy intervention.  Useful territory, and important to tease out what are adaptive responses and what are excessive and maladaptive.  Exploring this may well lead (a little further into the treatment) to a whole series of "emotional exposure" challenges. 

Emotional avoidance typically occurs before emotions actually occur, in an attempt to not experience them.  Barlow & colleagues introduce the term "emotion-driven behaviors" (EDB's) to describe responses that occur after an emotion has been triggered.  These EDB's typically act to reduce the intensity of the emotion being experienced.  EDB's may be appropriate & adaptive or inappropriate & maladaptive.  So, for example, I'm due to give a short talk at a seminar soon.  I'm a little "anxious", wanting it to go well.  If this anxiety results in an emotion-driven behaviour to prepare appropriately (not too much, not too little) for the talk, this is fine.  If the anxiety results in excessive preparation, maybe difficulty sleeping, and constant thinking about the talk, then these EDB's are inappropriate & maladaptive.  I have a handout - "Emotions, arriving' & ‘leaving' - that illustrates this point pretty well.  In my experience, EDB's that are maladaptive are typically due to the current situation being misperceived & reacted to inappropriately due to unhelpful conditioning from the past.  Often a maladaptive EDB gives short-term relief/reward at the cost of more major longer term loss.  As discussed in the blog post "Embodied cognition: posture & feelings", it may be helpful to see EDB's as often involving body position & facial expression as well as more obvious physical actions. 

The sixth module of the eight in the unified protocol is "Awareness & tolerance of physical sensations" (usually covered in one session).  Many cognitive-behavioural therapists will see this issue as relevant for people who suffer from panic disorder.  Barlow & colleagues, however, think that this area is often relevant more generally across emotional disorders.  It certainly seems true that emotional reactions can be seen as complex networks of physical sensation, imagery, thought, impulse & so on.  Activation of one aspect of an emotion network tends to trigger a spreading activation of other aspects.  Physical sensations may well lead to overall emotional network activation, and this in turn may be associated with attempts to avoid experiencing the physical sensations.  So, for example, as a teenager (and occasionally still) I was troubled by blushing.  I notice that I have a tendency to avoid experiences of feeling particularly warm in social situations as it links with memories of "getting overheated", flushed & embarassed.  However I'm quite good at sport and have happy memories associated with physical exertion, getting hot & sweaty, and having a lot of fun.  Fascinating how the same physical sensations - getting flushed & sweaty - I can interpret as evidence of appropriate effort/commitment in sport but as evidence of inadequacy in a social situation.  This module looks for ways of activating physical sensations that link with emotion networks that we have difficulty with.  This might involve deliberately hyperventilating, or breathing through a straw, or spinning to produce dizziness, and so on.  The aim is to be able to experience the sensations without avoidance, and increasingly without catastrophising or having them lead to maladaptive emotion-driven behaviours.  In the well-known "Bus driver metaphor" this means encouraging a particularly distracting physical sensation "bus passenger" so that one can practise "driving the bus" in the direction of one's priorities (adaptive behaviours) without being pushed off course.  

Tomorrow's post - the last in this six part series - is on "Unified protocol - interoceptive/situational exposure and relapse prevention".