In recent years we have witnessed a great deal of interest by researchers and therapists in the factors that are common to most emotional disorders, which are referred to by professionals as the Transdiagnostic Factors, that is, factors that are common to various emotional problems.
First of all, a short explanation: Why trans-diagnostic?
David Barlow, the famous psychologist, suggests in his trans-diagnostic protocol developed in 2008 that instead of focusing, for example, only on depression, or only on anxiety, or on isolated symptoms that vary between different emotions, it is best to conduct a more comprehensive therapy intervention, tending to the entire range of emotions rather than to one particular emotion, thus allowing the patient to cope better with the whole range of unpleasant emotions instead of just one emotion.
In the same way, Matthew Mackay in his book Mind and Emotions, notes that most treatments that tend to symptoms and their reduction, without addressing the common factors that generate and intensify the emotional disorders – the trans-diagnostic factors – are not as effective as an extensive and comprehensive therapy to all problems.
At present there are three type of therapy based on various studies for the treatment of emotional disorders in a comprehensive manner. All three address the common factors that create the disorder and the emotional regulation.
Dialectical Behavior Therapy – DBT
This approach (DBT; Linehan 1993) addresses the following to overcome emotional disorders:
Emotional alertness and acceptance
Patience to distress
Doing the opposite
Regulation of emotion
ACT: Acceptance and Commitment Therapy
This approach (Act, Hayes Strosahl and Wilson, 1999) focuses on forming psychological resilience by developing capabilities in the following fields:
Distinction and acceptance of emotions
Neutralization (by observing and distancing from thoughts)
The third approach (Barlow 2006, Mchugh and Barlow 2008) highlights the following capabilities:
Awareness and acceptance of emotions
Reorganization of the cognitive
Change of behaviors driven by emotion
In addition, emotional regulation therapy provides solutions to all emotions and addresses positive emotions as well. Therapy is based on the cognitive-behavioral approach and integrates tools from the second and third wave, thus enabling the patient to develop and improve emotional regulation abilities.
What are the common factors?
McKay (2011) points out 5 different ways of emotional repression. All five patterns of repression have the same basic implications. Although they offer a short-term solution and benefit, they end up causing long-term problems. In other words, repressions can help us avoid unpleasant emotions at a certain moment, but after a while the same emotion reappears, and it must be repressed again, creating a cycle of unpleasant emotions that affects our lives.
Studies have consistently shown that suppression strategies have destructive effects because they usually lead to a paradoxical increase in the undesirable experience and physiological arousal (Cioffi & Holloway, 1993; Gross, 1998; Gross & Levenson, 1997; Wegner & Zanakos, 1994).
Campbell-Sills, Barlow, Brown and Hofmann (2006) investigated the perception of acceptance versus the suppression of negative emotions in subjects with anxiety and mood disorders. Participants were instructed to suppress or accept their emotional response to an emotionally moving movie. The results showed that accepting participants exhibited less negative emotions during the post-movie recovery period, while suppressing participants demonstrated an increase in cardiac arousal and inhibition of mood recovery (Gross 2012).
The five different ways of emotional repression:
This is the most common form of repression. In situational repression, we tend to evade and move away from places, people and activities that may cause us emotional distress. For example, if you are shy, and social settings make you anxious, you may stay away from parties or large gatherings, you may even try to avoid eye contact with certain people or to avoid situations where you have phentermine to socialize with strangers. It may be that every time you go to your mother-in-law you get very angry at her attitude towards you, and you choose to avoid visiting her despite the damage to your marriage and family relationships. It may be that every time you meet with your old friend from school, you feel terribly jealous for his professional success, so you decide to stop seeing him.
Evading stressful mental images, anxiety-provoking thoughts, and painful memories by consciously denying them by saying “Don’t think about it, just don’t go there”. Sometimes, such thoughts are exchanged for other thoughts that create a false sense of control and security: instead of feeling anxious about the future, people preoccupy themselves obsessively with thoughts about what may happen, what can go wrong, they think of different scenarios which supposedly allows them early prevention or at least some sort of preparation. Although such thoughts generate a certain sense of security, they become a problem in themselves, as they tend to take over, in a sense that the person finds themselves busy with them at all times.
In defensive repression we avoid dangers or risks through various obsessive defensive behaviors, such as checking that the house is locked, that the stove is turned off, that the light is off, etc. In other cases, this sense of security is dependent on carrying something that has real or imagined protective properties, such as lucky charms, a telephone you may use to call for help, a whistle or anti-anxiety medications.
Defensive repression can also be expressed through obsessive activities such as obsessive cleaning, hand washing, or wearing gloves in the bathroom. Even perfectionism and over-doing of homework or other assignments can be a form of defensive repression. Any such form of defensive repression constitutes a kind of “safety pin” that protects the person from overwhelming emotions.
According to Barlow, the main problem with using a “safety pin” is the belief that this artifact or amulet is what helps me cope, and thus we are prevented from getting used to experiencing the emotion in full. We do not experience the negative emotion when we employ defensive repression, thus we cannot grow to cope with it (Barlow 2008). This creates a growing dependence on the “safety pin” and an inability to calm down when it is unavailable for some reason: a perfectionist child who does not have enough time to prepare for an exam will feel overwhelmed; an obsessively clean person will feel anxious when stepping into a place that is not clean enough; a person who has forgotten their “amulet” will panic, etc.
In this type of repression, people try to avoid physical sensations that relate to emotional distress, such as shortness of breath, exhaustion or heat waves. They may also avoid normal and pleasant feelings such as sexual arousal or positive excitement because of their particular similarities to feelings of anger or anxiety (e.g., an increase in heart rate, “butterflies in the stomach”).
This form of repression involves replacing the feeling of distress with another. For example, you may replace jealousy with another strong emotion that you can tolerate better, like anger. Eating food, drinking alcohol or using drugs are way to distract oneself and avoid painful emotions. There are people who turn to the thrill of gambling, reckless and dangerous behavior, computer games, or porn as a substitute for the painful emotions they try to avoid.
The protocol for emotional regulation developed by the Center for Emotional Regulation provides tools to help children develop their ability to cope with “pleasant” emotions and “unpleasant” emotions as part of their daily experience, thus allowing children to lead meaningful lives and achieve their goals without avoiding anything due to overwhelming emotions.
The following are some examples of fascinating processes I led with patients using my set of tools.
An example of work on situational repression.
Emma, a 15-year-old girl, came to with a case of extreme shyness in social settings that prevented her from attending parties and events outside of school.
Emma tries to avoid this emotion of shyness in social situations and is willing to give up meetings, parties, school events and even texting in the class’s chat group so as not to be exposed to this feeling of shyness.
Emma’s 16th birthday is coming soon and her parents wish to throw her a big party with the entire family; that’s the reason she came for therapy.
To this day, Emma has used situational repression and avoided many situations.
In my work with Emma we got to know her emotion of shyness, what it looks like, when does it comes, what thoughts does it comes with and how it feels in her body. We also decided that we wanted to deal with this feeling of shyness, and Emma began to gradually expose herself to situations where she felt shy, instead of avoiding them.
Emma attended a place and setting that provoked her shyness and saw that even when the emotion reaches a climax, if she agrees to stay with it, it eventually subsides. Later, Emma was exposed to additional unpleasant emotions, and learned to stay with them and accept them as part of her emotional experience.
The Behavior Change in Stressful Times section assists in my work with children on alternative behaviors. Thus, in the above example, instead of avoiding situations where she experienced shyness, Emma went to a party. Instead of fleeing from a situation where she felt angry and avoiding conflict, Emma chose to stay in this situation and implement an assertive behavior.
In this method children are asked to choose different situations during the week from which they would avoid for long periods of time due to the desire to avoid unpleasant emotions and change their impulsive behavior: instead of staying in bed when feeling depressed, they go out to meet friends while still feeling depressed.
An example of work on cognitive repression
Many children tend to think that if they don’t want to feel anything unpleasant, they must avoid thoughts that evoke negative emotions.
Unfortunately, this method is ineffective in the long term, and can even be a trigger for thoughts that never stop coming. We all know the “do not think about a white elephant” effect. The very attempt not to think about a white elephant makes us not stop thinking about it. Thus, any attempt to repress a thought can also cause it to be stuck in your mind.
Irit Sedan’s “The Best Witches’ Club” makes an attempt to legitimize all good and bad thoughts as one: “In the best witch club you’re allowed to think and feel anything!”, “It’s a private club and you can tell anything, all your worst, best, saddest most frightening thoughts and feelings and fantasies…”
In order to expand the ability to observe thoughts and not to get stuck with them, I usually talk to the children about the legitimacy of their thoughts, invite them to start their own club and choose who or what may come into the club. Then I provide them with techniques to observe thoughts and I teach them how not to be frightened by them.
An example of work on defensive repression
Noah, a 7-year-old boy who has difficulty parting from his parents in the morning, takes a cell phone with him to feel safe in case he his heart beating fast or any other unpleasant feeling. Noah has rarely used his mobile phone to contact his parents, but the very fact that he is carrying the phone with him in case he needs to makes him feel safe.
One day, the school principal passed a rule by which all cellphones must be left at the school gate or not brought at all. Noah had trouble going to school without his cellphone since he believed it helped him cope, and it was only with his cellphone that he managed to feel safe.
I proceeded with Noah by gradual exposure to stressful situations with his safety pin (his cellphone) and without his safety pin. At first, we created an exposure echelon that included all the frightening and to most frightening situations. Noah learned to identify the emotion of fear, to identify the thoughts that evoke this emotion and together we tried to make friends with his fear and not act out of it, because if there is no danger there is no point in running away.
In the final stages, Noah was able to leave the house without his cellphone and thus his therapy was concluded. He was exposed to the emotion or thought: “Perhaps I will not be 100 percent certain that my parents will be available to me, and this will cause fear or anxiety in me, but I can stay with that feeling. I do not have to make myself dependent on objects to help me”.
Safety pin section
This section enables us to be exposed to an emotion, while understanding that we use “safety pins” instead of experiencing and coping with unpleasant emotions.
As we have seen in Noah’s example, we create a gradual exposure to the ability to stay in a situation without our “safety pin”.
An example of work on somatic repression
Many children and adults have difficulty distinguishing between emotions and sensations. Whenever they feel something in their body that reminds them of an unpleasant emotion, they try to avoid it, although this feeling may also be part of a pleasant emotion.
Guy, a 24-year-old student, had trouble entering the university premise every morning, out of fear that they see who he really was and would not like him. He underwent therapy for this and managed to overcome it a great deal, but towards the end of therapy he said that in some situations he feels his fear coming back, and he is unable to control it.
When we examined these specific unpleasant situations, it turned out that he was now ready to be exposed to intimate situations with girls and was even trying to ask girls out. The nervousness in these situations reminded him of the fear of entering the university, and made him want to avoid any situation that made him feel that way.
In therapy Guy understood that this time this feeling should be pleasant, and at this stage we made a distinction between different physiological sensations and emotions. Guy realized that a physical sensation such as accelerated heart palpitations, is typical of a number of emotions – anger, anxiety, and positive excitement.
This section is an example of understanding the initial stage of the distinction between pleasant sensations and unpleasant sensations.
At a later stage you can work with the Physical Sensations Section (see below) that distinguishes between various emotions and sensations.
Physical Sensations Section
Openness to emotions
Once we have identified the different types of repression, we can now diagnose our (or our patient’s) type of repression and choose more effective long-term strategies.
This can be likened to looking through glasses (short term emotional regulation strategies) as opposed to looking through binoculars (long term emotional regulation strategies).
Long-term effective strategies usually consist of gradual exposure to situations that evoke a negative emotion without attempting to run away from it.
Thus, we may realize that we can cope with some degree of negative emotion, and there is no need to avoid it. It subsides on its own, and it may be tolerated while it is “active”. In fact, our goal is to shift from repression to emotional openness.
According to the three approaches I mentioned, the DBT, the ACT and the trans-diagnostic model, the non-avoidance of painful emotions allows patients to have a fuller experience of life and to develop the ability to cope with their entire range of emotions.
Negative emotions do not kill us, and if we relinquish fighting them (or intensifying them), they subside overtime. In addition, effectively coping with unpleasant emotional states provides a tremendous sense of empowerment, and increases self-confidence in dealing with this emotion the next time it is evoked.
And most importantly, openness allows us to live a fuller life – since with openness decisions are made based on values and desires, and not based on our fears and emotional issues.
Shelley Zantkern, My Emotions and Me – A Journey to Managing Emotions; Therapy bundle
Steve Hines, ACT
James J. Gross PhD, Handbook of Emotion Regulation, Second Edition
Matthew McKay PhD and Patrick Fanning, Mind and Emotions: A Universal Treatment for Emotional Disorders (New Harbinger Self-Help Workbook), Jul 1, 2011
Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: Therapist Guide-2010
Jill Ehrenreich, Transdiagnostic Treatments for Children and Adolescents, May 2014; Guilford
Emotion Regulation, Gross