Matthew McKay - Emotion Efficacy Therapy: A Brief, Exposure-Based Treatment for Emotion Regulation Integrating ACT and DBT

For my dear friend, Jeff Wood, PsyD.

Matt

For my parents, Robert and Peggye.

April

Emotion efficacy is defined as how effectively a person can experience and respond to a full range of emotions in a contextually adaptive, values-consistent manner. As such, emotion efficacy encompasses both the beliefs people have about their ability to navigate their emotional life as well as their ability to do so. The more people can effectively experience difficult emotions, regulate their emotions through coping, and express their values, the higher their emotion efficacy.

In conceptualizing emotion efficacy therapy (EET), we reviewed the full range of factors that make up a persons relationship with his or her emotions, and we identified key factors implicated in emotion efficacy. We concluded that low emotion efficacy is likely to be the result of key vulnerabilities or patterns of maladaptive behavioral responsesbehaviors enacted in response to emotional pain, or the desire to avoid pain, which fuel and maintain psychopathological processes. Some common vulnerabilities and patterns may take the form of one of more of the following:

• Biological predisposition or sensitivity that leads to high levels of reactivity
• Significant levels of emotion avoidance (sometimes also called experiential avoidance)efforts to avoid experiencing uncomfortable sensations, emotions, and cognitions triggered by internal or external cues
• Significant levels of distress intolerancethe perception or the belief that one cannot tolerate aversive emotions
• Significant lack of emotion-shifting skills to downregulate emotion
• Consistent and significant socially invalidating environments

Individuals with these vulnerabilities often develop significant emotion problems. They may also lack understanding of their emotional experience and the clarity or tools to either tolerate difficult emotions, make values-consistent choices, or regulate their emotions. Over time, these vulnerabilities and life-long patterns of maladaptive behaviors can result in chronic emotion dysregulation and its downstream symptoms of depression, anxiety, and stress. In fact, these maladaptive patterns become so ingrained that they are all but hardwired and very difficult to change, leaving individuals feeling trapped, stuck, and hopeless.

In EET, we define emotion dysregulation as the full range of thoughts, feelings, somatic sensations, and behavioral urges that are contextually maladaptive. Emotion dysregulation is also problematic in that it frequently leads to behavior dysregulationacting on emotion in contextually maladaptive ways. In this way, emotion dysregulation and behavior dysregulation lead to low emotion efficacy.

The impact of low emotion efficacy is wide and far reaching. Some data suggest that low emotion efficacy creates and maintains tremendous suffering for the more than 75 percent of people who seek psychotherapy across multiple diagnostic categories (Kring & Sloan, 2010). In addition, pervasive emotion problems can significantly impact clients across multiple domains including interpersonal, work, school, and legal. Low emotion efficacy can significantly impair quality of life, and, in more extreme cases, it can be life interfering.

For example, research shows emotion dysregulation has been correlated with higher levels of depression, anxiety, impulsivity, and suicide (Garnefski & Kraaij, 2007; Carver, Johnson, & Joormann, 2008; Kleiman & Riskind, 2012); reduced quality of life; increased distress and restricted life functioning; increased suffering and pain; impaired memory and problem solving; and diminished contact with meaningful and valued life activities (Richards & Gross, 2000; McCracken, Spertus, Janeck, Sinclair, & Wetzel, 1999; Marx & Sloan, 2002; Hayes, Luoma, Bond, Masuda, & Lillis, 2006). Additionally, emotion dysregulation has been linked to lower social skill functioning, substance abuse, low lifetime achievement, and low sense of self-efficacy (Berking et al., 2011; Eisenberg, Fabes, Guthrie, & Reiser, 2000; Caprara et al., 2008).

Despite the prevalence of emotion-regulation problems, available treatments often treat just the symptoms and fail to identify and target the underlying drivers of the problem. In addition, treatments may teach clients how to use skills but can lack the experiential component essential to accelerate learning new ways of relating to and responding to difficult emotions. Even current evidence-based treatments show only modest treatment effects for improving emotion regulation and its downstream symptoms (Kliem, Kroger, & Kosfelder, 2010). Emotion efficacy therapy attempts to provide a more effective, portable, universal protocol for emotion problems.

The underlying philosophical premise of EET is that while pain is unavoidable, suffering is not. Suffering comes, in part, from not knowing how to enact values that bring meaning to life. More often, it comes from the unwillingness to experience difficult emotions, which then fuels distress and leads to more suffering. Moreover, suffering is maintained and even increased when clients try to avoid or control their pain through maladaptive behavioral responses. To the extent that clients can learn how to powerfully navigate the space between being emotionally triggered and their response, they can be empowered to create lives that are increasingly values-consistent and fulfilling.

We believe EET stands to help millions of people increase their emotion efficacy through increasing their ability to regulate their emotions and make choices that are consistent with their values and intentions. Ultimately, high emotion efficacythe ability to experience a full range of emotions and respond with mindful acceptance, values-based action, and mindful copingmeans a world where more people create lives that are more authentic, powerful, and conscious.

EET was conceived as a transdiagnostic, theoretically driven, contextually based treatment integrating findings from affect science, traditional and third-wave cognitive behavioral therapies, and learning theory. As such, EET is an outgrowth of several cognitive behavioral therapies, integrating components of acceptance and commitment therapy (ACT) and dialectical behavior therapy (DBT) into an exposure-based treatment. ACT is a mindfulness-based therapy developed by Steven Hayes, Kelly Wilson, and Kirk Strosahl that teaches clients to accept distress instead of trying to control it, and to commit to action that originates from client values (Hayes, Strosahl, & Wilson, 1999). DBT was developed by Dr. Marsha Linehan and is used in treating severe and complex mental disorders involving serious emotion dysregulation (Linehan, 1993).

The rationale for EET is based on research that supports foundational ideas for its treatment structure and content:

Data suggests there are more commonalities than differences across diagnostic disorders, which further underscores the need for transdiagnostic approaches to treatment (McEvoy, Nathan, & Norton, 2009). Instead of focusing on reducing symptoms, as in diagnostic treatment, transdiagnostic formulation identifies and targets the mechanisms driving the symptoms as a focus of intervention. From a philosophical perspective, transdiagnostic formulation posits that suffering is not a result of a disorder and its originating pain but rather of the vulnerabilities and maladaptive behavioral responses to the pain.