AFFECT REGULATION

TOOLBOX
Tenth International Conference
on Ericksonian Approaches to Hypnosis & Psychotherapy
December 6 – 9, 2007
Phoenix, AZ

Presenter: Carolyn L. Daitch, Ph.D.

28592 Orchard Lake Rd., #301
Farmington Hills, MI. 48334
www.anxiety-treatment.com
Carolyn.daitch@mac.com
248-626-8151 1
Topics

„ Over reactivity
„ Consequences of over reactivity
„ Interventions
„ Applications

2
Over Reactivity: Definition

The distorted and unnecessarily

intense reaction to routine stimuli of
daily life and interpersonal contact with
accompanying psychophysiological
hyper-arousal.

3
Three Components of
Over Reactivity

„ Physiological
„ Psychological
„ Temperamental

4
 Over Reactivity: Experience

„ Frequently includes the internal

experience of being overwhelmed with
emotion and feeling out of control.

(Daitch, 2007)

5
 Stress and Over Reactivity

„ Stress is part of the normal experience of

being human.

„ With sufficient levels of stress, each of

us can be flooded with a release of
neurochemicals that elicit and maintain
a state of hyperarousal and reactivity.

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Flooding
„ One of the hallmarks of affect
dysregulation is flooding.

„ Flooding leads to emotional (escape)

conditioning.

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The Emotional Brain
„ Fear conditioning
„ A process in which the amygdala plays a
crucial role (phobias)

„ Chronic Stress
„ HPA Axis (G.A.D)

„ Impulsivity
„ Prefrontal Cortex

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Fear Conditioning
and the Amygdala
„ Brain is adept at storing long-term
memory events when experience fear
ƒ Amygdala plays a crucial role
ƒ Adaptive
ƒ Problematic for those with anxiety
disorders

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Normal Reactions vs.
Over Reactions

The distinction between normal

reactions and over reactivity is when
the reactivity creates chronic
discomfort, impedes life functioning,
and/or seriously interferes with
relationships.

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Profile of the
Over reactive Client
„ Experience a series of conflicted
relationships, particularly intimate
and/or work relationships.
„ Displays symptoms of anxiety.
„ Experience psychosomatic illnesses
and over reactions to bodily symptoms.

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Painful Consequences
of Over Reactivity
„ Excessive emotionality can disruptive
the accomplishment of goals
„ Intensity exhausts others
„ Parents lose effectiveness and
closeness with children
„ Leads to addictive behaviors as an
attempt to self soothe

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Skills Needed

„ Remain calm and clear in the face of stress.

„ Observe and reflect on their emotions and

behavior.
„ Tolerate uncomfortable, “negative” affect or

concurrent conflicting emotions without

defensiveness.
„ Suspend judgment

„ Soothe themselves or their partners.

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Underlying Assumptions
„ Talk therapy is often insufficient.
„ One must diffuse the stress response
first before a change of interpretation of
an event or reaction is possible.
„ Rehearsal and practice of new
responses must be an integral part of
the treatment.

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Speed and Power

Since the over reaction is triggered

so quickly and powerfully, the
therapist must teach clients to
intervene with rapidly induced calm
states.

15
 Transfer and Maintenance

„ Skills mastered in the therapeutic

setting often do not transfer into the
home.

„ Long lasting changes of interpersonal

patterns are hard to effect.

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The Toolbox

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The Affect Regulation Toolbox

The Affect Regulation Toolbox

comprises a collection of therapeutic
interventions consisting of four
components or “tiers” to help clients
develop new ways of thinking, feeling
and behaving.

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 Toolbox Tiers
„ Tier 1: Recognition of an overreaction, and
initiation of a brief pause to interrupt it.
„ Tier 2: Standard hypnotic induction and
deepening techniques.
„ Tier 3: A set of tools aimed at shifting
unhealthy reactive styles.
„ Tier 4: Tools to address therapeutic
transfer of suggestion and practice.
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Tier 1: Identify the Start of an Over
Reaction and Respond Appropriately

„ Tool 1: Recognizing somatic,

cognitive and emotional cues

„ Tool 2: Time out

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 Tier 1: Time Out
„ Response patterns cannot be
spontaneously altered.
„ Individuals must be trained to take an
immediate “cease fire”.
„ Establish a habit of taking a time out to
practice the self-regulation tools.
(Daitch, 2007)
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Tier 1: Interrupting and
Identifying Over reaction

„ Somatic cues

„ Dysfunctional cognitions

„ Emotions

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 Tier 2: Focus, Calm, Deepen

„ Focus: These tools help clients narrow

and focus their attention on their internal
experience.

„ Calm: Eliciting a calm state is the first

goal of reversing the stress reaction.

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Tier 2: Deepen

„ Provide suggestions for deepening

the relaxation experience.

„ Facilitates optimal receptivity to

interventions in Tier 3.

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Tier 2: Tools for Deepening
„ Arm and leg heaviness
„ Hand warming
„ Elevator / Stairway

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Tier 3: Healing Strategies
„ Interventions designed to prepare the
client to regulate affect.
„ Include a variety of approaches that
incorporate imagery, cognitions and
affect.

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Tier 3: Therapeutic Objectives

„ Mindfulness
„ Sensory awareness and cues
„ Impulse control
„ Coexisting affective states
„ Resource utilization
„ Positive affect development

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Objective: Mindfulness

Development of mindful, detached

observation of transient affective
states.

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 Mindfulness

“Paying attention in a particular way on

purpose, in the present moment, and non-
judgmentally.” Kabt-Zinn, 1994

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Mindfulness

„ I am my feeling

„ I breathe through my feeling

„ I am more than my feeling

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Objective: Sensory
Awareness and Cues

„ Develop awareness of bodily

expressions of stress

„ Regulate and modify somatic

expressions

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 Objective:
Sensory Alteration: Anesthesia

„ Create tangible evidence for client that

the mind can alter one’s response.
„ Make a link between physical and
psychological numbing.
(Edgette and Edgette, 1995)

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Objective: Impulse Control

Master a combination of regulatory

interventions for impulse control.

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Thought Stopping

„ Interrupt intrusive thoughts

„ Use cognitive, visual and kinesthetic

approaches

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Self-statements
„ I am fully present in this moment
„ I choose to stay calm
„ I breathe through my fear (anger,
irritation, impulse, etc.)
„ I can handle it
„ I release judgment of him/her
„ “Om… grow up!”

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Kinesthetic Cue
Goals:
„ Quickly access a calm state.

„ Establish an “anchor” with an Ok

signal.
„ Signal to him or herself that

everything is fine or “OK” in the

moment.
„ Focus attention to the present

moment.
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Objective:
Coexisting Affective States

The ability to have two conflicting

feelings or thoughts at the same time.

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Coexisting Affect States

„ Juxtaposition of two feelings

„ Ego states
„ Switching channels
„ Alternating hands

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 Juxtaposition of Two Feelings
„ Tolerate the juxtaposition of two opposing
feelings
„ Recognize that we can elicit an alternative
affective state
„ Elicit a feeling of amusement to help soften
reaction to a stressor or trigger
„ Know that there is always more than one
feeling available
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Alternating Hands

Experience the merging of negative

and positive feelings.

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Objective:
Resource Utilization

„ Imaginary support circle

„ Parts of self
„ Watchman

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Objective: Positive Affect

„ Gratitude … incompatible with

anxiety and conflict
„ Age regression
„ Age progression

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Tier 4: Rehearsal and Practice

„ Behavioral Rehearsal
„ Practice Rehearsal

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Developing New Responses

Referring to yoga wisdom, internationally

recognized yoga teacher Shakta Kaur
Khalsa (2001) stated that it takes 40 days
to change a habit, 120 days for the new
habit to become who you are, and a
thousand days to master the habit.

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 Practice

„ With repeated practice, we retrain our

neural pathways to respond differently.
„ Rehearse newly acquired behaviors and
the home practice sessions while still in
the hypnotic trance.

45
Homework
and Success of Therapy

A client’s willingness to engage in

therapeutic “homework” is directly
related to the success of the therapy.

46
Why Hypnosis is Helpful with
Affect Regulation

„ Identifies diffuse physiological arousal

„ Calms arousal response with relaxation
„ Rehearse appropriate responses

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Why Hypnosis is Helpful (cont’d)

„ Hypnosis increases effectiveness of

cognitive behavioral treatment.
(Lynn, Kirsch & Rhue, 1996)

„ Hypnosis can help patients to notice

early warning signs and prevent full-
blown flooding response.

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Applications of the Toolbox

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Applications
„ Anxiety disorders
„ Marital relationships
„ Other relationships

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Anxiety Disorders

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Anxiety Disorders
„ Most common type of psychological
disorder affecting both children and
adults
„ Often goes untreated
„ Women are particularly
vulnerable…three times the rate of men

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Common Anxious Profiles
„ Specific phobias and aversive
associations
„ Generalized anxiety
„ Somatic manifestations
„ Obsessive compulsive disorders
„ Post-traumatic stress

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 Anxiety and the Brain
„ Anxiety is very easy to acquire, but once
the brain circuits are in place they are very
difficult to delete.
„ The wiring of the brain at this point in our
evolution is established so that connections
from the emotional systems to the cognitive
systems are more developed.
(LeDoux, 1996)

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Components of the Anxiety
Response
„ Overestimates risks
„ Underestimates available resources
„ Repeats rigid behavior patterns
(Yapko, 2003)

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Characteristics of Individuals
Vulnerable to Anxiety and Phobias

„ Sensitivity to bodily stimuli

„ Unusual capacity for vivid imagery
„ Excellent focused-attention, absorption
„ High hypnotic susceptibility
(Crawford & Barabasz, 1993)

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 Treatment Goals
for Anxiety Disorders
„ Mastery over self with calming responses.
„ Skills to interrupt negative and irrational
thoughts.
„ Diminishment of worry.
„ Elimination of fear of future anxiety
reactions.
„ Increased resiliency in face of short- or long-
term stress.
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 Treatment Goals (Cont’d.)
„ Diminishment of restlessness and irritability.
„ Diminishment of somatic expressions of
anxiety such as racing heart, sweating,
dizziness.
„ Improved sleep and/or well-modulated
appetite.
„ Diminishment of obsessive thoughts.

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Often Missed yet Critical
Aspects of Assessment

„ Assess for side effects of prescription

medications
„ Assess for over the counter drugs
„ Assess caffeine consumption
„ Assess diet

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Case Example:
Using the four tiers of the toolbox

Client with G.A.D.

ƒ History of trauma
ƒ Temperament
ƒ Life stress

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Treatment Goals
„ Proportional emotional reactions and
worry to triggering events.
„ Diminishment of focus on the future.
„ Acceptance of uncertain outcomes.
„ Diminishment of somatic expressions.
„ Diminishment of irritability.

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 Tier 3
„ Dialing Down Anxiety
„ “Think of a stressor. . .
notice what number
the needle on the dial
is registering. . . use
the power of your
imagination to dial the
number down. . .”
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 Gratitude Intervention:
The Glass Half Full
„ After induction and deepening, patient is
told that anxiety is incompatible with
gratitude.
„ Introduced the glass half full metaphor
„ Client is directed to imagine a large glass (she
chose a large brandy snifter).
„ Spoke of glass half empty/half full themes.
„ Directed to fill the glass with symbols, representing
the things in her life for which she was grateful.
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Mindfulness Intervention
Attending to the symptom inevitably
softens its intensity.
„ “I am aware of my anxiety.”
„ “I breathe through my anxiety.”
„ “I am more than my anxiety.”

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Thought Stopping Intervention:
Interrupting Obsessive Thoughts
“. . . and now I’d like to teach
you three things for when you
are ruminating....I’d like you to
bring your right arm up as if
you’re stopping traffic...see
that stop sign....and say stop
it!...bring your right arm up as
if you’re stopping traffic...see
that stop sign....and say stop
it!.…” (Daitch, 2007)
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 Rehearsal in Fantasy:
Screen Technique
ƒ “Imagine yourself on a screen, looking up
and seeing yourself beginning to have an
anxiety attack. Imagine three scenes in
succession with different ways you could
cope with it.”
ƒ “And you can be curious, about just how
easily you can develop strategies that will
enable you to handle what ever emotions
arise.”
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Sensory Anesthesia for
Diminishing Emotional Reaction

Numbing / Sensory Anesthesia

ƒ Hypnotic anesthesia diminishes
sensation. It is typically used in pain
management but it can also be used
to diminish psychological suffering.
(Edgette and Edgette, 1995)

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 Imaginary Support Circle

Client is directed to imagine a circle of

people who would be loving and supportive
to surround her when she was afraid.
Supporters could be people she actually
knew, or people from history or religious
entities. In trance she was directed to
imagine her imaginary circle.

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Tier 4: Behavioral and
Practice Session Rehearsal

„ Extended time out

„ Mini sessions
„ When triggered or anxious
„ When triggered or anxious but unable to
take a time out

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Rehearsal of Self-Talk

Direct client to see herself in a variety

of anxiety provoking scenes supporting
herself with affirming self-statements.

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 Setting the Right Tone
in the First Session
„ This initial session is particularly
important to the client who suffers from
anxiety because this population is
particularly reluctant to seek treatment.
„ Anxious patients are typically in a hurry
to yield quick results from therapy.
„ Crucial that this session provides much
needed reassurance.
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Affect Regulation in
Relationships
„ Couples
„ Adult child/parent
„ Friendships
„ Siblings
„ Co-workers

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 Treatment Goals for the Couple
„ Develop skills of self-soothing and
soothing of partner
„ Develop ability to tolerate vulnerability
„ Diminish reactivity to slights and criticism
„ Develop attitude of curiosity

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Challenges of Transfer and
Maintenance of Skills

„ Skills mastered in the therapeutic

setting often do not transfer into the
home.

„ Long lasting changes of interpersonal

patterns in couples are hard to effect.
(Jacobson and Addis, 1993)

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 Challenges of
Relationship Therapy
The need to…
„ Create a safe space for both people

„ Assist people to manage over-reactions

„ Help them survive power struggle without

exiting the relationship
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Case Example:
A Couple in Conflict

Characteristics
„ Flooding/withdrawal patterns

„ Minimizer/ maximizer dynamic

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 Treatment Goals
„ Contain verbally damaging exchanges.
„ Increase empathy.
„ Close “exits.”
„ Establish date nights together, away from the
children.
„ Develop positive expectations about the
relationships.
„ Increase awareness of impact of verbal and
non-verbal communication.
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Interventions
„ Tier 1
„ Time Out
„ Tier 2
„ Arm and leg heaviness

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Tier 3
„ Parts of self
„ Age progression

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Positive Affect

Gottman asserted that the most

important finding in his extensive
research was that “more positive affect
was the only variable that predicted both
stability and happiness in marriages”.
(Gottman, J. 1998, p. 11)

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 Specific Strategies Are Needed

„ Transition to mature love cannot

happen through insight alone
„ Specific hypnotic tools are useful to
develop new patterns
„ Tools must be practiced repeatedly (in
and out of the office)

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 Structuring the Sessions
„ Audio-tape the long trance sessions with
the recommendation that the client listens
to the tape daily.
„ Practice quick interventions five times
daily, or when symptomatic.
„ Provide the patient with notes that
delineate the steps of the self-hypnotic
interventions.
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The First Steps in Treatment

„ Setting the right tone

„ Psycho education
„ Structuring the session

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 Setting the Right Tone
„ The therapist must communicate that they
are in capable hands with a clinician who
has a clear treatment plan to address and
treat their symptoms.
„ Build positive expectancy in the client.
„ Milton Erickson suggested that “a good
therapist should be utterly confident”.
(Zeig, 1980, p. 61)

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 Self-Care
„ All too often we teach well, but we don’t
always practice what we teach.
„ Inward attention is mandatory when we
spend so much time with an external focus.
„ Setting aside time each day for meditation
or self-hypnosis is crucial to maintaining
one’s own equilibrium and for avoiding burn
out.
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 References
„ Crawford, H.J., & Barabasz, A. (1993). Phobias and fears: Facilitating their treatment with hypnosis. In
J. Rhue, S. Lynn, & I. Kirsch (Eds.), Clinical handbook of hypnosis. (pp. 311-337). Washington, DC:
American Psychological Association.
„ Daitch, C. (2007). Affect Regulation Tool Box: Practical and effective hypnotic interventions for the
over-reactive client. New York: Norton.
„ Edgette, J.H., & Edgette, J.S. (1995). The handbook of hypnotic phenomena in psychotherapy. New
York: Brunner/Mazel.
„ Gottman, J.M. (1998). Marital therapy: A research-based approach. Seattle: The Gottman Institute.
„ Jacobson, N.S., & Addis, M.E. (1993). Research on couple therapy: What do we know? Where are we
going? Journal of Consulting and Clinical Psychology, 61(1), 85-93.
„ Khalsa, S. (2001). K.I.S.S. guide to yoga. London: Dorling Kindersley.
„ Lynn, S.J., Kirsch, I., & Rhue, J.W. (Eds.) (1996). Casebook of clinical hypnosis. Washington , DC:
American Psychological Association.
„ LeDoux, J. (1996). The emotional brain: The mysterious underpinnings of emotional life. New York:
Simon & Schuster.
„ Yapko, M.D. (2003). Trancework: An introduction to the practice of clinical hypnosis. (3rd ed.). New
York: Brunner/Routledge.
„ Zeig, J.K. (Ed., with commentary). (1980b). A teaching seminar with Milton H. Erickson. New York:
Brunner/Mazel.

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