Emotion identification, expression, and regulation techniques are typically included in EST manuals for anxiety disorders in general (Kendall and Hedke 2006; Rapee et al. 2006); for panic disorder (Pincus, Ehrenreich, and Mattis 2008) and post-traumatic stress disorder (Cohen, Mannarino, and Deblinger 2006) in particular; and for major depressive disorder, too (Brent and Poling 1997; Lewinsohn, Clarke, Hops, and Andrews 1990; Curry et al. 2005). Session structures vary across manuals but typically involve a combination of individual (youth or parent alone) and family (youth and parent together) involvement, depending on developmental level, the nature of a youth’s relationship with parents, and the stage of treatment. Parent involvement promotes parent emotion regulation skills, emotion regulation modeling, and parents’ providing youth with supportive coaching. In addition, ESTs target emotion identification, expression, and regulation training through a combination of targeted treatment modules (see, e.g., “Identifying Anxious Feelings,” in Kendall and Hedke 2006) and informal components of related treatment modules (for instance, emotion identification and expression may begin during early rapport building, as identified in Brent and Poling 1997; Cohen et al. 2006). Therapists who are less familiar with CBT may overlook these skill areas or may address them inadequately, either due to gaps in their knowledge of behavioral theory or as a result of their relying inflexibly on a particular treatment manual. Even seasoned therapists who typically address these areas might benefit from understanding additional ways to teach clients in greater depth emotion identification, expression, and regulation skills. Hence therapists must consider the specific techniques involved as well as the underlying principles of cognitive and emotional development (see Chapter 5), the nature of anxiety and depressive disorders, and the specific theoretical rationale for emotion identification, expression, and regulation skills (see Chapter 8 for the theoretical knowledge of anxiety and depressive disorders).

Key features of therapist competencies in emotion identification, expression, and regulation training

Training in emotion identification and expression teaches youth to understand the nature of emotions, identify signs or symptoms of specific ones, differentiate between them, and assess and rate the intensity of their own emotional experiences. Emotion regulation involves teaching youth to monitor the intensity of their emotions and subsequently engage in activities to moderate their emotions and behavior. Training methods include assessing youths’ current abilities, didactic instruction via psycho-education, discussions, role-plays, games, modeling, therapist-directed coaching activities, contingency management, and homework assignments.

Emotion identification training begins during the assessment process, as youth start answering in-person interview and self-report questions regarding their presenting symptoms. Even at this early stage, therapists should attend to youths’ familiarity and comfort with talking about their emotions. While some youth may have insight into, and feel comfortable reporting, their emotions, most – particularly when they are anxious or depressed – experience some difficulty discussing these symptoms. Conducting informal functional analyses can highlight whether these difficulties are due to underlying performance deficits or to skill deficits – categories that are described below.

Performance deficits may include underreporting due to lack of trust or experiential avoidance. Intense emotional arousal can impair youth’s ability to process and express their emotions (for many youth, this arousal can be triggered by simply thinking or talking about their emotions). A therapist can identify when a performance deficit is present by looking at whether there is a discrepancy between the child’s or adolescent’s self-report (on a self-report measure) and his/her endorsement of symptoms in the clinical interview, where the youth is forthcoming on self-report measures but would underreport or become emotionally dysregulated. Under these circumstances, rapport building or therapist-guided distress tolerance activities may be necessary (e.g., the therapist facilitates distress tolerance by directing the youth to focus on neutral or emotion-incompatible activities). Skill deficits may include underlying cognitive or language difficulties that impair the processing and expression of one’s emotional experiences. It can be helpful to compare how well youth report on other areas of their lives in order to form a baseline of cognitive or language functioning. When available, neuropsychological evaluations should be used to inform these treatment factors as well.

To assist in emotion identification training, therapists and youth should collaborate to identify which emotions the youth are already familiar with. This can be done through games or friendly competitions in which the youth are encouraged to identify as many emotions as possible in a few minutes. Therapists should then provide youth and caregivers with a rationale and background information about the nature of emotions, including the adaptive function of primary emotions (happiness, sadness, anger, fear). This helps to validate and normalize a client’s emotional experience. It can often be helpful to describe emotions as “signals” analogous to a seatbelt alarm or a low battery light on an electronic device (e.g., “low-battery light signals the need to charge batteries, fear signals a danger, anger signals that something is unfair, happiness signals a desire to do something again, and sadness signals a need for help or a loss”). Incorporating the notion of “signals” helps youth to begin developing the language needed to understand and express their emotional experiences (e.g., I am angry because it feels unfair that you are making me go to school”) (Madigan and Kurtz 2013). Once youth appear to grasp the adaptive functions of emotions, the discussion should incorporate the role of “false alarms” or maladaptive cognitions, emotions, and behaviors (the three-component-model of CBT). For example, youth could be taught to view their cognitions as triggers that send off a “false alarm” to our brains to make our bodies feel fearful physical sensations. In turn, these physical sensations can trigger us to feel alarmed and thus to avoid situations that are actually not dangerous or threatening. It is critical to teach youth the ways in which avoidance can only “re-ignite” the cycle, as the maladaptive thoughts get reinforced. Thus the “thoughts–feelings–behavior” components of CBT can be broken down for youth. It is typically helpful for the therapist to ask the child or adolescent to think of a maladaptive cognition that (s)he commonly has, and then for the therapist and client to actually draw out the three-component model by using blank circles that depict the cycle. In this way the three-component-model can be tailored to each client’s situation.

Another core skill is identifying the physiological symptoms or sensations associated with specific emotions (e.g., “When I feel nervous my heart beats faster, my hands get sweaty, and I get the ‘butterflies’ in my stomach”). Developmentally appropriate explanations about the function of each symptom or sensation help to normalize clients’ physiological sensations and can begin to correct related cognitive distortions. This is particularly important for youth with panic disorder or generalized anxiety disorder, who often experience a significant number of anxiety-related somatic symptoms. In depression, it may be helpful to identify sensations such as feeling “heavy,” “weighed down,” “numb” or “low energy.” Using drawing or coloring activities, youth can identify which parts of their body are affected when they are feeling anxious or depressed (e.g., by using a blank outline of a person’s body, the child can then draw a butterfly in the stomach, color in the lungs and heart, and so on).

Therapists must also be competent in teaching youth to differentiate between emotions. This can be done through “blending” activities in which secondary emotions are characterized by having components of the primary emotions. Younger clients may benefit from assigning colors to represent each primary emotion (e.g., happiness, sadness, anger, and fear), then “blending” colors to form more complex colors and emotions (e.g., mixing the feelings of nervous-blue with mad-red may form the secondary emotions of irritable or annoyed-purple; mixing the primary feelings of sadness and fear might form the secondary emotion of embarrassment). This scaffolding technique can also be implemented through activities such as making an “emotion soup” and a “feelings pizza” to represent and distinguish between primary and secondary emotions that may be occurring in the present or that have occurred in the past.

Emotional expression involves teaching youth to express what, why, and how intensely they are experiencing a specific emotion. To begin, therapists should teach youth to conduct behavioral chain analyses. This can be taught through interactive discussion, written activities, and role-play, or more concretely through interactive activities such as “matching” or making “emotion trains.” For example, therapists should encourage youth to draw connections between situations, emotions, “signals,” and behaviors (Madigan and Kurtz 2013). “Matching” activities can aid in this process by drawing two-step connections between situations and emotions to help children understand the kinds of situations that can lead to different emotions. “Detective” activities can be a fun and engaging way to begin teaching more complex behavioral chain analyses by filling in the gaps to hypothetical or client-specific examples. This can be particularly helpful for youth who experience difficulty identifying early symptoms of emotions and for youth whose internalized emotions may be masked by externalized emotions (e.g., reported anger at parents for making them go to school may be masking an underlying anxiety). By playing “detective” and working backwards from behaviors that occur at the end of a chain (these are often much easier for youth to identify), youth learn to recognize the key antecedent thoughts and emotions that led to the identified behavior. This skill will help youth identify emotional escalations leading to episodes of emotion dysregulation; and, if they can identify and intervene on the nervous, embarrassed, or sad thoughts and feelings, secondary outbursts of anger or panic may be more easily prevented.

For example, a sample conversation might look like this:

At this point the therapist may choose to continue “playing detective” and develop another “emotion train,” sequencing the youth’s preceding feelings of anxiety and embarrassment. The two trains or chains can then be linked together to form a larger behavioral chain. In either case, the therapist can help the youth use coping strategies to intervene or “break the train.”

To improve emotion expression and ultimately emotion regulation, therapists must teach youth to rate and monitor the intensity of their emotions, so they can then take action to regulate these emotions before they are overwhelmed by them. To train youth to monitor the intensity of emotions, therapists should orient them to a developmentally appropriate rating scale (e.g., 0–10 scale, feelings thermometer, emotion-faces scale, etc.). Therapists and youth should collaborate to develop situation- and symptom-specific anchors at each level on the scale. Youths’ prior behavioral and emotional difficulties should be anchored on the scale to highlight likely triggers of future emotion dysregulation. Symptom-specific anchors should also be assessed, in order to encourage youth to identify warning signs that they may become overwhelmed.

Emotion regulation strategies are designed to facilitate affective control to the degree required for the person to remain in control, have the use of other coping skills (Brent and Poling 1997), and be able to encode and comprehend new material during stressful treatment activities. Many CBT interventions designed to improve youth’s overall ability to regulate their emotions and, ultimately, their symptoms of anxiety and depression require these youth to learn how to focus on, and tolerate, difficult emotions (e.g., through imaginal or situational exposure). However, it may also be necessary to teach youth to regulate their distress during acute moments of dysregulation, particularly early in the treatment (sometimes this is referred to as a “distress tolerance” skill) (Miller, Rathus, and Linehan 2007). These strategies are designed to divert the client’s attention away from upsetting content and feelings by refocusing it on neutral or emotion-incompatible content. Youth should be encouraged to utilize these strategies when their emotions are either too intense to manage (e.g., they become too overwhelmed to cope adaptively) or when it is more appropriate for them to focus on their current environment (e.g., listening in math class, spending time with friends, trying to fall asleep). Many youth who come for treatment have become reliant on ineffective or maladaptive strategies for the regulation of their emotions. Given this, therapist-guided distress tolerance activities may be required to facilitate youths’ emotion regulation while they learn to regulate them independently.

To assist emotion regulation training, therapists must provide a rationale for why and when it may be necessary to redirect their clients’ attention to neutral or emotion-incompatible activities. This idea can be presented through a mental exercise analogy, where youth compare success in avoiding “thinking about a pink elephant” by “trying to stop thinking about it” with focusing on or engaging in another task. Activities designed to help youth regulate their emotions include maintaining a present focus (i.e., mindfulness) and distraction techniques (i.e., distress tolerance). These activities should be individualized to youth’s abilities and common triggers. Therapists should start by identifying adaptive coping strategies already in place (e.g., playing video games or listening to music when upset). When emotions are particularly intense and difficult for youth to cope with, therapists should utilize activities that are more physical (e.g., going for a walk or jog, doing pushups, taking a shower). Cognitive strategies are also important, as they are more readily generalizable to a variety of contexts. Thought interruption and positive imagery can be taught to youth who are developmentally able to identify negative thoughts and subsequently refocus their attention to positive or incompatible coping thoughts and images (see Chapter 13 for a full coverage of these cognitive strategies). Activities designed to elicit incompatible emotions are also quite useful (e.g., watching a funny movie or you tube video, listening to pleasurable music, reciting one’s favorite music lyrics or movie scenes).

Present-focused thinking (also known as a “grounding technique”) involves refocusing a client’s attention to what is going on around him/her at a specific moment. Depending on youth’s comfort and stage of treatment, it may be counter-indicated to focus on certain trauma-related environmental stimuli. Cultivating present-focused thinking as a distress tolerance activity involves teaching youth to “scan their senses” (e.g., by asking themselves what they see, hear, feel, smell, and taste). As youth master present-focused thinking, therapists can begin directing them to focus on their thoughts and emotions. This will support subsequent cognitive restructuring (described in Chapter 12) and exposure tasks (described in Chapter 14) by enhancing youth’s ability to focus more effectively on their negative cognitions and emotions, respectively. Therapists should continue to utilize these strategies until youth are reliably able to identify and regulate their emotions and tolerate exposure tasks.

Competence in treating anxiety disorders and depression

When working with depressed youth, emotion identification strategies should be woven into mood and activity monitoring. Clients can record daily “levels” of various emotions they experience, such as anxiety or sadness, by using a “feelings thermometer,” which is a visual scale that depicts “amounts” of emotion on a graded scale from 0 to 8, for example, or on any other visual scale. As a homework assignment in both depression and anxiety treatments, clients are asked to record information about the daily fluctuations in their mood, as part of a weekly record of anxiety and depression. This weekly record is a chart that provides ample space for the client to specify the level of anxiety, anger, or sadness that they experienced each day of the week. Youth can then bring this mood-monitoring homework form to session, and therapists can utilize these data to gain important information on their clients’ ability to identify and monitor the levels of emotion they experience. The emotion-monitoring form can also be used as a springboard for discussion, between the client and therapist, about the former’s week, and can be utilized throughout therapy to assess whether the CBT techniques the client is learning result in an improvement of mood. Emotion identification training with depressed youth should also target somatic complaints specific to depression, which may vary considerably from those of anxiety.

When treating youth with panic disorder, it will be particularly important to ensure the that the client firmly understands the adaptive function of each physiological symptom of anxiety, as cognitive distortions around these symptoms (e.g., “my heart beating faster means I’m having a heart attack”) often exacerbate and/or maintain panic-related symptoms. Youth with depression, trauma, and anxiety disorders will especially benefit from learning to track and regulate emotions, as gaining a sense of mastery over their emotions may enhance their compliance and motivation to engage in later exposure activities.

Emotion regulation skills can be tailored to children with anxiety specifically by talking about how emotions such as anxiety are natural, necessary, and harmless, and are experienced by everyone, across cultures. The therapist can discuss with the client ways in which anxiety can be helpful (e.g., in athletes performing in a competition, or in getting off the road if a car is approaching). The therapist might say: “So sometimes anxiety can be good and helpful because it protects you from danger, but sometimes anxiety is not helpful – when there is no real danger.”

Competence in treating both children and adolescents

Related posts:

Effective Training Methods I: Generic Therapeutic Competencies III: Specific CBT Techniques Changing Maladaptive Behaviors, Part 1 Theoretical Foundations of CBT for Anxious and Depressed Youth Managing Negative Thoughts, Part 2

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