Managing Negative Emotions Without Drinking

A Workbook of Effective Strategies

Paul R. Stasiewicz, Clara M. Bradizza, Kim S. Slosman

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781315405841
• Edition: 1
• Topic: Psicología
• Subtopic: Emociones en psicología

Managing Negative Emotions Without Drinking is the ideal companion to Emotion Regulation Treatment of Alcohol Use Disorders. Each of the 12 individual weekly treatment sessions presents scientifically tested strategies for managing emotions without alcohol, including mindfulness practices, direct experiencing of emotion, and cognitive and behavioral skills to manage high-risk drinking situations and prevent relapse to alcohol use. The step-by-step exercises, user-friendly worksheets, and in-session and between-session skill practice help clients gain a basic understanding of the role that emotions play in harmful alcohol use and assist them in developing the skills needed to manage these emotions and cravings without alcohol.

Chapter 1

Introduction

What Is Alcohol Use Disorder?

Alcohol use disorder (AUD) involves continued use of alcohol despite experiencing significant alcohol-related problems. As shown in Table 1, people with AUD have four major types of symptoms that correspond to:

• Impaired control
• Social impairment
• Risky use
• Pharmacological criteria

AUDs range in severity from mild to severe, with severity based on the number of symptom criteria that are endorsed. Changes in severity can occur over time as reflected by decreases or increases in the frequency or amount of alcohol use and alcohol-related problems. If two or more of the symptoms occur within a 12-month period, and result in significant impairment or distress, then this program, a combination of cognitive-behavioral therapy (CBT) for alcohol dependence and Emotion Regulation Treatment (ERT), can help.

What Is an Emotion?

The word emotion is derived from the Latin verb movere, to move. Simply stated, emotions provide a source of motivation for behavior; they move us to action. In the case of negative emotions—a focus of this treatment—they are experienced as unpleasant, unwanted, or aversive, and typically motivate us to act in ways that will reduce, terminate, or help us to avoid these emotions. In the case of positive emotions, they are experienced as pleasant or desirable and typically motivate behaviors to increase, initiate, or approach them. There are many definitions of emotion, but most include the following common elements: (1) emotions communicate information to ourselves and others to help guide our behavior so that we can pursue our goals; (2) emotions vary in intensity (from mild to intense), valence (positive or negative), duration (short or long), and whether they are primary (an initial emotional response) or secondary (an emotional response to an emotional response); (3) emotions have three components, experiential/cognitive (i.e., awareness of the response, a feeling), physiological (e.g., facial flushing, increased respiration or heart beat), and behavioral (e.g., laughter, aggression, alcohol use); and (4) emotions can be modified. Although emotional responses may arise suddenly and sometimes feel like they will never end, knowing that they can be modified gave rise to the ERT described in this workbook.

Table 1 Symptoms of Alcohol Use Disorder

Impaired Control
1. Alcohol is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use. 3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects. 4. Person experiences craving, or a strong desire or urge to use alcohol.
Social Impairment
5. Recurrent alcohol use results in a failure to fulfill major role obligations at work, school, or home. 6. Alcohol use continues despite having persistent or recurrent social or interpersonal problems caused or intensified by the effects of alcohol. 7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
Risky Use
8. Recurrent alcohol use occurs in situations in which it is physically hazardous to drink. 9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or intensified by alcohol.
Pharmacological
10. Tolerance, as defined by either of the following: a. need for noticeably increased amounts of alcohol to achieve intoxication or the desired effect b. A noticeably diminished effect with continued use of the same amount of alcohol 11. Withdrawal, as demonstrated by either of the following: a. A known withdrawal syndrome for alcohol as indicated by two or more of the following symptoms upon stopping or reducing alcohol use that has been heavy and prolonged: autonomic hyperactivity (e.g., sweating, increased heart rate), hand tremor, insomnia, agitation, seizures, nausea or vomiting, anxiety, transient (temporary) visual, tactile, or auditory hallucinations b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms

Adapted from: American Psychiatric Association (2013).

Emotions and Alcohol Use

Which emotions motivate alcohol use? Both positive and negative emotions can motivate alcohol consumption. An individual who is experiencing a positive emotion (e.g., joy, contentment) may drink to extend or enhance the positive emotional state. Drinking that occurs in celebratory social situations (e.g., a weekend barbecue with friends, a college graduation party) represents alcohol consumption that is motivated by a positive emotional state. In this case, alcohol may provide a source of positive reinforcement or reward, and increases the likelihood that the behavior will be repeated in similar situations in the future. In contrast, an individual experiencing a negative or unpleasant emotion (e.g., frustration, anxiety, irritability) may drink to reduce or stop the unpleasant feeling. In this case, alcohol provides a source of negative reinforcement or escape (i.e., reduces or removes an unpleasant emotional state) and increases the likelihood that the behavior will be repeated in similar situations in the future. Please note that in both cases—drinking for positive or negative reinforcement motives—the behavior of drinking is strengthened and maintained. Importantly, as a person moves from a pattern of nonproblem to problem use of alcohol, a shift occurs from positive reinforcement or reward drinking to negative reinforcement or escape drinking. Therefore, people with an AUD often drink to escape or avoid unpleasant or uncomfortable emotional states. In fact, unpleasant emotions are the most common reasons for drinking among people receiving treatment for an AUD. Unpleasant emotions also account for nearly 40% of relapse episodes following treatment. Included in this discussion of unpleasant emotions are the uncomfortable physical sensations that may arise when a person stops or reduces a period of heavy or prolonged drinking. Although many individuals with AUD may not experience severe withdrawal symptoms (i.e., hallucinations, seizures), milder symptoms such as increased irritability, while not identified by the person as a symptom of alcohol withdrawal, may be experienced as an uncomfortable emotional state and may be relieved by the consumption of alcohol. To the extent that alcohol use and related behaviors reduce or eliminate the unpleasant physical state, the behavior of drinking is further strengthened and maintained (i.e., negatively reinforced). In this way, through the process of positive and negative reinforcement, individuals learn to modify or regulate their emotional states by drinking.

What Is Emotion Regulation?

Like emotion, many definitions of emotion regulation have been proposed. A current definition by James Gross (1998) defines emotion regulation as the “processes by which individuals influence which emotions they have, when they have them, and how they experience and express these emotions” (p. 275). Several other features of this definition deserve discussion. First, an emotion can be regulated at different stages in its development. Strategies that are used early in the emotion-generative process are called antecedent-focused. An example might help to illustrate this point. A former client, we will call him “Tom,” was invited to his 25th high school reunion. As the reunion drew closer, he became increasingly anxious about attending. When asked why he felt anxious, he reported having thoughts about not being very successful and concerned that his peers would find him uninteresting. He imagined going to the reunion, standing alone, looking kind of awkward, and therefore standing out. As he talked about this situation his heart was beating faster and he considered not showing up to the reunion. In this example, Tom was choosing to interpret this situation in a negative way—namely, that he was uninteresting, his peers would shut him out, and he would be left standing alone with no one to talk to. That would be unpleasant for most anyone! In order to help Tom understand his emotions, his therapist worked with him to understand how he was interpreting the situation. In this case, Tom’s appraisal of the reunion was very negative and this negative interpretation affected the way he felt. So, before going to the reunion, Tom’s therapist worked with him to develop alternative ways of interpreting the situation. We call this Cognitive Reappraisal; that is, Tom was thinking only of the worst-case scenario, which was still in the realm of possibility, but certainly not the only possible outcome. By acknowledging alternative possible interpretations (e.g., “Even if one person finds me uninteresting, certainly not everyone will.” “Other people that I have met have found me interesting.”), Tom was able to effectively decrease his anxiety to manageable levels before attending the reunion. This is why Cognitive Reappraisal is called an antecedent-focused emotion regulation strategy. You will learn more about Cognitive Reappraisal in Session 4 of this treatment. Alternatives to antecedent-focused strategies are response-focused strategies, which are used to regulate an ongoing emotion. Deep breathing when a person is experiencing increased anxiety is an example of a response-focused strategy—the person is trying to regulate an emotion they are currently experiencing.

A second feature of the definition of emotion regulation is that emotion regulatory strategies can target pleasant as well as unpleasant emotions. Although our ERT emphasizes the regulation of unpleasant emotions by drinking, drinking can also regulate pleasant emotions. For example, a person who drinks while watching a football game with friends may experience greater social pleasure. Finally, it’s important to consider the purpose of emotion regulation. In the earlier example, it may seem that the individual is drinking to enhance social pleasure. However, if the individual is socially anxious, then drinking in social situations may be an attempt by the individual to regulate (that is, reduce or remove) unpleasant emotions (i.e., social anxiety). Therefore, it is important to understand the relationship between alcohol consumption and a person’s reasons for using alcohol (e.g., down-regulate or reduce unpleasant emotions, or up-regulate or increase positive emotions) in specific situations. Individuals who are less skilled at emotion regulation may resort to a range of unhealthy behaviors, including excessive alcohol use, in an attempt to help regulate unpleasant emotions that they experience as unbearable.

What Is Emotion Regulation Treatment?

Emotion Regulation Treatment (ERT) combines a set of clinical strategies that have been adapted from current therapies that have been found to help clients develop skills to regulate unpleasant emotions in healthy ways. Although some of these treatment techniques may be unfamiliar to you right now, they will be explained in treatment and you will have an opportunity to ask questions and practice them over the course of treatment. Specific strategies adapted for use in ERT include behavioral analysis of drinking situations involving unpleasant emotions including situations in which you are with other people and those in which you are alone, and training in behavioral coping skills that help people manage their emotions. You will work with your therapist to learn mindfulness-based cognitive strategies in which you will learn the process of observing and experiencing emotion, designed to increase attention to the present moment and to experience the emotion without judgment or avoidance. Finally, you will work collaboratively with your therapist to develop unpleasant emotional imagery scenes taken from situations in your daily life that are associated with drinking. These imagery scenes will be used in the direct experiencing of emotion sessions as a way to increase your acceptance and tolerance of uncomfortable feelings and physical sensations that often lead to drinking. The goal of these direct experiencing of emotion sessions is to help you manage these types of unpleasant emotional situations in your daily life without alcohol.

ERT places a greater emphasis on emotion regulation strategies than other cognitive-behavioral treatments for changing drinking behavior. ERT is designed to help individuals regulate both pleasant and unpleasant emotions that often motivate alcohol use. With its emphasis on attention to the present-moment experience (i.e., the “here and now”), ERT provides additional skills for dealing with drinking triggers, especially emotional drinking triggers. The skills that are taught in ERT enable a person with AUD to cope with unpleasant emotions or uncomfortable physical sensations without reacting to them by drinking. Although effective use of these emotion regulation skills can improve alcohol treatment outcomes, the CBT component of the ERT treatment program provides important skills for achieving and maintaining abstinence from alcohol (e.g., drink refusal skills, coping with urges and cravings). Thus, the ERT program is a combination of emotion regulation skills and CBT coping skills that work together to help individuals with AUD to achieve and maintain abstinence from alcohol.

How Was the Program Developed?

ERT was developed by the authors at the Research Institute on Addictions at the University at Buffalo. During development of ERT, changes and refinements of different versions of the treatment manual were completed by the authors and were based on both oral and written feedback from expert consultants, therapists conducting the treatment sessions, and the clients themselves. For example, clients responded to questions about what was helpful during the treatment sessions, whether the session content was clear, and how the session content could be made more helpful; they also provided an overall rating of the session (1 = Poor or Not Helpful to 7 = Excellent or Very Helpful). Based on therapist and client feedback, the manual was revised and the process was repeated. After delivering the treatment to different groups of clients, the manual was again revised based on client and therapist feedback. The final version of the treatment manual was evaluated in a larger treatment study of people with AUD. The results of this study demonstrated the ability to train therapists to administer ERT, excellent client satisfaction with the treatment, and that the treatment was effective in reducing alcohol use among individuals with AUD.

What Are the Benefits and Risks of This Program?

Benefits

ERT was developed to enhance standard CBT for AUD. Thirty years of research on CBT has consistently demonstrated its effectiveness as a treatment for AUD. To this effective CBT treatment, ERT adds emotion regulation strategies taken from existing interventions that address a range of mental health disorders—such as anxiety, posttraumatic stress disorder (PTSD), and depression—including AUDs. Although there is evidence that standard treatments for AUD, like CBT, result in reductions in unpleasant emotions (e.g., Brown & Schuckit, 1988; Brown, Irwin, & Schuckit, 1991; Witkiewitz, Bowen, & Donovan, 2011), the addition of emotion regulation strategies to standard CBT in our study resulted in greater reductions in unpleasant emotions and better alcohol treatment outcomes for individuals with AUD.

Risks

The major risks associated with ERT are experiencing uncomfortable emotions and urges or cravings to drink alcohol, especially when participating in the imagery scenes during treatment (Sessions 7–10). ERT is d...