Elizabeth Cohn Stuntz and Marsha M. Linehan
Whether you have cancer or not, no one likes to be worried, sad, or irritable. Yet these feelings can be common reactions to life with cancer. Even knowing that others may feel as we do, we can give ourselves a hard time about having intense emotions. Do you tell yourself you should be handling your feelings differently? Are you looking for ways to manage strong emotions? How can you do that?
DBT teaches that although you can’t change unpredictable and uncontrollable situations, you can change how you respond. You can regain a sense of control and emotional balance by learning how to regulate strong emotions.
Negative Feedback Loop: An Unproductive Cycle of Emotions
Let’s assume Sara is anxiously awaiting an overdue call from her doctor with information vital to her course of treatment. Many of us would feel agitated in this situation. Sara’s initial response, frustration, is called the primary emotion. Physiologically this emotion, or any emotion for that matter, lasts only for approximately 90 seconds.
After that minute and a half, we have additional reactions, presumptions, and judgments about the situation. For example, Sara might now think:
This is outrageous!
Does my doctor know what it is like to be waiting? I am so aggravated. She is unreliable.
How am I going to trust someone so insensitive?
The doctor must be waiting for more time to talk because the news is so bad.
Am I just a bitchy, demanding patient?
These opinions and doubts can stir up secondary emotions such as indignation, mistrust, anger, apprehension, anxiety, or shame. Sara’s initial reaction of frustration is now maintained and/or intensified by these thoughts, body sensations, and emotional reactions that impact each other. Her subsequent feelings may be based on judgments about her frustration, as well as thoughts about the way her feelings can impact her and her relationships. These secondary emotions are also referred to as the second arrow because she is “hit” again!
So let’s look at how can you reduce this unproductive cycling of emotions.
The first step of emotion regulation is to pause to allow your feelings. We can’t control an emotion we don’t acknowledge. We are trying to manage feelings, not block them! In fact, complete emotional control is neither possible nor desirable. Trying to avoid emotions can be like playing with one of those Chinese paper finger traps. The more you try to pull away, the more you get stuck. Recall that blocking feelings actually intensifies them. What’s more, when we don’t acknowledge our emotions, we can miss their useful message.
Why do we try to avoid feelings? At times we may believe the myth that accepting the emotion means approving of or consenting to feeling as we do. We may also worry that admitting a feeling will open the floodgates and overwhelm us with uncontrollable emotion.
The goal of emotion regulation is to find a balanced place between avoiding feelings and allowing them without being overwhelmed by them. The ideal is to accept emotions, not push them away, hold on to them, or amplify them. I love an image a wise Zen teacher shared with me. He told me to think about lightly holding my feelings in a flat open palm instead of using a tight fist to try to hold on to them or punch them away. With an open palm we try to allow the feeling to come and then let it go, like surfing rising and falling waves.
Pause to Observe the Emotional Experience
Paying attention to where and how the emotion is expressed can help Sara recognize the factors in the feedback loop. She begins by stopping to recognize how she is feeling. Unlike me, Sara is in emotion mind and allows her feelings. She acknowledges her intense irritation. She attempts to pay attention to her thoughts without automatically accepting everything that comes to mind as fact. She makes an effort to notice where in her body she is reacting, discerning her flushed face, the tension in her jaw, and her clenched hands.
Describe the Experience
Sara tries to put words to a full picture of her inner experience. Labeling reactions is a crucial step in emotion regulation as it can help identify cues that may be intensifying the emotion by triggering a negative feed- back loop. What’s more, identifying a feeling literally helps to decrease its intensity.
Name the Emotion You Are Trying to Control
“Name it to tame it” reflects the research showing that labeling an emotion calms the central nervous system. Also recall that cancer patients who could categorize and label their emotions showed improved coping as well as other health benefits. Sara identifies her anger.
Naming your feelings is not always easy. I learned that it is even harder to label emotions that we are trying to avoid. At times we just don’t know what we are feeling or how our emotions connect to our actions. Our secondary emotions can make it even harder to recognize a primary emotion.
Label the Prompting Event
The next step for Sara in describing her experience is to try to recognize the source of her feeling. It is not always easy to identify what instigates an emotion. We typically think of the prompting event as an external experience, such as her not hearing from the doctor as needed and expected. Yet Sara’s anger may also be triggered by an internal experience such as a physical sensation like pain. It is also possible that ruminating thoughts such as fear about the news and/or her indignation refueling itself may be perpetuating her anger.
Identify Physical Reactions and Judgments/Assumptions
Now Sara tries to label her judgments or assumptions and put words to the way her body is responding. Identifying her reactions may help her be more aware of cues that may be intensifying her emotion.
She notices that her body expresses anger in her flushed face, the tension in her jaw, and her clenched hands. She recognizes that she is making black-or-white judgments about her doctor and herself. She labels her assumptions that either her doctor is insensitive, unreliable, and untrustworthy or she is just too demanding. Sara sees that she is also imagining that the news is bad.
Check the Facts
When the outcome is very important and/or the threat is likely to become reality, we are even more apt to have an intense and enduring reaction. Sara’s anger makes sense if she has repeatedly had unresponsive medical care and feels her health or peace of mind is compromised.
Yet it’s very valuable for Sara to be sure her assumptions are correct. Have her ideas been confirmed by facts? Although there may be a possibility her worst nightmares are true, her worries may not always be justified or give a complete picture of the situation. Believing inaccurate ideas can make her more emotional than may be warranted. She doesn’t want to add unnecessary distress by incorrectly assuming bad news.
Her goal is to check out the accuracy of her assumptions, including why she hasn’t heard from her doctor. She tries to name any threats she imagines. She recognizes that the threats are the possibility of getting unwelcome news, the risk of receiving insensitive, unreliable care, or the possibility that she is a difficult patient.
The next step is for Sara to use wise mind to take a wider, more balanced perspective. Are there other ways to look at her situation to get a fuller picture about her doctor and herself? Does the intensity of her anger fit the facts of her circumstances? She considers:
Are there other reasons the doctor may not have called? Could there be an administrative problem at her office? Could I have missed the call?
Is it possible that getting back to me is one of many priorities and she is caught up with other patients? When I stop to think about it, is my doctor usually reliable?
Is my irritation stronger than the facts warrant? Could my agitation be stronger because I’m awaiting important news about my health? I am indignant right now. Yet I am not usually an angry, demanding patient. Does my anger really define me?
Deciding Whether to Express Feelings
There is a difference between a natural urge to act on emotions and actually expressing them at this moment. You have a choice. Your wise mind can be a valuable guide to help you consider whether it is in your interest to act on your feelings right now.
When feelings are not confirmed by fact, the most constructive decision is often not to act right away. Sara’s experience with her doc- tor is that she is normally reliable. She recognizes that her feelings are stronger than the facts warrant and decides it is not in her interest to express her feelings to the doctor at this time. She does not want to risk compromising a relationship with someone she needs to rely on. Instead Sara decides to pause, correct her assumptions, and try to regulate her emotions.
On the other hand, what can Sara do if her assumptions are accurate? Suppose Sara’s doctor is not as responsive as she wants and needs. She may still wisely decide to try to reduce the intensity of her anger. Yet now it may be in her interest to address the problem by expressing her feelings and taking action.
Elizabeth Cohn Stuntz, LCSW, a psychotherapist in private practice in Mamaroneck, New York, is a cancer survivor and a Zen student. After many years of involvement with services for people with cancer and their loved ones, she developed a program of coping skills based on DBT. She serves on the faculty of the Westchester Center for Psychoanalysis and Psychotherapy.
Marsha M. Linehan, PhD, ABPP, the developer of DBT, is Professor Emeritus of Psychology and Director Emeritus of the Behavioral Research and Therapy Clinics at the University of Washington. Dr. Linehan’s contributions to clinical psychology research have been recognized with numerous prestigious awards. In 2018, she was featured in a special issue of Time magazine, “Great Scientists: The Geniuses and Visionaries Who Transformed Our World.” She is a Zen master.
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