Editor’s note: The following interview is with April West, PsyD, co-author with Matthew McKay, PhD of Emotion Efficacy Therapy: A Brief, Exposure-Based Treatment for Emotion Regulation Integrating ACT and DBT. West is a psychotherapist and emotion researcher based in the San Francisco Bay Area.
What is emotion efficacy and what does it mean when someone has low emotion efficacy?
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. Low emotion efficacy is likely to be the result of key vulnerabilities or patterns of maladaptive behavioral responses—behaviors 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 intolerance—the perception or the belief that one cannot tolerate aversive emotions
• Significant lack of emotion-shifting skills to down regulate emotions
• Consistent and significant socially invalidating environments
What are the causes—or transdiagnostic drivers—of low emotion efficacy, and how does Emotion Efficacy Therapy (EET) target those?
The underlying drivers of low emotion efficacy as we conceptualize it are emotion avoidance and distress intolerance. We define emotion avoidance as an unwillingness to experience difficult emotions, which then fuels distress and leads to more suffering.
Distress intolerance refers to a person’s inability to experience intense emotions. Both of these maladaptive responses to emotions typically result in responses that do not serve the individual in recovering from intense emotion triggers, or choosing responses consistent with their values.
If the goal is to foster high emotion efficacy, what would that entail? What does the behavior of a person with high emotion efficacy look like?
EET uses psycho-education, skills practice, and experiential activities to increase emotion efficacy. By integrating the components of emotion awareness, mindful acceptance, values-based action, and mindful coping within exposure-based skills practice, clients learn to tolerate their distress, down regulate emotions when necessary, and make choices that are consistent with their values.
Ultimately, a person with high emotion efficacy would be able to respond to intense emotion triggers by “surfing” their emotion waves through observing and accepting all parts of their emotional experience. They would be able to choose behavioral responses based on their values and/or mindful coping strategies to downshift their emotional activation.
What are the five treatment components of EET, and how do they interact in order to increase emotion efficacy in clients?
Each EET session focuses on one or more of five treatment components that build on each other as follows:
Emotion Awareness. Emotion awareness is the ability to make present-moment contact with emotion. Emotion is experienced through its four components, and clients learn to recognize how it manifests through thoughts, feelings, sensations, and urges. Often clients know they are feeling an emotion, but they’re not sure what it is. Or they may know the emotion but not realize how it is manifesting in the components of emotion. Emotion awareness also entails understanding the origin or trigger of the emotion as well as the typical lifespan of an emotion wave. Having an awareness of one’s emotional experience is the first step toward increasing emotion efficacy.
Mindful Acceptance. Building on emotion awareness, mindful acceptance is the practice of nonjudgmental and non reactively observing one’s emotional experience and allowing (accepting) each of the components of an emotion: thoughts, feelings, sensations, and urges. Clients learn to tolerate a distressing emotion by learning to experience the emotion—and each of its components—without trying to alter it. Together, emotion awareness and mindful acceptance offer an alternative to emotion avoidance, giving clients concrete skills to practice in place of attempts to avoid or alter their emotional experience.
These two core components form the foundation for emotion efficacy therapy. Emotion awareness and mindful acceptance position clients to identify the moment of choice—the space between an emotional trigger and a response—when they are able to choose how they respond to their pain. More specifically, clients learn to locate the moment of choice even in the face of difficult or aversive emotions. In this moment, they can choose to just “surf” the emotion wave instead of reacting to it or acting on it.
Values-Based Action (VBA). VBA is the practice of mindfully enacting a valued intention in the moment of choice. Having increased distress tolerance through emotion awareness and mindful acceptance, clients are now positioned to recognize a moment of choice and make values-consistent choices in the face of aversive emotions. With values-based action, clients first identify what their core values are in a variety of contexts, such as work, home, community, family, and so on. By naming what they value in each of these contexts, clients can then identify specific values-based actions that allow them to express themselves—in the moment of choice—in a manner consistent with their values. As with all the EET skills, clients practice choosing values-based actions in an activated state through exposure-based skills training.
VBA is essential to increasing emotion efficacy, as it enhances motivation to commit to new behavioral responses that are difficult. By choosing values-based action instead of reacting through maladaptive emotion-driven behaviors, clients further increase their distress tolerance as well as the quality of their life.
Mindful Coping. Mindful coping is developed through the practice of using mindful acceptance to recognize a moment of choice, and then utilizing coping skills to down regulate emotion. Sometimes individuals can become so overwhelmed by difficult emotions that they aren’t able to practice mindful acceptance and surf the emotion wave until it resolves, much less choose values-based action in the moment of choice. In these situations, they need strategies for regulating emotion to keep from making a bad situation worse (Linehan, 1993). When clients’ capacities to observe, accept, and/or choose values-based action are exceeded by emotional pain, they can choose mindful coping skills to down regulate emotion.
While coping has been typically conceptualized as an attempt to change and alter emotional experience, mindful coping uses mindful acceptance as a portal to choosing emotion-regulation skills. The concept of mindful coping is new with EET and represents an attempt to give clients essential emotion-regulation skills in crisis situations, while also encouraging them to choose coping only as a last resort—after first practicing mindful acceptance. Instead of choosing coping skills to avoid or change aversive emotion, mindful coping is chosen with the intention of expanding choices and to help clients recover so they can choose values-based action.
Exposure-Based Skills Practice. This practice refers to the use of EET skills in an activated state using both emotion and imaginal exposure (also called imagery-based exposure). In emotion exposure, clients learn to intentionally activate themselves as a way to practice mindful acceptance and mindful coping. In addition, clients learn to use imaginal exposure—using imagery from a situation to become emotionally activated, and then visualizing enacting values-based action. As previously discussed, practicing skills in an activated state improves learning, retention, and recall; creates new neural pathways; and makes it easier to enact effective choices in the face of distressing emotions.
The exposure-based skills training piece seems to be one of the unique elements of EET. What is the function of this training in boosting emotion efficacy?
The exposure-based skills practice in EET is drawn from what we know about how people acquire “new learning.” Grounded in theory and research that support the effectiveness of exposure therapy and state-dependent learning, exposure-based skills practice is the application of skills in an activated state of distress to facilitate trans-emotional learning (Szymanski & O’Donahue, 1995).
State-dependent learning is the concept that whatever state a person is in when learning occurs becomes encoded and paired with the stimuli. This has several implications for the use of emotion in therapy. For instance, some research suggests that, in studies, participants had superior recall when the same affective state was induced at both exposure and retrieval, compared to those whose affective state was different between learning (exposure) and recall (retrieval) (Szymanski & O’Donahue, 1995). In addition, some studies show that mood may increase access to the neuronal networks that are online and paired with specific affect states (Persons & Miranda, 1992).
EET leverages state-dependent learning through exposure, which facilitates new learning in emotionally activated states by increasing learning, retention, and recall of EET skills. Clients are guided using both emotion and imaginal exposure to face difficult internal and external emotional experiences while applying EET skills to enact contextually adaptive, values-consistent behavioral responses.
What was it in your clinical work or experience that suggested there was a need for EET?
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, we have seen both in our clinical work, and based on the research, that while treatments may teach clients how to use skills, they often lack the experiential component essential that appears 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 efficacy—the ability to experience a full range of emotions and respond with mindful acceptance, values-based action, and mindful coping—means a world where more people create lives that are more authentic, powerful, and conscious.
Is EET empirically-supported?
EET integrates components of empirically supported treatments, including ACT, DBT and exposure therapy. In addition, initial outcome studies for EET show medium to large effect sizes for increasing emotion regulation, distress tolerance, and for decreasing symptoms of depression, anxiety and stress, and experiential or emotion avoidance. Our research is ongoing, and we are open to supporting clinicians and researchers who want to test the protocol with new populations in either an individual and group format.
Although EET is a transdiagnostic, integrative approach, are there any specific populations that you foresee benefitting most from this approach?
The beauty of a transdiagnostic protocol like EET is that is accessible for anyone struggling with emotion problems, ranging from anxiety and mood disorders to trauma. Since the research suggests that more than 75% of people seeking therapy present with low emotion-efficacy, as long as individuals are not actively psychotic or using substances or using anxiolytics during exposure-based skills practice, they are likely to benefit from EET.
Which therapeutic orientations are most compatible with EET?
EET is consistent with ACT, DBT and CBT. However, because it is a skills-based protocol it could also serve as a powerful adjunct treatment alongside more insight oriented therapies for individuals struggling with low emotion efficacy.
For more about Emotion Efficacy Therapy, check out West and McKay’s manual Emotion Efficacy Therapy.
Kliem, S., Kroger, C., & Kosfelder, J. (2010). Dialectical behavior therapy for borderline personality disorder: A meta-analysis using mixed-effects modeling. Journal of Consulting and Clinical Psychology, 78(6), 936–951.
Linehan, M. M. (1993). Cognitive-behavioral treatment for borderline personality disorder. New York: Guilford Press.
Szymanski, J., & O’Donohue, W. (1995). The potential role of state-dependent learning in cogni- tive therapy with spider phobics. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 13(2), 131–150.