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Introduction

Emotion Regulation Therapy (ERT) is a treatment that integrates components of cognitive-behavioral, acceptance, dialectical, mindfulness-based, and experiential, emotion-focused treatments. The goals of ERT are for individuals to learn to identify, differentiate, and describe their emotions, increase acceptance of affective experience and ability to adaptively manage emotions when necessary; decrease use of emotional avoidance strategies (such as worry, rumination and self criticism); and increase ability to utilize emotional information in identifying needs, making decisions, guiding thinking, motivating behavior, and managing interpersonal relationships and other contextual demands (Mennin & Fresco, 2013).

Theory

Dialectical behavior therapy (DBT) is a specific type of cognitive-behavioral psychotherapy that engages the client by validating his/her current emotional and functional state while promoting change in skills, behavior, and thinking. It emphasizes individual psychotherapy and group skills training to help people learn and use new skills and strategies to develop a meaningful life. The main focus of DBT treatment protocol is acquisition, strengthening, and generalizing of emotion regulation and other behavioral skills such as mindfulness, interpersonal effectiveness, and distress tolerance (Scheinholz, 2011).

Evidence

A study by Eisner et. al (2017) explored the effects of DBT on the psychological well-being, emotional regulation, emotional reactivity, and residual mood symptom of adults with Bipolar I disorder. Thirty-seven participants were recruited and completed 12-weeks of DBT in a group setting which focused on acquisition of skills in mindfulness, emotional regulation, and distress tolerance. Both clinician-rated and self-reported measures were implemented at baseline, post treatment, and at a 3-month follow-up to evaluate the areas of depression, mania, mindfulness, emotional dysregulation, emotional reactivity, distress tolerance, and overall well-being and functioning. Researchers found that clinician-rated measures of depression and mania post-treatment were unchanged, although, this may have been in relation to low levels of depression and mania at baseline, as well as, exclusion criteria of those experiencing a major depressive or major manic episode. However, what can be taken from these finding is that depressive and manic symptoms remained low to the end of treatment and through to 3-month follow-up indicating that DBT group skills training may have a buffering effect on the recurrence of such symptoms. Additionally, the researcher found an increase in mindfulness and distress tolerance and a decrease in emotional dysregulation and reactivity among the study population post-treatment, and these skills were maintained at the 3-month follow-up. Taken together, this study shows that the primary treatment targets of DBT (i.e. mindfulness, emotional dysregulation, and distress tolerance) can be taught to individuals with bipolar disorder for improving mood, well-being and psychological functioning.

Case Study

Leah, a 29-year old married, mother of a young child age 2, who works as a graphic designer, presented with a history of recurrent and disabling depression and headaches.  Several weeks prior to presentation, she became severely depressed and had difficulty moving, had diminished appetite, had crying spells much of the day, and felt suicidal.  At the time she presented, she was on Prozac 20 mg a day, and described herself as feeling “manicky” because of her medication.  By this, she meant that she was “rushing around, laughing a lot, and having more anxiety.” There was also a history of alcohol abuse before she had a child. She also described a history of mood swings for many years and family history of bipolar disorder. Because of the suggestion of Manic Depressive / Bipolar Disorder by personal and family history, she was placed on Seroquel 100 mg at bedtime and is currently undergoing DBT with a psychotherapist. She was referred to occupational therapy because her condition was affecting her roles and occupational functions, including parenting her two-year-old daughter, work, home management, and health management. The occupational therapist will focus treatment on mindfulness and interpersonal skill training.

Intervention Plan

Problem Statement

Leah’s inability to regulate her emotions affects her social relationships with colleagues at work.

Long Term Goals

1. Leah will incorporate the use of emotion regulation techniques 5 times during the group session in order to improve social relationship at work by d/c.
2. Leah will practice mindfulness meditation once a day as evidenced by her journal entries in order to improve her emotional regulation for more efficient functioning at work by d/c.

Short Term Goals

1. Leah will learn to identify and describe her emotions 3x during the next group session in order to improve her social relationships at work in 2 weeks.
2. Leah will practice mindfulness regulation techniques 3x during the next individual session to increase distress tolerance in 2 weeks.
3. Leah will participate in a recorded role playing with a peer during a group therapy in order to receive feedback on her ability to effectively handle stress by next tx session.

Intervention Format

Group, Individual

Setting

Leah will meet with the occupational therapist at the outpatient clinic for a 30 minute individual session followed by a 30 minute group session twice a week.

Supplies

None.

Agenda

• Greet Leah (3 min)
• Review and discuss goals (7 min)
• Teach and practice mindfulness meditation (15 min)
• Session reflection and feedback (5 min)

Documentation

S: Client stated that she is severely depressed and has major mood fluctuations. Client noted that she has a diminished appetite, random outbursts of crying spells, and anxiety.

O: Client participated in a 30 minute session focused on emotional regulation training. She appeared flushed and agitated. At approximately 5 minutes into the therapy session, Client began laughing for no apparent cause. Client performed one mindfulness exercise to improve positive implementation of efficient modulation of stressors. Client was also instructed to describe emotions associated with anxiety and depression present during her daily occupations and the current approaches used to support the barriers.

A: Client presents with difficulties in maladaptive strategies resulting in decreased self-regulation and inability to fulfill her roles and occupational functions. The client demonstrates good insight by identifying the areas of concern and discussing healthy strategies that would aid in the recovery process, however, the client needs improvement in implementing the use of emotional regulation and mindfulness techniques at home and work. Client would benefit from further OT services to help implement a plan of action to further assist in altering her maladaptive strategies in order to be successful.

P: Client will benefit from continuing therapy sessions 3x a week for 4 weeks with emphasis on learning new strategies to incorporate into daily routines to decrease symptoms of anxiety, depression, and manic episodes affecting her roles and occupational functions at work and home.

References

Eisner, L., Eddie, D., Harley, R., Jacobo, M., Nierenberg, A. A., & Deckersbach, T. (2017). Dialectical behavior therapy group skills training for bipolar disorder. Behavior Therapy, 48, 557-566. Retrieved from https://ac.els-cdn.com/S0005789417300011/1-s2.0-S0005789417300011-main.pdf?_tid=271cae40-06d3-11e8-a3bb-00000aab0f27&acdnat=1517436640_97245adf944ff67a130c1e55d815a157

Mennin, D. S., & Fresco, D. M. (2013). Emotion Regulation Therapy. In J.J. Gross (Ed.), Handbook of Emotion Regulation (Second Edition). New York: Guilford Press.

Scheinholz M. (2011). Emotion Regulation. In C. Brown  & V. C. Stoffel, (Eds.), Occupational Therapy in Mental Health (pp. 350-351). Philadelphia, PA: F.A. Davis Company.