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Introduction

Emotional regulation refers to efforts to control emotional states (Brown, Stoffel, & Munoz, 2011). Being able to experience a variety of emotions are an important part of the regulating process. By allowing the feeling of all types of emotions, an individual will have more control over deciding how to behave and still be successful in their daily roles and routines. According to Gratz and Roemer (2004) this conceptualization of emotional regulation states that an individual will have the ability to:

• Inhibit inappropriate behavior related to strong emotions
• Accept and willingly experience negative emotions as part of a meaningful life
• Organize oneself independent of mood state to act to attain external goals
• Refocus attention in the face of strong emotions

The inability to regulate emotions denotes an impairment in modulation, known as emotional dysregulation (Brown, Stoffel, & Munoz, 2011). Emotional dysregulation can be damaging to an individual who may already be living with a psychopathological disorder such as anxiety, depression, eating, and personality disorders. Emotional dysregulation can have significantly negative effects on individuals not living with a psychopathological disorder as well (Edwards, Rhodes, Mann, & Loprinzi, 2018).

Theory

The sensory integration (SI) model is based on the work of Dr. Jean Ayres and is formally known as Ayres Sensory Integration (Lisa Raymond, 2017). Occupational therapist commonly use the theory of SI as an effective approach to address emotional regulation and behavioral dysregulation in clients who have experienced psychosocial trauma (Warner, Cook, Koomar, & Lary, 2013). The SI model provides therapists and clients with the tools they need to address self-regulation (Warner, Cook, Koomar, & Lary, 2013).  Self-regulation is often dysregulated due to issues in sensory modulation and discrimination, which if impaired disrupt emotional and behavioral regulation (Lisa Raymond, 2017).  The sensory modulation technique is useful to therapists who are trying to understand if their clients are having difficulties reacting appropriately to incoming sensory information (Lisa Raymond, 2017).  On the other hand, therapists use the sensory discrimination technique to establish if their clients are having trouble discriminating incoming sensory information (Lisa Raymond, 2017). Overall, using SI model as a guideline in treatment planning is most appropriate when the therapist and client are working together to improve regulation (Warner, Cook, Koomar, & Lary, 2013).

Evidence

Sensory integration has informed therapeutic approaches for a variety of populations. A study focused on traumatized populations used a bottom up approach to address vestibular, auditory, and visual input and found positive changes in emotional regulation and self perception (Warner, Cook, Koomar, & Larry, 2013). According to Warner et al. (2013) emotional and behavioral dysregulation lead to problems in daily living with other people that could impact community life. Sensory input can be seen as a valuable regulating tool such as addressing the individuals needs through a sensory diet or by having an occupational therapist identify regulatory strategies for the individual for daily living and tasks based on their sensory profile and needs (Warner, Cook, Koomar, & Larry, 2013). A sensory diet can be useful to provide optimum functioning through coping skills and adapting the environment (Villeda, 2004). For example, based on the clients needs for the sensory diet, the auditory system can be stimulated by a rainforest stick, a flowing waterfall, or humming/vibrating sounds. Evidence suggests that sensory treatment needs to begin with a calm and passive approach (Villeda, 2004). In addition, if there is any sign of sensory overstimulation (anxiety/fear, increased heart rate/perspiration, inability to calm down) then treatment needs to be reduced or terminated and proprioceptive input should be applied (Champagne, 2003).

Case Study

Samuel is a 28-year-old veteran of the army national guard. During a patrol in Afghanistan as a combat medic his convoy encountered an improvised explosive device (IED), suffered from a TBI and was later diagnosed with PTSD. Due to the complications from the PTSD, Samuel has frequent troubles with emotional regulation. Samuel came in for the initial evaluation where the occupational therapist heard his struggles and limitations in social participation. The occupational therapist completed a sensory profile that indicated Samuel having sensory hypersensitivity to auditory stimuli. Importantly, because of his hypersensitivity, low levels of auditory stimuli may be perceived as higher levels of sound. This leads to Samuel becoming overwhelmed often, especially in areas with a lot of people. This evokes anxiety in Samuel and leads to increased difficulty regulating his emotions. Samuel expresses this concern and wants to be able to socially interact with people and control his emotions especially his anxiety when in public places.

Intervention Plan

Problem statement

Client is unable to regulate his emotions for social participation due to his hypersensitivity to auditory stimuli.

Long Term Goals

1. Client will be able to use his sensory diet strategy in a public outing with no emotional distress to improve social participation in 4 weeks.
2. Client will interact with a stranger at his local coffee shop without experiencing anxiety symptoms to improve social participation in 4 weeks.

Short Term Goals

1. Client will identify 3 auditory input preferences for his sensory diet to improve his social participation in 2 weeks.
2. Client will interact with the therapist for 2 minutes in a public place for social participation with no more than 2 verbal cues to reduce emotional discomfort in 2 weeks.
3. Client will tolerate 3/5 of common noises in public places to improve emotional regulation for social participation in 2 weeks.

Intervention Format

Individual

Setting

Samuel will meet with the occupational therapist individually at an outpatient clinic for 40 minutes 4x per month.

Supplies

Pen, notebook, pad

Agenda

• Meet with Samuel to discuss any situations that he had during the past week in public places that brought on strong emotions (5 minutes)
• Client will identify three auditory sensory preferences for his sensory diet (10 minutes)
• Client discuss how he can incorporate his preferences into is daily routine (10 minutes)
• Client will listen to some common noises that occur in the environment and describe how he feels (10 minutes)
  • Questions the OT might ask after each noise:
    • How does that noise make you feel?
    • Why do you think you feel that way?
    • Do these noises remind you of anything?
    • How do you think your techniques have helped you?
• Summary of the treatment session / discuss next treatment session (5 minutes)

Documentation  

S: Client expressed concerns that noisy crowded places cause him anxiety. He expressed he is frequently startled by common sounds and begins to panic when he cannot control his emotions in public places.

O: During the treatment session, client identified common noises in the environment and responded to the OT’s questions on how they make him feel. He was able to have a conversation with the OT and required 2 verbal cues to address his emotional discomfort. Client required a break during the session to reorient himself from the auditory stimuli. The OT demonstrated appropriate techniques for emotional regulation to Samuel to help him manage his anxiety levels in public places.

A: Client became increasingly hypersensitive to the auditory stimuli in the environment during the treatment session. During the OT questionnaire on how he felt hearing certain sounds, the client showed increasing anxiety levels to more high pitched sounds indicating he requires further desensitization to less averse and lower sounds before grading up. Client needed verbal cueing indicating that his anxiety levels were overwhelming and he could not appropriately identify and use his self-selective strategies for emotional regulation on his own.

P: For the next treatment session, client will engage in a 40-minute session focusing on reinforcing the client’s use of his sensory diet to emotionally regulate his anxiety levels in public places. Client’s auditory hypersensitivity needs to be needs to be challenged and reassessed to determine improvements.

References

Brown, C., Stoffel, V.C., & Munoz, J.P. (2011). Occupational therapy in mental health: A vision      for participation. Philadelphia, PA: F. A. Davis Company. ISBN-10: 0-8036-1704-6

Champagne, T. (2003). Sensory Modulation & Environment: Essential Elements of Occupation, General Handbook & Reference. North hampton, MA: Paradise Copies.

Edwards, M. K., Rhodes, R. E., Mann, J. R., & Loprinzi, P. D. (2018). Effects of acute aerobic exercise or meditation on emotional regulation doi://doi-org.ezproxy.fiu.edu/10.1016/j.physbeh.2017.12.037

Gratz, K.L. & Roemer, L. (2004). Multidimensional Assessment of Emotional Regulation and           Dysregulation: Development, Factor Structure, and Initial Validation of the Difficulties in Emotion Regulation Scale. Journal of Psychopathology and Behavioral Assessment, 26, 41-54. Journal of Psychopathology and Behavioral Assessment 26: 41. https://doi.org/10.1023/B:JOBA.0000007455.08539.94

Lisa Raymond. (2017). Frequently asked questions Retrieved from http://academicguides.waldenu. edu/disability-services/faqs

Villeda, M. I. (2004). Sensory based occupational therapy treatment for adults with psychiatric        disabilities (Order No. 1478420). Available from ProQuest Dissertations & Theses A&I;        ProQuest Dissertations & Theses Global. (250722755). Retrieved from                http://ezproxy.fiu.edu/login?url=https://search-proquest-com.ezproxy.fiu.edu/docview/250722755?accountid=10901

Warner, E., Cook, A., Koomar, J., & Lary, B. (2013). Can the body change the score? application of sensory modulation principles in the treatment of traumatized adolescents in residential settings Retrieved from http://ezproxy.fiu.edu/login?url=http://search.ebscohost.com.ezproxy.fiu.edu/      login.aspx?direct=true&db=edswss&AN=000324869900009&site=eds-live