Mind and Emotions (21 page)

Interoceptive emotion exposure isn’t used extensively in either dialectical behavior therapy or acceptance and commitment therapy. Dialectical behavior therapy wasn’t designed specifically to target anxiety; rather, it focuses on the broader problem of emotion dysregulation. And although acceptance and commitment therapy does target anxiety, it focuses on accepting feelings and sensations, rather than desensitizing to them.

Why Do It?

When you stop fearing and resisting the physical sensations associated with painful emotions, you habituate to them, so they no longer trigger distress and avoidance. Interoceptive emotion exposure targets the transdiagnostic factor experiential avoidance, the maladaptive coping strategy that seeks to avoid painful feelings in the short term but actually worsens them in the long run. You can learn to experience these sensations as merely uncomfortable, rather than frightening or as something to avoid. When these feelings are no longer associated with significant distress, you’ll find yourself altogether less vigilant and concerned about them.

What to Do

What you are about to do is re-create, in a safe way, body sensations that accompany the emotions you’re working on in this book. Interoceptive emotion exposure is done in three stages. In the first, you briefly do twelve specific physical activities, notice the sensations they produce, and then rate how similar these sensations are to those you experience with your target emotions. The second stage involves making a hierarchy of sensations that you rated as 40 percent or greater in similarity to sensations you experience with your target emotions. In the third stage, the actual desensitization process, you briefly induce the sensation for the least distressing item on your hierarchy and rate the amount of distress it causes on a scale of 0 to 10, where 0 is no distress and 10 is the highest level of distress. Then you’ll keep repeating the exposure until the distress associated with this sensation rates no more than a 2. At that point, you’ll move up to the next item on your hierarchy and continue in this way, following this same process for each sensation in your hierarchy. We’ll guide you through the process in a detailed, step-by-step way as follows.

Stage 1: Initial Exposure

As you first expose yourself to each of the twelve sensations detailed below, use the following Interoceptive Assessment Chart to record the level of distress it causes and how similar it is to sensations you experience during your target emotions. Note that the list provides the duration for each exercise so you’ll know when to stop the exposure.

1. Shaking your head from side to side for 30 seconds
   
2. Repeatedly lowering your head between your legs and then lifting it for 30 seconds
   
3. Running in place for 60 seconds (check with your doctor first)
   
4. Running in place for 60 seconds while wearing a heavy jacket
   
5. Holding your breath for 60 seconds or as long as you can
   
6. Tensing major muscles, particularly in your abdomen, fists, forearms, and shoulders, for 60 seconds or as long as you can
   
7. Spinning while you sit in a swivel chair (not while standing up) for 60 seconds
   
8. Breathing very rapidly for up to 60 seconds
   
9. Breathing through a narrow straw for 120 seconds
   
10. Staring at yourself in a mirror for 90 seconds
    
11. Hunching your head down while frowning and tightening your jaw for 90 seconds
    
12. Walking with a ten-pound weight held to your abdomen for 120 seconds
    

As soon as possible, set time aside to do each of these exercises. At the end of every exposure, rate how distressing it is on a scale of 0 to 10, where 0 is not at all distressing and 10 is the greatest level of distress. Then assess the percentage of similarity to sensations you associate with your problematic emotion. In case you’re doing exposure for sensations related to more than one emotion, we’ve included two columns for assessing the similarity (and you can add more columns if need be). Fill in the target emotion in the heading for the columns you’re using. However, you’ll still need only one distress rating, because that assesses your level of upset regardless of the associated emotion.

Renee, a forty-three-year-old veterinarian, completed the following Interoceptive Assessment Chart for two emotional problems: anxiety and depression. Here’s what her chart looked like.

The assessment was challenging for Renee. It took three sessions for her to make it through all of the activities. But she found the outcome interesting because it helped her see that many of the sensations she associated with anxiety didn’t have much of a connection to depression, and vice versa.

Stage 2: Creating Your Interoceptive Hierarchy

Now it’s time to create a hierarchy of distressing sensations from your assessment chart. You’ll make a separate hierarchy for each target emotion you’re working on. Each hierarchy should include only activities you rated as 40 percent or greater in similarity to sensations that accompany the target emotion. The first item (row number 1 on the following blank Interoceptive Hierarchy Chart) should be the least distressing activity; the next (row number 2) would be the next most distressing item. Just to be clear, the items in the hierarchy aren’t arranged by percentage of similarity to the target emotion; they’re arranged by the amount of distress they cause. You may find it easier to cross out items with a similarity less than 40 percent and then arrange what remains according to distress rating.

Make a copy of the chart to fill out, leaving the version in the book blank for future use. Then, in the column for trial 1, write the distress level (0-10) you assigned to that item on the Interoceptive Assessment Chart.

Renee completed two Interoceptive Hierarchy Charts, one each for anxiety and depression.

Stage 3: Practicing Induced Interoceptive Emotion Exposure

Now it’s time to commence actual exposure. Start with the first item on your hierarchy—the one that provokes the least distress. If you need to have a support person present during your first few exposures, that’s perfectly okay. Eventually, however, you need to do the exposures on your own. Here are detailed instructions for working your interoceptive hierarchy:

1. Begin the first exercise and observe the point where you first feel uncomfortable sensations. Continue the exposure for at least thirty seconds after the onset of uncomfortable sensations. The longer you continue, the better, but thirty seconds is the minimum.
   
2. During the exposure, avoid using any coping strategies or trying to suppress the sensations or your awareness of them. Don’t try to relax or use positive thoughts. Just feel the experience as fully as possible.
   
3. As soon as you stop the exercise, rate your distress in the box on the hierarchy chart for that trial.
   
4. Following each trial, let your distress diminish until it rates no more than a 2 on the scale of 0 to 10. If your distress doesn’t drop on its own, do something calming for a few minutes to get it down to a 2 or less. (If need be, see chapter 8, Self-Soothing, for ideas.)
   
5. Continue doing exposure trials with the first item until you’ve achieved significant desensitization, meaning your distress level doesn’t exceed 2. In other words, when any exposure trial rates a 2 or less, you’re finished with that item and can go to the next higher item on your hierarchy.
   
6. Continue working through your hierarchy in this way, until none of the items provoke a distress level greater than 2. There’s no formal limit on the number of exposure trials you can do in any given session. When you’re tired, stop, but don’t stop in the middle of a trial.
   

When Renee began doing exposure trials on her anxiety hierarchy, she started with an item that she initially rated as only a 3: repeatedly lowering and lifting her head. However, trial 2 lasted only forty seconds before she reached a distress level of 4 and wanted to stop. That’s not unusual; distress levels often go up for the first few trials. Between trials, Renee looked out the window and relaxed. By trial 4 her distress was going down and she was pushing the exposure to sixty seconds. By trial 5 her distress level didn’t exceed 2, so she was ready to move on.

Renee managed to get through the first three items on her hierarchy relatively quickly, with no more than five trials for any of them. But the fourth item—running in place while wearing a heavy jacket—was tougher. The feeling of being hot greatly disturbed Renee and triggered significant feelings of anxiety. The second trial pushed her distress to a 9—far greater than during trial 1, the assessment exposure. But she kept at it, relaxing by reading a book between trials. It took eight trials for her distress to reduce even to a 5, and a total of twelve before it got down to 2.

While working with the final item on her hierarchy, rapid breathing, Renee noticed another challenge. She found herself trying to shut down and distract herself from the sensation. It took real perseverance to stay with the feeling and keep her attention on what it felt like in her body. However, after ten trials, Renee had reduced even this, her most disturbing sensation, to a distress level of just 2.

Practicing Interoceptive Emotion Exposure in Daily Life

In the previous exercise, you practiced interoceptive emotion exposure with induced sensations so you could desensitize to them. In this exercise, you’ll learn how to desensitize to these feelings naturally, as they occur in daily life.

As discussed, all emotions are accompanied by physical sensations. These are an integral part of all affect. So in this exercise you’ll use mindfulness to watch for and accept these feelings whenever they show up. Here’s what you’ll do:

1. Commit to watching for the target emotion. This feeling will be a red flag for mindful observation. Try to recognize the first signs that you’re starting to feel anxious, angry, sad, or whatever emotion you’re watching for.
   
2. Once you’re paying attention to the emotion, zero in on the physical sensations. Notice where the emotion is centered in your body.
   
3. Try to find words for the sensation. How big is it? What does it remind you of? Describe to yourself every aspect of this experience.
   
4. Keep watching until the sensation fades or changes. Try not to distract yourself from the feeling. Experience it just as it is, with full awareness.