Keywords

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

1 Vicious Cycle #4: Amygdala Activation and Avoidance Reactions

Slide 61: So far in our training, we have talked about three examples of vicious cycles that can cause negative emotions to increase in their intensity and duration. Now, let’s talk about another vicious cycle that can also develop. In the process of regulating amygdala activation, the prefrontal cortex may activate more on the left or on the right. Leftward activation has been associated with approach behavior, while rightward activation has been associated with avoidance behavior (Berkman & Lieberman, 2010; Spielberg et al., 2011), such as forming a goal “to not feel emotions.”

figure a

This goal of not feeling emotions, however, is hard to attain. Emotions cannot be controlled by sheer force of will. They are usually beyond the realm of direct conscious control. The reason for this is that the amygdala and other parts of the limbic system act largely autonomously from the areas of the brain that initiate willfully controlled behavior. This functional autonomy of the limbic system was a significant evolutionary advantage to our ancestors. If those prehistoric men had been able to consciously control their feelings, they would have likely given in to the temptation to simply shut down unpleasant emotions. By doing so, they would not have received the important benefits of negative emotions such as “anger,” which prepared our ancestors’ bodies and minds for assertive action such as self-defense.

Another reason why it is difficult to control emotions is that emotional reactions often cause significant changes in the body. These changes take time to dissipate, and as long as they are present, they impede the ability to make emotional changes. For example, it is difficult to quickly stop being angry when the body is flooded with stress hormones. Since emotions cannot be controlled by will alone, and since changes in the body make it difficult to control emotions, we see why the goal of getting rid of an emotion instantly and completely is often unattainable.

When a person is unsuccessful at their attempts to instantly rid themselves of a negative emotion, their failure will consequently lead to increased amygdala activation. The goal of getting rid of these negative emotions now becomes even stronger and more important, since the person is also experiencing increased distress due to the additional amygdala activation. However, the goal of avoiding the emotions is even more difficult at this point because of the heightened negative arousal. This leads to an even greater likelihood of failure to avoid the negative emotions, which causes more amygdala activation and so on. Thus, in this vicious cycle, the more the person attempts to get rid of the negative emotions, the stronger the emotions become.

2 ART Skill #4: Acceptance and Tolerance of Emotions

Slide 62: So if fighting to avoid our negative emotions is likely to make them stronger through the vicious cycle we described, what can we do instead?

figure b

Slide 63: The opposite—accept and tolerate our emotions. But what does it mean to accept and tolerate our emotions? Let’s talk about what acceptance and tolerance does and does not mean. (The therapist may choose to pass out copies of Appendix H—Understanding Acceptance and Tolerance to the participants.)

figure c

Slide 64: Acceptance and tolerance …

  • Does not mean you have to like or enjoy the emotion you are trying to accept

  • Does not mean you have to accept everything always

  • Does not mean you accept the situation that triggered the negative emotion (only the emotions cued by the situation)

  • Does not mean you give up and stop fighting to improve the situation

Instead, acceptance and tolerance does mean …

  • I intentionally permit negative emotions to be present, at least for the amount of time necessary for them to change. This is helpful because fighting against emotions is likely to make them even stronger.

figure d

Emotions exist to convey information to us. Once emotions have delivered their information, they will naturally change or subside unless we maintain them through avoidance. Accepting and tolerating, and hence openness to experiencing an emotion, is paradoxically an effective way of eventually changing the emotion. The concept of how acceptance and tolerance can change a negative emotion can be understood with the following metaphor:

Since the purpose of emotions is to convey important information, emotions can be thought of as a highly motivated mailman who wants to deliver a letter to us. Since he is conscientious, he will knock on your door and try to deliver it to you in person instead of just leaving it in your mailbox.

Now, say you are at home and you hear the mailman knocking at your front door. You look out of the window and see him. However, you decide not to open the door and receive the letter because you feel that it contains unpleasant information. The good mailman leaves, but he returns later in the day and knocks on your door again to deliver the letter. If you keep ignoring the mailman, he will continue to come back, since his/her sole purpose of existence is to deliver important letters. Thus, regardless of whether you barricade the door, put land mines in your front yard, and get a nasty watchdog, this highly dedicated mailman will keep trying to deliver the letter.

The most effective way to make the mailman stop bothering you is to simply accept the letter. You don’t have to follow the advice written in the letter, but you need to accept it and find out what it says. Emotions function in much the same way as the mailman in this story. Your emotions will keep bothering you unless you experience them and consciously process the information your emotions want you to have.

For example, if you feel anxious, you could choose to allow yourself to focus on your anxiety and experience it without fighting against it. You could say to yourself, “This is anxiety,” and then begin to explore what this emotion is trying to tell you. For example, the anxiety may be telling you there is a really important exam coming up, and you should study hard in order get a good grade on it. You could then determine if this information is correct. Regardless of whether or not the information is correct, the first step is to simply allow the emotion tell you the information it wants to tell you. Once the emotion has done its job, it is far more likely that the body’s regulatory functions will naturally kick in and reduce or change the emotion.

So we see how avoidance maintains our negative emotions, while acceptance and tolerance can begin the process to change them. I’d like to hear some of your ideas of how we could encourage acceptance and tolerance of our emotions. I will write your ideas on the flip chart. (The therapist writes the participants’ ideas to foster acceptance and tolerance on the flip chart.)

Slide 65: Thanks for all of the great feedback! Many of the ideas that you came up with are part of a specific method I am going to describe that we can use to help us accept and tolerate our negative emotions. In ART, this method is summarized in the 5-Step Acceptance and Tolerance Plan. (Therapist hands out copies of Appendix I.)

figure e

Let’s review the plan together.

Step 1. Set acceptance and tolerance as a goal

Since accepting and tolerating negative emotions can be challenging, we will probably not do so without intentional effort. So first we must intentionally decide to make acceptance and tolerance of our emotions our goal. For example, you could say to yourself, “I will work to accept and tolerate my current emotion, even if it is difficult for me at the moment.”

Step 2. Give reasons for focusing on acceptance and tolerance

Since the brain prefers changing things instead of accepting and tolerating them, we need to give our brain good reasons for engaging in this “second-rate” strategy. One of the most convincing reasons is that fighting against negative emotions often makes them stronger. Thus, it is smart to use acceptance and tolerance as a tool to calm down the system. This will significantly increase our ability to eventually change the emotion. For example, you could say to yourself, “I can’t just turn off my feelings. If I try to fight them, I will only make them stronger, so I will accept and tolerate them at least for a certain period of time. This can bring me a sense of peace and calm that will help me eventually change my emotions.”

Step 3. View your emotions as helpful

Viewing your emotions (especially challenging ones) in a more positive light can help you be more accepting and tolerating of them. One way to view emotions more positively is to see them as your allies, which are trying to give you important information and facilitate helpful behaviors.

So what are our emotions telling us? Positive emotions tell us that our needs and goals are generally being met, and because they feel good, they reinforce the behaviors that helped us meet our needs and goals. Since our needs and goals are being met, positive emotions are generally signals that we do not need to change anything or that we have attained a goal and can now rest and allow the positive emotions to recharge our “mental batteries.”

Negative emotions, on the other hand, signal that our needs and goals are not being met. When we experience negative emotions, we can remind ourselves that our emotions are trying to let us know that our needs and goals are in some way not being met, and the specific kinds of emotions we experience provide us with important clues about what specific goals and needs are not being met. For example, you could say to yourself, “Although painful, these emotions are providing me with valuable information. They are helping me protect my needs and goals.” You could also ask yourself, “What needs and goals are they telling me are not being met? What are they telling me I should do about these unmet needs and goals? What beneficial behaviors are facilitated by these feelings?” Say you are experiencing anger. You may find that anger is telling you that somebody or something is purposefully hindering your efforts to attain a certain important goal and that it might be helpful to prepare to fight and assert your rights, so you do not continue to be exploited by others. Think of what happens to individuals who are unable to get angry and use the anger to assert themselves. Right! They get exploited at work, end up with selfish partners, are unable to meet their needs, and eventually get severely depressed. So anger in this situation is providing you with really important information.

Note to the therapist:

Initially, it is often very challenging for the participants to positively reframe their negative emotions. In order to help the participants successfully reframe their negative emotions (e.g., by providing examples or using guided discovery techniques), therapists should have knowledge of the positive aspects of a broad range of emotions that are relevant to well-being and mental health. For additional information, refer to the Challenging Emotions chart (Appendix J), the Positive Emotions chart (Appendix K), as well as the following section that describes the positive and helpful aspects of various emotions:

Stress and Tension: Stress and tension informs us that the attainment of personally relevant goals may be threatened and that currently available resources may be insufficient to cope with these threats (conservation of resources theory; Hobfoll, 2001). Stress enhances the awareness of these threats and helps mobilize mental and physical energy to deal with them. For example, in a physically dangerous situation, stress focuses our thoughts on resolving the threat while causing increased respiration and muscle tension in order to flee (if the stress response turns into fear) or fight (if the stress response turns into anger).

Anxiety and Fear: Similar to stress, anxiety and fear promotes alertness for identifying and coping with potential threats. The more a potential threat turns into an actual threat (from the perspective of the individual), and the less it is believed that the threat can be managed successfully, the greater the likelihood that “stress” will turn into “anxiety and fear.” The anxiety and fear response facilitates flight responses (getting out of the way of the threat) and sometimes freezing (not responding at all).

The flight response helps us get out of the danger zone as quickly as possible, such as when someone jumps out of the way of an oncoming car. Freezing probably developed originally as a successful protective evolutionary adaptation. When you stop moving and freeze, predators, including humans, have a more difficult time seeing you, since it is easier to detect moving objects instead of stationary ones. In modern times, it can be argued that freezing helps us to avoid doing something that may cause even greater harm. For example, a person may freeze when getting yelled at by their boss, since reacting could cause them to be fired.

Anger (also Annoyance and Irritation): Anger provides information that someone or something is impeding our goals and there is no valid excuse for the impediment. Believing that someone or some circumstance does not constitute a valid impediment of our goals is an important element in the development of anger, since we tend to feel angry only when we cannot justify what is happening to us. Anger facilitates the fight response, which fosters assertive action that helps us attain our goals, even when others object, and prevents us from being exploited by others.

Guilt, Shame, and Embarrassment: Guilt, shame, and embarrassment are often called the “self-conscious emotions” (Tangney & Tracy, 2012, p. 446). Although the terms have overlapping features, there are distinctions between them including their adaptive qualities. Guilt is experienced when a person breaks an important (moral) rule they have set for themselves (e.g., “I should not have acted cruelly toward that person.”). Shame usually involves a rather global, negative self-evaluation that can occur in the context of a particular situation (e.g., “I am a bad person because I acted that way.”) or in response to a generalized self-perception (e.g., “I am a bad person.”) (Lewis, 2008). Embarrassment is experienced when a person believes some aspect of their identity and/or behavior is being judged negatively by others (e.g., “When I tripped up the stairs, I felt like such a klutz!”) (Tangney & Tracy, 2012).

Social interaction is vitally important for health and survival. Guilt, shame, and embarrassment warn us that we are acting in a way that could cause us to be excluded by others and encourage us to take corrective actions. Therefore, these emotions can be regarded as very helpful for maintaining social connections (Tangney, Miller, Flicker, & Barlow, 1996). Specifically, guilt facilitates actions that make amends for misdeeds. The reparative actions that guilt facilitates, such as asking for forgiveness or compensating for damages, can serve to rebuild important social bonds.

The tendency to withdraw when feeling shame and hiding out until the problem blows over may at times be the most appropriate way to remain socially connected when we have violated a serious social norm. Withdrawal also strongly communicates an admission of wrongdoing, which can reassure others of our desire when we feel shamed to stop the social offense and our desire to remain socially connected. Feelings of embarrassment encourage us to take action to fix whatever we perceive is being judged by others in the moment (Tangney & Tracy, 2012), which could increase our standing in the group. Outward displays of embarrassment (i.e., blushing) maintain social inclusion by communicating to others we realize we have committed a faux pas and reassures others that it was not done on purpose (Leary, Landel, & Patton, 1996).

Sadness and Disappointment: Whereas stress and anxiety signal that goals are being threatened, sadness signals that important goals will not be achieved and disappointment signals that certain expectations will not be met. Both sadness and disappointment help us disengage from goals and expectations and cause us to reflect on why our goals will not be achieved or our expectations will not be met. As a result, sadness and disappointment allow us to eventually set new (and hopefully more attainable) goals and expectations.

Those who do not allow themselves to experience sadness and disappointment have difficulty letting go of unattainable goals and expectations. Since they do not let go of their unattainable goals and expectations, they continue to feel miserable, which may eventually turn into a mental disorder. By continuing to hang on to unattainable goals and expectations, they also reduce their opportunities to identify and achieve more realistic ones.

Depressed Mood: Whereas sadness refers to a specific event, a depressed mood signals to a person that (1) all their important goals have not been attained, (2) they do not possess the means to attain these goals, and (3) the impediments to attaining their goals are likely to persist. A depressed mood leads to withdrawal, inactivity, and rumination about the upsetting aspects of the situation. This is a very painful state, but depression can also be helpful. The distress that is experienced in a depressed mood encourages an individual to finally let go of all unattainable goals. The withdrawal feature in depression can provide a person with the critical time and space necessary to ponder a complete reorientation of his/her goals and the ways to best attain them.

Since a depressed mood is related to many or even all of a person’s unattained goals, a reorientation of their goal structure does not occur quickly. Longer periods of time are often needed to work this through, and this important process does not happen without suffering. This is why depressed moods tend to last longer and be more upsetting than other emotional reactions. (For additional reading on adaptive conceptualizations of depression, see Nesse, 2000; Sharpley & Bitsika, 2010; Teasdale & Barnard, 1993.)

With this knowledge on the positive aspects of negative emotions, the therapist now facilitates an exercise in order to reinforce the idea that emotions are helpful allies. The therapist continues speaking to the participants:

Now let’s go through an exercise to help us better understand the idea that challenging emotions give us important information and encourage helpful behaviors. I am going to give three index cards to each participant. I would like each person to write the name of an emotion (negative or positive) they have experienced during the past week on one side of each of the three cards. Then on the back of each card write down (1) what information was being communicated by this emotion and (2) the helpful behavior that this information facilitated.

As an example using a negative emotion, the “anxiety” you experienced during this past week may have communicated that any errors in the business report you were preparing could have threatened your goal of receiving a promotion. The feeling of anxiety could have encouraged you to double-check your report before you gave it to your boss. As an example using a positive emotion, the “contentment” you experienced during this past week may have communicated that you have reached your goal of getting a certain type of position at the business where you work. In this case, contentment reinforced the hard work that went into getting that last promotion, which encouraged you to continue to be diligent at work.

Note to the therapist:

To help the participants with this exercise, the therapist may choose to pass out copies of the Challenging Emotions chart (Appendix J) and the Positive Emotions chart (Appendix K) that describes the positive function of various emotions. After spending 5–10 min to fill out the index cards, the participants take turns placing their cards on the floor (emotion name face up) in the center of the group and state for each card (1) the emotion they are referring to, (2) when this emotion occurred, (3) what important information the emotion communicated, and (4) what helpful behaviors the emotion facilitated. This exercise is often challenging, so the therapist should be ready to help coach the participants on the helpful aspects of emotions. To illustrate the value of aversive emotions, the therapist could pose the question, “What happens when people are unable to experience and utilize … (anger, anxiety, depression, etc.)?” It can also be helpful to explain that these emotions need to be unpleasant in order to motivate us to do something that is unpleasant but necessary. After everyone has discussed what they wrote on their cards and laid their cards on the floor, the therapist should check to see if any of the common negative emotions were not discussed. If some of the common negative emotions were not brought up by the participants, the therapist should take this opportunity to provide psychoeducation on the helpful aspects of these negative emotions as well.

The ART therapist may choose to implement a variation of this group exercise. In this variation, each participant writes the name of an emotion on an index card. The index cards are collected and shuffled. One of the index cards is then taped to each participant’s back with the name of the emotion facing forward, without allowing the participant to see what is written on the card. The participants then move around the room and say to each other, “I am the emotion written on my back. What could I be trying to say?” (e.g., Anger—“My rights have been violated.”) The participant also asks, “How could I be helpful?” (e.g., Anger—“I help you stand up for yourself.”) Based on the responses, the participant with the card taped to his/her back tries to guess which emotion is listed on the card.

After the exercise, the therapist continues explaining the 5-Step Acceptance and Tolerance Plan:

Step 4. Remind yourself how tough and resilient you really are

Let’s continue with the 5-Step Acceptance and Tolerance Plan. In Step 4, you take steps to remind yourself how tough and resilient you really are. Difficulties with accepting negative emotions are often caused by underestimating your ability to tolerate them. The influential psychologist Albert Ellis jokingly called this “syndrome” I-can’t-stand-it-itis. It can be helpful to remind yourself that you may be underestimating your ability to endure negative emotions. To strengthen this argument, it is often helpful to remember that you have been able to endure negative feelings in the past on numerous occasions. Given such evidence of your resilience, you could say to yourself, “I have frequently proven that I can endure negative feelings, so I can do it again. I can tolerate these feelings even though they are painful!”

Note to the therapist:

Therapists should be aware that the idea of accepting negative emotions can be frightening to some participants based on their catastrophic assumptions about what would happen if they allowed themselves to accept and experience negative emotions. Common beliefs include, “If I allow my emotions to surface, they will overwhelm me, and I will become completely crazy, depressed, anxious, etc.,” or “If I accept my feelings of depression, I will stop fighting them, and I will never be able to get rid of them.” These beliefs are often the result of painful emotional experiences that have occurred in the past.

In such cases, therapists should first attempt to understand and validate the individual participant’s avoidant reaction toward negative emotions that is based on her past experiences. For example, the therapist may validate her reaction by saying, “I can understand how you would feel that way, since emotions have felt so painful in the past. Avoiding your feelings in the past was probably very helpful during previous times in your life when you didn’t have the ability to regulate your emotions, but now you have an opportunity to ask yourself if avoidance is still a helpful strategy for you.”

After the therapist has gained an understanding of the participant’s avoidant patterns and then validated these patterns, the therapist should gently and empathically confront her beliefs that underestimate her own ability to endure negative emotions. Confronting these beliefs involves showing the participant that despite experiencing many distressing emotions in the past, her darkest fears have not yet proven true (e.g., she did not die, go completely “crazy,” etc.). In fact, the participant has managed to endure all of her prior negative emotions, since she is alive in the ART session with you this day.

For participants who have particular difficulties believing in their own ability to tolerate negative emotions, the “Good Times—Bad Times” exercise can be used (Fig. 13.1). Due to time constraints, this exercise would most likely be used when working on specific emotion regulation issues in adjunctive individual therapy. In this exercise, the participant is asked to plot the major past events of her life on a timeline, curving upward in good times and downward in unhappy times.

Fig. 13.1
figure 1

Good times—Bad times

Full size image

The timeline can then be analyzed from various perspectives. For example, to identify change-related skills, therapists can focus on sudden gains in happiness and analyze what the participant did to bring about these positive changes. However, when using this exercise to identify tolerance abilities, the therapist instead focuses on extended periods of unhappiness and asks the participant how she was able to endure such difficult times for so long.

The rationale behind this exercise is that (1) the participant almost certainly has had to deal with some painful situation in her past that she could not change and (2) she did obviously somehow survive the negative emotions during the painful situation, since she is alive and participating in ART. The exercise challenges the therapist to be both empathic and at the same time confront the participant’s faulty beliefs in her own supposedly insufficient tolerance capacities.

While the timeline will help some participants gain insight into their ability to tolerate emotions, others will interpret the timeline as additional evidence that they do in fact lack the ability to tolerate their emotions. For example, a participant may make statements such as, “I did try to kill myself, but they found and rescued me. This proves that I cannot tolerate my emotions.” It may be helpful in this situation to clarify how often the participant attempted suicide and mark those incidents with an “x” on the timeline. The therapist could then (very empathically and seemingly naively) point out all of the low points on her timeline without an “x,” showing that there were in fact periods when she suffered but did not attempt suicide. The therapist could ask the participant to account for these times. Through this dialogue, the therapist leads the participant to the point where she does not so strongly oppose the hypothesis that “she may be more resilient than she thinks.”

It should be noted that the focus in this exercise is not to quickly convince the participant that she is resilient, but rather to gently question the “evidence” that she is not resilient and to point out that just maybe … she has underestimated herself. It is important not to get stuck in an argument with the participant regarding whether she is resilient or not. Instead, the participant should be presented with the option of challenging her belief that she lacks resilience. The therapist could, for example, say, “If you decide that you want to foster your ability to accept and tolerate your emotions, it can be helpful to remind yourself of the many times you have successfully tolerated aversive emotions in the past and allow yourself to see that this means that you do, in fact, have the ability to tolerate negative emotions.”

The therapist continues discussing the 5-Step Acceptance and Tolerance Plan:

Step 5. Remind yourself that emotions are temporary

In the final step of the plan, you remind yourself that an emotion does not last forever. Emotions communicate information. So, if you give the emotion an opportunity to convey its information, it will fade away sooner or later. Reminding yourself that no emotion lasts forever can help you better accept a negative emotion, since you will only need to tolerate it for a limited period of time. You may find it helpful to tell yourself something like, “This emotion is only temporary. I will not have to endure it forever.”

Note to the therapist:

After the 5-Step Acceptance and Tolerance Plan has been discussed, participants are invited to pick an emotion that has been difficult for them to accept and tolerate in the past. The participants are then asked to utilize the 5-Step Acceptance and Tolerance Plan Worksheet (Appendix L) to increase their acceptance and tolerance of this challenging emotion.

At the end of the worksheet each participant is directed to develop a personal Acceptance and Tolerance Statement. This should be a summary of the phrases that were developed in the individualized 5-Step Acceptance and Tolerance Plan. An example of this personal Acceptance and Tolerance Statement is, “It’s okay that I feel the way I do. This emotion is helping me see how I can get my needs met. I can tolerate these feelings for a while if necessary, and I know that they won’t last forever.”

The participants may work in teams of two to help each other complete the worksheet and develop a meaningful Acceptance and Tolerance Statement. While the participants are completing the worksheet, the therapist answers any questions that arise and proactively ensures that the participants understand how to complete the steps in the worksheet.

Later, the participants take turns presenting their Acceptance and Tolerance Statement. As the participants share their Acceptance and Tolerance Statements, the therapist encourages the participants to repeat their statements several times, aloud, to the group. This is done to ensure that the Acceptance and Tolerance Statement feels authentic to each participant. If necessary, the therapist gently helps participants modify their statement until they say it feels right to them.

When all of the participants have formulated an Acceptance and Tolerance Statement they feel comfortable with, the therapist explains to the group that it takes time and practice for the statement to actually trigger acceptance and tolerance of a challenging emotion. The participants are then encouraged to close their eyes and silently repeat their Acceptance and Tolerance Statements to themselves, until they begin to feel more accepting and tolerant of an emotion they may be experiencing at the time.

The participants are then encouraged to share their experiences of going through the 5-Step Acceptance and Tolerance Plan and creating an Acceptance and Tolerance Statement. The therapist answers any questions and addresses any problems they encountered prior to including ART Skill #4 into the ART Sequence.

3 ART Sequence with ART Skills #1–4

The therapist continues speaking to the participants:

So far, in the ART Sequence Exercises, we have tensed and relaxed our muscles in groups of specific muscles. However, starting with this next ART Sequence Exercise, we will tense and release all of these muscles at once. Let’s try this together. Okay, now clench your fists. Angle your fists inward. Angle your forearms toward your upper arms. Pull your fists to your shoulders. Clench your teeth. Turn the corners of your mouth outward. Press your tongue against the roof of your mouth. Carefully squeeze your eyes shut. Furrow your eyebrows. Pull your shoulders up and then back. Tilt your hips forward, and arch your back. Press your buttocks together. Straighten and slightly lift your legs in front of you, and point your feet downward. Now hold the tension for a moment. (Slight pause) Continue breathing as calmly and deeply as possible. (Slight pause) And now, with the next out-breath … relax your muscles. Pay attention to the difference between the tension you felt before and the relaxation you feel right now. Keep breathing calmly and regularly, and let your muscles become more and more relaxed with each out-breath. (15 s pause)

Okay, one more time. Clench your fists. Angle your fists inward. Angle your forearms toward your upper arms. Pull your fists to your shoulders. Clench your teeth. Turn the corners of your mouth outward. Press your tongue against the roof of your mouth. Carefully squeeze your eyes shut. Furrow your eyebrows. Pull your shoulders up and then back. Tilt your hips forward and arch your back. Press your buttocks together. Straighten and slightly lift your legs in front of you, and this time point your feet back toward your face. Now hold the tension for a moment. (Slight pause) Continue breathing as calmly and deeply as possible. (Slight pause) Now, with the next out-breath … relax your muscles. Pay attention to the difference between the tension you felt before and the relaxation you feel right now. Keep breathing calmly and regularly, and let your muscles become more and more relaxed with each out-breath. (15 s pause)

Does anyone have questions about this shortened version of muscle relaxation?

Slide 66: At this point in the training we have learned the first four ART Skills: Muscle Relaxation, Breathing Relaxation, Nonjudgmental Awareness, and Acceptance and Tolerance of Emotions. (Acceptance and Tolerance of Emotions—ART Skill #4 is achieved through the completion of the 5-Step Acceptance and Tolerance Plan. The steps of this plan are now combined with ART Skills #1 through #3 that have already been added to the ART Sequence.)

figure f

We will now practice linking these four ART Skills together in the ART Sequence. We will use the shortened version of muscle relaxation during this ART Sequence Exercise.

The therapist leads the participants in the ART Sequence with ART Skills #1–4:

Just as before, I will provide the instructions as we go through the exercise together. The therapist may guide the ART Sequence Exercise using the “Exercise Three” audio that can be downloaded from the ART website, or the therapist may guide the exercise using the following instructions:

We will start the exercise after the sound of the bell.

Sound of the bell

Find a comfortable sitting position. Close your eyes. Exhale slowly. Relax your body, and bring your attention to your muscles. In a moment, we will begin tensing and then relaxing our muscles. (3 s pause) Now, tense the muscles in your body by doing the following: Clench your fists. Angle your fists inward. Angle your forearms toward your upper arms. Pull your fists to your shoulders. Clench your teeth. Pull the corners of your mouth outward. Press your tongue against the roof of your mouth. Carefully squeeze your eyes shut. Furrow your eyebrows. Pull your shoulders up and then back. Tilt your hips forward and arch your back. Press your buttocks together. Straighten and slightly lift your legs in front of you, and point your feet downward. Now hold the tension for a moment. (Slight pause) Continue breathing as calmly and deeply as possible. (Slight pause)

Now, with the next out-breath … relax your muscles. Pay attention to the difference between the tension you felt before and the relaxation you feel right now. Keep breathing calmly and regularly, and let your muscles become more and more relaxed with each out-breath. (5 s pause)

Now, we will tense the muscles again, just like last time. Clench your fists. Angle your fists inward. Angle your forearms toward your upper arms. Pull your fists to your shoulders. Clench your teeth. Pull the corners of your mouth outward. Press your tongue against the roof of your mouth. Carefully squeeze your eyes shut. Furrow your eyebrows. Pull your shoulders up and then back. Tilt your hips forward and arch your back. Press your buttocks together. Straighten and slightly lift your legs in front of you, and this time point your feet back toward your face. Now hold the tension for a moment. (Slight pause) Continue breathing as calmly and deeply as possible. (Slight pause)

With the next out-breath … relax your muscles. Pay attention to the difference between the tension you felt before and the relaxation you feel right now. Keep breathing calmly and regularly, and let your muscles become more and more relaxed with each out-breath. (5 s pause)

Now, we will start to practice nonjudgmental awareness. Focus your attention on the sensations of your breath—the way it flows … in … and out again … without trying to control it. Say to yourself “in” when breathing in and “out” when breathing out, and do your best to focus on the sensation of your breathing in your abdomen. When you realize that you’re getting distracted or that other thoughts are crossing your mind, use a word to label what is happening, such as “planning,” “worrying,” or “remembering,” and gently bring your attention back to your breathing. Every time you become aware that you are distracted, praise yourself for noticing it, and then focus on your breathing again. We’ll now spend a minute simply focusing on our breathing. Remember to say to yourself, “in” … and … “out.” When you become distracted, use a word to label what is happening such as “planning,” “worrying,” or “remembering,” and gently bring your attention back to your breathing. (40 s pause)

Now we are going to practice shifting our focus and awareness onto other things. First, gently shift your attention from your breathing onto any sensations you are feeling in your body at the moment. (20 s pause) Now pay attention to what you are hearing at the moment. (20 s pause) Next, notice any smells you are aware of. (20 s pause) Now see what thoughts are crossing your mind. (20 s pause) Notice any desires you have right now. (20 s pause) Be aware of any emotions you are experiencing right now. Label each emotion. (5 s pause) Which of these emotions do you feel more strongly? (20 s pause) What other emotions are maybe more subdued but are still present in the background? (20 s pause) Estimate the intensity of each emotion you have labeled on a scale from 0 to 10, and become aware of how you feel these emotions in your body. (20 s pause)

Now I will guide you through the 5-Step Acceptance and Tolerance Plan to specifically address either a negative feeling that you have become aware of presently or a negative feeling that has been challenging for you in the past. Select which emotion you would like to work with. First, set a goal to accept your present emotion as much as possible, and strengthen this goal with a reason. For example, you might tell yourself, “I will work on accepting my feeling because I need to experience my emotion before I can regulate it,” or “If I fight against my feeling, I will only make it stronger.” Take some time now to set a goal for yourself to accept your emotion. Also decide for yourself why this goal is important to you. (20 s pause)

Now do your best to create a positive attitude toward your feeling. For example, complete the following sentences in your head, “This feeling is helpful; it is telling me that….” (15 s pause) “It is trying to help me to….” (15 s pause)

Next, remind yourself that you can tolerate challenging emotions, at least for a period of time. Think of ways you have been able to endure intense negative feelings in the past. Perhaps say to yourself, “I can tolerate this feeling. I have already endured difficult feelings in the past, so I am able to tolerate my present feelings.” Take some time now to create a sentence you can believe in that reminds you why you are able to tolerate your present feelings. (10 s pause)

Now continue by reminding yourself that feelings are not permanent. Maybe you say to yourself, “Feelings come and go, and even difficult and distressing feelings will not last forever.” Keep experimenting with this sentence until you believe it. (10 s pause)

Finally, take the most helpful ideas from the 5-Step Acceptance and Tolerance Plan and summarize them to create an Acceptance and Tolerance Statement. For example, you may say, “It’s okay that I feel this way. These feelings are an important part of me, and they are trying to help me by providing me with valuable information. I can tolerate them for a period of time if I have to because I know they won’t last forever.” Take some time to create this Acceptance and Tolerance Statement for yourself, and then repeat this statement several times in your head. (15 s pause)

Now relax all the muscles in your body: hands, forearms, upper arms, face, neck, back, stomach, buttocks, and legs. Breathe calmly and regularly, and let your muscles become more relaxed with each out-breath. (5 s pause)

Now slowly bring your attention back into the room at your own pace by breathing in deeply (audible inhale), stretching and flexing your body (demonstrate), opening your eyes, and lightly tapping on your thighs a few times, so that you become fully alert again.

Sound of the bell

Note to the therapist:

As usual, a debriefing occurs at the end of the exercise. If the training setting and schedule permit, therapists may integrate additional exercises that focus on acceptance and tolerance. Here are a few examples of such exercises:

In the “tree-in-the-storm-exercise,” a participant stands with his legs locked straight and together in the middle of a small circle made by the other participants who face the participant in the center. The surrounding participants lock hands tightly. The participant in the center allows himself to fall slightly sideways, forwards, and backwards, while the other participants catch him with their arms and gently push him back toward the middle of the circle. The participant in the middle is stiff like a board and is being moved according to the participants who encircle him.

In another variation of this exercise, the ends of a long rope are tied together to form a circle. The participants stand in a circle inside of the circle of rope. The participants hold the rope at waist level behind them, so the rope runs along the backs of the participants. The participants then all lean back at the same time against the rope, so the group does not fall. Sometimes, however, the group does fall, which gives the therapist the opportunity to discuss the idea that even if our fears do in fact come true, they will probably not be as horrible as we imagine.

Mindfulness meditation can also be used by the therapist as another tool to train the participants in the skills of acceptance and tolerance. All of these types of experiential exercises can be a helpful counterweight to the didactic portions of ART.