Throughout this blogsite we have argued that addictive behaviours are rooted in inherent stress/emotion dysregulation and in emotion processing deficits such as alexithymia.
These emotion processing deficits give rise to undifferentiated emotion states which are not utilised in reasonable prefrontal cortex based decision making but instead prompt more motoric sub cortical areas in distress based impulsivty.
In simple terms this emotion processing deficit means there is an urgent impulsive desire to escape distress states often resulting in a decision making tendency to regulate negative emotion my external means e.g via substance use of maladaptive behaviours.
This emotion regulation and processing deficits result in impulsive decision making which initiates and perpetuates the addiction cycle to it’s compulsive endpoint, where compulsive behaviours relieve chronic emotional distress.
Alexithymia, Emotional Dysregulation, and Recovery From Alcoholism
This fascinating article (1), just published, ties in with many of these ideas and supports much of what we have discussed and forwarded as essential aspects of the pathomechansim of addictive behaviours.
It also shows how learn to identify emotions more clearly helps the recovery process.
“Evidence of existing alexithymia and emotional dysregulation, dominance of negative mood, and increasing ability to identify, accept, and regulate mood as part of recovery was found.
Alexithymia is the difficulty in identifying, naming, and expressing emotions (Kauhanen, Julkunen, & Salonen, 1992; Timoney & Holder, 2013). Its prevalence among individuals with AUD is reported to be between 45% and 67% (Thorberg, Young, Sullivan, & Lyvers, 2009). Alexithymia is associated with additional risk factors such as higher levels of negative emotion, more distressing somatic symptoms (Connelly & Denney, 2007; Lumley, Ovies, Stettner, Wehmer, & Lakey, 1996; Taylor, Parker, & Bagby, 1990; Thorberg et al., 2009), and immature ego defense mechanisms (Helmes, McNeill, Holden, & Jackson, 2008; Parker, Taylor, & Bagby, 1998; Stasiewicz et al., 2012), as well as higher rates of behavioral addictions, such as eating disorders and gambling (de Sousa Uva et al., 2010; Kun & Demetrovics, 2010).
Emotional dysregulation includes factors that define alexithymia but is more comprehensive, representing difficulty in modulating emotions and using emotional cues adaptively to interact effectively with the environment (Gratz & Roemer, 2004;Gross & Muñoz, 1995; Stasiewicz et al., 2012). Berking identifies the structural components of successful emotion regulation to include factors associated with recovery from alexithymia (e.g., being aware of emotions, identifying and labeling emotions, and accurately interpreting body sensations related to mood) and factors related to effective response to emotion (e.g., using emotional cues to inform action, accepting and then modifying negative emotions, confronting versus avoiding distressing situations, and being able to self-soothe when in distress; Berking, 2010;Berking et al., 2011). In a study of individuals with AUD, those with fewer emotion regulation skills at baseline were more likely to drink during treatment, and those with fewer emotion regulation skills at discharge were more likely to drink at follow-up (Berking et al., 2011).Therefore, when participants stated that rating their mood was helpful, we suspected this was indicative of larger, important processes related to mood and the AUD recovery process.
To our knowledge, no previous study has explored the lived experiences of individuals with AUD as they grapple with mood, alexithymia, and emotion regulation while pursuing AUD recovery. Orford (2006) identified a “neglect of the client’s perspective in the alcohol problems treatment field” and argue that “asking clients about their experiences is likely to be one helpful source of information” in addictions research (p. 68).
we observed clear stages through which many participants described moving, from discovering hidden feelings to identifying whether the feeling was positive or negative, to interpreting those feelings, to acting based on the feelings.Figure 1 provides a visual representation of the sequence of stages we observed.
This study used the Positive and Negative Affect Schedule (PANAS), a widely used psychometric instrument, used to measure changes in positive and negative affect, dependent variables of the parent study, by asking participants to rate the degree to which they felt 23 different emotions1 on a daily basis for 14 days (Watson & Clark, 1994; Watson, Clark, & Tellegen, 1988).
Becoming aware of hidden affect
Completing the PANAS seemed to help participants plumb an inner boundary, a kind of psychic membrane, which separated emotion that was within conscious awareness from emotion that was beyond conscious awareness.
Half of the participants specifically noted difficulty in identifying their emotions even when presented with the list of feelings that are part of the PANAS instrument. They mentioned that it was “hard” or “a struggle” to identify what they were feeling at a particular moment:
[The PANAS was] challenging because it’s a matter of understanding where I’m really at and I know that’s still something I struggle with. What am I trying to tell other people that I want to believe about myself, and what’s real? Where am I really at?
That was a struggle to pay attention to every single day: “How am I feeling today? What’s really going on inside of me?”
The level of difficulty reached the point of discomfort for some. One participant noted that his challenges in identifying feelings made being a participant in the study a less enjoyable experience for him, to the point of finding it both “tedious and difficult.” Some not only had a hard time identifying the feelings themselves but also had difficulty rating the extent to which they felt them on the 5-point Likert-type response scale, describing that it was hard to determine the depth and intensity of the feelings they had identified.
Some participants indicated that the PANAS was a challenge because it diverged from the ways in which they usually dealt with feelings. One participant, by way of explaining his earlier attempts at increasing emotional awareness, mentioned that he could name his feelings in the context of processing issues in a treatment group, but that he shied away from the practice when alone, preferring to “move on” when feelings emerged. Two participants mentioned that they secluded themselves from outside distractions and settled down quietly before completing the PANAS to be able to give careful consideration to what they might be feeling and accurately identify and rate their emotions.
In fact, many described taking time while completing the instrument or immediately before to identify their feelings. One recalled a need for “some time and some peace and some reflection” to connect with his feelings. He noted he would close his office door and “try to put myself in a space where I could be more in touch with how I was feeling at that point.” These were practices they did not normally engage in but that were necessary to tap these emotional domains.
The need to sit quietly before identifying feelings suggested that distractions would make this task more difficult. In fact, a participant mused that those in the early stages of their recovery would probably face even greater challenges with the PANAS because of the stressful and often chaotic circumstances that attend early recovery. Another echoed the possibility of obstacles or distractions in identifying feelings by noting that he found the exercise easier on days when he felt physically well.
Some connected their difficulties completing the PANAS with the relationship between emotions and drinking. Another admitted that “a big part” of her substance use had been about numbing her emotions, and described how getting sober involved a new process involving feeling her feelings. This experience was also frustrating because it was hard to identify which mood was pressing to the surface at a given time.
She implies here that when feelings come up, the urge to drink can follow, because “that’s what your natural response is”:
You’re so used to burying, you’re so used to not feeling because of the drugs and alcohol. You’re just numb for so many years. In a lot of cases it’s years that you’ve done that to yourself. When you take away drugs and alcohol those feelings are going to start coming up which is very difficult to deal with because it’s new. It becomes a new thing to actually feel feelings and to recognize them. It gets frustrating because sometimes you can’t put your finger on it. And it gets frustrating because naturally you’re just so used to shoving those feelings down with the drugs and alcohol that that’s what your natural response is.
Given the stated difficulty of experiencing emotions again after using alcohol to numb affect, the PANAS seemed genuinely helpful to individuals with the difficult task of identifying what they were feeling.
Its very structure appeared useful in guiding the process, by asking whether the respondent was feeling 23 distinct feelings one-by-one, and then providing an opportunity to rate each feeling’s intensity. Multiple participants expressed that they preferred completing the scale to providing a narrative response about their feelings because the scale provided a list of possible emotions and a visual representation of overall mood furnished by the Likert-type scale:
I think those adjectives and words really helped me determine, “Yeah, that’s how I’m feeling.”
This participant also noted that the longer list of feelings offered on select days was “helpful” by offering her a greater variety of potential feelings “because it made [her] really think further” about what emotions she might be experiencing. Another participant recalled a six-item feelings list from his treatment program, and how he felt confined and “really frustrated” by having to choose feelings that were not entirely accurate reflections of his emotional state.
In general, participants commented that the PANAS helped them become aware of what they “really” felt:
And from [the PANAS] you kind of look, you know, “Have I really been feeling like this?”
Again going back to the adjectives that were used [in the PANAS] and thinking about, “Gee, I really feel that way.”
Participants described this experience as eye opening and revealing:
It opened my eyes to look at and think “Wow, okay. That is what’s going on.”
To do [the PANAS] on a daily basis . . . it revealed a lot.
Three participants’ progress through the model stopped at the discovery stage, with no mention of interpreting results or acting because of them. However, they still found the increased awareness to be useful on its own and potentially beneficial in their recoveries from AUD. One participant reflected on his difficulty in identifying his emotions at a given point in his recovery, and used that experience to reflect on how others might grapple with emotions during the early stages of recovery and theorize about the best time in recovery to address emotional issues, a line of thought echoed by others in the Interpreting phase below.
For another participant who appeared to stop at the discovery stage, the process of becoming aware of emotions through completing the PANAS brought to mind a more global awareness of her decreased reactivity to stimuli that had previously angered her, as well as her improved ability to cope with stress. She noticed how far she had come by witnessing a relative become angry and thereby realized how much she herself had changed.
Identifying positive and negative emotion
Immediately upon gaining awareness of previously hidden mood came the identification of the valence of that mood, that is, whether the mood was “positive” or “negative.” While two participants discovered positive emotion, the majority of participants (12/14, 85.7%) discovered negative emotion.
Interpreting those discovered emotions, making sense of them, and ascribing meaning to them took place in these data only in response to negative mood. This process was also reported as both challenging and helpful.
Many participants were surprised to realize that they felt worse than they had thought. The surprise seems to indicate that participants believed that, on a daily basis, they struggled with fewer negative feelings than the PANAS revealed. One participant even felt that she had been “delusional” about her feelings prior to the study, meaning that she was not aware of the extent of her negative feelings. Another felt the discovery of negative feelings “kind of triggered some odd stuff for myself, a realization,” and she went on to say that even after completing the gratitude exercise, she
still had a lot of lousy feelings about myself and fears, anger, anxiety, and stuff like that. I mean I knew they were there but I guess I never realized how much a part of my thought they really are.
Multiple participants viewed their affect as a marker of their progress in recovery. When they felt bad, they interpreted it not as a passing mood but as an indicator that they were not as far along in recovery as they had previously thought. Some were surprised that they still felt negative affect, with one summarizing the sentiment with, “I think I should be feeling better now.” When asked whether it was upsetting to realize that he felt worse than he thought, one participant responded,
Not necessarily upsetting, just taught me that, like I said, I’ve been working on a lot of things for a long time and it’s just how much more work I have to do. A realization, I thought I was progressing but in a lot of ways I haven’t and that’s not good.
Interpretation of negative affect seemed helpful to some participants. For some, the realization of negative affect led them to think about its relationship to their alcohol use and the coping mechanisms they had developed in recovery. One participant thought it might be helpful to see if the urge to drink was stronger on days when his negative affect was higher. This participant hypothesized the two would co-occur, suggesting that such insights might help him resist drinking urges more effectively. Other participants noticed that negative mood helped engage existing coping mechanisms, such as spirituality and processing feelings with others.
For some, the interpretation stage was useful because the surprise of discovering negative affect enabled them to recognize a measure of self-delusion about their feelings. One participant recalled anxiety in reviewing his responses to the PANAS, knowing that the responses would reflect “the real me,” but did not mention any benefits of this realization. Another found the results “distressing, but insightful,” indicating possible benefits from this realization.
Others, however, considered this information valuable because the surprise itself pushed them closer to a readiness to deal honestly with their emotions or because knowing their real feelings could prevent them from acting destructively including erupting in anger and/or drinking:
When you start recognizing how you’re feeling, then sometimes you might not snap that much at people. For me, I kept everything up and it’d be the wrong person just did something that was the most stupid, minor thing but I’ll just let them have it because everything was piling on and I had to have it, let it go. And if you don’t let it go, then I drink.
Although the majority of participants reported that they discovered negative mood, one participant stated that the PANAS was helpful because it made him realize theabsence of negative mood:
[The PANAS] was a great tool to realize whether I was hyper or agitated; it made me feel good about myself because I wasn’t having a lot of those [negative] feelings. Some days I was just so totally calm that it’s just unbelievable.
Several participants found this phase helpful and stopped at this stage.
After discovering hidden emotion and finding it to be negative in valence, some participants generated a plan of action to down-regulate these difficult feelings.
The realization of persistent negative affect might have been discouraging, but ultimately four participants created an action plan to address negative mood. The majority expressed no plans for action, and this in and of itself might indicate difficulties with this stage, perhaps suggesting the presence of direct obstacles or a lack of options in terms of what steps might be helpful. For example, one participant expressed a great deal of discouragement related to the discovery of negative mood without mentioning any ideas for moving forward.
Taking action was reported as a problem-solving mechanism that was implicitly helpful. Four participants interpreted their feelings as showing them what they needed to work on with specific attention to doing things to fix or be rid of negative mood:
And if it’s a bad feeling, if I . . . do feel a little complacent then okay, what can I do to fix that?
And if it wasn’t a lot of positive feelings then there’s something that I need to work on.
Again going back to [the list of feelings] and thinking about “Gee, I really feel that way.” Or “I need to help myself get out of, particularly, the negative area.”
Participants wished to go into action to address negative affect, though they varied in their approaches. Some mentioned bringing up their responses in counseling. One participant who had brought her newly discovered feelings into a counseling session said that she found the PANAS daily record to be a good complement to the work she was doing with her therapist, reinforcing the idea that keeping track of feelings was a good way to monitor treatment progress and to draw attention to areas of life that needed greater focus. One mentioned that negative mood indicated trouble with his “spiritual connection.” He described that when feeling bad he might “work on my spirituality, maybe reminders of how I could be of better service to others, just getting out of my head on how I’m feeling that day.”
Another participant described how he would notice feeling bad, but then his mood improved after taking action: “[A]fter I slept on it or talked to my sponsor, then I can say, I’m okay. I’m okay here.” One participant described the whole process as helpful, linking his emotional discoveries quite closely to actions that would assist with mood improvement:
As I’m learning and will continue to learn, feelings and how you deal with them [are] very important. Especially for recovery, but I also think that they are important for anyone in normal daily living. It’s nice to be able to read a question [on the PANAS] and realize that that’s the feeling you’re having, and maybe find a way if it’s a bad feeling to make it a better feeling. And if it’s a good feeling, how to keep it.
One participant took a form of cognitive action, during the interview itself. She was distressed at discovering negative emotion, wondering, “Now what’s wrong with me still?” Rather than allowing negative thoughts to spiral, however, she countered this tendency with a more realistic reframe:
And I know [recovery] is not a magic fix either because I didn’t expect, if you get sober to be all of a sudden everything is perfect. That’s not the way it works. . . . So it’s going to take you a little longer to feel better.
One participant described taking action in a way that was helpful to her, but which did not fit within our conceptual framework. She talked about taking action as part of the “discovery” phase. This participant described that when she is “going through something” she isn’t sure what to make of it: “ . . . I don’t know what’s going on. I don’t know what to think.” During these times, she would,
. . . sit down with people and bounce some ideas off each other and get it off your chest and stuff. That’s very helpful and that kind of helps me, like saying it out loud to identify where I’m actually at.
Participants’ difficulties with the PANAS depict the classic characteristics of alexithymia. Half of the sample admitted it was hard for them to identify their emotions, which is in keeping with the definition of alexithymia. Being unaware of emotions is another feature of alexithymia. While all participants identified hidden mood, they did so because their interaction with the PANAS enabled discovery. Without completing the PANAS, it is conceivable that their feelings would remain hidden until, if at all, another circumstance brought them to the surface.
Participants’ desire to act in response to negative mood can be viewed in two ways. Down-regulating negative mood is a feature of healthy emotion regulation. Difficulty tolerating uncomfortable feelings, however, is a sign of emotional dysregulation.
It is noteworthy that we observed several examples of the desire to eliminate negative mood and no examples of the wish to sit and better tolerate distress.
…improved tolerance of emotional distress is a skill related to healthy emotion regulation (Berking, 2010; Berking et al., 2011; McKay, Wood, & Brantley, 2007) with specific implications for AUD and relapse; in one study, higher tolerance of negative emotions predicted lower probability of drinking in a sample of individuals in treatment for AUD (Berking et al., 2011).
A minority of participants interpreted negative feelings as global markers of overall emotional ill health and poor progress in recovery, for example, “I think I should be feeling better now” and “I thought I was progressing but in a lot of ways I haven’t and that’s not good.” Here, participants realize they are experiencing negative feelings and understand it as suggestive of a larger negative phenomenon, for example, that they are not “better now” and not “progressing” as previously thought. This type of negative globalization is a type of cognitive distortion.
1. Krentzman, A. R., Higgins, M. M., Staller, K. M., & Klatt, E. S. (2015). Alexithymia, Emotional Dysregulation, and Recovery From Alcoholism Therapeutic Response to Assessment of Mood. Qualitative health research,25(6), 794-805.