Healthy and Unhealthy Guilt

Guilt is one of the most difficult emotions for many clients (and therapists) to cope with. It is the emotion we experience when we fail to meet our internal standards or self-expectation. Even though it may feel like it comes from outside of us, it really comes from within – from the part of us that wishes to be perfect, or much closer to perfect than we can ever actually be. It arises from our highest aspirations, and tells us when we’ve broken our personal set of moral guidelines. Guilt is the mechanism that helps us recognize right and wrong, treat others the way we want to be treated, and live peacefully with each other. When we feel guilty about something, we try not to repeat it because guilt is uncomfortable.

We learn guilt from people around us as we are growing up: from the moral behavior that adults model for us, from the spoken rules and moral guidelines they tell us, and from how they react to our behavior. Rewards and approval communicate that our behavior was “good” while punishment and disapproval communicate that our behavior was “bad.” Ideally, the messages we get about our behavior are appropriate, realistic, and healthy. However, sometimes they are not. Sometimes we are taught moral standards that are unrealistic and unreachable. Sometimes we are taught to feel guilty about healthy behavior (setting limits or boundaries, for example), or for having certain emotions (even though emotions are healthy). Somewhere along the line we may have learned that we are responsible for the well-being of others – perhaps we had to take care of siblings, or had a relative with disability, or our parents had problems and we had to take care of them. We may have started assuming things are our fault because our family members could not take responsibility for their actions, and blamed us instead. These lessons led to unhealthy guilt.

While it is appropriate and healthy to take responsibility for genuine mistakes and failures, it is not appropriate or healthy to feel guilty when we have done nothing wrong. If someone feels like they are to blame for everything that goes wrong in their life, they are probably taking responsibility for things that they actually have no control over. Healthy guilt motivates people to assess their behavior according to reasonable moral standards. Unhealthy guilt makes them feel guilty whenever they take care of their own needs, and say no to someone else’s. Signs someone may have excessive guilt are saying they are sorry when it’s unnecessary, or apologizing excessively beyond what is necessary; assuming they are wrong and other people are right; and constantly berating themselves for imagined wrongdoing.

When guilt is healthy, coping with it effectively (rather than becoming trapped in pain and regret) requires us to forgive ourselves by: (1) understanding the circumstances and our response; (2) taking responsibility for our own behavior (but not aspects of the situation beyond our control); (3) making ammends to repair whatever damage was done; (4) problem-solving so that we respond differently in the future; and (5) accept what's done is done, and make the decision to let it go.

When guilt is unhealthy, coping with it effectively requires us to (1) understand the circumstances and what internal expectations/ideals are fueling our guilt; (2) evaluate these internal expectations/ideals and recognize when they are unfair, unrealistic, not something we consciously believe in, and/or something we would object to if applied to anyone else; (3) consciously "edit" the relevant expectations/ideals; (4) when the thing that is making us feel guilty is not objectively wrong, engage in the behavior repeatedly until it stops producing the same emotional reaction (approach rather than avoid). The last step can be really hard and may require some outside help - to verify whether the guilt is unjustified, and provide support to approach and push through the guilty feeling rather than avoid.

How do you help clients, or yourself, deal with guilt?

FEELING better vs. feeling BETTER

People often come to therapy in order to "feel better" - less depressed, more happy, less anxious, more calm, etc. We might even be able to help people feel better, if the bad feelings are the result of a mental health problem. However, just as many mental health problems seem to be the RESULT of trying to "feel better" by getting rid of the unpleasant emotions that are a normal part of life. Abusing substances, sex, gambling, and one's own body are all in service of numbing the pain. Therefore, recovery has to involve coming to terms with the fact that life can be painful.
In these cases, the goal isn't feeling BETTER - it's FEELING better. In other words, becoming better at feeling.

What does it mean to become better at feeling?

First, it means accepting - even welcoming! - the full range of human emotions. We have them for a reason. They provide us with invaluable information about our environment, they communicate with us and those around us, and allow us to move through life in ways that are both more effective and more satisfying than if we were guided by thoughts alone. (Think about it: satisfaction itself is an emotional response!). In order to reap these benefits from feeling, we have to open ourselves to the full range of emotions. We don't get to be selective. If we try to turn off one emotion (sadness, or fear, or anger, for example), we also sacrifice joy and all of the other pleasant emotions. Numb is numb. (And, really, numbness isn't sustainable: sooner or later all those icky feelings we've been avoiding will explode, implode, or leak at inconvenient times, without our having much control over it).

Once you've accepted that you're stuck with the whole gamut of emotions, it means learning to (1) notice when you are having a feeling, and (2) identify and label those feelings. Emotions are complex. They vary in intensity. They involve physical sensations and cognitive interpretations. You can have several at the same time. You can even have feelings about feelings. It takes practice to sort them all out, especially if you've been in the habit of turning them off. Sometimes it helps to have a list of feeling words available when you first begin trying to observe and describe your emotions.

Finally, it involves having a feeling and doing nothing about it - not acting on it, or trying to change it, just sitting with it, knowing that it will pass when it's ready, because emotions come and go. Ultimately, it means being able to decide when to act on an emotion, and when not to.
Mindfulness is a useful practice to cultivate, to help you become better at feeling, because it creates space to notice feelings of various shapes and sizes, observe how they shift and change, and separate from them enough to take in the information they provide without acting impulsively. Journaling can develop increased emotional awareness, and writing about emotional things has also been shown to lessen distress. Self-soothing is useful to know to help you ride out intense feelings when they come. What other practices help you be better at feelings (rather than necessarily feeling better)?!

The Problem With Anger

Anger is a normal human emotion. It's hardwired into the human species, and therefore one of the universal emotions (along with happiness, sadness, fear, disgust, and surprise). It's unavoidable.

It's also useful. Anger serves an evolutionary purpose: it motivates us to respond protectively to perceived threats. While fear tells us to respond to threats by fleeing, anger tells us to respond to threats by fighting. Provided that we fight effectively, fighting is much more likely than fleeing to prevent the same threat from happening again. (Any child who has been bullied will tell you this: as much as we admonish them to walk away, the bully rarely stops unless the child fights back).

Of course, fighting with fists (or other weapons) is not considered appropriate in our culture (it's called assault, and illegal). I'm using the word "fight" metaphorically, here. We all need to learn to express our anger in ways that are constructive rather than destructive, ways that protect ourselves from threats without threatening others. However, the biggest barrier to learning these skills is our own discomfort with anger. It's unfortunate that so many of us were taught in childhood that anger was not ok. We may have been told it was wrong, something to feel guilty about (because we were scolded for anger), or we may have been taught that it was dangerous, something to fear (often by witnessing adults' uncontrolled anger). As a result, we may avoid experiencing our own anger, often by suppressing/internalizing it, or ignoring/denying it until it escalates into rage we can't ignore. The former contributes to depression, anxiety, self-injury, eating disorders, and addiction, while the latter contributes to aggressive, explosive, and destructive behaviors.

Neither of these strategies works very well as a long-term solution: they don't resolve whatever situation triggered the anger, but do lead to painful consequences. The answer? Become both familiar and comfortable enough with anger to notice it early and cope with it actively. That means recognizing the physical and emotional signs that we are becoming angry (irritable, annoyed), calming our bodies with breathing, relaxation, or exercise, recognizing and reframing unhelpful or distorted thinking, communicating directly and assertively, and engaging in problem solving with an open mind. Of course, this is easier to say than do, and does take some time and practice, but is well worth it in the long run!

Talk It Out, Don't Act It Out

Emotions, both positive and negative, are an inevitable part of life. We all have them, for a very good reason: emotions give us information about things that are important to us. For example, fear is supposed to warn us of danger; anger tells us our needs, rights or preferences have been violated; and sadness indicates loss. Unfortunately, many people have learned to tune out, turn off, or otherwise ignore their feelings. As a result, their feelings may end up coming out in less helpful ways, either internal (anxiety, depression), or external (maladaptive behavior). 

There are several reasons clients may "act out" their feelings instead of acknowledging, expressing, and processing them. Most either haven't learned how to recognize and identify emotions (this is called alexithymia), or have been learned/been taught that emotions (especially negative emotions) are bad or dangerous. However, acting feelings out tends to be dissatisfying for the client and whomever they're communicating with through their behavior: behavior is an imprecise way of communicating feelings that causes misunderstandings and doesn't move toward any form of resolution.

The solution, of course, is to learn how to identify and express one's emotions more directly. (Easier said than done, of course). Here are some steps for dealing with emotions when they happen in a relational context (i.e., when you might otherwise act out your feelings, leaving the other person to translate your meaning).

Step 1 is to identify what you're feeling - everything you're feeling, because most of the time, emotions come layered or mixed together. I will write other posts on identifying emotions. Suffice it to say that it involves scanning physical sensations, thoughts, and impulses, and connecting them with feeling words based on category and intensity (e.g., anger vs. sadness, rage vs. irritation). 

 

Step 2 is to balance or regulate any emotions that are out of proportion to the situation at hand (e.g., to reevaluate our assumptions about someone else's motives to avoid overreacting). It's important to remember that feelings are not facts - for example, just because we feel anxious doesn't mean there is danger. It's important to sort the two out before we try to communicate our feelings.

Step 3 is to describe the full spectrum of emotions accurately, and without adding judgments, blaming, or assuming anything about the other person's feelings or intentions, or presenting our feelings as facts. If you need to reference someone else's behavior, stick to the facts. For example: "I felt frustrated and confused when you didn't call, and those feelings made me anxious about our relationship." (This is what is often called an "I statement" because you're focusing on your own experience, and beginning with "I feel..."). 

Step 4 is to make room for the other person's feelings - yes, they are entitled to whatever emotions they have as well. This can be especially challenging if the other person takes on a defensive or blaming posture, or isn't as skilled in emotional expression. 

Step 5 is to request the response you would like from the other person. If you just want to be heard, tell them you want them to understand (rather than change) how you feel. If you want them to change their behavior in some way, be specific, direct, and concrete (again, leaving out judgments and assumptions about intent). If there is something you want them to do to "fix" your feelings, be clear about that, too. 

Step 6 is to thank them for listening, or responding as you've requested, and (if/when you're ready) see if there is something they need you to do, hear, or say.

Are there other strategies you use to identify and express emotions? What makes this process difficult?

Facing Disappointments

The day after the Patriot's disappointing 4th quarter loss to the Giants in the Super Bowl seems like a good occasion to think about disappointment. Disappointment is perhaps one of the most common kinds of negative emotion. It happens when our hopes don't turn into realities. It happens so often that we tend to discount or dismiss it...but, under the surface, it can contribute to a host of problems that clients bring to therapy.

Like all emotions, disappointment serves a purpose. It helps us get our needs met by recognizing which of our desires are healthy and realistic (and which aren't), whom we can count on (and whom we can't), and what is (and isn't) in our control. However, for individuals with depression or low self-esteem, disappointment easily lends itself to cognitive distortions such as: "Nothing ever goes right for me," "nobody cares about me," or "I don't deserve to have good things happen."

The first step in coping with disappointment is to guard against these kinds of distortions, and try as much as possible to keep your thoughts balanced. Recognize that it's normal to feel disappointed sometimes, and that the disappointment is limited to this specific time and circumstance (in other words, don't overgeneralize). Put it in perspective by reminding yourself that other good things will come along (as sports fans say, "There's always next year!"). When in doubt, get someone you trust to serve as a sounding board. If necessary, implement distress tolerance skills.

Once the worst of the disappointment has passed, look back at the situation to see if you might have contributed in some way to the disappointment - for example, through unrealistic expectations, denial, or self-sabotage. If any of these things are present, they are good topics to cover in therapy, especially if they are patterns or habits.

Finally, re-focus on your goals and use your problem solving skills and creativity to figure out what it is you really need, and how you can move in that direction in spite of the disappointment. As the old adage says: "Where there's a will, there's a way!"

(Adapted in part from The Food and Feelings Workbook)

Avoiding Avoidance, Revisited

A few months ago, I wrote about the potential for forms of avoidance to contribute to emotional and psychological problems. Most basically, avoiding aspects of human experience that may be uncomfortable or distressing alleviates discomfort/distress in the short-term, but exacerbates difficulties in the long-term by intensifying anxiety about that aspect of experience, and inhibiting the ability to cope with and modulate distress.

The most empirically-supported treatment for the various anxiety disorders (panic, phobias, OCD, PTSD), is called "exposure and response prevention" - in other words, a guided process of exposure to triggers for anxiety while preventing "safety behaviors" (ways of stopping/avoiding the anxiety without dealing with the trigger). The person experiences anxiety in response to the trigger, but waits for the anxiety to dissipate (like other emotions, when allowed to happen, anxiety peaks and then lessens on its own). Each time the person is exposed to the trigger the "peak" of anxiety is less intense, as a result of the previous exposures, until eventually the trigger is no longer triggering.

DBT expands the use of exposure, to apply to any emotion that causes a client problems in functioning (e.g., anger, guilt, shame, fear). It also expands our understanding of exposure to include anything that evokes the immediate or remembered experience of the emotion. Finally, it clarifies that the exposure has to include a "corrective" experience - in other words, the exposure should not reinforce the problematic emotional response, but should "correct" in with incongruent information or an incompatible emotional response. The same principle applies with classic exposure and response prevention - the idea is that when nothing bad happens as a result of exposure to a feared trigger, the fear begins to be disproven.

Based on all of this, it seems obvious that, for therapy to be effective, it is necessary for it to expose clients to the distressing emotions (and triggers thereof) that are causing problems for them. However, while doing so, it's also important to keep the overall level of emotional arousal within the "therapeutic window" - neither so little arousal that there is no real exposure to the emotions, nor so much arousal that the client's internal processing system is overwhelmed and the exposure itself becomes traumatic.

In group therapy, a significant challenge is to keep exposure to emotions within each individual group member's therapeutic window, so that nobody is traumatized, but everyone has the opportunity for growth. I've been filling in at a day program location (while waiting for my own location to open) that has dealt with concern about group process becoming traumatizing for someone by making it their policy to avoid triggering anyone (i.e., to avoid exposure altogether). As a result, everyone tip-toes around the issues, and nobody work through the issues that brought them to the program. Yesterday, one of my clients expressed frustration with this dynamic, and i have to say I'm frustrated too.

So, what is the answer? How do we bring emotional exposure into the therapeutic window, when clients are at very different levels of emotional tolerance/arousal? I'm interested in hearing your suggestions!