The Dysregulated Adult: Integrated Treatment Approaches

Index

Chapter 1

Problems of Self-Regulation in Adults

Problems of self-regulation are common among adults with a range of psychiatric diagnoses. These problems may include difficulties with self-consoling, sleep, eating, attention, sensory hypersensitivities, and/or mood regulation (i.e., irritability, anxiety, and depression). The common diagnoses of individuals who have poor self-regulation include bipolar or mood disorder, anxiety, obsessive–compulsive disorder, Asperger’s syndrome, eating or sleep disorder, attention deficit disorder, borderline personality disorder, and post-traumatic stress disorder.

Poor self-regulation is a process deficit that impacts the person’s everyday functioning and interpersonal relationships. Often, problems of self-regulation are lifelong and have roots in the person’s early childhood development. As problems with self-regulation become entrenched, the person struggles with self-soothing and mood regulation. It impacts the capacity to modulate arousal for sustained attention, to be motivated for purposeful activities, to process and tolerate a range of sensory stimulation, and to tolerate change and handle everyday stress. Frequently, the person struggles with coping skills, impulsivity, and self-control. As a result of the regulatory disorder, the person is apt to have difficulty developing a clear sense of identity, purpose in life, and self-efficacy.

Most of the research on regulatory problems is on infants and young children (DeGangi, 2000; Greenspan, 1992); however, the diagnosis of regulatory disorder as defined by Zero to Three (1994) has wide application to adults experiencing similar symptoms. Because adults with these behaviors are commonly observed in clinical practice, it is important to understand how self-regulation develops; the symptoms underlying various regulatory problems; and how difficulties with self-regulation impact adaptive behavior, everyday functioning, and interpersonal relationships.

In this chapter, an overview of regulatory processes in adults is presented and a conceptual model of self-regulation is proposed. The symptoms that constitute a regulatory disorder in adults are described. The different types of regulatory disorders that have been proposed by the Diagnostic Classification: 0–3 are modified and described in relation to current research on adults with emotional problems. Case examples are presented to depict the symptomatology of the different subtypes. Checklists are provided to assist the clinician in diagnosing adults with problems of self-regulation. The Adult Symptom Checklist can be used in helping clients understand their own regulatory profile. In addition, the Adult Emotional Observation Scale is presented for use by therapists to better understand the client’s capacity for self-regulation and to serve as a guide for treatment.

1. The Concept of Self-Regulation and its Development

1.1 Overview

In the developing person, the early regulation of arousal and physiological state is critical for successful adaptation to the environment. The development of homeostasis is important in the modulation of physiological states including sleep–wake cycles, hunger and satiety, body temperature, and states of arousal and alertness. It is needed for mastery of sensory functions, self-calming, and emotional responsivity. It is also important for regulation of attentional capacities (Als, Lester, Tronick, & Brazelton, 1982; Brazelton, Koslowski, & Main, 1974; Field, 1981; Sroufe, 1979, 2005; Sroufe, Coffino, & Carlson, 2010; Tronick, 1989, Tronick & Beeghly, 2011).

Self-regulatory mechanisms develop and refine early in the person’s life. Some of the important milestones include the formation of affective relationships and attachments, reciprocal communication and language, the use of self and others to control internal states, an understanding of causal relationships in human behavior, and the development of self-initiated organized behaviors. It is generally recognized that self-regulatory mechanisms are complex and develop as a result of physiological maturation, caregiver responsivity, and the person’s adaptation to environmental demands (Lyons-Ruth & Zeanah, 1993; Rothbart & Derryberry, 1981). If these essential processes are not in place early in life, it impacts the person lifelong, compromising his or her ability to develop self-control and mindful behavior.

1.2 Fundamental Skills Needed for Self-Regulation

1.2.1 Level 1: Homeostasis

Reading and Interpreting One’s Body Signals

The foundations of self-regulation lie in the person’s capacity to develop homeostasis early in life. This is especially important for self-soothing and the ability to read one’s own physiological responses and bodily rhythms (e.g., body temperature, sleep–wake cycles, and hunger–satiety). In a normally developing individual, the person regulates internal arousal states and attentional focus for learning and processing information. To accurately read bodily states, the person needs clear internal feedback from the body, the ability to differentiate and interpret body states (e.g., I’m hungry and it’s time to eat), and the ability of the mind to control the body under different environmental demands or situations (e.g., I’m tired but it’s not time to sleep and I need to find a way to increase my arousal to stay awake and alert).

A complex interplay between the person’s psychological experience and internal physiological state makes self-regulation possible (Porges, 2003, 2009). A dynamic bidirectional communication occurs between the peripheral nervous system and the brain, providing a feedback loop between the vagal system and the brain. For example, increased changes in heart rate help support fight-or-flight behaviors, whereas decreased heart rate supports social interactions and affective and communicative signaling. Specific cues in the environment elicit physiological states associated with safety or danger (e.g., high, piercing scream). Internal feedback between the vagus nerve, a primary component of the autonomic nervous system, and the brain helps the person with breath control, physiological relaxation, and to achieve an overall state of calmness when self-regulation is needed. This is accomplished through the vagus nerve’s influences on the heart and breath control. The polyvagal system also provides feedback to the body to prepare it for flight or fight when physical threat is imminent. In the polyvagal theory, the autonomic nervous system responds to social interactions, environmental demands, and sensory stimulation. It also provides feedback to the brain to modulate how the nervous system should react to real-world challenges.

Processing Sensory Stimulation

Self-regulation depends on the person’s capacity to observe and process sensory stimulation from the outside world (DeGangi, 2000; Greenspan, 1989, 1992; Lachmann & Beebe, 1997). This includes the person’s ability to process and tolerate a range of sensory stimulations, such as touch, movement, visual, auditory, and olfactory inputs. Greenspan (1992) described the infant’s first task as learning to regulate him- or herself and to take interest in the world. Modulation and processing of the range of sensory experiences allows for social engagement and attachment to others. A person who is easily overwhelmed by sounds, touch, movement, or visual stimulation may avoid interactions with persons or situations that are highly stimulating. In contrast, the person who does not process sensory input unless it is very intense may develop a pattern of thrill seeking, high stimulation, and risky behavior.

Distortions in the sensory systems can cause a person to misconstrue or misinterpret attempts at soothing from caregivers. For example, a child who cannot stand to be touched or held because of tactile sensitivities may arch, pull away, or cry when touched. A responsive caregiver may develop a hands-off approach to soothing a tactually defensive child, using movement or visual or auditory stimulation as a means to soothe his or her baby. This can have wide-reaching implications for adult functioning. Karen was such an individual who could not tolerate any physical contact from others, whether routine, affectionate, or sexual in nature. She misconstrued any touch as attacking or hostile, and she reacted by withdrawing and cringing when touched. Sometimes she would strike a person who accidentally bumped her or tapped her to get her attention. This impacted her work and family relationships and resulted in her choice to live alone and never date. Karen was quite lonely and wished for intimacy, but she did not know how to make inroads into social relationships with others. She often puzzled about whether she might have been abused as a young child, but she had no memories or evidence of trauma. One possibility might have been that her parents did not know how to console her as an infant and did not recognize her withdrawal from touch as a sign that she perceived touch as aversive. Without treatment to help her with this problem, she continued to perceive touch in ways that felt disorganizing and intrusive.

Internalizing Self-Soothing from Others

In early development, self-regulation depends on the responsiveness of caregivers. For a young infant, the caregiver soothes the infant when distressed and facilitates state organization (Als, 1982). As the person develops, he or she internalizes the soothing role of the caregiver, learning to recognize signs of internal distress and finding suitable ways to self-soothe and modulate states of arousal and alertness for everyday tasks. The neural mechanisms that allow for this include the polyvagal system, which provides a feedback loop between the autonomic nervous system and the brain, and the hypothalamus and reticular activating system, which help the person develop an internal awareness of physical self-states (i.e., arousal levels, fatigue, hunger, agitation, and stress reactions). Persons who are unable to take in the soothing of a caregiver, who have unreliable internal feedback mechanisms of self-states, or who cannot plan and organize their own soothing activities will be highly compromised in self-regulation.

Kate was a middle-aged woman who had a highly dysfunctional nervous system. Her body interpreted everything as a physical threat. She interpreted nurturing gestures or soothing situations as aversive. Sitting in my office, she complained that the soft, comfortable chair felt hard on her body. She complained that the rug made her feet itch inside her shoes. She squinted at the light even when indoor lights were dimmed. She startled at the slightest sound in the hallway and was agitated by ambient noise from the radiator. It was impossible to help her feel calm, and things developed into such an extreme situation that she could not sleep in her own bed at home or eat meals with her family. Within weeks, she began to sleep in her car outside the house because the sounds from the house kept her awake, or she went to a hotel hoping for relief. In addition, she had many physical complaints—headaches, stomachaches, and extreme muscle fatigue. These problems seemed to change day-to-day. Kate described herself as struggling with these issues her entire life, but the problems emerged after a botched cosmetic surgery made her physical appearance much worse. This case example depicts a person with extreme sensory processing disturbance, unreliable body feedback mechanisms, and sensory and psychological distortions that significantly impacted her emotional well-being.

Just as the baby learns how to self-soothe early in life by sucking, holding onto his hands or feet, or looking at sights or listening to pleasant sounds, the adult must engage in self-soothing activities to maintain a well-balanced nervous system. This may take many forms—sitting in a rocking chair and reading, taking a long run in the park with the dog, or playing music on the piano. Frequently, adults find themselves in situations in which they are overworked or highly stressed, having no time for self-soothing activities. Without daily self-soothing activities, an adult can quickly deregulate into high irritability, impulsive actions, withdrawal, explosive or angry reactions, and high stress or overwhelming feelings.

Anna was a 35-year-old woman who depended heavily on her husband, Rick, to keep her calm and organized. Without his constant help, Anna could not plan and organize even the simplest of tasks, such as turning on the faucets to take a shower or retrieving and opening the mail. Every night, she needed to cuddle with Rick on the sofa, covered together with a heavy comforter while they read or listened to music. Without his reassuring and organizing presence, Anna felt overwhelmed and unable to function through the day. She recounted that as a young child she was clingy and unable to separate from her mother, needing her mother by her side to feel calm and to initiate purposeful activity or play. Anna is an example of a person who never learned how to internalize soothing experiences from a nurturing caregiver to self-soothe independently or to use the persons in her adult life in a more differentiated and mature manner.

In normal development, a caregiver who is responsive to the young infant’s distress helps the child learn to self-soothe. The child internalizes these self-soothing activities and gradually learns to apply these soothing activities for him- or herself. As people mature, they learn to self-observe, to read their own bodily cues, and to predict what strategies will work for them in different situations. Without a responsive caregiver, people may never learn this task, or they may develop, as in the example of Anna, highly dependent relationships with the persons in their lives. It can also impact their internal emotional life in a negative way. For example, Freddy was a 40-year-old man who was overlooked by his parents when he was a young child. The needs of his severely handicapped older sister consumed his parents’ attention. Freddy was expected to be the good child, not causing any extra demands or problems for the family. Poignantly, he remembers staring at his dinner plate full of food, wanting to tell his parents about his good report card but being put off by them as they struggled to feed his older sister. In Freddy’s work and family relationships as an adult, he continued this pattern of feeling invisible, feeling that he did not deserve to be nurtured and that he was a person unworthy of attention from others. His regulatory adaptation was to shut down and withdraw from the world.

Even in a well-regulated person, times of high stress, trauma, or exceptionally unpleasant or devastating life experiences can induce dysregulation by elevating stress hormones (e.g., cortisol levels). The person who is grossly overworked or overwhelmed may stop taking care of himself, not eating or sleeping well, which in turn compromises his ability to function at near optimal levels at work or home. Examples of people who may be dysregulated due to high stress include the person who works long hours for fear of losing his job to a younger, lower paid employee; a young mother who struggles day-to-day with a sleepless and irritable child; and the person who takes on too many projects with not enough time to complete just one. Trauma can exist in many forms and result in extreme dysregulation. A person serving in the military may be exposed to horrible trauma, seeing people killed and risking his own life in day-to-day combat. Many persons exposed to this never get over worries for personal safety and devastation at loss of fellow soldiers. Examples of people who may be dysregulated by trauma include a young woman raped at knifepoint, an elderly man robbed as he enters his home, and a young couple who lose their first-born baby soon after birth. Each of these situations can cause a person to dysregulate, and if the person does not pay extra attention to his or her need for self-regulation, the person may remain in a state of dysregulation for many years.

Signaling Communication About One’s Own Needs for Self-Soothing

Self-regulation is dynamic and requires that the person take in feedback from others while also communicating effectively through gestures and words to signal information about his or her internal state of being and physiological needs. Mirror neurons in the brain help the person take in and process models of self-soothing or other adaptive behaviors for use in a variety of situations. Mirror neurons are located in the frontal and parietal lobes and are activated when one person sees another doing a specific action. Neurons in the motor cortex fire to create an imitative response in the observer (Rizzolatti & Arbib, 1998; Rizzolatti & Fabbri-Destro, 2008; Rizzolatti, Fabbri-Destro, & Cattaneo, 2009). The baby cries in distress when uncomfortable, and the mother places her hand on the baby’s abdomen and soothingly talks to her baby. Her smiling and loving face is processed in combination with the tactile and vocal input, and soon the baby mirrors her soothing, modulating from a scream to a content and calm state. In this way, the person adapts to incoming signals from others and the environment to help modulate a regulatory response. Mirror neurons play a vital role in facilitating mutual reciprocity and signaling between persons during self-regulation (Solms & Turnbull, 2002).

Lucy was a woman with borderline personality disorder who seemed to lack all capacity to take in verbal, affective, or gestural communication from me and other persons in her life. Upon entering my therapy room, she would immediately sit down in the chair, gaze out the window, and talk almost nonstop about her problems, rarely pausing to allow me to respond in any way. On a few occasions, she would glance at my face but clearly had no interest in taking in what I might offer her. We made some inroads into this when I suggested that she try the mirror experiment. Because she could not tolerate reciprocity in social interactions and she also seemed flooded by affective or gestural communication from me, I suggested that she focus for the next few weeks on noticing what she saw when she looked in the mirror at herself, thus distilling the feedback to only herself. By mirroring herself, she began to think about how she saw herself and how others might see her. Gazing at her reflection, Lucy had thoughts such as Who is this person in the mirror? What is she really like? and What do others see when they look at me? Following this experiment, Lucy could glance at me in small bits, taking me in without being quite so overwhelmed and becoming slightly more interested in what feedback I might offer her in therapy.

1.2.2 Level 2: Purposeful Communication and Planning of Thoughts and Actions

Planning and Organizing Thoughts and Behaviors

In the normally developing person, the next level of self-regulation involves the capacity to process and generate effective gestural and verbal language to communicate intentions, the ability to adapt to a range of everyday routines, and the ability to respond contingently to the expectations of others (Kopp, 1987, 1989, 2009, 2011; Tronick, 1989). The prefrontal lobe plays an important role in planning and organizing behavioral schemes. The language cortex and associated areas (temporal lobe and Wernicke’s and Broca’s areas) help the person communicate thoughts through verbal and gestural language. Likewise, the parietal lobe, basal ganglia, and cerebellum engage in planning and execution of motor actions. It is a complex neurological process for the individual that can be derailed if basic homeostasis is not accomplished at the prior stage of development.

As the person develops the capacity to plan and organize thoughts and behaviors, he learns to adapt to changing family, interpersonal, and life expectations and to plan for future actions. We see this in the individual who can control her body and mind for a specific purpose or goal without becoming distracted. This is accomplished, for example, by individuals who have learned to meditate, slowing their active minds and bodies down to concentrate on a precise, single stimulus.

This level of self-regulation requires the development of intentionality, reciprocal interactions, organized affects, and an awareness of situational meanings. This stage is critical for the adult to learn how to modify actions, thoughts, or feelings in relation to events in his life. It is accomplished through the person learning to initiate, stop, modify, or change responses as situations occur, thus allowing him to engage in more adaptive behavior (Zimmerman, 2005). The person may need to inhibit the desire to sleep when in a business meeting or the urge to eat more when he has just finished a meal. This ability to inhibit actions may prevent the person from fleeing from a stressful situation when staying and coping is required. It can also help a parent stop himself from yelling at his child for doing something upsetting such as spilling his beverage on the computer keyboard.

At this stage of self-regulation, the person learns to initiate, maintain, and inhibit physical actions or impulses. This is the basis for problem solving, intentionality, and awareness that actions lead to a goal. On a neurophysiological level, higher cortical control (e.g., prefrontal lobe) overrides lower brain centers (e.g., reticular activating system and hypothalamus) that control basic bodily functions. Feedback loops between the reticular activating system, deep limbic structures to the cortex, and the prefrontal lobe help the person to develop intentionality, purpose, and motivation. The prefrontal lobe plays an especially important role in self-stopping, in generating ideas, and in maintaining motivation for adaptive behavior. It is this dynamic feedback loop that helps the person evaluate her internal bodily state, to self-observe readiness to respond, to read external situational demands, and to integrate past learning and responses to apply to the current situation. The ability to plan and organize thoughts and actions comprises three main components, which are described in the sequence in which they occur in behavior.

Developing Ideation

This is the first step—to develop a clear thought, desire, or target behavior. It is a function of the prefrontal lobe and involves turning the search light on a particular idea and making it clear for execution. If the idea is not well formed, as often occurs with attention deficit disorder or executive functioning disorder, the person may be aimless, disorganized, and restless. Even when there are clear environmental cues, the person may not register the importance of the goal and the need to act. For example, many people are not fazed by a messy kitchen overflowing with dishes or a house stacked with unpacked boxes even when there is not a single clean dish to be had and the important, unfound object is frustratingly hidden away. Sometimes the person exists in a constant state of conflict and cannot act on an idea. Jillian was a young, stay-at-home mother who had no idea how to organize a schedule for herself, let alone her kids. She was constantly late for appointments or showed up on the wrong day. She could not seem to set a schedule for meals or bedtime for herself or her children. Her house was a complete mess, with boxes stacked in the living room and basement all the way to the ceiling, with only a small path to make one’s way through. She saved everything, including baby toys from when her youngest, a 7-year-old, was a baby. One of her children had attention deficit/hyperactivity disorder (ADHD) and had no place to move inside the house to channel his hyperactivity. He often got his hands on things that were potentially dangerous, such as a can of bug spray. Jillian was completely unable to get started on anything. For example, she still had not unpacked her suitcase, which was sitting on the coffee table, from a trip she had taken months ago. Jillian’s home environment was a mirror of the chaos she must have felt internally.

A typical problem that occurs when the lower brain centers prevail over the executive planning frontal lobe is that the person cannot resist temptation. This is seen in the person who loves to eat, wishes to lose weight, but cannot. It is also seen in the person who feels chronic fatigue and restlessness when at work, knows that he needs to get the job done, but his mind drifts off and next thing he knows, he is surfing the Internet for real estate web sites instead of doing his work (Baumeister, 1991a, 1991b).

Another common problem when a person cannot develop a clear idea and goal-directed focus is cognitive indecisiveness. This is common among persons with high anxiety or obsessive–compulsive disorder. They may ruminate repeatedly about when to start, what to do, whether it will be correct, how to do it, etc. Often, they have multiple ideas in their mind but cannot focus on one or prioritize them in proper sequence. Christine was a young woman who felt compelled to check her purse approximately 25 times per day to see if she had everything she needed and to be sure she had not forgotten something (e.g., her wallet, tissues, and keys). She worried constantly about whether the house was clean and ended up vacuuming the floors for 9 hours per day. When she was not vacuuming, she was cleaning her refrigerator, worried that items were not fresh or had expired dates. Christine was unable to work because her day was filled with these repetitive tasks, none of which accomplished any real purpose for her. She yearned to go back to college but had no idea how she would fit studying and classwork into her life.

Self-Control and Self-Monitoring

The emergence of self-control is the next level of planning and organizing thoughts and behaviors. Volitional control requires self-monitoring, self-control, and self-limiting behavior. The person must be self-aware and mindful of her own actions while engaged in doing a task. Verbal mediation of thoughts and actions helps the person organize self-regulatory behavior (Kopp, 2009; Kopp, Krakow, & Vaughn, 1983). In normal development, the person begins to differentiate emotions and her sense of self from others. This is the stage of development when the person learns to express negative affects, frustration, and aggression. If a person is derailed at this stage of development, she is apt to be constantly frustrated, explosive, and aggressive toward others. With children, the caregiver attaches affective meanings to situations and provides social expectations and values related to specific emotional responses. This helps the child to label and understand emotions (Kopp, 1987). The development of certain behaviors, such as self-talk, distracting oneself, self-monitoring, or external supports (e.g., list making, timing devices, and prompts from others), helps in attainment of emotion regulation (Kopp, 1989, 2011).

As the person develops self-control, he learns to internalize routines and requests made by others. These routines are established early in life—for example, a set bedtime, meals at certain times, or doing certain activities such as exercise at specific times. There are considerable individual and cultural differences that influence these schedules and routines, but what is important is that there is an established rhythm and pattern to the person’s daily activities that allow him to function well in life. Many persons with severe ADHD live moment-to-moment with no capacity to plan for a regular schedule. Carley was a middle-aged woman who went to bed at different times each night, often awakening during the night because she remembered something she forgot to do during the daytime. She would get up, pay the bills, do the laundry, pack her children’s lunches, and do other activities that would awaken and agitate her. Carley lived in a chronic state of fatigue and stress overload due to her erratic sleep–wake rhythms. During the day, she often found herself highly irritable toward family members and unable to cope with unexpected problems.

In the process of planning and organizing actions, the person needs to attend to relevant details, gather important information for the task at hand, and then engage in proper actions for task achievement. The person needs to be mindful of her actions and self-monitor as she engages in the task. Allocating attentional resources is critical for self-monitoring. Many persons think they can multitask efficiently, but often they allocate only part of their attentional resources for each task (e.g., texting, writing a paper, and talking on the phone). Often, they do not complete any of the tasks optimally unless the activities are rote or habitual in nature (e.g., talking on the phone while ironing). Self-monitoring requires that people resist urges to respond to off-task or impulsive wishes. They need to delay gratification and stay focused and intent on their goal. Persons who struggle with self-monitoring have poor self-control, poor self-awareness, restlessness, and usually cannot delay gratification. This is often seen in persons who are chronically stressed and have poor mood modulation. Living with them is overwhelming to others because they become angry easily when they cannot handle the stress anymore. A person may have poor self-awareness and not recognize that she is exhausted before it is too late and then fatigue and fail in the task at a critical juncture (e.g., a diver practicing for hours to perfect a particular dive and then hitting the diving board when fatigued).

An important aspect of this phase of development is learning to delay one’s own actions and to comply with social expectations without needing external cues. Gina was a 32-year-old woman who could not stop her impulses to eat, shop, or do anything that came into her mind. She appeared to be a free spirit, full of joie de vivre, when in fact she was constantly overwhelmed and feeling depressed that she could not fulfill the simplest of goals. She felt incompetent with regard to the basics of life. Her impulsive spending had placed the entire family in financial jeopardy. She had also become grossly obese and could not begin to take charge of this problem through diet and exercise. Gina tended to say whatever thought popped into her head and frequently alienated many people. She was unable to hold a job because of her tardiness and erratic schedule, and her husband was on the verge of leaving her because her impulsive behavior had caused the family so much strife.

Self-control relies on the person’s development of forethought, planfulness, volitional control, and self-reflection (Zimmerman, 2005). In forethought, the person analyzes the task before her, sets goals, and plans a strategy to accomplish her goal. If the idea is not well formed in her mind, which is often the case for persons with attention deficit disorder or executive functioning problems, she may struggle to get started. The person needs to be able to attend to relevant information about the task and feel motivated to do it. Self-control depends on being able to sustain effort, manage time, remain focused on the goal, and resist distractions that might divert one from one’s goal. Common problems at the ideation or forethought stage might be aimlessness, disorganized or risky behaviors, procrastination, or conflicting or ambivalent goals (Baumeister, 1991a, 1991b). The person is apt to feel indecisive, emotional distress, or confused about her own identity because she lacks purposefulness.

Breakdowns in self-control are commonly observed in clinical practice. Hostility, aggression, irritability, high frustration, and violence may be manifested in persons with poor self-control. The ability to resist temptation, resist the urge to respond when it is inappropriate, and delay gratification is central to self-control. To develop better self-control, the person needs to be able to evaluate himself while in the process of doing a task or engaging in an interaction, all of which require mindfulness of self and others.

Finally, the capacity to self-stop or self-limit is important to self-control. It involves both mental and physical exertion and control to override the impulse to act when the task or situation requires them to inhibit or stop. Some persons cannot resist temptation as in the case of overeating, drug or substance abuse, or other addictive behaviors. There may be extreme peer pressure or external forces that urge a person to act when she should not. In addition, internal states of fatigue or high stress may break a person down and cause poor self-control.

Charles was a highly successful businessman with a wife and three children. When he was promoted to vice president of his company, he felt that his whole life had begun to spiral downward. His wife, Melissa, noticed that he was always on edge, yelling at her and the children for the slightest thing. It was when Melissa found his bank statements and credit card bills that she realized that something was very wrong with Charles. In the course of 3 years during which pressures from his job mounted, Charles had lost self-control on many fronts. He had started to self-medicate to cope with the pressure using a mixture of cocaine and valium in addition to overuse of alcohol. He hid this well from his family because he engaged in substance abuse only when traveling for business, which he did frequently. He lived high off the hog, spending money the family did not have on custom-made clothes, a fancy sports car, and, it turned out, expensive jewelry for his mistress. Melissa soon realized the lies and deceit in which Charles had engaged. It was unbearable for her, and within the year, the couple divorced. However, Charles was helped by participating in a substance abuse/addiction program. He also discovered through therapy that he had long-standing issues from his childhood related to his inability to self-control and self-monitor. His parents indulged his every whim as a child and never allowed him to experience wanting for something or frustration that something might not occur. This revelation allowed him to work on how to tolerate simple distress and frustration, to learn to wait for things, and to plan carefully to achieve goals.

Planning and Organizing Adaptive Responses

This is the last observable step in the planning sequence. During this step, the person engages in purposeful actions for task completion, adjusting his behavior as the task unfolds. The person gathers feedback as he does the task and receives internal feedback to allow for motor or cognitive adjustments for errors, mistakes, and performance standards (i.e., go faster, make smaller movements, etc.). Self-discipline and the capacity to stop oneself are important features of organized behavior. For example, the person may feel fatigued and wish to stop performing, knowing that it is time for a break or he will fail in the task. He may feel highly stressed by the situation (e.g., performing on stage) and wish to escape. There may be outside pressures to do something else, such as peer pressure that distracts the person from his primary goal. The person may derail himself by engaging in a behavior that impairs his cognition (i.e., substance abuse) or may be unable to resist sensory pleasures—alcohol, drugs, sweet desserts, or sex—at times when he needs to focus efforts on more purposeful, goal-directed activity.

Emotional dysregulation can cause a person to lose the capacity to plan and organize. There are instances of short-acting emotional dysregulation, such as when a person is writing a document, the electricity fails before she saves it, and all that she had been working on is lost. The person tantrums, takes a walk, and then returns to begin the task all over again. In contrast, a person can have long-standing, chronic stress, such as in the case in which a mother constantly says deeply injurious, nasty comments to her children. The rage that is elicited is apt to persist for quite some time.

In clinical practice, we often hear examples of how poor inhibition and problems with self-initiation impact the entire family. Stacey complained that when she would walk in the door after a long day at work, she would find her 2-year-old child hungry and crying for attention. Her husband, Curt, was unemployed and depressed with his plight at staying home with the toddler. As soon as Stacey would see her husband lying on the sofa reading a magazine and still in his pajamas and oblivious to their child’s distress, she was instantly triggered. Within moments, Stacey would begin shrieking at her husband for not starting dinner for their child, raving that the house was a complete mess and that he was clueless about her work exhaustion. Curt’s lack of intentionality and awareness of the situation not only led him to being dysregulated in a withdrawn, shut-down state but also pitched the entire family into a state of dysregulation. Stacey’s dysregulation went to rage and was in opposite action to Curt’s withdrawal, but both felt distress, frustration, and irritability at their terrible situation.

Differentiating One’s Own Thoughts and Actions from Others: Theory of Mind

A growing awareness of self as a separate identity contributes to the person’s ability to differentiate her responses from the actions of others. Brianna, a young mother with a history of emotional and physical abuse, could not see herself as separate from her 30-month-old child. At our multifamily group therapy session, we asked Brianna if we could serve her child some cottage cheese during snack time. She replied, Oh, he won’t like it. I don’t like it, so he won’t like it. When we further inquired if he had ever eaten cottage cheese, she replied, Of course not. It is a simple example, but this spilled over into many activities for Brianna, who could not tolerate her young child exploring new things. When playing with her child, she was very controlling of what he was allowed to play with and how, often introducing play ideas that were far beyond the capabilities of a 30-month-old. For example, she might tell him, Count the pieces. Now tell me the colors. Don’t touch that. Do as I say. Let’s start over and count them right this time. Unlike most 30-month-olds, the boy stood frozen in fear, staring at the colored puzzle pieces and not knowing what to do or say. In our work with Brianna, she frequently expressed how she was raised with such an iron hand that she never grew up to know who she really was: It was like I was invisible, even when my mother looked at me. I had to do what she wanted me to do and never could do anything I wanted to try. Now she was doing the same thing with her young child, and we were trying to stop the cycle and allow both Brianna and her young son to blossom.

The ability to mentalize affective experiences first develops through the person exploring the many meanings of his own actions and the actions of others. In this process, the person becomes increasingly aware of his own emotions as he interacts with objects and persons (Fonagy, Gergely, Jurist, & Target, 2004). Two key processes help the person construct an internal experience of affective experiences. One way is through the symbolization of experiences or pretend play expressed in young children. The child picks up a small acorn and animates it in his hand, bobbing it up and down on top of a piece of bark. The child then exclaims, Look. It’s daddy. He’s going on a magic carpet ride. The symbolization allows the person to express a range of emotions—pleasure and excitement, separation and individuation, assertion and aggression, as well as negative emotions of frustration, fear, anger, or sadness. As the child enacts emotions through play, he begins to make sense verbally and nonverbally of his internal emotional life.

Adults continue to do this through expressive arts such as dance, art, music, and story writing. Sometimes it is only after a person has symbolized a story that he truly begins to understand what he might have been struggling with for many years. For example, Robert was deeply troubled his whole life until he wrote a story about witnessing his younger brother being killed in a tractor accident. They lived on a farm and, at the time, the boys were 8 and 10 years old. Every day of his life, he thought of his brother and felt a terrible guilt that he could not save his brother from death. Robert found that he made many life decisions based on this pivotal traumatic event and sometimes engaged in risky behavior (taking drugs, stealing, and driving while intoxicated). When he put pen to paper, he finally came to understand himself better and the impact this experience had on him. Through the symbolization of the written narrative, he helped gain a new perspective and insight into this traumatic event.

A second major way that we mentalize symbolic experiences is through empathic affective mirroring. It is very powerful to experience the reflective mirror of another’s face and voice attunement, response, and reflection as we express our own internal emotional experience. Emma, who was a highly anxious child, repeatedly played that she was injured and had to go in the ambulance to the hospital, and then once healed, she could finally feel free, riding the horses at the stables with abandon. Her attuned father joined her play, reflecting on the overwhelming fear that Emma felt. Emma was a selective mute and was paralyzed by new situations and places, not being able to speak or move. As her father reflected on her worries that something dangerous would happen to her and that she worried that something was seriously wrong with her, Emma began to blossom.

As adults, we experience empathic affective mirroring in a range of ways. For example, whenever Diane spoke in therapy about something emotionally stressful to herself, she choked up and could not speak, and then she reached for her bottle of water to soothe herself. In this moment, she sought to self-distract and self-soothe herself, pushing emotionally charged feelings aside as she comforted herself. I asked her to pay attention to what happened at the moment when she paused to take her sip of water. With empathic attunement, I reflected how distressed she was as she talked about how her mother criticized her about all kinds of things, from her body appearance to how she never quite met her mother’s extremely high standards and comparisons to her older sister. I simply inquired, Every time you speak of your mother, you stop and take a sip of water. Do you know why you do that? She replied, I feel this terrible sensation of being choked when I talk about my mother, like I don’t have any air left to breathe. I urged her to tell me more, and instead of changing the topic as she usually did, she described how her mother made her feel suffocated, dictating who she must be and how she must act down to the simplest of actions. Instead of being criticized and judged, I provided for her an empathic attunement that allowed her to experience a different affective experience while also thinking about her mother.

Table 1.1 provides a summary of the conceptual model for self-regulation in adults.

Table 1.1. Summary of the Self-Regulatory Process

2. What is a Regulatory Disorder in an Adult?

A number of etiologies can cause problems of self-regulation in adults. In most individuals with a regulatory disorder, the problem is lifelong and is often constitutionally based. Some persons are born with a difficult temperament and struggle with irritability from the time they are babies. Hereditary mental illness such as bipolar illness, anxiety, and depression become evident in early to middle childhood and have a major impact on personality formation, mood stability, attachment relationships, coping skills, and adaptation to change. When these problems are accompanied by sensory hypersensitivities, which is often the case, the person often reacts in maladaptive ways to overstimulation from others and the environment, misinterpreting soothing sensory experiences as aversive, and associating anxiety with certain types of sensory stimulation (e.g., certain types of touch, movement, sights, or sounds).

In other individuals, the problem may be secondary to exposure to high stress, trauma, or other distressing external events. If the person has been traumatized or subjected to overwhelming levels of stress, the stress hormone, cortisol, elevates and induces a state of high alert and arousal in the individual that is highly deregulating. Often, persons who have been traumatized develop a learned helplessness that can lead them to believe that they are a failure and unable to tackle what they perceive as unsolvable problems (Baumeister, Heatherton, & Tice, 1994; Mikulincer, 1989). Likewise, dissociated states of mind can occur when a person has been traumatized, providing the brain with an escape mechanism and a way to cope with the unspeakable.

Whether the regulatory problem is hardwired biologically or related to traumatic events, the person struggles with a combination of symptoms including high irritability, poor self-calming, an intolerance for change, a hyper-alert state of arousal, as well as an inability to regulate the mind. In the adult, problems of self-regulation often cause the person to have poor self-control, impulsivity, low distress tolerance, inadequate coping skills, impaired judgment, ineffective problem solving, and negative self-esteem. It appears that the problem of self-regulation in adults is related to a neural instability in the deep limbic regions of the brain (Siegel, 1999). Dysfunction in the limbic system can have a profound effect on the brain’s overall capacity to process information, focus attention, regulate mood and affect, and engage in interpersonal