It’s Not All in Your Head: Affect Regulation in Psychotherapy

The term “affect regulation” is seen more often in the clinical literature as research on the neurobiology of emotions advances. It refers to the capacity to tolerate intense affect (positive and negative) without using avoidance strategies such as dissociation, substance abuse, or other defenses (Briere). For deep exploratory work in therapy, our patients require this emotional resilience.

Such flexibility develops from an early secure attachment relationship. Allan Schore integrates modern neuroscience findings with the studies of John Bowlby. Schore describes how the mother’s attunement helps physiologically structure her infant’s nervous system. His work fits with earlier infant observation studies (Stern, Beebe).

Affect regulation is governed by the autonomic nervous system (ANS), which keeps the body in homeostasis (balance). The ANS links the brain stem with the rest of the body. It is activated by external demands on the person. The sympathetic branch of the ANS energizes us to deal with challenges (e.g. fight/flight), while the parasympathetic branch discharges this arousal, so we can relax when encounters end. Under normal conditions, a gentle flow and rhythm prevails between the two, producing a feeling of well-being and confidence that we can handle what life hands us.

Many clients suffer from a chronic imbalance of their autonomic nervous systems, due to early attachment problems and/or trauma. They don’t feel in charge of their bodies or their emotions. Many are highly reactive. Others use avoidance for fear of being triggered and feel deadened, lonely or depressed as a result.

As children they likely confronted overwhelming situations, and were left without comfort. Their bodies may rarely have felt “safe” enough to truly rest and recover. Thus, they are stuck in hyperarousal (the sympathetic NS) or numbness (the parasympathetic NS), or they fluctuate wildly between the two. The symptoms of PTSD reflect this instability: the hyperarousal of irritability, sleep disturbance and hypervigilance, and the numbing of withdrawal, avoidance and detachment.


Psychoeducation about the role of the nervous system in emotional distress can diminish our patients’ shame. It can also increase their hope. Research shows we can positively influence the ANS through psychological means. Although the most common remedy for autonomic instability is medication, self-regulation skills can be taught, with more permanent results. As patients learn ways to regulate themselves, they feel empowered. It strengthens their capacity to confront painful issues in therapy.

Research shows that this “body-up” approach may be more effective than verbal processing with dysregulated clients. Trauma expert Bessel van der Kolk’s brainscan studies showed that the language area of the brain shuts down as patients remembered their traumas. He believes PTSD patients must learn to quiet their physiological arousal to allow their minds to work. Marsha Linehan’s effective work with borderlines also emphasizes distress tolerance skills.

Therapists can teach how self-regulation is a normal task faced by everyone. Tools range from exercise to Ipods. We can ask patients how they achieve “a good mood”, e.g. gardening, talking with friends. Positive somatic memories are also antidotes to distress, as described by Babette Rothschild in The Body Remembers.

Two innovative approaches, Somatic Experiencing Therapy and Sensorimotor Psychotherapy, posit that many traumatized clients are stuck in a “freeze response” because danger prevented their exercising instinctive survival responses. Focus on positive sensations in the body brings some initial relief. Clients are then gently guided toward discharging thwarted defense responses (fight, flight). These methods reduce excess activation in the nervous system by helping the client locate bodily sources of strength and calm.

Imagery can also help patients discover inner resources. For example, in Ego State Therapy, a patient is encouraged to ‘float back’ to an earlier time when the current distressing sensations, emotions and negative self-beliefs were present. Once there, the invitation to imagine a different scenario, (“What needs to happen to feel better?”) can help the person recall supportive figures or even fantasy characters their child-self used to achieve stability in the past.

Our clients often feel ashamed and desperate because they have felt out of control for so long. They appreciate education about what’s happening in their bodies as well as their minds. This can increase their realistic hope and facilitate deeper work in therapy.