Question 1

Do you use the actual term "neuroticism" with your clients? It has so many negative connotations and might be off-putting for them. What is the language that you use in talking with clients about this concept?

Shannon Sauer-Zavala · Accepted Answer

Although I don't use the term neuroticism with my clients, I do describe the tendency to experience negative emotions as a risk factor for developing symptoms. In fact, I have some boiler plate language I typically work into a first session. It is worth noting that my clients usually present with symptoms of more than one condition (e.g., social anxiety and depression, generalized anxiety and disordered eating). Here's what I might say:

"We've just reviewed the difficulties that brought you in to treatment and I want to let you know that, based on what you told me, you likely meet criteria for [insert client's conditions.] Having more than one condition is actually really common because there are shared risk factors that make a person broadly vulnerable; if you're high on those risk factors, it makes sense that you would have symptoms of more than one condition.

So, what are these risk factors? First, most people that seek treatment at this clinic experience emotions really strongly. The way humans experience emotions is on a continuum; some people aren't particularly bothered by stressors and don't react very strongly, whereas other tend to react more strongly to stressors when they come up. If you were to place yourself on this continuum, would you put yourself on the less reactive side or the more sensitive side? [note: not surprisingly, most clients place themselves on the more emotionally-reactive side of the continuum. Then, I normalize this experience]. Being emotionally sensitive isn't necessarily a bad thing - its just a biological difference on which people vary, like pain tolerance or metabolism. At the same time, if you experience your emotions really strongly (like viscerally in your body), you have to work harder to cope with stressors than someone on the less reactive side of the continuum - that's what makes emotional sensitivity a risk factor. However, I want to be really clear that being emotionally sensitive does not mean that having a mental health condition is set in stone.

In fact, there are two other risk factors that are probably more important when it comes to developing mental health conditions. The next risk factor is having negative reactions when strong emotions come up. For example, when you have an emotional reaction, do you tell yourself things like: "I hate this feeling," "It is weak to feel this way," "no one else has these reactions," "this racing heart is unbearable," "these intrusive thoughts mean I am a bad person."  [note: usually the client is nodding along with me as I'm giving these examples]. So, to summarize the risk factors so far, you're an emotionally sensitive person, and when negative feelings come up, you're really hard on yourself. That's leads us to the last risk factor: emotional avoidance. Because you don't like emotional experiences very much, it makes sense you'd try to get rid of them as quickly as possible. For example, you said you [insert examples of emotional avoidance that are relevant to your patient like "leave situations when you panicky," "take a nap when you're feeling down," "call friends for reassurance when making a decision"]. Unfortunately, although avoidant coping works well in the short-term (i.e., you feel better right away), it backfires in the long-term (i.e., by leaving a situation if you feel panicky, you confirm to yourself that physical sensations are a sign of danger), making you more likely to experience negative emotions in future situations."

So, that's essentially how I describe neuroticism (frequent, strong negative emotions), along with the processes that maintain them, with clients. From here, I usually talk about how the goal of our treatment together will be to help develop a more willing, approach-oriented stance toward emotions as a means to reduce reliance on that avoidant coping that maintains symptoms (and neuroticism, itself).

Question 2

I'm considering purchasing the Unified Protocol book to learn more about how to implement this theory/treatment plan into my practice. What other materials would be helpful for me to learn how?

Shannon Sauer-Zavala · Accepted Answer

One of my favorite things about the Unified Protocol is that it is relatively easy to learn, especially for therapists with a CBT background. In fact, a big reason we developed the UP was in response to how burdensome it is for therapists to have to learn a different treatment for every disorder in the DSM. Ultimately, our goal is get evidence-based treatment out to patients, and we believe that transdiagnostic treatments in which therapists need learn only one protocol to be able to competently care for most folks on their caseload is a way to do that. We bring that same attitude to training - we don't want the UP to be behind a paywall, limiting therapist (and ultimately, client, access).

I would start with the UP patient workbook.  Clinicians can read the chapters along with their patients - the key concepts are all in there. The UP contains familiar CBT skills (e.g., mindfulness, cognitive restructuring, behavior change/exposure), but the focus is shifted to how patients experience emotions, rather than symptoms. Many providers can competently deliver the UP simply by picking up the workbook!

If you are interested in more background on why we incorporated skills into the UP and descriptions of how we phrase certain concepts, the UP therapist guide would be a nice addition to your bookshelf. Additionally, the UP Applications text provides case examples of applying this treatment to individuals with complex comorbidities, posttraumatic stress disorder, insomnia disorder, eating disorders, borderline personality disorder, to name a few.

Patient Workbook: https://www.amazon.com/Protocol-Transdiagnostic-Treatment-Emotional-Disorders/dp/0190686014/ref=sr_1_2?dchild=1&keywords=unified+protocol&qid=1617373427&sr=8-2

Therapist Guide: https://www.amazon.com/Protocol-Transdiagnostic-Treatment-Emotional-Disorders/dp/0190685972/ref=sr_1_3?dchild=1&keywords=unified+protocol&qid=1617373786&sr=8-3

UP Applications: https://www.amazon.com/Applications-Transdiagnostic-Treatment-Emotional-Disorders/dp/0190255544/ref=sr_1_5?dchild=1&keywords=unified+protocol&qid=1617373786&sr=8-5

Finally, we offer expert consultation at unifiedprotocol.com.

Question 3

Can people realistically make a lasting change to their neurotic temperament?

Shannon Sauer-Zavala · Accepted Answer

Short answer: Yes.

Long answer: Although personality traits have long been thought to be stable over time, there is increasing evidence that neuroticism changes over time and in response to treatment. With regard to naturalistic, population-based change in neuroticism, several studies suggest that this trait gradually decreases across the lifespan (Roberts et al. 2006; Roberts & Mroczek 2008; Eaton et al. 2011). In addition to naturalistic change, the malleability of neuroticism has also been explored in the context of treatment for mental health difficulties. Roberts and colleagues (2017) recently conducted a meta-analysis exploring the magnitude of change in neuroticism in response to treatment. This work generally suggests that neuroticism may respond to intervention. Our own work with the Unified Protocol, a treatment developed to address neuroticism, demonstrate large decreases in this trait across 16 weeks, even when controlling for fluctuations in depressive and anxiety symptoms (Sauer-Zavala et al., 2020).

Question 4

Is neuroticism about experiencing negative emotions more frequently or is about how the person relates to having these emotions like feeling like they have no control over their negative thoughts and emotions?

Shannon Sauer-Zavala · Accepted Answer

Neuroticism is the trait-like tendency to experience negative emotions. Although we think this trait is, in part, biologically based (i.e., some people are hardwired to react to stressors with negative emotions), how one responds responds to negative emotions when they come is also extremely important. This is because these responses can maintain and exacerbate neuroticism. Perhaps more importantly, how one responses to negative emotions is malleable with treatment!

Specifically,  we think neuroticism is maintained by aversive/avoidant reactions to negative emotions. In other words, when people view their discrete negative emotion as aversive (e.g., "it's weak to feel this way," I hate this feeling," "get this feeling away from me"), they are more inclined to engage in coping strategies aimed at pushing their feelings away (e.g., avoiding/leaving social situations, drinking after a bad day, engage in self-injurious behaviors). There is ample research showing that avoidant coping works in the short-term (i.e., provides relief from negative emotions), but back-fires in the long-term, leading to more frequent/intensive negative emotions (i.e., neuroticism, itself!).

Question 5

Is neuroticism just about more negative emotion or does it also come with the tendency to experience less positive emotion?

Shannon Sauer-Zavala · Accepted Answer

Typically, neuroticism is viewed as the tendency to experience negative emotions (anxiety, sadness, shame, anger). Other definitions include viewing the world as a dangerous, uncontrollable place, along with the sense the you wouldn't be able to cope with setbacks that arise.

Deficits in positive emotions are actually not associated with neuroticism. Experiencing energy, vitality, and positive emotions is associated with a different personality trait: extraversion.  People can vary on both of these traits, independently. For example, people can be high on neuroticism (i.e., experience frequent/strong negative emotions) and high on extraversion (i.e., also experience frequent positive emotions) - this is a common presentation for some anxiety disorders. Alternatively, a person could be high on neuroticism and low on extraversion - this is a presentation we see in clients with depression and social anxiety. Some people are low in neuroticism and high in extraversion, whereas others are low in both neuroticism and extraversion.

Question 6

What methods or techniques would be helpful to implement in psychological therapy when working with a client with neuroticism?

Shannon Sauer-Zavala · Accepted Answer

Neuroticism is the trait-like tendency to experience negative emotions. Although we think this trait is, in part, biologically based (i.e., some people are hardwired to react to stressors with negative emotions), there are also psychological processes that maintain and exacerbate it. Specifically, neuroticism is maintained by aversive/avoidant reactions to negative emotions. In other words, when people view their discrete negative emotion as aversive (e.g., "it's weak to feel this way," I hate this feeling," "get this feeling away from me"), they are more inclined to engage in coping strategies aimed at pushing their feelings away (e.g., avoiding/leaving social situations, drinking after a bad day, engage in self-injurious behaviors). There is ample research showing that avoidant coping works in the short-term (i.e., provides relief from negative emotions), but back-fires in the long-term, leading to more frequent/intensive negative emotions (i.e., neuroticism, itself!).

Given the psychological processes that maintain neuroticism, successful treatments for this trait should target aversive/avoidant responses to emotions. Fortunately, many existing treatment strategies already do this for disorder symptoms (i.e., exposure to physical sensations in treatments for panic disorder). With a little tweaking, existing treatment components can be tweaked to focus on the experience of emotions, broadly, rather than focusing on specific symptoms. Here are the components from the Unified Protocol, a treatment developed to address the aversive/avoidant reactions to emotions that maintain neuroticism:

Understanding Emotions: Provide psychoeducation about the adaptive nature of emotions. We're hardwired to experience anger, anxiety, fear, sadness, joy, and guilt for a reason!

Mindfulness Training: Teach patients to view their emotions with nonjudgmental, present-focused awareness

Cognitive Flexibility: Teach patients to restructure negative thoughts about emotions, themselves. For example "It's weak to feel this way" becomes "Of course I'm feeling this way because I really care about this relationship."

Behavior Change: There is no better way to teach yourself that it is okay to feel emotions than by deliberately bringing them on yourself. Encourage patients to engage in  behaviors that put them in contact with strong emotions, especially if those activities are in line with their values.

Interoceptive Exposure: This particular form exposure refers to doing in-session exercises (e.g., breathing through a coffee stirrer, hyperventilating, spinning in an office chair) to deliberately bring on  physical sensations associated with strong emotions.

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