Going with the flow: emotion regulation and coping

I’m in two minds about attempting to regulate emotions. From ACT, and in particular, mindfulness, I’m learning that trying to control emotions and thoughts is darned near impossible – and unhelpful. From the research on the effect of pain on emotions and subsequently on self regulation, goals and coping, it seems that pain strongly influences emotion and that negative emotions in particular, influence the range of coping strategies and goals we choose – and success or failure in turn generates further emotion, and so on.

As Hamilton, Karoly and Kitzman say ‘the primary function of pain is to disrupt other ongoing activities and to direct attention toward the cause of injury or the extent of tissue damage’ – of course, in chronic pain, there may no longer be any injury or tissue damage, and instead we are left with the experience of disruption to activities without a purpose. Pain by definition involves negative emotions, which we have seen over these posts recently, can activate ‘harm-avoidance’ strategies. Over time, pain can reduce the attention given to, and pleasure obtained from, activities that are usually enjoyable, and can reduce how well we process normally positive information.

So, pain detracts from normally enjoyable activities and reduces the benefits we usually get from achieving goals, probably makes us less likely to choose goals that are driven by curiosity or positive benefits and instead increases the chance we’ll choose ‘harm avoidant’ goals, and when things go wrong, pain makes it much more difficult for us to look creatively at ways to cope.

Self regulation is influenced therefore by emotions – but at the same time, self regulation can influence emotions. Pain management goals in one study were not only influenced by negative emotions but also by the level of social support people had. Maybe routinely including family and social networks into pain management goal setting with people with pain would be helpful. I’m noticing that over the past 20 years, the number of people who attend assessments and pain management programmes with partners or family members has dropped considerably. It’s almost as if the person with pain is the only one who ‘has’ to cope. A couple of posts ago I discussed the need to ensure that people have adequate coping resources before setting self regulation goals, because these resources become depleted (and there is no doubt self managing pain is hard work!).

Yesterday I mentioned ’emotional complexity’, or the ability to tolerate opposing moods.
Hamilton, Karoly and Kitzman think that this ability is something that is acquired rather than a trait, and suggest that CBT and ACT may, because they help people understand the relationships between thoughts and emotions, help people develop the ability to regulate emotions. Of course, ACT suggests that rather than trying to control either thoughts or emotions, we simply acknowledge them and they will pass.

By maintaining focus on values, or what is really important, ACT suggests that we’re able to tolerate the fluctuations in emotions and thoughts and remain engaged with things that we value. ACT theory suggests that by allowing the moods or thoughts to flow, the natural ebb and flow of emotions continues rather than building up to an intolerable level, or being judged negatively.

This is a different approach to self regulation from CBT where CBT suggests that by logic we can reassess our thinking patterns and replace them with more helpful ones, and in turn these will influence emotions. I think CBT has its place, but more and more I’m finding that at least part of the time I’m encouraging people to ‘sit with’ negative emotions and thoughts in order to reduce the threat value or judgements about them, and help people recognise that they will survive and can continue to do what is important even if at times they feel different feelings, including negative ones.

A good deal of pain management works on helping people cope with the stress associated with having pain. The authors suggest that it might be just as important to consider working towards approach-oriented goals, that is, doing things that have positive reward, such as social goals, because these both support self regulation, as well as generate positive emotion. ‘Therapists must emphasise to paitents that it is important to maintain focus on other goals, even during painful flare-ups…both patients and therapists [can] become focused on distress management and lose sight of goals related to an enhanced sense of wellbeing.’

The way I interpret this is that it’s just as important to help people identify social activities, leisure activities and have fun and grow as it is to persist with getting better sleep, return to work, or use relaxation to cope with a flare-up. I’ve been including scheduled pleasant events every day with patients for quite a while now – and it can be unbelievably difficult! Some people have never ‘had fun’, never had time to be sociable, never thought of relaxing or having a hobby or being creative.

I remember with one patient, we instituted a whole ‘Pyjama Day’ where she could take the phone off the hook, watch DVD’s, paint her nails, have a soak in the bath and read trashy novels! Initially it was really difficult for her to do this without feeling guilty, but later on she enjoyed it and started to look foward to it, and then started to plan self development ‘creative’ things she could do on that day. Yes, painting or photography or baking or learning a foreign language can be part of pain management!

This won’t be the last post on self regulation, coping, emotions, goals and chronic pain. It seems to neatly tie in with the focus of living a good life despite having pain, and especially of living according to values. I think self regulation is one of those ‘occupational performance components’ that might be overlooked by some occupational therapists who focus on occupational performance, or function, but might not consider the underlying skills and resources that need to be present for someone to function well. Occupational therapists have as a core philosophy that ‘doing is being’, and by doing functional activities, people become well. It looks like that assumption has some support from the literature, now it’s time to look at how to help people ‘do’.


Hamilton, N., Karoly, P., & Kitzman, H. (2004). Self-Regulation and Chronic Pain:The Role of Emotion Cognitive Therapy and Research, 28 (5), 559-576 DOI: 10.1023/B:COTR.0000045565.88145.76



  1. An interesting article. I have chronic pain and depression, and have recently undertaken a course of CBT. Luckily for me, my therapist was very keen on mindfulness and also recommended I investigate ACT.

    I can see how in some ways CBT and ACT seem to contradict each other. For me, however, ACT is part of the ‘how’ of changing my thinking. Accepting what IS, rather than focusing on it in a highly negative way as I was doing before, is a much more helpful way of viewing my feelings and pain.

    I don’t know if I am explaining myself very well. It’s something fairly new to me still, and I’ve not tried to express it to others before!

    1. You’re doing well with your explanation! I hadn’t thought of it that way, but you’re exactly right. It’s about the ‘how’ rather than the ‘what’ that CBT focuses on. Thanks for taking the time to comment, it’s really helpful.

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