This is a concept that you may find helpful in understanding the impact of emotional dysregulation. I would like to share this with you because it is a useful concept in helping us not only understand and help our clients to manage emotional ‘overwhelm’ but can also help us to regulate our own emotional roller-coasters! So what is it? The Window of tolerance was a term used by Dan Siegel to describe the optimal zone of arousal in which we can function most effectively. When people are within this zone, they are typically able to readily receive, process, and integrate information (i.e. learn and be creative) and otherwise respond to the demands of everyday life without much difficulty. In this zone, we can think calmly, be more rational, and are not in state of overwhelm or overloaded withdrawal. Here’s a useful way of imagining it: As you can see from the diagram, either side of the optimal window zone, there are other 2 states. During times of extreme stress, we can experience periods of either hyper- or hypo-arousal. 1. The Hyper-arousal zone is otherwise known as the fight/flight response. We can feel hypervigilant, or very anxious, scared or panicky. Thoughts may be racing and all the physiological symptoms of the Sympathetic Nervous System being stimulated are likely to be present (increased heart and breathing rate, dry mouth, butterflies in the stomach, shaking etc). At its most extreme, people in this zone may experience a range of symptoms associated with posttraumatic stress, such as flashbacks, nightmares an derealisation. 2. The Hypo-arousal zone is otherwise known as the freeze response. In this state, we may be emotionally numb, feel empty or at its most extreme even psychologically paralysed (‘rabbit caught in headlights’). At its most extreme, people in this zone may dissociate, have memory issues, and experience feelings of depersonalization. In either the hyper or hypo arousal zone, we cannot process information effectively because the prefrontal cortex region of the brain goes ‘off-line’, in a manner of speaking. In contrast, the sub-cortical regions (such as the reptilian brain and the limbic system) are ‘running the show’. This is because we are in Survival Mode. This will naturally affect our ability to think rationally, and thinking can become overly rigid or chaotic. When we are in either of these zones, we are therefore out of our Window of Tolerance. Everybody has a different range or capacity for being in their window of tolerance. People who have experienced trauma, or sustained periods of extreme stress, may find that their windows are pretty narrow. They may feel that it doesn’t take much to flip onto either Hyper or Hypo zones and it can be tricky to stay on the Window for very long. The window of tolerance can also be affected by environment: we are generally more able to remain within the window when we feel safe and supported. How can we manage our emotions to stay in our Windows of Tolerance? The evidence-base indicates that a range of techniques can help an individual to get into or stay in their Window of Tolerance. These techniques help to bring ‘on-line’ the prefrontal cortex and calm down the over-activated parts of the brain (sub-cortical regions). Techniques such as grounding exercises and breath-focussed strategies can be effective ‘emotional first-aid’ strategies. Any technique that regulates and calms the breath will help. Mindfulness skills help us to remain in the present moment and are a ‘pre-fontal cortex activity’. Body-focussed therapies and apporaches such as gentle massage and yoga (if it feels safe for the individual) can also be soothing and grounding. With regular Mindfulness practice, and for some, psychotherapeutic support, many individuals are able to widen their window of tolerance and, by doing so, increase their sense of calm and become able to deal with stress in more adaptive ways. Further Reading: Mindsight. By Daniel Siegel The Mindful Therapist. By Daniel Siegel Dr Sarah Halliday Senior Consultant Clinical Psychologist Halliday Quinn Limited, Nov 25 2019 

Many studies have shown that traumatic brain injury can result in difficulties with recognising emotions (39%), particularly fear and sadness and also in reduced empathy (60%). As therapists we are aware of the impact of these changes on relationships: when loved ones need comforting the most i.e. when they are frightened or upset, they are unlikely to get it from their injured partner who can appear detached and uncaring - often very different from how they used to be. In treatment, a relational approach to this difficulty is essential (Neumann et al 2017) (Kreutzer (2015) so that those around the client as well as clients themselves are assisted to understand, adjust and adapt to such profound changes. After all, empathy’s social role is to serve as the origin of the motivation for cooperative and pro-social behaviour as well as effective social communication. Empathy as a concept links loosely to both Tom and Lauren’s earlier blogs….. Empathy seems to be associated with activity in the ventro-medial pre-frontal cortex (the VMPFC), the area that may hold the key to the so-called executive paradox (Lauren’s topic). The executive paradox complicates assessment of capacity in many highly intelligent people. The VMPFC seems to contribute importantly to decision making where multiple factors apply and when situations are uncertain, ambiguous or specifically financial. These ingredients are often present in the decision making scenarios that prompt the need for capacity assessments. In a 2018 study (Beadle et al), people with VMPFC injuries behaved with little empathy in a financial context towards a man who was in a state of suffering compared to matched uninjured controls. The choices made by people with VMPFC injuries were also more likely to contribute to negative social impacts and evaluations. Andrew Worthington argues in the April edition of The Neuropsychologist that attention should be directed a bit less when assessing capacity at dorso-lateral pre-frontal cortex (DLPFC) related skills and more at ventro-medial function i.e. everyday tasks, social function and pre-injury behaviour as Lauren has pointed out. The overlap with empathy deficits may be relevant. Moving to Tom’s musical theme……A study reported in Nature last month by Novembre et al suggests that there may be some mileage in musically based tasks to promote cooperation in those who have difficulty with empathic perspective taking (EPT). When asked to be the leader of a pair engaged in synchronising musical output using e-music boxes, low EPT as well as higher EPT individuals were able to modify their movements and speed to make it easier for their musical partner to synchronise with them. Does this finding support the idea of a relational approach to treating reduced empathy? It is not clear whether treatment approaches alter only the cognitive aspect of empathy (the capacity to understand another's perspective or mental state). The emotional aspect (the capacity to respond with an appropriate emotion to another's mental state) may be more elusive. Is it the same missing ingredient that applies in the executive paradox where decision making needs the additional input of more emotional, “gut instinct” reasoning? Louise Russell Senior Consultant Clinical Neuropsychologist Halliday Quinn Limited, Sep 13 2019

Research shows the benefits of using music as a tool for improving various mental health conditions, including depression, trauma, and schizophrenia (to name a few). Music acts as a medium for processing emotions, trauma, and grief - but music can also be utilised as a regulating or calming agent for anxiety or for dysregulation. Active Music Listening Music can be utilised to regulate mood. Because of its rhythmic and repetitive aspects, music engages the neocortex of our brain, which calms us and reduces impulsivity. We often utilise music to match or alter our mood. While there are benefits to matching music to our mood, it can potentially keep us stuck in a depressive, angry or anxious state. To alter mood states, play music to match the current mood of the person and then slowly shift to a more positive or calm state. It has been generally accepted that both listening to and creating music can have various positive effects on mood and mental health. Incorporating music into your everyday life can help to: ▪elevate your mood and motivation ▪aid relaxation ▪increase the efficiency of your brain processing. Tom Hughes Practice /Business Manager Halliday Quinn Limited, Jul 3 2019

Research shows the benefits of using music as a tool for improving various mental health conditions, including depression, trauma, and schizophrenia (to name a few). Music acts as a medium for processing emotions, trauma, and grief - but music can also be utilised as a regulating or calming agent for anxiety or for dysregulation. Active Music Listening Music can be utilised to regulate mood. Because of its rhythmic and repetitive aspects, music engages the neocortex of our brain, which calms us and reduces impulsivity. We often utilise music to match or alter our mood. While there are benefits to matching music to our mood, it can potentially keep us stuck in a depressive, angry or anxious state. To alter mood states, play music to match the current mood of the person and then slowly shift to a more positive or calm state. It has been generally accepted that both listening to and creating music can have various positive effects on mood and mental health. Incorporating music into your everyday life can help to: ▪elevate your mood and motivation ▪aid relaxation ▪increase the efficiency of your brain processing. Tom Hughes Practice /Business Manager Halliday Quinn Limited, Jul 3 2019