- Universidad de Málaga, Campus de Teatinos Universidad de Malaga 29071, Spain
Academic Editors: Sok Cheon Pak and Soo Liang Ooi
Special Issue: Health Benefits of Meditation
Received: August 23, 2018 | Accepted: March 05, 2019 | Published: March 14, 2019
OBM Integrative and Complementary Medicine 2019, volume 4, issue 1 doi:10.21926/obm.icm.1901017
Recommended citation: Ramos Díaz NS. Proposal for a Compassionate Emotional Accompaniment Technique (CEAT) Based on Mindfulness to Manage Disturbing Emotions. OBM Integrative and Complementary Medicine 2019;4(1):13; doi:10.21926/obm.icm.1901017
© 2019 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.
Different researchers converge on the idea of the functional and adaptive value of emotions. There is general agreement on their importance in motivating cognition and action, and in being a valuable source of information to facilitate coping, adaptation, social affiliation and well-being . However, this primary functional value of emotions ceases to be as such and becomes pathological when an emotion is of an excessively intense nature and appears to incite an individual to carry out actions which have a negative effect on themselves and/or their environment. In such cases, emotions are found to be disturbing. One of the characteristics of pathological disorders is precisely their link to the presence of disturbing emotions and the patient`s inability to regulate them.
The introduction of mindfulness within the realm of the "third generation" of cognitive and behavioural therapeutic treatments  has brought both advantages and disadvantages. This can be exacerbated by the fact that in psychology there is no unanimous definition of the concept of "mindfulness", which has been alluded to as; a psychological process, a result, a general method, or even as a collection of various techniques . The authors of the Psychological Flexibility Model define mindfulness in the terms of an open-ended response technique (Defusion and Acceptance) and focussed (Flexible Attention to the Present Moment and Self-as-Context), thus providing a viable definition of mindfulness . It is beyond the scope of this article to go into great detail on each of these component parts, but it can be underlined that this model asserts that a conscious and flexible attention to the "here and now" enables the person to activate the skills of Defusion and Acceptance, and when called upon engage them in value-based action .
The emergence of mindfulness in an academic context [6,7] introduced an ideal framework to experience emotions in the present moment by paying conscious attention to them and spawned a series of individuals who did not need to judge nor over-react to their first sensations. In other words, mindfulness implies observation without judgment and simple acceptance which in turn, foster curiosity and compassion. As a result "mindfulness" became a valid tool to facilitate the natural regulation of varied emotional states.
1.1 Mindfulness as a Tool to Manage Emotions
Emotional Intelligence (EI) has been defined as the ability to perceive, evaluate and express emotions accurately, the ability to monitor and / or generate feelings that facilitate thinking; the ability to understand emotions and discriminate among them, and the ability to regulate emotions promoting emotional and intellectual growth . The emergence of this theoretical construct demonstrated the importance of emotions, and the need for their adequate integration as a means of addressing everyday problems. Emotions form the basis of decision making, and how they affect us is a fundamental determinant of both physical and psychological well-being, and therefore by default for the prevention of psychopathology.
Gross  refers to emotion regulation as "those processes by which people exercise an influence on the emotions they have, on when they have them and on how they experience and express them" . The emotion regulation model of Gross  distinguishes two types of emotional strategies; the first focuses on the antecedents of emotion (exposing ourselves to certain situations, trying to modify situations, dealing with some aspects of the situation and extracting some meaning from the situation), and the second focuses on the regulation of the emotional response provoked by that experience (expression, physiological activation or suppression).
That said, emotion dysregulation comes about due to either emotion-regulation failures; i.e., not engaging regulation when it would be helpful to do so, or emotion misregulation; i.e., using a form of emotion regulation that is poorly matched to the situation . One of the key elements of the emotion regulation model is the moment in which individuals attend to the emotional states themselves; a strategy of avoidance being very characteristic of emotional disorders leading to individuals developing non-adaptive attentional strategies (e.g., distraction, suppression of thought, worry and rumination). In other words, strategies that can be thought of as being active, but which are beyond personal control, or perpetuate a state of distraction from the emotional experience .
In this regard, there is a broad body of research that demonstrates that experiential avoidance is associated with a wide variety of pathological disorders . Experiential avoidance is strongly related to depression, stress and anxiety . In fact it is related to symptoms that appear throughout different categories of classification systems, a reason why it seems to be a key process in the transdiagnostic approach to psychopathology, being considered a functional dimension of psychopathology, in whose extreme acceptance and openness to experience would be found . In fact, experiential avoidance is a central theme of the Psychological Flexibility Model . From a dimensional approximation to the pathological phenomenon it would be necessary to offer therapeutic interventions whose main objective was to decrease the occurrence of processes (such as experiential avoidance) that form the basis of the pathology . Recent psychological approaches are based precisely on exposing the patient to, or helping them to accept those particular emotions that they are trying to suppress, as it has been empirically verified that avoiding emotion leads precisely to their exacerbation .
In this sense, it seems that acceptance strategies are a positive and adaptive alternative, and in this regard mindfulness appears to be an effective tool and could play a crucial role in the prevention or adequate management of disturbing emotions, without disregard for other interventions that could be very useful too. Mindfulness, as a tool recently incorporated into therapeutic practice, emphasizes the importance of generating a space for fostering emotional experience, and is founded on compassion and a sense of non-judgmental awareness of the present moment. Hence, it may be understood as a means of experiencing the "here and now" consciously, or as a way of being, or as an attitude towards life [7,17,18]. When it comes to managing difficult emotions, it would require an attitude of openness toward an experience regardless of the hedonic tone of the emotion involved, and welcoming that experience with compassion . A growing number of studies reveal the relationship between the practice of mindfulness and the regulation of emotions. In fact, it has been associated with less negative and more positive affect, less perceived stress and reductions in symptoms related to anxiety, guilt, depression, emotional lability and impulsivity [20,21,22,23,24,25,26].
Individuals should attend to their emotional experiences within an "optimal area of physiological activation" , located between two extremes; hyperactivation and hypoactivation known as “the window of tolerance" , wherein they find themselves in an optimal zone for the integration of internal and external emotional information. In this activation zone cortical functioning will be maintained, which is essential to integrate the information at the cognitive, emotional and sensorimotor levels. From the mindfulness perspective a disturbing emotion is defined as one which moves us away from the present, regardless of its hedonic tone, and is considered more disturbing when the reaction to it is greater . One would therefore assume that adopting a mindfulness attitude would favour the emergence of an emotion within the "window of tolerance" defined by .
Dealing adequately with difficult emotions would therefore imply addressing them in the same way they are faced during mindfulness practice. That is to say; we stop, bring a sense of awareness and openness to the emotion, and replace any attitude of judgment or evaluation with another of a compassionate nature . Therefore, it seems that attending emotions mindfully will facilitate the processes of emotional recovery.
1.2 The Mindfulness and Emotional Intelligence Program (PINEP)
Ramos and Salcido  argue that the management of emotions can be represented on a continuum which comprises: 1) An absence of emotional strategies both at the theoretical level; possessing only basic knowledge about emotion regulation, and at a practical level; showing an inability to respond adequately to emotional stimuli, expressing reactivity and relying on automatic responses. 2) An intermediate level in which the individuals know (at least theoretically) the best way to respond to emotional stimuli, but they are still very reactive to them. 3) A level of optimal emotion regulation in which the individual can respond consciously to different emotional stimuli.
With the idea of facilitating the regulation of emotions through mindfulness, the Mindfulness and Emotional Intelligence Program (PINEP) was developed. PINEP can be defined as a conscious emotional management program whose objective is to help participants in the process of "learning to feel ", and to provide individuals with sufficient resources to accompany their own emotional states and those of third parties. This could result in their becoming aware of the automatisms which inhibit the achievement of personal goals in situations of high emotional intensity, and thus restore the adaptive value of an emotion . This implies that PINEP, through the formal and informal practice of mindfulness, helps the individual to deal with highly emotional situations.
PINEP combines two independent training objectives; that of EI and that of Mindfulness, and relies on the integration of both. On the one hand, the program includes exercises from other basic mindfulness training programs [6,7] and on the other, it employs mindfulness as a tool to foment contact with the trainees own emotional experience (both positive and negative). It also fosters compassion and allows an individual to gain perspective over the emotional situation to which they are being exposed .
In recent years the PINEP group has been focused on demonstrating the effectiveness of mindfulness as a technique to regulate emotions; instigating the original design of PINEP to integrate both Mindfulness and EI, and the subsequent verification of its effectiveness through scientific research.
To this end, Ramos et al.  analyzed the effectiveness of a combined Mindfulness and EI training during 8 weekly 90-minute sessions on a non-clinical population. The results show a decrease in negative emotions and higher scores in problem-solving, as well as a greater ability to appreciate the positive. Moreover, there was less tendency to blame oneself and others, and decreased levels of anxiety. In addition, changes in the cognitive strategies of emotion regulation were observed and these individuals were found to present a lower number of intrusions in relation to their daily problems.
Enríquez, Ramos and Esparza  applied PINEP to a university population in the field of social sciences in Ciudad Juárez, Mexico. The intervention lasted 8 weeks with sessions of two hours per week. Significant results were observed related to; emotional repair; extroversion; mindfulness (acting with awareness); empathy (perspective-taking); cognitive emotion regulation (planning solutions, positive reassessment and putting into perspective). In addition, a decrease in burnout and engagement levels was found.
Páez-Gómez, Ramos-Díaz and Hernández-Osorio  noted effects on biological parameters after training with PINEP. The results in a post-test revealed a significant decrease in immunoglobulin (IgA) concentrations in complement 3 (C3) and complement 4 (C4) fractions. Hence it was shown that a combined 8 session training in Mindfulness and EI produces changes in immune modulation in a general population.
Salcido, Ramos, Jiménez and Blanca  provide evidence on the effectiveness of PINEP in its online version. The training consists of 12 weekly sessions of an hour and a half with additional homework tasks. The results obtained show improvements in mindfulness skills; increased capacity of description and an increase in non-judgement and a decreased level of reactivity.
Body, Ramos, Recondo and Pelegrina  presented a study on the impact of PINEP on 90 teachers carried out in two teacher training centers in Malaga, Spain. This training consisted of 9 two-and-a-half hour weekly sessions. The results show that the teachers who received the training develop a greater capacity to identify, understand, assimilate and regulate their emotions on an intra and interpersonal level.
Ramos, Jiménez and Lopes  conducted a laboratory study in which the difference between mindfulness trait and state is demonstrated. The results indicate that a mindfulness trait was associated with fewer intrusive thoughts 24 hours after the induction of a stressor, but with no change in effect immediately after induction. In contrast when applied to a mindfulness state an opposite pattern was evident; there was more of an effect immediately after the induction of the acute stressor but this had no effect on intrusive thoughts 24 hours later. These results suggest that people predisposed to mindfulness states may have difficulty using mindfulness effectively in the face of an acute stressor. In addition, they suggest that the effects of brief interventions in mindfulness may be too ephemeral to cope with acute stressors over time. Therefore, it would be important to develop programs that involve not only the intensive practice in mindfulness, but also include specific training which helps people to use the mindfulness tool to deal with stressors that may appear in their daily lives.
It can be concluded that a basic requirement for accompanying people who suffer is that the therapist masters the basic skills of emotion management which they require to deal with the difficulties of their patients, as well as to become an effective coping model. In this sense, therapeutic training would include the clinician's exposure to various situations that evoke emotions of certain intensity. With this in mind, PINEP could be employed to guide therapists in the learning of conscious emotional management [31,37]. In tandem, the Compassionate Emotional Accompaniment Technique (CEAT) [38,39], which will be introduced in the next section, and whose rudiments rely on the therapeutic value of addressing emotions with a mindfulness attitude, has its origin in PINEP . This technique can be classified as a brief mindfulness intervention, and will be explained in continuation [36,40].
1.3 Proposal of Applying the Compassionate Emotional Accompaniment Technique (CEAT) as a Brief Mindfulness Intervention
One of the characteristics of PINEP  is that it includes a wide range of activities to explore emotions which prepare the individual for a broad-spectrum emotion approach in distinctive evocative situations. When the objective is to verify the effectiveness of this type of therapeutic approach, it becomes necessary to recreate situations of greater experimental control aimed at understanding the mechanisms behind the interaction of mindfulness and emotion, and moreover, if this interaction is therapeutic for an individual.
In order to exercise greater control over interventions based on mindfulness, a brief intervention is suggested, which can take place with or without the prior training of the patient. To this end the participants receive mindfulness instructions in a laboratory context with the aim of verifying the benefits when faced with disturbing experiences. Under these conditions it is easier to control the variables that can explain the results, as well as to better understand the mechanisms of action through which the therapeutic effects are obtained.
Eifert & Heffner  were the first to study the effects of a brief mindfulness-based intervention on exposure to aversive interoceptive stimuli by submitting two 10-minute periods of air enriched with 10% carbon dioxide. The authors were able to witness how this exposure given to participants who had received an instruction to accept the experience, generated less anxiety than the instruction based on suppression and control of the effect. Since then, new studies have also shown the short-term benefits obtained in interventions based on mindfulness, thus allowing a more thorough exploration of the variables that mediate the observed effects.
A study by Campbell-Sills, Barlow, Brown and Hofmann , presents a similar experiment, but in this case provoking emotions in the participants through the viewing of fragments of films of a differing nature. The acceptance group showed less negative effect as well as a lower heart rate in response to the film clips.
Similar results were found among a group of individuals with a high profile in emotion regulation, with the exception that they did not manage to reduce their discomfort while being exposed to an anguishing film, nor were differences found in the level of skin conductance . These results could mean that evocative situations of greater emotional intensity require more effective or longer lasting interventions to achieve the desired effects.
Subsequent studies that analyze the effects of brief mindfulness-based interventions have shown a reduction in cardiovascular reactivity to stress , lower acute distress , less suffering/distress , a decrease in state anxiety and negative affect in extremely dependent persons; the mindfulness instruction being more effective than the distraction strategy .
When the effects of brief interventions in mindfulness are checked over time, the results reveal that despite the immediate decrease in negative affect in the face of stress induced experimentally with disturbing memories, 24 hours after the intervention there is no evidence of a decrease in intrusions on memory . This study also highlights how people who scored high on mindfulness trait showed no benefit from this trait on exposure to the stressor, if they had not received an explicit instruction to maintain a state of mindfulness during the exposure to the stressor. So even though mindfulness presupposes opening oneself to an experience in the present moment, it cannot simply be inferred that people will face that experience with a mindful attitude. When an individual faces an emotion which invokes discomfort of certain intensity, it is quite probable that they will naturally generate a rejection of that experience, and try to control it in a similar way to that demonstrated in the conditions of experimentally induced emotional suppression. The “Window of Tolerance”  can serve to understand how certain emotional experiences can be outside the integration zone, complicating exposure to them. In this way a paradox could occur, according to which some people, despite trying to bring full attention to their emotional experience, in fact, were trying to control their internal emotional processes. Linehan  argues that an important capacity to regulate emotions consists simply in the contemplation of emotion from the moment it appears, until its return to "baseline"; a return that will inevitably occur if we allow ourselves to sit with the emotion without reacting to it. These studies seem to be in line with others that showed how people communicate their emotions because they presuppose that doing so will help them overcome difficult situations and disturbing experiences. However, emotional communication alone does not guarantee a positive integration of the experience, if it is not accompanied by a true acceptance of the felt emotion .
Therefore it can be concluded that fundamental importance needs to be given to the state in which the individual finds him/herself at the time of integrating their emotions. Consequently, it may be of special interest for clinical practice to find ways of facilitating a state or attitude of mindfulness that will make correct assimilation and management of emotions possible.
In this sense, CEAT is based on research that points to mindfulness as an adequate tool for emotion management. The objective of this technique is to facilitate an attitude of mindfulness in the face of the emotional context expressed by the patient, thereby facilitating the regulation of their emotions. In this way "conscious emotional expression" can be achieved and can be understood as that which occurs within the tolerance zone, therefore ceasing to be a reactive experience and becoming one of acceptance and emotional integration.
This technique is characterized by the therapist accompanying the patients and helping them to approach their emotional reality by facilitating a state of mindfulness when faced with disturbing emotions. It is not an issue if the patient has had any previous training in mindfulness or not. Hence, the therapist becomes a reference model on how to remain in the presence of potentially disturbing emotions, and at the same time offers affective and effective support by way of an interactive dialogue. Therapists trained in mindfulness could therefore facilitate a state of mindfulness in their patients through this technique. It should also be noted that the attitudes required for the practice of mindfulness are very similar to those that Rogers argues should be present in the therapeutic context; unconditional acceptance, lack of judgment and authenticity [48,49].
Through this technique, the therapist helps the patient to connect with their painful emotion in an experiential way, encouraging them to maintain calm without feeling the need to escape. Accompanying a person who is reliving a painful emotional experience in this way helps them to maintain the necessary calm to attend to and integrate the emotions in an appropriate way by providing a positive coping model based on mindfulness. Furthermore, the therapeutic relationship constitutes a resource for patients in a double sense. On the one hand, the patient internalizes the quality of the relationship, which results in their validation as a person and, at the same time, the patient observes the way in which the therapist relates to their painful emotions, which results in a validation of their experience.
Finally, one of the characteristics of this technique is that in its application the patient is accompanied not only by the physical presence of the therapist, but also that this accompaniment is expressed through a physical contact between patient and therapist. In this way, the therapist will accompany through touch the sensation of the painful emotion in the part of the body where it manifests, providing of course that the patient has given their consent. More than a century ago William James [50,51] documented the importance of physical contact when establishing relationships between individuals. Touch is the most developed sensory modality at birth, contributing to cognitive and socio-emotional development during childhood and adolescence [52,53,54], and it is possible that it is a very important factor throughout our subsequent development.
A lack of physical contact could become pathological, if the importance that it has in the social development of the individual is not fully comprehended. In fact, alterations at this level could be a common denominator in many disorders. For example, in reference to depressive caregivers and their inability to make affectionate contact with their offspring, or in the lack of affectionate contact in sufferers of depression or social anxiety, or the lack of contact as an index of marital and family discord in bipolar disorder . However, despite its importance, there is little data available on how touch could be involved in the development of emotional disorders and thus could present a promising line of research .
The CEAT technique includes the need to consider physical contact within the therapy as a way to facilitate emotional awareness and to bond with the patient. It is known that traumatic experiences are translated into sensorimotor reactions; images, sounds, smells, intrusive bodily sensations, physical pain, constriction, numbness etc., and that a holistic mind-body approach is appropriate to be able to apply effective treatment. However, conventional therapy models, while fundamentally useful, exclude body work, focusing mainly on the idea that change takes place by virtue of verbal expression .
Different studies verify the advantages that could be obtained directly through physical contact and it can be related to a decrease in discomfort. For example, it has been proven that babies who were held by mothers during a painful medical procedure cried 82% less and exhibited a decreased heart rate compared to those who were not . Touch also seems to be related to safety. For example, babies who were transported in baby carriers that facilitate physical contact manifest a more secure bond with their attachment figure when exposed to "The Strange Situation" of Ainsworth . Touch reinforces reciprocity, generating complicity and cooperation . It enhances pleasure; activating the region of the prefrontal cortex that is involved in the processing of rewards, through the simple caress of an arm with a soft and velvety cloth . Furthermore, Hertenstein, Keltner, App, Bulleit and Jaskolka  found that touch is a powerful instrument of communication and people can transmit various emotions through touch, including; anger, disgust, fear, sadness, love, compassion and gratitude. More recent studies also show that physical contact produces an effect of calmness and relaxation in the patient .
Therefore through physical contact with the patient, we can expect not only an increase in the degree of bodily awareness (identifying physical sensations and the emotions associated with them inherent in the therapeutic process), but also a greater warmth and closeness between patient and therapist. However apart from seeking consent, certain care must be taken to avoid harming the patient, especially if the patient has some problem associated with physical contact.
After being overlooked for a considerable time in the history of psychology, emotions now seem to be taking centre stage. They have evolved from their conception when they were considered as “intrusive" elements that prevented correct thinking, to models of mental functioning that provide a lead role in decision-making. Moreover, interest in their study has grown substantially and there is greater understanding of their role in helping us to adapt to our environment.
In this regard it seems that a key element when referring to the adaptive value of emotions has to do with the way in which the individual relates to them once they arise; reacting to them could tilt the balance toward a poor adaptation, while giving them space with non-judgement and curiosity could be key to recovering mental health.
Even so, in spite of their importance in therapy, there is a lack of resources aimed at helping patients assimilate emotions and facilitating their management. CEAT [38,39] which has its origin in PINEP  has been proposed in this article as a facilitator of conscious emotional management. However, both of these approaches could be equally valid when applied to enhance the processes of acceptance and contact with the present moment in the flexibility model.
Within the therapeutic process, working with disturbing emotions to explore certain situations at the emotional level by facilitating a presence in the "here and now" with an underlying aim of helping the patient to approach these emotions from a position of serenity and in a non-reactive way requires more research. The general proposal of CEAT is to modify the way in which the patient relates to their emotions and to recover their adaptive value, and thereby serve as the basis for good decision-making. In terms of the Psychological Flexibility Model , this technique would facilitate the processes linked to mindfulness (Acceptance, Defusion, Self-as-context and Flexible attention to the present) preparing the individual to act in concordance with their values. Thus, the objective of this technique is not to feel reactive toward emotions, but rather to propagate a conscious reception of them.
Finally as a general conclusion to this article the following points can be highlighted:
a) One of the critical moments for emotion regulation to occur results from the way in which individuals attend to their own emotional states, as avoidance is characteristic of mental disorders . Mindfulness implies giving full attention to the present in a non-judgmental way, through the observation of what is occurring moment by moment in thoughts, emotions, and bodily sensations. Mindfulness-based interventions therefore could fulfill this purpose, and be especially helpful; taking into account the current circumstances where therapeutic resources aimed at facilitating healthy coping strategies are not so readily available.
b) CEAT can be conceived as a technique that fosters emotional management in a clinical population through the application of mindfulness facilitated by a therapist. It also has the advantage of lending itself to laboratory studies that can provide evidence of mindfulness-based brief interventions.
c) CEAT includes not only verbal affective support, but also physical contact and exploring bodily sensations; strategies which are frequently relegated in the clinical setting. In this technique the therapist facilitates an attitude of mindfulness, accompanying the patient through both dialogue and physical contact. In this way, the patient could benefit from the therapeutic effects of physical accompaniment too.
The author has completed all the work.
The authors have declared that no competing interests exist.
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