Available online at www.sciencedirect.

com

ScienceDirect
Cognitive and Behavioral Practice 26 (2019) 201-213

www.elsevier.com/locate/cabp

Affect Labeling to Facilitate Inhibitory Learning: Clinical Considerations

Elizabeth H. Marks, Rosemary S.W. Walker, Heidi Ojalehto, Michele A. Bedard-Gilligan,
Lori A. Zoellner, University of Washington

Exposure-based treatments known to be effective for a wide range of psychopathology are thought to work via inhibitory learning, where
new learning acquired during exposure exercises inhibits previously learned fear and avoidance responses. One way in which this
inhibitory learning may be enhanced is through affect labeling, during which clients verbalize their internal emotional experiences.
Theoretically, affect labeling may be a subtle, implicit form of emotion regulation and may facilitate more explicit forms of extinction
learning. Experimental research suggests that affect labeling may lead to attenuated fear responses to emotionally evocative stimuli in
healthy samples and may be a helpful strategy in reducing physiological arousal experienced during exposure tasks, particularly for
clients with inhibitory deficits. Research with clinical samples is limited and mixed, at best. Case examples illustrate how affective
labeling may help get a client “unstuck” from unproductive processing loops, can contribute to shifts in perspective and meaning
making, and may modulate distress and promote distress tolerance. We argue that routine use of affect labeling in clinical care is
premature. When used, it should be employed strategically within a broader case conceptualization and may be of a limited benefit
beyond what is already employed in quality exposure therapy.

E XPOSURE is a common technique used in cognitive-

behavioral therapy, particularly for anxiety and
stressor-related disorders. The basic tenets of exposure
evoking stimuli and progressing to the most intense
stimuli, termed “graduated exposure,” to starting with the
most intense stimuli, sometimes termed “flooding.” In
include emotional engagement with the fear-provoking general, exposure-based techniques are some of the
or avoided stimuli and systematic prolonged and repeated strongest empirically supported interventions for anxiety,
exposure to the stimuli, with the primary goal of learning distress, and traumatic stress-related disorders (e.g.,
new, corrective information such as its lack of dangerous- Bisson, Roberts, Andrew, Cooper, & Lewis, 2013; Institute
ness or the tolerability of the related distress. Although of Medicine, 2008; Norberg, Krystal, & Tolin, 2008;
exposure-based techniques are used to treat a wide range Powers & Emmelkamp, 2008). As the research focus has
of psychopathology including specific phobias, panic shifted from efficacy to effectiveness and dissemination,
disorder, social anxiety disorder, posttraumatic stress research now focuses on understanding for whom
disorder (PTSD), depressive disorders, and obsessive- exposure works best, why it works, and how to optimize
compulsive disorder (OCD), the approach differs de- exposure treatments in order to enhance treatment
pending on the client’s primary presenting problem and outcomes.
symptom presentation. Exposure may be conducted as More specifically, recent work has emphasized under-
real-life exposures to situations, places, or objects, termed standing how we can enhance corrective learning (e.g.,
“in vivo exposure,” or via exposure to thoughts, memo- Craske et al., 2008; Craske, Treanor, Conway, Zbozinek, &
ries, or imagined situations, termed “imaginal exposure.” Vervliet, 2014). Learning models have shifted from
Individuals also learn to block maladaptive responses to conceptualizing the processes involved in exposure as
feared stimuli such as the use of of safety signals and erasing the original association between conditioned
compulsive behaviors as a part of exposure. Procedures stimuli (CS)—that is, neutral stimuli (e.g., dog approaching
can range from starting with mildly to moderately distress- or running)—which serve as predictors of an uncondi-
tioned stimulus (US; e.g., dog bite), to learning of a new
inhibitory association that is contextually gated (e.g.,
Bouton, 2002; Bouton, Westbrook, Corcoran, & Maren,
Keywords: affect labeling; exposure; inhibitory learning; emotion
regulation; PTSD 2006; Bouton, Winterbauer, & Todd, 2012). This suggests
that repeated exposure to nondangerous stimuli that were
1077-7229/18/© 2018 Association for Behavioral and Cognitive initially learned to predict danger (CS) creates a new
Therapies. Published by Elsevier Ltd. association that then inhibits the conditioned fear
202 Marks et al.

response, making the meaning of the CS ambiguous. The processes. Labeling of emotions may be a conduit to
individual then uses information around him or her—that enable cognitive emotional processing—namely, the
is, context (e.g., friends’ reactions)—to determine whether theoretical process by which emotional disturbances are
the CS is signaling danger or no danger. This new corrective thought to be tolerated and eventually decline, allowing
learning is considered weaker, is considered weaker for other experiences and behavior to occur without
learning learning, with the default being the earlier disruption (Foa, Huppert, & Cahill, 2006; Foa & Kozak,
excitatory danger association. The weakness of this new 1986; Rachman, 1980, 2001). As reviewed below, affect
inhibitory association and its contextual gating make return labeling may enhance this process by interrupting
of the original fear (e.g., relapse) a possibility. More intrusive processes (e.g., when a client is “stuck”), by
recently, some have argued that memory reconsolidation— helping shift the meaning of the learned associations
or the occurrence of fear extinction within a specific time themselves, and by increasing distress during the expo-
frame after the activation of a fear memory when the sure exercises. These are theorized ways that affect
memory is particularly vulnerable to updating via protein labeling may enhance exposure, rather than empirically
synthesis—may actually disrupt the original learning rather tested ways in which it may function.
than create new inhibitory learning, potentially reducing
the likelihood of a later return of fear (e.g., Schiller et al., Interrupting Unproductive Loops: Getting “Unstuck”
2010). Augmentation strategies, whether altering the
Affect labeling may serve as a technique to help clients
original learning or strengthening new inhibitory learning,
get “unstuck” from repetitive loops in negative thinking.
may enhance outcomes and prevent relapse.
Repetitive negative thinking, as seen in worry or
Theoretical Underpinnings of Affect Labeling rumination, is a transdiagnostic construct common across
a wide range of psychopathology, including anxiety
One specific technique that has been proposed to
disorders, traumatic stressor-related disorders, and de-
potentially enhance this new inhibitory learning is known
pression (e.g., McEvoy, Watson, Watkins, & Nathan,
as “affect labeling.” As the name suggests, affect labeling
2013). When clients stay stuck in these thought patterns,
refers to verbalizing or putting words to one’s emotional
they are unable to access new information and instead the
experiences. Affect labeling is not proposed to be a stand-
unproductive processing loop is reactivated again and
alone process accounting for improvement during
again, leading to what some have termed a “downward
exposure therapy. Further, as will be reviewed below,
spiral,” maintaining or increasing negative emotions.
the evidence for its ability to substantially alter subjective
Even if potentially corrective information that could
experience or long-term outcomes is weak at present.
inhibit the undesired response is presented, given these
Nevertheless, theories of how affect labeling works have
unproductive processing loops, the information is most
been proposed and are reviewed briefly here.
likely to be assimilated into the current set of maladaptive
Activation of higher cortical regions during affect labeling
beliefs rather than acting as new, perspective-shifting
such as the right ventrolateral prefrontal cortex (PFC) may
information (Hayes, 2015). Thus, techniques that inter-
facilitate a subtle form of emotion regulation (e.g., Ochsner
rupt or alter these patterns are imperative to changing
& Gross, 2005) or more broadly facilitate executive
emotional and behavioral responses. Accordingly, affect
functioning modulation during exposure exercises, consis-
labeling may serve to interrupt repetitive, intrusive
tent with enhanced PFC activation observed during extinc-
processes, resulting in the patient getting “unstuck”
tion learning (e.g., Phelps, Delgado, Nearing, & LeDoux,
from the unhelpful loop and thereby allowing for new
2004). Labeling one’s emotional state in such a way as it
learning to occur.
disrupts the experience of the emotion may be an implicit,
incidental rather than explicit, intentional form of emotion
regulation (e.g., Burklund, Creswell, Irwin, & Lieberman, Creating Expectancy Violations and Meaning Making
2014; Niles, Craske, Lieberman, & Hur, 2015). This may A second way in which affect labeling may promote
differ from explicit strategies such as cognitive reappraisal or constructive processing is setting up expectancy violations
expressive suppression. As suggested by LeDoux (2015), and making the meaning of the CS ambiguous (e.g.,
exposure therapy is hypothesized to involve both extinction Craske et al., 2014; Hofmann, 2008). An expectancy
of implicit, fear-related memories and changes in maladap- violation is when the actual frequency or intensity of an
tive beliefs that result from more explicit, or conscious, aversive outcome during an exposure exercise is incon-
memory processes. Thus, affect labeling may facilitate these sistent with what the client anticipates. This type of
more implicit processes rather than the explicit, conscious violation sets up an opportunity for more in-depth
memory processing in extinction. processing of the stimuli for altering the meaning of the
Facilitation of these implicit extinction processes may CS for the individual. Processing at a more conceptual
then, in turn, facilitate more conscious, explicit extinction level helps the individual put stimuli and associated
 Affect Labeling and Inhibitory Learning 203

responses in context, make meaning of the experience, reduce avoidance of the emotion and the specific
and alter future responses. This meaning-making process memory content and facilitate activation of more specific
involves reducing the discrepancy between how an memory content (e.g., Williams, 2006). In the case of a
individual has appraised an experience’s meaning and client who is not fully engaging with an emotion during
that individual’s global system of beliefs and goals (Joseph exposure due to his or her fear of being unable to tolerate
& Linley, 2005). Ultimately, the person is able to be more the emotion or due to the aversive experience of the
flexible, gaining access to other appraisals and the larger emotion, labeling an emotion can be a way of gaining
meaning of the experience (e.g., Brewin, 2014; Hayes, specificity of the client’s experience (e.g., “I feel really
2015; Park, 2010; Watkins, 2008). sad” instead of “I feel off”) while also moving him or her
Affect labeling may facilitate cognitive and emotional toward the emotion by decreasing experiential avoidance
flexibility through increased specificity of a client’s (e.g., putting words to the internal emotional experi-
current emotional experience and her feared outcomes ence). When avoidance is reduced, a client will likely
of exposure (i.e., expectancies). Increased specificity experience an increase in emotional intensity and
through the use of affect labels (e.g., “I will get so anxious distress. In this instance, affect labeling can indeed
that I will throw up” vs. “I will throw up”) can allow for function as a way to increase emotional experiencing
enhanced likelihood of expectancy violation, as well as for those who may be underengaged during an exposure
more nuanced outcomes (e.g., “I got anxious but I exercise.
tolerated it and didn’t throw up” vs. “I did not throw Emotion labeling can also help concretize the inter-
up.”). It may also help change the eventual meaning for pretation of the event for an individual and open the door
the individual. For example, it is common for individuals for more in-depth, constructive processing that may not
who were severely intoxicated during a sexual assault to occur without increasing emotional engagement during
have a profound sense of shame or responsibility for what the exposure. This experience is much more revelatory
occurred, even being ashamed of telling the story to for the client and may be accompanied by a flood of
another person. By labeling both the shame and the fear emotion. Examples of these experiences that represent
during imaginal exposure to the trauma memory, an increased revelation are statements such as “I was
expectancy violation can occur when the client’s therapist terrified. I really thought he was going to kill me”; “I
helps her process the assault in a nonjudgmental manner. was so helpless, there was nothing I could do”; and “I was
This helps the client to discriminate between the shame frozen with fear, like a corpse, and could not move my
felt during the traumatic event and the shame she feels body to fight back.” In these examples, the labeling of the
related to herself, and she learns that her therapist does emotion helps alter the meaning of the CS–US associa-
not judge her or reject her for what happened, which is tion for the individual.
inconsistent with what she expected prior to beginning As a natural consequence of increasing emotions and
the imaginal exposure. This may help alter the meaning distress, learning to tolerate high levels of distress
of her shame to be less global. becomes an important goal of exposure exercises. This
ability to tolerate distress is a form of new, inhibitory
learning that occurs during the exposure (e.g., Craske et
Increasing Distress and Learning Distress Tolerance al., 2014). If a client believes that he or she will lose
A third way in which affect labeling may help to control by engaging fully in an exposure and will be
facilitate therapeutic change is through increasing unable to tolerate the painful emotions each time he or
distress, which can then help teach a client to tolerate she emotionally engages and effectively tolerates the
distress during exposure. Consistent with some of the distress, the client is strengthening this new, inhibitory
literature reviewed below, in our clinical experience, we learning. This produces an expectancy violation, as the
have observed that affect labeling at times can temporarily client’s preconceived expectations regarding his or her
increase distress by drawing attention to the crux of the ability to tolerate an exposure are repeatedly violated, and
meaning of an event or situation for the client. For a client new learning occurs.
who is avoidant during exposures, labeling an emotion Taken together, affect labeling may allow for more in-
quite literally draws the client’s attention to the presence depth processing of the exposure exercises, whereby the
of that emotion, thereby increasing the intensity of his or client gains insight and awareness into his or her
her emotional experience and decreasing avoidance. emotional experience and how that experience changes
Theoretically, overly general memories of one’s experi- over repeated exposures. Affect labeling can be used to
ences are thought to prevent overwhelming negative modulate emotional engagement and distress up or down,
emotions, truncating the memory search before specific depending on the client, and can provide a gateway to a
details and negative emotions are activated (e.g., wide range of shifts in perspective or meaning that are
Williams, 2006). Labeling of the specific emotion may critical in enhancing treatment outcomes.
204 Marks et al.

Evidence for Affect Labeling Altering Emotional Despite these divergent findings, there may be specific
Responses neurocognitive pathways by which affect labeling attenu-
An emerging line of research has identified potential ates emotional reactivity. Neural regions implicated are
effects of affect labeling, but the overall findings are mixed primarily the amygdala, a brain region involved in
and clinical translation of this line of research to date emotion generation, specifically fear, and the ventrolat-
remains limited. Affect labeling is typically studied using a eral or ventromedial PFC regions implicated in inhibitory
within-subjects manipulation by showing individuals a processes. Notably, these are also regions implicated in
series of briefly presented affectively valenced and neutral extinction learning, with activation of the PFC dampening
pictures and asking them to select an emotion word that amygdala response (e.g., Phelps et al., 2004; Quirk,
corresponds with the picture. Control conditions usually Likhtik, Pelletier, & Pare, 2003). During affect labeling
have some form of passive image viewing and some tasks in comparison to control tasks, there are higher
alternative labeling condition, asking the participant to levels of PFC activity (e.g., Hariri, Bookheimer, &
label or match such things as gender or the object in the Mazziotta, 2000; Lieberman et al., 2007; Memarian,
picture. Several studies using emotional pictures suggest Torre, Haltom, Stanton, & Lieberman, 2017; Torrisi,
that some kinds of affect labeling result in diminished Lieberman, Bookheimer, & Altshuler, 2013; Tupak et al.,
subjective distress or emotional arousal in healthy adults 2014), lower levels of amygdala activation (e.g., Hariri et
(e.g., Constantinou, Van Den Houte, Bogaerts, Van Diest, al., 2000; Lieberman et al., 2007; Memarian et al., 2017;
& Van den Bergh, 2014; Lieberman, Inagaki, Tabibnia, Torrisi et al., 2013), and negative modulation of PFC and
Crockett, 2011). Compared to “passive viewing” (i.e., amygdala activation (e.g., Hariri et al., 2000; Lieberman et
viewing pictures without any emotion labeling), affect al., 2007; Memarian et al., 2017; Torrisi et al., 2013).
labeling reduces self-reported arousal and distress in the Indeed, affect labeling may promote activation specifical-
short-term (milliseconds to seconds). These studies also ly of the right ventrolateral PFC or right inferior frontal
required participants to select the emotion depicted by the gyrus, arguing for its critical role during implicit emotion
picture, rather than labeling their own emotional experi- regulation (Memarian et al., 2017; Tupak et al., 2014).
ence, which is potentially more clinically relevant. Notably, in several studies, despite consistent activation
Although the above studies suggest labeling external patterns, affect labeling did not lower subjective distress
stimuli can reduce emotional experience, results from or skin conductance (e.g., Herbert, Sfärlea, & Blu-
studies examining the specific consequences of labeling menthal, 2013; Nils & Rimé, 2012), though others have
one’s own internal affective state during image viewing have shown improvement in subjective well-being (Memarian
been more mixed, with evidence suggesting that labeling et al., 2017). More often than not, subjective experience
internal emotions may increase physiological arousal and of emotion was not reported. In a recent meta-analysis,
emotional intensity and others suggesting the opposite (e.g., the use of language with emotional experience may
Matejka et al., 2013; McRae, Taitano, & Lane, 2010; Ortner, activate brain regions associated with semantic processing
2015). McRae and colleagues (2010) found that labeling (Brooks et al., 2017), arguing that affect labeling may help
one’s subjective emotional experience of emotional stimuli facilitate conceptual or meaning changes.
leads to increased physiological arousal measured via skin None of the studies above utilized clinical samples.
conductance response (SCR) compared to trials where When compared to a clinical sample, the pattern of
participants objectively labeled the stimuli. Ortner (2015) results may be altered. Burklund, Craske, Taylor, and
found no differences in autonomic arousal among subjective Lieberman (2015) recently examined the neural sub-
affect labeling, objective labeling, and passive viewing strates of affect labeling in individuals with social phobia
conditions, but affective labeling increased emotional compared to a healthy control group. During an affect
experience more than passive viewing based on Likert scale labeling task, individuals with social phobia exhibited
ratings more than passive viewing. In contrast, Matejka and increased amygdala activation but no differences in right
colleagues (2013) found that emotion labeling led to ventral lateral PFC activation compared to healthy
decreased autonomic arousal measured via SCR compared controls, with those with social phobia and comorbid
to talking about facts, but talking about facts reduced depression showing the largest upregulation of the
perceived emotional intensity more than emotional labeling. amygdala activity compared to healthy controls. This is a
Taken together, although findings are inconclusive regard- reversal from the patterns observed above, arguing that
ing autonomic and subjective arousal, including showing clinical samples, particularly those with depression, may
divergence between these indices, there is some evidence to not experience corresponding reductions with affect
suggest that there are certain conditions where labeling labeling. In this same sample, greater symptom reduction,
one’s own internal emotional state may actually increase, regardless of therapeutic modality or wait-list, was
rather than decrease, self-reported emotional arousal and associated with more negative amygdala–PFC functional
physiological arousal in healthy adults. connectivity from pre- to posttreatment during affect
 Affect Labeling and Inhibitory Learning 205

labeling (Young et al., 2017), arguing that these processes its nascent stages, with a lack of knowledge from the
move together. importance of actual verbalization to the importance of the
Ferri and colleagues (2017) reported that those with accuracy of the subjective label. In nonclinical samples, affect
treatment-resistant depression showed more blunted amyg- labeling may decrease emotional arousal to aversive stimuli,
dala activity compared to healthy controls during an affective as indexed by reduced amygdala activity and increased right
labeling task, inconsistent with Burklund and colleages ventrolateral PFC activity—however, this may not be the case
(2015) for those with social phobia and depression— in clinical samples, where amygdala activation may actually
however, higher baseline activation during the affect labeling increase with affect labeling. Notably, the impact of affect
task was associated with later improvement in depressive labeling on subjective experience of distress or on symptom
symptoms across psychosocial interventions. As such, treat- improvement is not clear. This raises the issue of the clinical
ment approaches that enhance the capacity of prefrontal significance of the observed effects, as it appears unlikely that
regions to dampen amygdala responses or compensate for using an affective label will substantially alter the experience
impairments may be helpful, and, critically, further work is of emotion during exposures for a client to a clinically
needed to investigate the impact of common comorbidities, meaningful degree (i.e., shifting distress from “moderate” to
particularly depression, on these effects. “severe” or from “severe” to “moderate”). Other emotion
Notably, none of the above clinical studies directly regulation strategies like reappraisal may confer similar or
examined using affect labeling during therapy. Analogue even stronger activation of specific PFC regions and lower
clinical research has started to emerge examining the self-reported distress (e.g., Burklund et al., 2014; Payer, Baicy,
impact of affect labeling on exposure-like tasks. Tabibnia, Lieberman, & London, 2012).
Lieberman, and Craske (2008) have shown immediate Although very preliminary, probably the most inter-
and somewhat longer-term (8 days postexposure) benefits esting implication across the experimental and clinical
of affect labeling on emotional responding in undergrad- studies to date is the speculation that affect labeling may
uates with a fear of spiders. Repeated presentation of be most useful for clients with amygdala–PFC inhibitory
pictures of spiders with the negative labels, in comparison deficits. This argues that tasks such as affect labeling may
to passive viewing, resulted in larger attenuation of SCR have the potential to augment exposure therapy, partic-
over time but had no effect on heart rate deceleration. ularly for the clients who may need it the most. Yet,
Extending this work to a clearer clinical analogue, Niles common comorbidities such as depression, which are
and colleagues (2015) examined whether affect labeling almost always present with severe anxiety or stressor-
of one’s internal experience enhanced exposure effec- related disorders, may alter observed patterns. Taken
tiveness in participants with public speaking anxiety. together, the evidence base to date is simply too sparse to
Exposures consisted of ten 1-minute speech trials in front confidently predict how affect labeling will operate during
of three confederates. Prior to each speech, participants specific exposures with a client or whether it will enhance
in the affect labeling group were prompted by the long-term exposure therapy outcomes or prevent relapse.
computer to choose words to label their emotions (e.g., Given these critical unknowns, the clinical use of this
“afraid,” “frustrated,” “blue,” “other”) and words to label technique should not be considered empirically support-
their feared consequence from the audience (e.g., “laugh ed at the present time.
at me,” “notice I am nervous,” “be disinterested,” How and When to Use Affective Labeling
“other”). Participants in the affect labeling condition
showed a steeper decrease in heart rate (small effect) and As researchers and clinicians, we are eager to augment
SCR (large effect) at days 3 and 8 than the exposure-alone exposures and enhance therapeutic outcomes, yet, with
control group, but no differences emerged related to self- regard to affect labeling specifically, we need to be
reported distress or self-reported levels of public speaking thoughtful about for whom it may help and why.
anxiety. Notably, the benefits of affect labeling on skin Although the concept of affect labeling appears quite
conductance were most pronounced for those who used straightforward and intuitively helpful, as illustrated in the
more anxiety-related labels during exposure and for those review of the research above, we need to be mindful of
with deficits in incidental emotion regulation, defined by how quickly we incorporate strategies based almost solely
a lack of subjective distress reduction during a separate on experimental, nonclinical research into exposure-
affect labeling task. based interventions with our clients.
In summary, at the present time, there is simply a paucity
of studies examining clinical samples and no studies to date How to Label Affect
utilizing affect labeling to enhance conventional exposure The explicit or routine use of affect labeling should be
therapy in the treatment of clinically significant mental viewed as an “experimental technique” that is potentially
disorders. Although thoughtful control conditions have been efficacious rather than a proven technique to enhance
employed, the “how to” most effectively label affect is also in new inhibitory extinction learning during exposure
206 Marks et al.

therapy. Given that affect labeling frequently occurs in be done, if necessary, to point to the emotion being
routine exposure already, greater clinician awareness may experienced but should only be used as a teaching tool
help facilitate the strategic use of affect labeling. This is within the context of targeted querying. If done, the
consistent with its use as part of a larger functional analysis therapist likely should discontinue this direct labeling
and case conceptualization rather than a stand-alone quickly, shifting back to querying. Ideally, the therapist
technique that is incorporated into every exposure wants the client to learn to identify the emotion and its
exercise. The necessity of the latter is simply premature related consequence by him- or herself. If repeated
given the lack of current evidence. problems identifying the emotion persist, the therapist
On the surface, the clinical process of affect labeling can use tools like simplified “feelings charts” to help
appears reasonably simple. The therapist asks, “What are increase emotional awareness and specificity. Psychoedu-
you feeling?” and the patient responds with a specific cation about the nature of emotions and distinctions
emotion. This assumes, however, that the client both between them can be helpful for some patients, particu-
identifies that an emotion is present and can label the larly those for whom emotional experiences have been
emotion properly. As discussed above, the goal may not be consistently invalidated. That said, these charts often have
the labeling per se, but the ability to use the emotional multiple terms and labels, which can confuse rather than
information to alter future perceptions and behaviors in a help a client struggling to identify a specific emotion.
more adaptive way. Thus, labeling emotions in therapy is a Notably, it seems like the goal ought to be to have the
strategy that can be used to facilitate insight and change, client be able to quickly and easily identify basic emotions
and, if used, ought to be used intentionally and with a goal that he or she is experiencing, rather than to have an in-
in mind on the part of the therapist. depth affect labeling vocabulary.
Although there is considerable debate in the field Sometimes two or more apparently contradictory
about the nature of emotions, there is reasonable emotions can be held seemingly simultaneously. These
agreement that emotions related to fear, anger, disgust, include the pairing of happiness and sadness and the
sadness, and happiness are generally universal across pairing of fear and sadness. These emotions may be
individuals and cultures, and some agreement around the experienced concurrently or one emotion may serve to
universality of the emotions of shame, surprise, and “block” or prevent the experience of the other. When two
embarrassment (Ekman, 2016). In many respects, this list or more emotions exist, labeling both emotions allows for
is generally sufficient for most therapeutic affect labeling more in-depth processing of the meaning of the
that is applied to enhance inhibitory learning. Both a experience, realizing events, people, and things can
therapist and client can easily get caught in a quagmire of have both good and bad qualities simultaneously—that
minute definitions, terms, and details of various second- is, accepting the presence of the dialectic or contradic-
ary emotions, which is generally to be avoided in exposure tion. This is often the case in memories of traumatic
exercises as it can derail and distract from therapeutic events from childhood, where certain key people from
processes. As done in Niles and colleagues (2015), clients someone’s childhood were awful and other key people
selected among only four labels (an anxious word, an were warm and trustworthy. Probably two of the more
anger word, a sad word, or other) and selected among the common contradictory pairs of emotions are the combi-
feared object or consequence of the exposure prior to the nations of anger with fear or sadness, with the latter often
start of the exposure task. The additional labeling of the taking a form of helplessness. Anger is often viewed as an
feared consequence or object may be an important appraisal of wrongdoing and an action tendency to
clinical addition to typical affect labeling to explicitly counter that wrongdoing in some way (Fernandez &
connect stimuli, thoughts, and emotions. Johnson, 2016)—however, the distinction between anger
Accordingly, one way to utilize affect labeling is to and other emotions in terms of physiology (e.g.,
incorporate it prior to every exposure task. However, as autonomic activation) or specific brain activation has
discussed above, we consider this premature, as its clinical been elusive (e.g., Stemmler, 2010). In general, common
benefits have not been well studied. We discuss below its clinical impressions are that experiencing and expressing
more strategic clinical use, as affect labeling may not be intense anger can interfere with the processing of other,
needed for all clients or across all exposure exercises. potentially more clinically critical emotions (Feeny,
When the client has problems labeling emotions, Hembree, & Zoellner, 2003; Hembree, Rauch, & Foa,
clinically, it is preferable to ask directed questions rather 2003). Clinically, it is important to acknowledge the
than explicitly label the emotion for the client. These validity and appropriateness of the anger. It is also helpful
questions can help isolate emotional experiences, such as to explain how anger can be used to direct or channel
querying about valence, magnitude, autonomic physio- one’s focus on getting better and moving on to the next
logical arousal, triggers, related behaviors, or urges for chapter of one’s life. However, it is also helpful to explain
action. Explicitly labeling the emotion for the client can that anger is a “hot” or “quick” emotion and how it can
 Affect Labeling and Inhibitory Learning 207

sometimes be an easier feeling to access than the more (SUPs) scale, particularly when we are monitoring
“hidden” emotions of fear or sadness. Anger can serve to positive mood, when tasks are focused on reducing
block other emotions that are more difficult to experi- anhedonia or behavioral activation rather than targeting
ence or tolerate, such as fear. As suggested by Hembree et fear per se. Other emotions can also be put on this scale to
al. (2003), the client may need to move anger aside to monitor clinical changes.
focus on other aspects of his or her experience. This will In summary, the labeling of emotions themselves is not
likely take practice and potentially multiple clinical always straightforward. The therapist needs to focus on
conversations. the function or purpose of the labeling to make good
Finally, teaching the observation and labeling of clinical decisions about when to label, what to label, and
gradations in emotion is often important for the client when not to label emotions. Good use of affect labeling
and for the clinician to monitor change and implement may help appropriately increase or decrease client
strategies to increase or decrease specific emotions. In the distress in order to facilitate new learning and create
anxiety and traumatic stressor-related disorders, monitor- new meaning of their experiences.
ing of distress during exposure exercises is commonly the
most useful approach. This is typically done through
either the use of a fear thermometer or subjective units of When to Use Affect Labeling
discomfort or distress scale (SUDs; e.g., Wolpe, 1969). At present, affect labeling is a potentially helpful
Typically, zero is set as the most calm and relaxing image, experimental technique that therapists should implement
place, or state imaginable (e.g., watching a sunset, feeling strategically, based on the therapy process and case
the sun while lying on the beach) and the top of the scale, conceptualization. Given that affect labeling is thought
usually a 10 or a 100, is set as the most distress ever to be effective in increasing or reducing distress by
experienced or imagined (e.g., the most awful panic promoting increased constructive processing and altering
attack imaginable, the traumatic event itself). The choice meaning of emotions and beliefs, it may be a strategy that
of the upper-end anchor of 10 or 100 is largely arbitrary— is employed routinely at the beginning of exposure
however, if it is anticipated that the client will have therapy as a client is learning to observe and label
problems with gradations, sometimes a scale limited to 11 affective experiences. In the case of a client for whom this
options is better than one with 101 options. The more process comes naturally, the therapist may take more of a
simplified scale is frequently used for children and “backseat” role in reinforcing this behavior and encour-
adolescents, where initial emotion gradation labeling is aging the client to verbalize affective experiences. In the
either “not present” to “present” or “okay” to “awful” with case of a client for whom labeling affect is more difficult
little differentiation. Before using the scale, it is often or nonintuitive, the therapist may be more active in
helpful to set specific anchors, usually mild (25), helping this client devise and apply emotion words to the
moderate (50), and severe (75) discomfort. The more affect. Regardless, at the beginning stages of exposure, it
these anchors can be stable (i.e., not treatment targets is likely that affect labeling may be most useful as a client
that are likely to shift during therapy), the better they are first begins to approach difficult situations, places, or
as anchors (e.g., having a cavity filled, riding a roller memories. This is in contrast to later in therapy as clients
coaster). If anchors are chosen that are therapeutic have become more accustomed to exposure exercises.
targets (e.g., recounting the memory of the trauma), the Here, affect labeling becomes more of a strategic, and
scale consistently has to be recalibrated over the course of possibly optional technique, to be employed particularly
therapy. The discussion of anchors can also help with with a client who either is not putting a verbal label on his
psychoeducation in terms of getting finer gradation on or her affect or is labeling affect in a manner that is
labeling emotional experiences. Often, when teaching inaccurate or incomplete. In these cases, a therapist may
this gradation, it is helpful to use physiological, emotional, put particular emphasis on encouraging the client to
and behavioral anchors. For example, “When your accurately label affect in order to open up pathways for
anxiety is at a ‘75’ or ‘severe,’ you may feel your heart discussion about the emotional experiences that have not
pounding hard, feel light-headed, you know that you are yet been processed.
really upset, and you feel like you need to immediately The timing of labeling within session is also an
escape the situation and you are not sure you can handle important component to consider. Labeling affect,
it.” Once anchors are established, the fear thermometer which may trigger an in-depth discussion of affective
or SUDs can be used to identify and label anticipatory experiences, is usually best avoided at the conclusion of a
anxiety, peak anxiety, and anxiety after exercises in session, as that type of processing may not be able to be
session, during homework, and around specific events fully achieved with limited time remaining in the session.
or activities. Finally, instead of solely focusing on distress, For example, a client may identify shame for the first time
we have also started using a subjective units of pleasure at the end of an exposure session and is thus not allowed
208 Marks et al.

adequate time to process this emotion with the support of sweating, you feel afraid. What happens next?” can help a
the therapist and have the corrective experience of not client move through an imaginal exposure during which
being negatively judged for his or her actions. This client he or she is overengaged and stuck on the worst moment.
may then leave the session ruminating on his or her Similarly, statements such as “You feel really sad as we talk
experience of shame and may actually experience an about the loss. What other emotions do you feel when you
increase in shame that results in unhelpful coping think of the son you lost?” can be used to decrease a
responses (e.g., getting drunk to numb the shame) or in client’s emotion to a level where you can then discuss
avoidance of future therapy sessions. Ensuring that context and meaning and help the client move forward.
emotions can be adequately dealt with before leaving Overall, affect labeling is a strategy that may be useful
the session is a crucial part of new and corrective learning in modulating distress during exposure, increasing
that needs to accompany exposure practices. Thus, constructive processing and meaning making, and should
labeling and discussion of affect should be timed to be applied purposefully when the therapy process or case
occur as soon as possible after the affect occurs but with conceptualization indicates its use. In order to illustrate
an explicit awareness of the need to fully process the specific ways in which affect labeling can be used clinically
experience before the client leaves the session. At times, across a range of psychopathology, we next describe a
providers may make the strategic choice to delay affect series of clinical case examples. These examples represent
labeling or processing, even when the opportunity combinations of issues we have seen with different clients
presents, in an explicit attempt to ensure that patients who we have treated; no one case represents a single
do not have the experience of needing to leave a session client and any identifying information has been altered in
feeling emotionally dysregulated, an experience that can order to protect client privacy. These examples are
make approaching future exposures difficult and does not designed to highlight ways in which affect labeling may
usually result in the corrective learning we hope for in uniquely contribute to facilitating exposure therapy, as
exposure. one potentially helpful strategy in the larger context of
In the absence of strong empirical data, individual case exposure therapy. In these examples, skilled clinicians
conceptualization will also inform when to label affect. may recognize that they intuitively already incorporate
For an emotionally avoidant client, he or she may not affect labeling strategically in their practice. Given the
benefit from exposure to affective cues because the client relative lack of empirical evidence for affect labeling as a
is not actually engaging with emotion. By labeling the crucial component contributing to the efficacy of
emotion, it can open the door to processing the exposure therapy, it is worth noting that the use of affect
experience. Alternatively, the therapist should be attuned labeling should always be rooted in theory and concep-
to when affect labeling may actually be counterproduc- tualization of individual clients and their presenting
tive. Extensive discussion of affect or emotion can serve problem. It also should be noted that we, as a clinical
the function of avoidance as it can serve to discourage the team, do not as of yet routinely incorporate explicit affect
therapist from moving forward in processing the emotion. labeling into our exposure therapy exercises. We, too, are
Similar to how overt behaviors such as crying or yelling awaiting strong clinical empirical evidence to show that
can redirect attention away from difficult topics, a client affect labeling facilitates inhibitory learning.
who spends a significant amount of a session talking about Clinical Case Examples of Affective Labeling
his or her emotions can also waylay a well-intentioned
therapist. In these cases, the therapist may actually want to Getting “Unstuck”
discourage the client from speaking explicitly about At times clients in exposure therapy may have difficulty
emotions. As discussed above, labeling affect can decrease making progress due to getting “stuck” in an unproduc-
or increase the experience of emotion—thus, in cases tive processing loop before, during, or after exposure
when a client is underengaged during exposure (i.e., exercises. One way that this process of becoming “stuck”
avoiding full contact with his or her emotions, showing in an unproductive processing loop manifests is when a
flat affect), labeling affect could be used as a way to client’s prolonged sobbing and incredibly high distress
increase emotional engagement by encouraging the (i.e., “overengagement”) during exposure prevents
client to increase expression of his or her affect. At the meaningful processing of the experience. In such
same time, after a difficult exposure, labeling the affect instances, affect labeling may have the potential to be
might be useful for decreasing the intensity of emotional used as a strategy to titrate emotional engagement down
experience by giving the client some distance from the during the exposure. For example, a client with PTSD
experience through verbalization. This could then related to years of repeated partner violence consistently
prompt a discussion of the affect and help new learning showed signs of being overengaged during imaginal
to occur following exposure. When used for this purpose, exposure (e.g., persistent rocking in her chair, scratching
statements such as “Your heart is pounding, you are her arms, shielding herself from imagined blows). She
 Affect Labeling and Inhibitory Learning 209

would become stalled during imaginal exposure, being so in-depth, meaningful processing of what happened. In
overwhelmed that she would be unable to continue with this case, it was important to discuss the process at other
her narrative of what happened and would weep for long times in the session rather than when the client was stuck
periods of time instead of continuing with the story. The in her sadness. This helped her eventually move through
therapist worked with her to put a label on her sadness, the sadness to revisit the memory of what happened and
actively at first by making direct statements such as drive again on freeways. Accordingly, the labeling of the
explicitly linking what she was remembering to the role of the emotion as part of the ruminative process can
emotions she experienced: “You see your son crying in then be used to prevent getting stuck in the negative
the corner and you are feeling sad and helpless.” feelings loop and also help the client learn skills to short
Gradually, the client began to name the emotion herself circuit this spinning or looping.
with only a little encouragement. By labeling the sadness,
she was able to move past the emotion itself and gradually
approach the other details associated with the memory, Meaning Making and Expectancy Violation
such as the degree of violence that she endured and the Labeling of emotional experiences can be a potent
intensity with which she protected her son, in a way that means for altering the meaning of one’s behavior and
helped her process her feelings of fear and anger. She experience. Sometimes the thought or emotion that is
eventually came to terms with the horrific nature of what identified by the client is not the actual feared stimulus or
happened and made a decision to move on for the sake of object, and affect labeling can serve as a gateway to
her family. By labeling the sadness and thereby gaining identifying the core fear, thus changing the meaning of a
some distance from the emotion, she was able to make client’s experiences and behaviors. Similarly, when a
room for other valid emotional reactions she had at the client approaches a previously avoided stimulus, expec-
time, including fear and anger, and was able to move past tancies of an aversive outcome are often out of proportion
maladaptive interpretations of failing her children and to what actually occurs. Affect labeling has the potential to
being solely responsible for the effects of the violence on be a useful strategy in highlighting when the experience
her son. violates the client’s expectation. In the treatment of an
Sometimes it is important to use the labeling of the older male with social anxiety disorder, the exposure
emotion as a means to help the client identify a critical exercise was to walk into a grocery store and ask several
process rather than solely focusing on the emotion itself. questions of a store employee. When the therapist
Clients with anxiety or PTSD often have comorbid inquired about how the exercise went, the client
depression; with an anxious and depressed client, responded that it was not worth trying to talk to store
ruminative spinning or looping can serve to keep a client employees because they were not actually knowledgeable
stuck in a depressed state. When this is the case, labeling about the store’s products and would not be able to
the emotion can be used to stop the spinning. For one of answer his questions accurately. In fact, he came across as
our clients who lost her entire immediate family in a being irritated, reporting that doing the in vivo exercise
freeway crash, approaching memories of the event and was not worth his time. His therapist asked him whether
driving on the freeway evoked not only considerable there were any other possible reasons that kept him from
anxiety but also immense sadness. Repeatedly over the talking to the cashier, specifically what his thoughts were
course of therapy, she would burst into tears, hardly able on the cashier’s perception of him. She also asked
to talk, and when driving she would pull the vehicle over whether he would talk to the cashier if he could be
and cry. During these times, she would either focus on certain that the cashier was knowledgeable, and how it was
how awful it felt or how alone she felt. Both of these that he knew for certain that the cashier was not
reactions were entirely valid—however, when the thera- knowledgeable. The therapist then asked more targeted
pist solely labeled the emotion as feeling “sad,” it only questions, such as “Was there a possibility that anxiety was
prolonged or even exacerbated the reaction. Note that influencing your decision to not interact with the
this is also an example of when affect labeling heightened cashier?” and “Was there any possibility that you were
an emotional experience rather than mitigated it, worried about being judged?” By eventually labeling the
pointing to the “tricky” nature of this technique. The client’s fear of judgment, they were better able to tailor
client was unable to process any new incoming informa- subsequent exposure exercises and start with an exercise
tion, essentially becoming stuck in the emotion, and being that would directly target the fear of judgment. In the
unwilling to further approach her driving exposure tasks. process, his therapist was able to revisit the rationale for
After observing this process over multiple sessions, the exposure and how doing repeated and prolonged
therapist shifted techniques and labeled the feeling of exposures would eventually help him to gather informa-
sadness as part of a “spinning” process that kept her stuck tion to challenge his fear that he would always be judged
in an unproductive processing loop and prevented more in social interactions and that he would not be able to
210 Marks et al.

handle it. The therapist was also able to highlight how the all of the tags from his clothes. Exposure exercises shifted
expected outcome of rejection was motivating his fear and to sitting with distress of those feelings—that is, the lack of
link the absence of rejection to decreases in his fear. Thus, control, rather than solely approaching or touching
labeling the affect appropriately helped illustrate how his disgusting substances. The therapist, parents, and teacher
actual experience violated his expectation, consistent with worked together, helping the boy learn to sit with his
expectancy violation as a critical process in exposure feelings of distress until those feelings dissipated, rein-
therapy. forcing that when things felt “yucky” it was important to
Affect labeling also has the potential to facilitate the wait for the feeling to go away, that the bad thing he
development of new meaning to previously held stimuli, expected to happen would not occur, and that eventually
responses, and associations. In individuals with PTSD, he would even forget that the “yucky” thing was still there.
specific aspects of a traumatic event often consume a Thus, the focus was not disgust per se but the fear of being
client’s focus at the expense of the role of emotional trapped or helpless to easily remove the object and his
experience during the event. One of the women we expectations around what would occur when he
worked with was focused on the questions “Why did I let approached these situations. Notably, this is also an
him rape me?” and “Why didn’t I fight back?” These illustration of how affect labeling (i.e., the focus on a
questions were in contrast to how she viewed herself as a “gross” or “yucky” experience) might actually backfire,
person before the event, as someone strong and able to leading a therapist away from the true core fear of being
take care of herself. During imaginal exposure, in the trapped. This again points to the “tricky” nature of affect
moments before the rape, the therapist queried about labeling and argues for careful case conceptualization
what she was seeing around her and what it felt like to be and functional analysis driving clinical intervention,
on the ground. These queries brought out important rather than assuming the accuracy of the affective label
details, including that the rapist was considerably bigger as part of that case conceptualization.
than her, his weight was crushing her, and he held a large Meaning of a client’s experience can also shift when a
rock next to her head. From this, she was able to identify therapist helps the client identify an emotion that may be
that she was terrified that he was going to kill her. This being “blocked” by a second emotion. The “blocked”
terror helped explain for her the answers to her questions emotion at times may be the more important emotion to
and helped reduce her feelings of shame about what had process in order for new learning to occur. One example
happened. of this is of a client who fixated on anger as her primary
A third example illustrating how labeling important emotional experience during a rape that occurred while
emotions during an exposure can shift the meaning of a she was in the military. She consistently was able to feel
client’s experience can be seen in a 7-year-old boy with and label her anger around how her perpetrator went on
OCD. One of his main fears was of sticky, gooey objects to have an “esteemed” military career, while she felt
such as glue, gum, masking tape, peanut butter, paints, “forced” to leave the military and spent years struggling
etc. He would avoid arts and crafts projects at school with depression and PTSD. She would report that the
because he described the glue sticking on his fingers as event itself did not feel like a “big deal” and invalidated
“really gross.” He also had a hard time during recess when her experience of her PTSD symptoms, saying that if she
it rained; instead of playing outside, he would stay close to had just been able to “get over it” she would have been
the building to avoid getting any mud on his shoes. He able to stay in the military. Her focus on anger and the
said that the mud was “yucky” and hated it when other aftermath of the rape kept her from identifying and
kids would wipe their feet on the mat coming inside. engaging with her fear during imaginal exposures and
Although the boy identified the gross, “yucky” feeling as kept her from acknowledging that the event was a
the primary emotion, it was the feeling of being trapped terrifying experience where her physical integrity was
or constrained that was truly the underlying fear. threatened. At the beginning of treatment, she reported
Exposure exercises (e.g., touching dried mud, paint) low SUDs levels during the imaginal exposure and
did not provoke any distress unless he could not easily consistently reported in processing that she did not find
remove the substance from his body. Although he labeled the recounting of the memory to be very challenging
the affect as “gross,” the clinical presentation in session given that her mind was already thinking about the
did not align; he did not demonstrate behavioral aftermath. In order to help the client be as present as
indicators of feeling disgusted but instead looked anxious possible during imaginal exposure, her therapist asked
and afraid. In this case, his inappropriate labeling of affect her what she was feeling at specific moments where her
helped the therapist recognize they were focusing on the actions suggested she was afraid, such as crawling on the
wrong emotion. Upon further exploration, the boy could floor to escape from the room. As she described reaching
not wear anything tight around his neck or arms (e.g., for her phone to call for help, the therapist asked, “What
turtlenecks, watches) and was having his mother remove are you feeling?” When the client responded that she
 Affect Labeling and Inhibitory Learning 211

wasn’t sure, the therapist followed up with questions public places. Using exposure and response prevention
about physical sensations, like “What are you feeling in for OCD, the therapist employed affect labeling to
your chest?” or “What are you feeling in your stomach?” enhance the corrective learning experience of tolerating
This helped the client to eventually identify fear, based on the distress during exposure exercises. One of the client’s
her behaviors and on her physical experiences. Before fears was “getting sick” after she touched doorknobs and
explicitly labeling her fear during the event, the client was railings in high-traffic areas, particularly if she was not
unable to process the full emotional experience of being allowed to engage in compulsive hand washing afterward.
assaulted and what that meant to her. When discussing the upcoming exposure exercises, the
therapist would label her fear of contracting methicillin-
resistant Staphylococcus aureus (MRSA) and dying a
Increasing Distress and Distress Tolerance terrible death, allowing for the uncertainty that it could
Affect labeling can also be applied to increase come true (e.g., “You are afraid that touching doorknobs
engagement with emotional experiencing. A common in this clinic and not washing your hands may result in
experience we see in individuals with PTSD is building, your getting sick, but despite your fear, it is unlikely”) and
metaphorically speaking, a protective emotional wall connecting the thoughts/feared consequence explicitly
around the traumatic event. One of our clients with with affect. By doing this in session, the therapist
PTSD, who would retell the “police report” version of her confirmed that the feared outcome was possible, and
childhood abuse during imaginal exposure (i.e., devoid of thus challenged the client to tolerate uncertainty around
emotion, smiling incongruent with content to mask contracting an illness (i.e., her feared outcome) and to
distressing emotions), benefited from affect labeling. tolerate the affect that accompanied that uncertainty.
During the most intense parts of the memory in imaginal This in turn enhanced the learning associated with
exposure, the therapist would probe gently with ques- exposure, as the client increased both her tolerance of
tions, such as “As he is telling you to sit on his lap, what are her anxiety and also her tolerance of the thoughts
you feeling?” and “What does the shame feel like to you?” connected to her emotions.
By encouraging her to label explicitly the emotional Teaching a client to tolerate distress and discomfort
experiences, the therapist gradually helped this client through exposure is also notable in the labeling of
intensify her recall of the trauma narrative, allowing her anticipatory anxiety. Identifying and labeling the antici-
to feel more of the distressing emotions associated with patory anxiety helps the client put the experience in
the abuse, such as fear, anger, and shame. Over time, perspective (e.g., “This is normal,” “This is to be
labeling the affect helped the client feel less afraid of expected,” “This is not a heart attack,” “I am not going
going back to those memories and ultimately helped her to die”) and alters subsequent behavior, such as reducing
differentiate emotional experiences she had as a small the urge to flee a situation and encouraging persistence
child from those she experienced as an adult while through the distress. One of our clients had extreme test
revisiting the memory. She learned she could tolerate anxiety and, as a new college student, was sure he was
these negative emotions and that she did have the skills to going to fail out of his most difficult courses. As part of
effectively cope with these feelings. This example also psychoeducation, the therapist explained the physiology
illustrates how many exposure therapists who utilize of anxiety, what anticipatory anxiety was, and used two
imaginal exposure likely already incorporate affect analogies with the patient. The first analogy was of anxiety
labeling to routinely increase emotional engagement being like riding a roller coaster, where the buildup to the
with some clients—what is being illustrated should not big first drop is often the worst part. The second analogy
come as a shock or anything new to experienced was of anxiety being like a surfer riding a wave,
therapists. understanding that the wave had a natural progression
A common therapeutic situation where affect labeling and would eventually dissipate. For homework, the client
contributes to new learning is through teaching a client was asked to track his anticipatory anxiety. This simple
that he or she can tolerate intense emotions and increase in knowledge and insight into his anxiety
associated distress. This can increase awareness and patterns identified through the tracking exercise shifted
salience of the feared consequence associated with the how he experienced taking tests and led to increased
pathological emotions and behaviors, including being confidence in his ability to “ride the wave.” Each time that
able to tolerate uncertainty of feared outcomes. A female he was able to label his anxiety as anticipatory anxiety and
client presented for therapy with a fear of germ stick with this emotion, he learned that he was able to
contamination accompanied by compulsive cleaning tolerate the discomfort, the physiological sensations, and
and washing that prevented her from participating in the fluctuations in emotional intensity. Over time, his
group meetings at the school where she taught, eating anticipatory anxiety lessened as his catastrophic thoughts
lunch in the lunchroom, and from attending activities in about needing to escape and being unable to sit with the
212 Marks et al.

distress decreased. Notably, across all three of these and brain mechanisms. Biological Psychiatry, 60, 352–360. https://
doi.org/10.1016/j.biopsych.2005.12.015.
clinical examples of using affect labeling to identify Bouton, M. E., Winterbauer, N. E., & Todd, T. P. (2012). Relapse
distress, increase or decrease engagement, and promote processes after the extinction of instrumental learning: Renewal,
distress tolerance, the use of affect labeling largely reflects resurgence, and reacquisition. Behavioural Processes, 90, 130–141.
https://doi.org/10.1016/j.beproc.2012.03.004.
good clinical instincts and what would be considered Brewin, C. R. (2014). Episodic memory, perceptual memory, and their
routine clinical practice for the expert exposure clinician. interaction: Foundations for a theory of posttraumatic stress
This may potentially argue that the incremental effects of disorder. Psychological Bulletin, 140, 69–97. https://doi.
org/10.1037/a0033722.
adding more systematic affect labeling may be modest, at Brooks, J. A., Shablack, H., Gendron, M., Satpute, A. B., Parrish, M. H.,
best, given its already common use in high-quality, & Lindquist, K. A. (2017). The role of language in the experience
standard practice. and perception of emotion: A neuroimaging meta-analysis. Social
Cognitive and Affective Neuroscience, 12, 169–183. https://doi.
org/10.1093/scan/nsw121.
Future Directions and Implications of Affect Burklund, L. J., Craske, M. G., Taylor, S. E., & Lieberman, M. D. (2015).
Labeling for Exposure Therapy Altered emotion regulation capacity in social phobia as a function
of comorbidity. Social Cognitive and Affective Neuroscience, 10,
Affect labeling is not a stand-alone technique necessary 199–208. https://doi.org/10.1093/scan/nsu058.
for therapeutic change to occur, nor do we have the Burklund, L. J., Creswell, J. D., Irwin, M., & Lieberman, M. (2014). The
common and distinct neural bases of affect labeling and
evidence base to say that it does indeed enhance clinical reappraisal in healthy adults. Frontiers in Psychology, 5221. https:
outcomes of exposure-based therapies. Furthermore, many //doi.org/10.3389/fpsyg.2014.00221.
clinicians likely already use this strategy, as identifying and Constantinou, E., Van Den Houte, M., Bogaerts, K., Van Diest, I., & Van
den Bergh, O. (2014). Can words heal? Using affect labeling to
labeling emotions is a basic component of many psycho- reduce the effects of unpleasant cues on symptom reporting.
therapies. That said, it is a relatively simple strategy that may Frontiers in Psychology, 5807. https://doi.org/10.3389/
be helpful to employ intentionally during exposure-based fpsyg.2014.00807.
Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury,
interventions for a range of psychopathology. Affect N., & Baker, A. (2008). Optimizing inhibitory learning during
labeling may serve as a gateway for new, inhibitory learning exposure therapy. Behaviour Research and Therapy, 46, 5–27. https:
and for in-depth emotional processing to occur. It may //doi.org/10.1016/j.brat.2007.10.003.
Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B.
serve to increase the experience of an emotion or give the (2014). Maximizing exposure therapy: An inhibitory learning
client some distance from his or her emotion. Rather than approach. Behaviour Research and Therapy, 58, 10–23. https://doi.
“being” the emotion, the client may be able to objectify his org/10.1016/j.brat.2014.04.006.
Ekman, P. (2016). What scientists who study emotion agree about.
or her emotion by identifying his or her emotional Perspectives on Psychological Science, 11, 31–34. https://doi.
experience with a label and further activate higher cortical org/10.1177/1745691615596992.
processes important to fear extinction. Feeny, N. C., Hembree, E. A., & Zoellner, L. A. (2003). Myths regarding
exposure therapy for PTSD. Cognitive and Behavioral Practice, 10,
To date, there is minimal clinical research that 85–90. https://doi.org/10.1016/S1077-7229(03)80011-1.
systematically examines the role of affect labeling; we Fernandez, E., & Johnson, S. L. (2016). Anger in psychological
were surprised at the lack of clinical research looking disorders: Prevalence, presentation, etiology and prognostic
implications. Clinical Psychology Review, 46, 124–135. https://doi.
specifically at extinction processes with and without affect org/10.1016/j.cpr.2016.04.012.
labeling, given the aspiration to augment exposure-based Ferri, J., Eisendrath, S. J., Fryer, S. L., Gillung, E., Roach, B. J., &
treatment outcomes. Future research should examine Mathalon, D. H. (2017). Blunted amygdala activity is associated
with depression severity in treatment-resistant depression. Cogni-
affect labeling in a manner more consistent with its tive, Affective, & Behavioral Neuroscience, 17, 1221–1231. https://
therapeutic applications and common comorbidities, so doi.org/10.3758/s13415-017-0544-6.
that we can better understand the mechanisms through Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear:
Exposure to corrective information. Psychological Bulletin, 99(1),
which it may function prior to implementing it systemat- 20–35.
ically in clinical settings. We need to understand how best Foa, E. B., Huppert, J. D., & Cahill, S. P. (2006). Emotional processing
to label affect and also begin to explore the magnitude of theory: An update. In B. O. Rothbaum (Ed.), Pathological anxiety:
Emotional processing in etiology and treatment (pp. 3–24). New York,
any effects in enhancing therapeutic outcomes for clients NY: Guilford Press.
in exposure-based treatments. Hariri, A. R., Bookheimer, S. Y., & Mazziotta, J. C. (2000). Modulating
emotional responses: Effects of a neocortical network on the
References l i m b i c s y s te m . N e u r o r e p o r t , 11 , 4 3– 4 8. h t t p s : / / d o i .
org/10.1097/00001756-200001170-00009.
Bisson, J. I., Roberts, N. P., Andrew, M., Cooper, R., & Lewis, C. (2013). Hayes, A. M. (2015). Facilitating emotional processing in depression:
Psychological therapies for chronic post-traumatic stress disorder The application of exposure principles. Current Opinion in
(PTSD) in adults. Cochrane Database of Systematic Reviews, Psychology, 4, 61–66. https://doi.org/10.1016/j.
12CD003388. https://doi.org/10.1002/14651858.CD003388. copsyc.2015.03.032.
pub4. Hembree, E. A., Rauch, S. A. M., & Foa, E. B. (2003). Beyond the
Bouton, M. E. (2002). Context, ambiguity, and unlearning: Sources of manual: The insider's guide to prolonged exposure therapy for
relapse after behavioral extinction. Biological Psychiatry, 52(10), PTSD. Cognitive and Behavioral Practice, 10(1), 22–30. https://doi.
976–986. https://doi.org/10.1016/S0006-3223(02)01546-9. org/10.1016/S1077-7229(03)80005-6.
Bouton, M. E., Westbrook, R. F., Corcoran, K. A., & Maren, S. (2006). Herbert, C., Sfärlea, A., & Blumenthal, T. (2013). Your emotion or
Contextual and temporal modulation of extinction: Behavioral mine: Labeling feelings alters emotional face perception: An ERP
 Affect Labeling and Inhibitory Learning 213

study on automatic and intentional affect labeling. Frontiers in down-regulation of negative emotions. Emotion, 12, 229–235.
Human Neuroscience , 7378. https://doi.org/10.3389/ https://doi.org/10.1037/a0027421.
fnhum.2013.00378. Phelps, E. A., Delgado, M. R., Nearing, K. I., & LeDoux, J. E. (2004).
Hofmann, S. G. (2008). Cognitive processes during fear acquisition Extinction learning in humans: Role of the amygdala and vmPFC.
and extinction in animals and humans: Implications for exposure Neuron, 43, 897–905. https://doi.org/10.1016/j.
therapy of anxiety disorders. Clinical Psychology Review, 28, neuron.2004.08.042.
199–210. https://doi.org/10.1016/j.cpr.2007.04.009. Powers, M. B., & Emmelkamp, P. M. G. (2008). Virtual reality exposure
Institute of Medicine (2008). Treatment of posttraumatic stress disorder: An therapy for anxiety disorders: A meta-analysis. Journal of Anxiety
assessment of the evidence. Washington, DC: National Academies Disorders, 22, 561–569. https://doi.org/10.1016/j.
Press. anxdis.2007.04.006.
Joseph, S., & Linley, P. A. (2005). Positive adjustment to threatening Quirk, G. J., Likhtik, E., Pelletier, J. G., & Pare, D. (2003). Stimulation
events: An organismic valuing theory of growth through adversity. of medial prefrontal cortex decreases the responsiveness of
Review of General Psychology, 9, 262–280. https://doi. central amygdala output neurons. Journal of Neuroscience, 23,
org/10.1037/1089-2680.9.3.262. 8800–8807.
LeDoux, J. (2015). Anxious: Using the brain to understand and treat anxiety. Rachman, S. (1980). Emotional processing. Behaviour Research and
New York, NY: Viking. Therapy, 18, 51–60.
Lieberman, M. D., Eisenberger, N. I., Crockett, M. J., Tom, S. M., Rachman, S. (2001). Emotional processing, with special reference to
Pfeifer, J. H., & Way, B. M. (2007). Putting feelings into words: post-traumatic stress disorder. International Review of Psychiatry, 13,
Affect labeling disrupts amygdala activity in response to affective 164–171. https://doi.org/10.1080/09540260120074028.
stimuli. Psychological Science, 18, 421–428. https://doi. Schiller, D., Monfils, M. H., Raio, C. M., Johnson, D. C., LeDoux, J. E., &
org/10.1111/j.1467-9280.2007.01916.x. Phelps, E. A. (2010). Preventing the return of fear in humans
Lieberman, M. D., Inagaki, T. K., Tabibnia, G., & Crockett, M. J. using reconsolidation update mechanisms. Nature, 463, 49–53.
(2011). Subjective responses to emotional stimuli during labeling, https://doi.org/10.1038/nature08637.
reappraisal, and distraction. Emotion, 11, 468–480. https://doi. Stemmler, G. (2010). Somatovisceral activation during anger. Interna-
org/10.1037/a0023503. tional Handbook of Anger (pp. 103–121).. https://doi.
Matejka, M., Kazzer, P., Seehausen, M., Bajbouj, M., Klann-Delius, G., org/10.1007/978-0-387-89676-2_7.
Menninghaus, W., & Prehn, K. (2013). Talking about emotion: Tabibnia, G., Lieberman, M. D., & Craske, M. G. (2008). The lasting
Prosody and skin conductance indicate emotion regulation. effect of words on feelings: Words may facilitate exposure effects
Frontiers in Psychology, 4260. https://doi.org/10.3389/ to threatening images. Emotion, 8, 307–317. https://doi.
fpsyg.2013.00260. org/10.1037/1528-3542.8.3.307.
McEvoy, P. M., Watson, H., Watkins, E. R., & Nathan, P. (2013). The Torrisi, S. J., Lieberman, M. D., Bookheimer, S. Y., & Altshuler, L. L.
relationship between worry, rumination, and comorbidity: Evi- (2013). Advancing understanding of affect labeling with dynamic
dence for repetitive negative thinking as a transdiagnostic causal modeling. NeuroImage, 82, 481–488. https://doi.
construct. Journal of Affective Disorders, 151, 313–320. https://doi. org/10.1016/j.neuroimage.2013.06.025.
org/10.1016/j.jad.2013.06.014. Tupak, S. V., Dresler, T., Guhn, A., Ehlis, A. C., Fallgatter, A. J., Pauli,
McRae, K., Taitano, E. K., & Lane, R. D. (2010). The effects of verbal P., & Herrmann, M. J. (2014). Implicit emotion regulation in the
labeling on psychophysiology: Objective but not subjective presence of threat: Neural and autonomic correlates. NeuroImage,
emotion labeling reduces skin-conductance responses to briefly 85, 372–379. https://doi.org/10.1016/j.neuroimage.2013.09.066.
presented pictures. Cognition and Emotion, 24, 829–839. https:// Watkins, E. R. (2008). Constructive and unconstructive repetitive
doi.org/10.1080/0269993090297141. thought. Psychological Bulletin, 134, 163–206. https://doi.
Memarian, N., Torre, J. B., Haltom, K. E., Stanton, A. L., & Lieberman, org/10.1037/0033-2909.134.2.163.
M. D. (2017). Neural activity during affect labeling predicts Williams, J. M. G. (2006). Capture and rumination, functional
expressive writing effects on well-being: GLM and SVM ap- avoidance, and executive control (CaRFAX): Three processes
proaches. Social Cognitive and Affective Neuroscience, 12, that underlie overgeneral memory. Cognition and Emotion, 20,
1437–1447. https://doi.org/10.1093/scan/nsx084. 548–568. https://doi.org/10.1080/02699930500450465.
Niles, A. N., Craske, M. G., Lieberman, M. D., & Hur, C. (2015). Affect Wolpe, J. (1969). The practice of behavior therapy, 4th ed. New York, NY:
labeling enhances exposure effectiveness for public speaking Pergamon Press.
anxiety. Behaviour Research and Therapy, 68, 27–36. https://doi. Young, K. S., Burklund, L. J., Torre, J. B., Saxbe, D., Lieberman, M. D.,
org/10.1016/j.brat.2015.03.004. & Craske, M. G. (2017). Treatment for social anxiety disorder
Nils, F., & Rimé, B. (2012). Beyond the myth of venting: Social sharing alters functional connectivity in emotion regulation neural
mode determines the benefits of emotional disclosure. European circuitry. Psychiatry Research: Neuroimaging, 261, 44–51. https://
Journal of Social Psychology, 42, 672–681. doi.org/10.1016/j.psychresns.2017.01.005.
Norberg, M. M., Krystal, J. H., & Tolin, D. F. (2008). A meta-analysis of
d-cycloserine and the facilitation of fear extinction and exposure
Preparation of this manuscript was funded in part by F31MH106194
therapy. Biological Psychiatry, 63, 1118–1126. https://doi.
(Marks, PI) and R01MH066347 (Zoellner, PI). Clinical examples
org/10.1016/j.biopsych.2008.01.012.
Ochsner, K. N., & Gross, J. J. (2005). The cognitive control of emotion. reflect a compilation across clients, with pertinent details changed to
Trends in Cognitive Sciences, 9, 242–249. https://doi.org/10.1016/j. conceal identities.
tics.2005.03.010. Address correspondence to Elizabeth H. Marks, University of
Ortner, C. N. M. (2015). Divergent effects of reappraisal and labeling Washington, Dept. of Psychology, Department119A Guthrie Hall, Box
internal affective feelings on subjective emotional experience. 351525, Seattle, WA 98195-1525; e-mail: ehm4@uw.edu.
Motivation and Emotion, 39, 563–570. https://doi.org/10.1007/
s11031-015-9473-2.
Park, C. L. (2010). Making sense of the meaning literature: An Received: December 21, 2016
integrative review of meaning making and its effects on Accepted: May 14, 2018
adjustment to stressful life events. Psychological Bulletin, 136, Available online 8 June 2018
257–301. https://doi.org/10.1037/a0018301.
Payer, D. E., Baicy, K., Lieberman, M. D., & London, E. D. (2012).
Overlapping neural substrates between intentional and incidental