Managing High-Intensity Emotions in Therapy

High-intensity emotions—such as rage, panic, shame, and grief—can dominate the therapeutic space. This article explores how therapists can best manage them.

Related articles: Disentangling Painful Emotions, The Window of Tolerance: An Essential Tool for Emotional Regulation, Working with Shame: Interventions for Deep Emotional Healing.

Introduction

High-intensity emotions—such as rage, panic, shame, and grief—can dominate the therapeutic space. While these powerful affective states may feel overwhelming, they often present valuable opportunities for healing and transformation. The clinician’s role is to provide a safe container for these emotions while helping the client build the capacity to explore, understand, and regulate them.

Mental health professionals frequently encounter high-intensity emotions in clients with trauma histories, mood disorders, personality disorders, and complex grief. Managing these states effectively requires a combination of emotional attunement, technical skill, and self-awareness.

This article explores structured, evidence-based strategies for managing intense emotions in therapy. It includes practical interventions, case illustrations, scripts, and considerations for clinicians’ own emotional responses.

Understanding high-intensity emotions

High-intensity emotions are affective states that overwhelm an individual’s capacity to self-regulate, leading to disruptions in thinking, behaviour, and interpersonal functioning. These emotions may arise suddenly or be sustained over time, and they often dominate the psychological landscape of the therapy session. For many clients, especially those with trauma histories or emotional dysregulation, such emotions are both feared and misunderstood.

The nature of high-intensity emotions

These emotional experiences are characterised by:

• Intense physiological arousal (e.g., racing heart, hyperventilation, muscle tension)
• Intrusive cognitions (e.g., catastrophic thinking, shame spirals)
• Behavioural urgency (e.g., yelling, withdrawing, dissociating)
• Loss of reflective functioning (i.e., inability to think clearly or mentalise)

They often reflect a threat response, whether the threat is real or perceived, immediate or symbolic. When clients are in this state, the limbic system, particularly the amygdala, becomes highly active, while prefrontal cortex functioning (responsible for reasoning and self-regulation) is reduced (Porges, 2011; Siegel, 1999).

Common high-intensity emotional states in therapy

While any emotion can become dysregulating under certain conditions, several are particularly relevant in clinical settings:

• Panic and acute anxiety
• Explosive anger or rage
• Shame and self-loathing
• Despair and grief
• Emotional numbing or dissociation

Understanding the function behind these emotions—rather than simply the content—is critical. For example, rage may serve as a boundary-setting mechanism for a client who has been chronically disempowered, while shame might represent an internalised relational trauma.

“Emotions are messengers—not problems to be solved, but signals to be understood.” – Adapted from Greenberg (in Muran & Eubanks, 2020).

The window of tolerance

The concept of the window of tolerance (Siegel, 1999) refers to the optimal arousal zone in which a person can function effectively – thinking, feeling, and relating at the same time. When emotional intensity pushes someone above this window (hyperarousal), they may experience panic, rage, or impulsivity. When pushed below it (hypoarousal), they may become emotionally numb, shut down, or dissociative.

Many clients with trauma histories have narrow windows of tolerance, meaning even moderate emotional stimuli can feel overwhelming. Therapy aims to expand this window by building emotion regulation capacity over time.

Useful resource (video): What is the Window of Tolerance?

Developmental and attachment roots

High-intensity emotions often trace back to early attachment experiences where the individual was left alone with emotions that were too big to process. For example:

• A child who cried and was ignored or punished may grow into an adult who feels ashamed or terrified when they become tearful.
• A child who experienced inconsistent care may develop difficulty tolerating uncertainty or emotional ambiguity in relationships, leading to panic or angry outbursts.

These early patterns shape emotion schemas—the unconscious templates that guide how we feel and react. Effective therapy often involves updating these emotional templates through relational repair, emotional processing, and self-reflection (Courtois & Ford, 2020).

The role of emotion dysregulation

Clients who present with chronic emotional volatility, such as those with borderline personality disorder (BPD), complex PTSD, or certain neurodivergent profiles, often struggle with emotion dysregulation. This involves:

• Difficulty identifying or labelling emotions
• Poor impulse control in response to emotions
• Maladaptive coping mechanisms
• Heightened sensitivity to emotional stimuli

Linehan (2014) conceptualised BPD as a disorder of emotional dysregulation, wherein biologically heightened emotional sensitivity meets an invalidating environment. This interplay leads to repeated experiences of emotional flooding and relational rupture.

Clinical implications of high-intensity emotions

For clinicians, understanding high-intensity emotions involves more than simply recognising their presence—it requires:

• Attunement: Picking up on early signs of emotional escalation.
• Tolerance: Remaining calm and connected even when emotions in the room feel threatening.
• Curiosity: Exploring what the emotion is trying to communicate rather than reflexively soothing or avoiding it.

This foundation enables the effective use of therapeutic techniques like grounding, validation, restructuring, and meaning-making.

The importance of the therapeutic alliance

A strong therapeutic alliance forms the foundation for working with high-intensity emotions. Empathy, safety, and emotional attunement foster an environment where clients can risk emotional vulnerability.

According to Norcross and Lambert (2018), the quality of the therapeutic relationship is one of the most consistent predictors of positive outcomes, especially when clients are emotionally dysregulated.

For many clients, particularly those with a history of relational trauma, the therapist may be the first consistent and emotionally available figure in their lives. In these cases, the alliance becomes not just a medium for healing, but the healing intervention itself. A strong alliance can repair internal working models that equate emotional vulnerability with danger or rejection.

Therapist script (early session): “If at any point you feel overwhelmed, know that we can slow down and work with that feeling together. You won’t be alone in it.”

It is also essential for therapists to tolerate ruptures in the alliance—which are common when high-intensity emotions are involved—and view them as opportunities for growth. Repairing ruptures fosters trust and teaches clients that conflict need not lead to abandonment.

Therapist script (during rupture repair): “It seems like something I said felt invalidating or made things harder. I want to understand that better—can we talk about what happened?”

Through consistent presence, non-defensive responsiveness, and emotional containment, therapists help clients internalise a sense of relational security. This, in turn, increases clients’ capacity to self-regulate.

Setting this tone from the beginning helps reduce fear around intense emotional experiences and provides a secure base from which to explore vulnerability.

Useful resource: Building the Therapeutic Alliance: A Guide for Therapists.

A phase-based approach to high-intensity emotions

A phase-based approach to emotional regulation – common in trauma-informed therapy – can guide interventions. This model includes:

1. Stabilisation and Safety
2. Processing and Integration
3. Consolidation and Meaning-Making

Let’s examine each phase in detail.

Phase 1: Stabilisation and safety

When clients are overwhelmed, the primary task is emotional containment—helping them feel grounded, safe, and regulated enough to remain present.

Grounding techniques

Grounding strategies redirect attention from overwhelming internal experiences to the external environment.

Technique – The 5-4-3-2-1:

• 5 things you can see
• 4 things you can feel
• 3 things you can hear
• 2 things you can smell
• 1 thing you can taste

Therapist prompt:“Let’s pause for a moment. Can you tell me five things you see in the room right now?”

Breathwork

Slow, deep breathing engages the parasympathetic nervous system and calms arousal (Porges, 2011).

Technique – diaphragmatic breathing:

• Inhale for 4 seconds
• Exhale for 6 seconds
• Repeat for 1–2 minutes

Therapist prompt: “Let’s take a few slow breaths together—breathe in… and out… Let’s do that again.”

Phase 2: Processing and integration

Once stabilised, clients can begin to explore and process their emotions more directly. The therapist’s role is to stay attuned and support insight without retraumatising the client.

Emotion labelling

Helping clients name their feelings reduces their intensity and promotes regulation (Lieberman et al., 2007).

Therapist prompt:“What’s the word for this feeling right now? Sadness? Anger? Something else?”

Using tools like emotion wheels or the award-winning How We Feel app can support clients with limited emotional vocabulary.

Validation and normalisation

Validating the client’s emotional responses strengthens the alliance and reduces internal shame.

Therapist prompt: “Given what happened, it’s completely understandable that you’d feel this angry. That emotion is trying to protect something important.”

Useful resource: Validation and Reassurance Worksheet.

Use of metaphors

Metaphors can help clients externalise and observe their emotions more safely.

Example – The emotional wave: “This emotion is like a wave—it rises, it peaks, and it passes. You don’t need to fight it. Let’s ride it together.”

Phase 3: Consolidation and meaning-making

In this phase, clients begin to integrate emotional experiences, reshape narratives, and develop new coping strategies.

Cognitive restructuring

Once arousal has subsided, distorted beliefs tied to the emotion can be explored using CBT techniques.

Case Illustration: Emily (27, BPD traits). Emily often felt overwhelming shame after arguments. She would think: “I’m too much for people.” Using a thought record, the therapist helped her gather evidence to challenge this belief.

• Automatic thought: “I ruined everything.”
• Evidence for: “I raised my voice.”
• Evidence against: “My partner said he still cares and wants to talk later.”

Through repeated practice, Emily became less reactive and more self-compassionate.

Values work

In Acceptance and Commitment Therapy (Hayes, Strosahl, & Wilson, 2012), values help clients direct intense emotion toward purposeful action.

Therapist prompt:“When you’re angry, what value is being violated? Is it fairness? Respect? Safety?”

Connecting feelings to values offers clarity and direction.

Managing the therapist’s own emotions

Working with emotional intensity can activate powerful countertransference, especially when therapists feel helpless, overwhelmed, or personally triggered.

Recognising emotional activation

Therapists should routinely ask themselves:

• “What am I feeling in this moment?”
• “Is this emotion mine or the client’s?”
• “Am I overidentifying or withdrawing?”

Self-awareness is essential for ethical, effective practice (Barnett, 2019).

Common therapist reactions

• Flooding: Feeling overwhelmed and unsure how to proceed.
• Rescuing: Trying to prematurely soothe the client to reduce discomfort.
• Avoidance: Changing the subject or glossing over intense material.

Internal reflection example: “I feel tight in my chest right now. I’m trying to make this emotion go away instead of sitting with it. Let me slow down.”

Self-regulation tools

• Brief grounding (between sessions):Step outside, stretch, engage with the senses.
• Supervision & consultation: Use trusted colleagues to explore emotional reactions and maintain perspective. Related reading: Trauma-Informed Supervision: Supporting Therapists Who Treat Trauma.
• Mindfulness practices:Regular mindfulness reduces therapist reactivity and promotes presence (Geller & Greenberg, 2012).

Modelling emotional containment

When therapists model calmness and curiosity toward emotion, clients internalise these patterns over time.

Therapist prompt (during an emotional outburst): “I can see how strongly you’re feeling this. I’m here with you. Let’s take it one step at a time.”

Cultural and developmental considerations

Expression and interpretation of emotion vary widely across cultural, developmental, and gender contexts. What might be perceived as emotional dysregulation in one context may be considered normal, appropriate, or even adaptive in another.

Cultural contexts

In some cultures, emotional restraint is valued, and open expression of strong feelings may be discouraged or even stigmatised. In others, passionate emotional expression may be considered a sign of sincerity and engagement. Therapists must approach clients with cultural humility and curiosity rather than assuming a universal standard of “healthy” emotional expression.

Therapist prompt: “How were strong emotions handled in your family or community growing up?”

Therapists should also consider systemic issues that may impact clients’ emotional experiences, such as racism, intergenerational trauma, acculturation stress, and marginalisation. These factors can shape not only how emotions are experienced but also how safe clients feel in expressing them in the therapeutic setting (Sue & Sue, 2016).

Gender norms

Gender socialisation plays a significant role in emotional development. Men may be conditioned to suppress vulnerability and express distress through anger or withdrawal, while women may be socialised to suppress anger and prioritise relational harmony. Non-binary and transgender clients may experience particular challenges related to the expression of emotion if their gender identity has been invalidated.

Clinicians should be aware of how gender norms can influence the presentation of high-intensity emotions and create space for more authentic emotional expression across the gender spectrum.

Developmental considerations

Children and adolescents may experience and express emotions differently than adults. Young children may somatise distress (e.g., stomach aches), act out behaviourally, or lack the verbal skills to articulate their emotional experiences. Adolescents may struggle with emotion regulation due to ongoing brain development and heightened sensitivity to social dynamics.

Therapeutic interventions with young clients often need to be adapted to their developmental stage. This may include:

• Using play, metaphor, or art to explore emotional experiences
• Involving caregivers to support co-regulation and modelling
• Simplifying language and using concrete examples

Case example: A 10-year-old expressing anxiety as stomach aches may benefit from drawing their feelings or identifying emotions in characters during a shared story.

By attending to cultural and developmental differences, therapists can more accurately understand emotional expression and tailor interventions accordingly (Ogden & Fisher, 2015).

Conclusion

High-intensity emotions can be unsettling, but with the right tools and mindset, therapists can transform these moments into opportunities for deep healing. A trauma-informed, phase-based approach—combined with strong attunement and therapist self-awareness—provides a solid foundation for working with emotional intensity.

Rather than fearing emotional storms, we can help clients learn to ride the waves.

Key takeaways

• High-intensity emotions offer opportunities for growth when managed skilfully.
• Begin with stabilisation: grounding, breathwork, and containment.
• Facilitate integration through emotion labelling, validation, and metaphor.
• Use restructuring and values-based approaches to consolidate insight.
• Attend to therapist emotions—seek supervision, practise mindfulness, and stay reflective.
• Tailor emotional work to the client’s cultural background and developmental stage.

Questions therapists often ask

Q: How do I quickly assess whether a client’s intense emotional state is within their window of tolerance?

A: Look for markers of hyperarousal (racing thoughts, agitation, pressured speech) or hypoarousal (flat affect, dissociation, slowed responses). If the client is losing access to reflective capacity, you’re already outside the window. The article emphasises using grounding and present-moment orientation early to bring arousal back into a workable range before touching deeper material.

Q: What’s the most effective way to interrupt emotional escalation without making the client feel shut down?

A: Name what you’re noticing and pair it with an invitation, not a command: “I can see this is getting overwhelming—can we slow it down together for a moment?” The article frames pacing as collaboration. The move is to regulate the process, not the client, so they still feel empowered rather than managed.

Q: How do I help a client differentiate between an emotion that needs expression and one that needs containment?

A: Use gentle inquiry into function: “What feels important about staying with this right now?” The article notes that expression is useful when it leads to insight or integration; containment is preferable when emotion is flooding the system or disconnecting the client from the therapeutic task. You’re helping them build internal discernment rather than deciding for them.

Q: What should I do when a client becomes emotionally overwhelmed despite preparation and pacing?

A: Shift to stabilisation immediately. The article highlights grounding, sensory orientation, paced breathing, and anchoring in the therapeutic relationship (“You’re not alone; we can slow this together”). Post-episode, debrief the process: what triggered the spike, what helped, and how to strengthen early detection next time.

Q: How can I introduce emotional regulation skills without the client feeling like I’m avoiding their deeper issues?

A: Frame regulation skills as tools that make deeper work possible rather than as distractions. The article suggests linking skills directly to the client’s goals: “If we can keep your system steady enough, we can explore these themes safely and more effectively.” When clients see regulation as enabling—not replacing—insight work, they’re far more receptive.

References

• Barnett J. E. (2019). The ethical practice of psychotherapy: Clearly within our reach. Psychotherapy (Chicago, Ill.), 56(4), 431–440. https://doi.org/10.1037/pst0000272
• Courtois, C. A., & Ford, J. D. (2020). Treating complex traumatic stress disorders in adults (2nd ed.). Guilford Press.
• Geller, S. M., & Greenberg, L. S. (2012). Therapeutic presence: A mindful approach to effective therapy. American Psychological Association.
• Gross, J. J. (2015). Emotion regulation: Current status and future prospects. Psychological Inquiry, 26(1), 1–26. https://doi.org/10.1080/1047840X.2014.940781
• Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). Guilford Press.
• Lieberman, M. D., Eisenberger, N. I., et al. (2007). Putting feelings into words: Affect labelling disrupts amygdala activity in response to affective stimuli. Psychological Science, 18(5), 421–428. https://doi.org/10.1111/j.1467-9280.2007.01916.x
• Linehan, M. M. (2014). DBT skills training manual (2nd ed.). Guilford Press.
• Muran, J.C., & Eubanks, C.F. (2020). Therapist performance under pressure: Emotion, difference & rupture. United States: American Psychological Association. http://dx.doi.org/10.1037/0000182-004
• Norcross, J. C., & Lambert, M. J. (2018). Psychotherapy relationships that work III. Psychotherapy, 55(4), 303-315. http://dx.doi.org/10.1037/pst0000193                             
• Ogden, P., & Fisher, J. (2015). Sensorimotor psychotherapy: Interventions for trauma and attachment. W. W. Norton.
• Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, self-regulation. W. W. Norton.
• Shapiro, F. (2017). Eye movement desensitization and reprocessing (EMDR) therapy: Basic principles, protocols, and procedures (3rd ed.). Guilford Press.
• Siegel, D. J. (1999). The developing mind: Toward a neurobiology of interpersonal experience. Guilford Press.
• Sue, D. W., & Sue, D. (2016). Counselling the culturally diverse: Theory and practice (7th ed.). Wiley.