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DBTDistressToleranceSkills:HelpingtheClientsThroughtheToughTimes(andYourself)

ClaraDoctolero,PsyDEi Resources,LLCandSeattlePsychStudio,LLC

clara@seattlepsychstudio.comJuly30,2019

*slidesadaptedfromDrs.Comtois,Korsland,andFleck

Overview

Goalsofdistresstoleranceskills

TeachingtheSkills• CrisisSurvival• RealityAcceptance

Clinicalapplications• Forclients• Foryourself

WhatisaCrisis?

Acrisisiswhenyouhaveaseriousproblembutyoucan’tsolveit(atleastnotnow).

Inacrisis,thereisapressure tosolvethe

problemanditisdifficulttostoptrying.

Inacrisis,emotionsarehighsotheproblemisdistressingandhavinghighemotions

generallymakesthingsworse.

Acrisisisshort-term.ü Ifitishappeningallthe

time,itisn’tacrisis,its’yourlife!

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Distresstoleranceskillsarefor…

Clientsfacemanystressors

ü Housingü Moneyü Drugsandalcoholü Dangerousneighborhoodsor

buslinesü Troublefindingandkeeping

workü Longwaitsforsocialservicesü Medicalproblemsandchronic

pain

Cliniciansfacemanystressors

ü Largecaseloadsü Difficultclientsü Hearingmanytraumaticstoriesü Inabilitytohelptheirclientsü Lackoftimeorresourcesto

helptheirclientsü Frustratinginteractionswith

socialservicesü Unhelpfulrulesorregulationsü Paperwork

CanyouSolvetheCrisis?

Ifyes,SOLVEIT

ü Stick with it, don’t take your eye off the ball, and do what it takes.

Ifno(ornotrightnow),STOPtryingtosolveit

ü Trying to solve something you can’t will often make it worse and send your emotions through the roof.

ü Focus on distress tolerance skills during an unsolved crisis.

Theseskillstaughtinthislecturearedesignedjustforanunsolved crisis.

Distresstoleranceissurvivingwithoutmakingthesituationworse.

Toleratingdistressisnotremoving– orsometimesevenreducing– distress.

ü Thereareotherskillsforreducingemotionsandproblem-solving.

Don’texpectdistresstoleranceskillstomakeyou

“feelbetter”.

ü The fact is that you often may feel better, but that is not the purpose of the skill.

ü The skills are so you won’t make the situation worse.

ü If the skills prevent the crisis getting worse but don’t make you feel better, DON’T STOP! If you do, things may get worse.

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Howcanyoumakea

crisisworse?

Yellingatsomeone

Usingdrugsoralcohol

“Retail therapy”with

money you can’t afford

to spendEatingtoomuch

Complaining so much folks

don’t want to talk to you

Givinguponsolvingthe

crisisaltogether

DistressToleranceskills:

•STOP(new2015)•ProsandCons•TIP•Distract•Self-Soothe•IMPROVEthemoment

STOP•Stop•Takeastepback•Observe•ProceedMindfully

-Whenimpulsivityandemotionmindtakeover-Whenyoudon’thavetimetouseyourskills-Tohelpyoustayincontrol

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Pros Cons

Making it worse by:____________

Tolerating distress by:____________

ProsandCons

Pros Cons

Making it worse by:getting drunk

-get to relax-won’t have to think about it

-won’t be able to function tomorrow when have to call guy back

Tolerating distress by: self-soothing

-get some relaxation-will be clear minded tomorrow

-will be worried all night-probably won’t sleep

Scenario:10pmSunnightandyoufoundanevictionnoticeonyourdoor

Pros Cons

Making it worse by:just go through the motions

-don’t have to focus when tired-don’t get my hopes up

-self-fulfilling prophesy-person will think you don’t care

Tolerating distress by:IMPROVE with meaning, prayer, and encouragement

-feel proud of the quality of my work-have hope-treatment more likely to work

-takes a lot of effort-may be disappointed (again)

Scenario:Thursafternoonandyouhaveanewreferralalotlikelast3whodropped

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DoProsandConsatyourbestmomentandmakelistfordarkestmoment.

Dowithclientorcolleagueor

friend

Afterwards,copytheConsofmakingitworseandthe

Prosoftolerating

distressontoonelist

Keepthelistwhereyouneedit

most!

Ifyouareatyourdarkestmoment,youwillnotbeabletoseetheprosandconsatallclearly

TIP• TippingtheTemperatureofyourfacewithcoldwater

• MammalianDiveReflex• https://www.youtube.com/watch?v=JkhGeHLzHJ8

•Intenseaerobicexercise•Pacedbreathing•Pairedmusclerelaxation

Distractionisdeliberatelyturningyourattentionawayfromthecrisis.

Activities

Contributing

Comparisons

oppositeEmotions

Pushingaway

Thoughts

Sensations

Remember,WiseMindACCEPTS

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Distractingwith...

Useanactivitythatfitsthemomentorwhatyouwouldbe

doingifyouweren’tdistressed

Sportsorexercise Hobbiesorusingyourtalents

BewithotherpeopleandDON’Ttalkaboutthecrisis

Watchamovie Gotothezoo,park,beach

Activities

Distractingby

Usuallymoredistracting

thananactivityforyourself

Bakesomeonecookies

Listen to someone

else’s problems

Writesomeonewhoislonelyaletter

Volunteer

Contributingisdoingan

activitythatprimarily

servesothers

DistractingbyComparisons

Get attention of the crisis but thinking about

other crises that are worse than yours

Someone or people who are suffering more than

you

A time in your life when you were doing worseRemember – your pain is still valid but put it on a continuum from easiest to hardest to bear and focus attention on the harder

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DistractingbyEmotions

Figureoutanemotiondifferentfromthenegativeoneyouarefeelingandtryandbringiton

• Ifangry,watchacomedy• Ifscared,watchsomeonedaring

• Ifsad,listentoupbeatmusic

Whenwearedistressed,oneortwonegative

emotionsdominatethe

scene

DistractingbyPushingAway

Imagineputtingitonashelf,inatime-releasesafe,inanotherroom

ImagineaLucitewallbetweenyouandtheproblemsoyoumaybeawareofitbutyouarecutoff

Imagine the “volume” of the problem being turned down

This means deciding that something cannot be dealt with now and putting it out of your mind

DistractingwithThoughts

Theideaistofillyourbrainwithotherthoughts,sothereisnoroomforthecrisis

• Singsonglyricsyoudon’tquiteremember•Dothetimestablestoanumberyouhavetocalculate•Decidewhatprofessioneveryoneonthebusdoes• Imaginedecoratingyourfuturehome

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DistractingwithSensations

Mobilizeyourbodyanditwillbringyourmindandemotionswithit

• Putyourfaceinicewaterorholdice

• Runupanddownstairs• Takecoldshower• Ifyouareinsidegotoutsideorifyouareoutsidegoinside

ThisisTHEBESTstrategytogetunstuckwhenyouare

verydistressed

Self-Soothe withFiveSenses

Vision Decorateyourspace,gosomewhereinspiring

Sound Music,soothingvoices,naturesounds

Smell Cooking,lavender,thebeach

Touch Comfortableclothes,petanimal,footmassage

Taste Favoritefood,hardcandyormint,goodcupofcoffee

Self-SOOTHEKIT§ Trytoincludethingsthatsootheall5senses.§ Useanycontainerthatworksforyou.Ifthecontainerissomehowspecialormeanssomethingpersonaltoyou,allthebetter.

§ Ifsomethingistoobigforwhatevercontaineryoudecidetostoreyourthingsin,considerputtingsomethingsmallbutsymbolicinitsplace.

§ Keepyourkitsomewherewhereyoucanseeitwhenyou’reupset.Itdoesyounogoodifyoucan’tfinditeasilywhenyouneedit.

§ TakethetimetomakeitspecialandpersonalTOYOU.Andfeelfreetoaddtoandrevisityourkitonceinawhiletoremindyouit’sthereandwhatwonderfultreasuresyouputinit.

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Skillstoacceptpainandreducesuffering

Imagery

Meaning

Prayer

Relaxation

Onethinginthemoment

Vacation

Encouragement

Imagery

Happyabeach,ahike,withfriends

Safeplacefar

away,placewithlocks

Relieflikewhen

thecrisiswillbesolved

Relaxedonawarm,comfortable

couch

Pictureaplaceyou

feel

Meaning

Whatcanthiscrisisortoleratingthiscrisisdoforyou?Whatwillyou

getoutofthis?

Whatareyourcorebeliefsorreligious

traditions?

“What doesn’t kill you makes you

stronger”

“God doesn’t give me more than I can

handle”“This too shall pass”

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Prayer

ExamplesSerenity Prayer

---

May I be filled with loving kindness.May I be well.

May I be peaceful and at ease.May I be happy.

Ancient Tibetan Buddhist meditation

Useandconnecttothereligiousorspiritualtraditionsthataremeaningfultoyou

Relaxation

Progressiverelaxation• Tighteneachpartofyourbodyfullyfor5secondsandthencompletelyrelaxit

• Startattoesandworkthroughfullbody

Walk,yoga,otherexercisethatrelaxesyourmuscles

Thegoalistoreducesufferingbyremovingphysical

stressfromthebody

OnethingintheMoment

Bringallofyourattentiontowhatishappeningrightinthismoment

Letgoofthoughtsaboutthepastandfuture

Describe(inyourmind,outloud,inwriting)whatyounoticeinthismomenttobringyourattentionjusttonow

A lot of distressis not in the present – it is in the past or is anticipated for

the future

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Vacation

Takeasmallvacationtotoleratethedistress

• Don’t talk to anyone for an hour

• Go to bed and forget the rest of the day

• Decide everyone can do without you for a while

• Get take out rather than cook

Key,aswithallvacations,isplanitaheadoftimeandhavea“return

ticket”

••Otherwiseyouarerunningaway!

Avacationiswhenyoudeliberatelystepawayfromyourlifetodosomethingmorerelaxing,fun,or

peaceful

Encouragement

Beyourowncheerleader• “Icandoit”• “Only3moredays…2more…1more…”

• “IhavebeenthroughworseandIcandothistoo”

Similartopositiveself-talk

Goalisnottobe“Pollyanna”aboutyourtroublesbutencourage

yourselftostickwithitandtellyourselfyouwillsucceed

SothosearetheDBTDistressToleranceskills.

Notnewideas–justconceptualizedandorganizedinsystematicway.

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FewTips

ü Ifyouhavetheurgetodie,ironingisprobablynotgoingtohelp!

Makesurethedistresstoleranceskillisclosetotheintensityofthedistress

ü Distracting with Sensations is a great way to get started but doesn’t last; so if crisis is long, pair with Activities or Contributing

ü Distracting with Thoughts lasts for minutes to maybe an hour – good for the bus, traffic, staff meetings, or the line at the DMV

ü Take a “vacation” for as long as time allows

Makesurethetimingoftheskillmatchesthesituation

FewTips

• Soothing by taste is not a good idea if you are a compulsive eater or are gaining weight

• Take too many vacations, you don’t get anything done• Distracting by watching a DVD TV series or reading

novels can take over your life

AnyDistressToleranceskillsoverusedcanmakethingsworse

• Often people see distraction - getting your mind off it - as the only way to cope when you can’t do anything about the problem

• Sometimes you need to stay with the problem such as staying in class or on the worksite or with your children (or with your clients)

• Be sure to learn Self-Soothing and IMPROVE as much as Distract for this

AvoidDistractionwhenitisavoidance

PracticeDBTDistressToleranceskills

Doeachskillonpurpose(even

ifitissomethingyoudoallthetime)

Practiceeachskilltillyouaregoodatit

Challengeyourselftousetheskillswhenyourdistressis

high

Observehowyougoaboutusingtheskill

Observewhatyoudowhen

theskilldoesn’twork

Thisiswhattocoach

clientstouse

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And,mostofall,practicethemwhenyourdistressishighsoyoucantolerateyourcrises

too…

RealityAcceptanceSkills• “Theseareskillsforacceptingyourlifeasitisinthemoment.Theyareparticularlyusefulwhenyouarelivingalifethatisnotthelifeyouwant.”MML

• Goals:• Reduceyoursuffering• Increaseyoursenseoffreedom

TheRealityAcceptanceSkills:üRadicalAcceptanceüTurningtheMindüWillingnessüHalf-smilingüWillinghandsüAllowingthemind:Mindfulnessofcurrentthoughts

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RealityAcceptanceSkills

• Whathastobeaccepted?1. Realityiswhatitis2. Everyone’sfuturehaslimitations3. EverythingintheUniversehasacause4. Lifecanbeworthlivingevenwhenitcontainspain

RealityAcceptanceSkills

• Whyacceptreality?• Rejectingordenyingrealitydoesn’tchangereality• Changingrealityrequiresfirstacceptingreality• Paincannotbeavoided• Rejectingrealityturnspainintosuffering• Acceptingrealitycanbringfreedom• Acceptingmayleadtosadness,butdeepcalmusuallyfollows• Thepathoutofhellisthroughmisery

RadicalAcceptance

• IsNOT:• Itisnotapproval• Itisnotcompassionorlove• Itisnotpassivity,givingup,orgivingin• Itisnotagainstchange

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PracticingRadicalAcceptance:StepbyStep

1. Observethatyouarequestioningorfightingreality2. Remindyourselfthattherealityisjustasitis3. Considercausesofrealityyouneedtoaccept4. Practiceacceptingwiththewholeself(Mind,Body,and

Spirit)5. Practiceoppositeaction6. Copeahead7. AttendtoBodySensations8. AllowDisappointment,Sadness,orGrieftoarisewithinYou9. Acknowledgethatlifecanbeworthlivingevenwhenthereis

pain10. DoPros/Cons

TurningtheMind

• Choosingtoaccept…yes,thisisachoice• Steps:

1.Observethatyouarenolongeraccepting2.Makeaninnercommitmenttoacceptrealityasitis3.Doitagain,overandover4.Developaplanforcatchingyourselfwhenyoudriftoutofacceptance

Willingness

• versusWillfulness• HowtogofromWillfultoWilling

1.Observethewillfulness2.Radicallyacceptthewillfulness3.TurntheMind4.TryHalf-smilingandaWillingPosture5.Ask,“What’stheThreat?”

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Half-smileandWillingHands• Half-smilingisawayofacceptingrealitywithyourbody

1. Relaxyourface…startingwiththeforeheadandgoingdownyourfacetothelowerjaw.2. Then,witharelaxedface,turnyourlipsjustslightlyupatthecorners,onlyuntilyoufeelit.

• Willinghandsisanotherwayofacceptingrealitywithyourbody…agoodwaytoregulateanger.

1. Handsuncleanched2. Palmsup3. Fingersrelaxed

AllowingtheMind:MindfulnessofCurrentThoughts• Thisisnoticingandradicallyacceptingourthoughts• Thisischangingourrelationshipwithourthoughts• Thegoalisnotamindemptyofthoughts

1. Observeyourthoughts2. Adoptacuriousmindaboutyourthoughts3. Rememberthatyouarenotyourthoughts4. Trynottoblockorsuppressthoughts