470 Distress Tolerance | Dialectical Behavior Therapy Skills for Depression Anger & Anxiety

this episode was pre-recorded as part of
a live continuing education webinar on demand CEUs are still available for this
presentation through all CEUs register at all CEUs comm slash counselor toolbox I’d like to welcome everybody today’s
presentation on distressed tolerance I am your host dr. dawn-elise Snipes today
we’re going to define the goals of distress tolerance some people think of
distress tolerance as suppression or ignoring and that’s not it at all so
we’re going to talk about that we’re gonna discuss why some clients
don’t choose distress tolerance explore a variety of distress tolerance and
reality acceptance skills including the list that’s right there I’m not gonna go
through that right now we’ll get to it would you rather start the day with an
inbox completely full and an outbox empty or start the day with an empty
inbox and outbox you know we really want to talk about distress tolerance and
figuring out what our perspective is on the day if we start the day with a bunch
of stress and a bunch of misery it’s gonna be hard to get our work done if we
start our day with a fresh slate every day it can be easier and it’s gonna help
us conserve some energy or have some energy at the ready to deal with
whatever the day throws at us the goal of distress tolerance is to accept find
meaning for and tolerate distress it happens pain in life is inevitable as
they say in acceptance and commitment therapy we’re going to have bad days
we’re going to have physical pain we’re going to have emotional pain
occasionally that’s just life and we need to help people not be afraid of
those feelings and learn how to find meaning in those feelings tolerate the
distress for the moment and then figure out how to improve the next moment pain
and distress are part of life and refusing to accept this leads to
suffering if you keep saying I shouldn’t be angry I shouldn’t be depressed I
don’t want to do anything that might make me feel uncomfortable you know is
that really living how much are you really living it’s also important to
remember that any attempt at change is going to produce distress
therefore distress tolerance skills are necessary what
of my mentors said that change causes crisis and crisis causes change and that
is stuck with me for 20-some odd years because it’s true think about New Year’s
resolutions this isn’t a huge change for most people but it is a change it causes
a little mini crisis if they’re trying to get in shape and they start going to
the gym and you know that’s all well and good but then a couple of weeks into it
they’re maybe not seeing the progress they wanted or they’re a little bit
uncomfortable and they’ve got to make that critical decision do I sit on the
couch and continue to binge on Netflix or do I get up and go to the gym that’s
a discomfort there is some dissonance between what they said they were going
to do with their resolutions and what they want to do and they’ve got to
figure out what to do with that and distress tolerance is helpful in these
situations if they say you know oh I really don’t want to go to the gym but I
said I was gonna do it so I’m gonna get up and go to the gym well they may not
be happy about it but what can they do to tolerate that distress the same thing
is true in counselling there’s a lot of things we ask clients to do and you know
we want them to be able to do it to tolerate the distress a little bit you
know we don’t want to overwhelm them with distress but it’s important that we
make sure they have these skills so when they start feeling overwhelmed when they
start feeling dysphoric they have some tools one of the first things that
people need to do in distress tolerance is be aware of it which means becoming
mindful and aware of the present moment what are their thoughts what are their
feelings what are their urges what are their wants and needs and what can and
can can they not control you know in the moment I’m accepting okay
I’m angry it is what it is now what am i angry about you know let me figure
figure out that what am i telling myself that I’m angry about what thoughts am i
having that are triggering that fight-or-flight response I’m feeling
that feeling of anger are there any other feelings I’m feeling
what are my urges right now if you think of acceptance a commitment therapy urges
often our away behaviors there are things that we do to avoid dealing with
whatever it is like sleeping or drinking or lashing out punching a wall whatever
it is but it often doesn’t help generally we don’t have the initial urge
or a lot of times we don’t have the initial urge to do what is in our best
interest our initial urge is to make the pain go away as quickly as possible be
damned what the long-term consequences are and distress tolerance helps us take
a breath and get into our wise mind and figure out okay you know I know what my
urges are I know what I want to do but is that going to help me move toward my
rich and meaningful life what are my physical feelings when people are
feeling dysphoric you know a lot of times fight-or-flight they’re gonna have
those excitatory responses they’re gonna have the stress response increased
breathing increased heart rate sweaty palms whatever just recognizing that and
recognizing it for what it is recognizing it as a stress response and
saying okay you know my body is gearing up to fight or flee should there be a
problem and what are my wants and needs in this situation and ultimately so my
wants and needs right now and what is the best choice from those
wants and needs right now to help me achieve my long-term goals encouraging
people when they have cravings for example when they’re recovering from
addiction or emotional eating being aware of the present moment what are
their thoughts their thought maybe I have to have that or I’m good you know I
really I need to have that I want to have that and that’s okay those thoughts
are okay being aware of them is what is most helpful and then we can unhook from
them and put that phrase in front of it I’m having the thought that I have to
have a pizza right now I’m having the thought that I need to go
upstairs and have a snack those are thoughts and we can help people start
learning how to unhook from their thoughts and evaluate them for their
effectiveness in helping them achieve their long-term goals when they’re you
know with cravings a lot of times they may feel anxious if they can’t access
what it is they want because a lot of times that behavior whatever it was was
used to escape from dysphoric feelings and they may feel anxiety if I can’t
access that I may feel I may get overwhelmed by my feelings I may not be
able to tolerate this whatever dysphoric feeling it is they
start feeling anxious that they are going to be consumed by that unpleasant
feeling they recognize that that’s okay you know recognizing I am feeling
anxious that I cannot have you know my addictive behavior I cannot have that
chocolate cake right now whatever it is acknowledge it that’s okay
helping people work through these becoming aware of the present moment and
telling themselves repeatedly it’s okay to have this thought it’s okay to have
this feeling it’s okay to have this urge it doesn’t mean I have to act on them it
doesn’t mean I have to keep having them I can choose which thoughts to hold on
to and I can choose which thoughts to you know whether I want to do some
cognitive restructuring or or whatever I want to do to improve the next moment
but becoming aware of what is in the moment and accepting it and telling
themselves all right it’s it’s fine it is what it is right now
what can I do to improve my next moment and the same thing is true for
depression when people are feeling clinically depressed becoming aware of
the present moment what thoughts are you having about your depression what
thoughts are you having that are contributing to your depression and what
do you want to do about them what feelings are you having associated with
your depression you may be angry that you’re still depressed or feeling
hopeless and hopeless or feeling anxious that maybe you’ll never get better or
feeling guilty because you don’t have the inner
to do the things which are kids that you want encouraging people to identify
what’s going on in the present moment where do your urges a lot of times
people when they’re depressed they either want to go to sleep a lot of
times people just want to crawl back into bed they may want to they may not
feel like they have the energy to do it anything so they may just want to sit on
the sofa and binge Netflix they may want to eat understanding identifying what
their urges are and acknowledging them my urge is to do this and then for each
urge saying is this the best choice to help me move towards my ultimate goals
so mindfulness distress tolerance is a natural progression from mindfulness
accepting non-judgmentally there’s the key oneself and the situation that’s the
other key non-judgmental of myself for my thoughts my feelings my urges they
are what they are they’re not bad they’re not good they are just what they
are and the situation it’s not bad it’s not good it just is and we can decide
what to do from there not trying to change the situation your feelings
thoughts or urges right then not trying to say I shouldn’t feel this way but
saying okay I feel this way it is what it is how can I improve the next moment
and that involves looking at your menu of options looking at those behaviors
that hope hopefully people have lists of you know what can I do when I’m feeling
this way and choosing the best response to help them get to what’s meaningful in
their life if they turn on the news and they watch the news and they get upset
because the news is typically upsetting okay they are angry they are upset
that’s fine what are they upset about those are the thoughts what are they
telling themselves okay that’s fine the situation whatever they watch it on the
news it is what it is okay now taking all that into consideration once we get
into our why’s my and what do I need to do about it in
order to move toward my rich and meaningful life in order to use my
energy to make my life meaningful does holding on to angst about the way a
story was reported does that have any long-term effect on my happiness and you
know if I answer no then I need to choose whether I want to hold on to that
distress over that particular issue or if I want to choose to let it go and
focus my energy somewhere else if it is something that is going to have
long-term consequences for my health and happiness then I need to decide okay I’m
aware of the situation what do I need to do in order to feel like I’m empowered
toward improving my situation politics is a perfect example right now if you
don’t like the way things are going what can you do can you get involved can you
advocate for a particular candidate can’t what can you do to improve you
know your ultimate goals to work towards those goals to feel like you made your
mark distress tolerance means surviving crises accepting life as it is in the
moment tolerance and acceptance however do not equate with approval you don’t
have to like the moment you sit in the moment and you say okay
you may sit in the moment and say you know this is pretty good
you may be ambivalent or you may really not be happy with where it’s at and you
feel angry or anxious or depressed that’s okay
it doesn’t mean you have to approve of what’s going on you have to identify it
and accept it and then figure out what do I need to do next if anything to deal
with this situation in order to achieve my goal of happiness sometimes people so
want others to understand how bad it is that they focus on that instead of
surviving the situation or improving the next moment
so for short-term gains they may want to try to prove to others you know look how
bad it is look what you made me do look how awful I feel right now in order
to control other people’s behavior they may go to the hospital in order to get
attention or to get a break and I’m not saying everybody that goes to the
hospital is doing it to get attention and you know I’m not I don’t want to
pathologize that I want to remember that behavior is communication if a person
has to get to the point that they are repeatedly checking themselves into the
hospital or going to the ER and it’s not actually a clinical emergency we need to
ask ourselves what are they trying to communicate and the first thing that
comes to my mind is they’re not feeling like they’re being heard for how bad it
is it may not rise to the level of admission to the hospital but they’re
wanting somebody to take them seriously they’re wanting somebody to hear how bad
it is thinking about why is it why is it that other people need to validate your
feelings you know why is it that you need to prove how bad it is to somebody
and why do you need others to say oh wow that is devastating sometimes it helps
if for some of us it helps if we have somebody who is understanding who can
paraphrase and recognize hey you are feeling devastated or you are just
really enraged right now and you can say yeah sometimes all people need is to
feel heard and feel validated and then they can make that next step but if the
people in your social network are not able to do that they’re not skilled at
paraphrasing or being intuitive they have low emotional intelligence whatever
it is then it’s important for the person to figure
out number one why do I need other people’s validation and number two if I
can’t get it what can I do because you’re not necessarily going to get it
encourage clients to remember a time they acted out to try to get someone
else to see how bad it was and look at the results sometimes people in
substance abuse will drink at someone else and that is look what you made me
do I was so stressed out because of what you did you made me relapse and that is
you know manipulative in in a lot of different ways it’s not a toward
behavior at all but it’s not an uncommon behavior and we want to look at what did
that relapse behavior what was that relapse behavior communicating and you
know there’s a lot of things there it was communicating the person didn’t have
the coping skills it was communicating the person didn’t feel supported it was
communicating the person was angry and didn’t have the ability to work that out
maybe you know we want to look at what was that behavior communicating well how
can we make a crisis worse when people are in distress they can yell they can
use alcohol or drugs they can give up they can complain so much that other
people just don’t even want to talk to them they can eat too much or shop too
much a little bit bit a little bit of retail therapy
none of those are going to generally solve the problem in the long term they
may it’s in a way behavior because it’s using a lot of energy to suppress the
problem or make you feel better right now but it may not solve the problem in
the long term when people are experiencing distress they may have
distress intolerant thoughts like I can’t stand this this is unbearable I
hate this feeling this is gonna go on forever I’m stupid or unacceptable for
feeling this way I’m gonna lose control I’m going to just completely lose my
mind if this doesn’t stop lots of different distress intolerant
thoughts and with mindfulness people are going to start becoming aware of their
distress intolerant thoughts and we can have them check the facts versus
emotions and get them more into factual reasoning what is the evidence that this
is unbearable and you cannot stand it and you’re going to go crazy show me the
evidence and a lot of times there’s no evidence I just I feel out of control I
feel helpless okay you know that’s a little bit different now let’s talk
about what you can do let’s talk about times when you felt this way before
and lo and behold you’re here now so you tolerated it somehow you you stood it it
didn’t consume you so let’s look at what you did let’s pull on those strengths
when people are in distress they may use self-injury in order to
redirect their attention to something that they can
control they may use self-injury for a variety of reasons and there’s other
classes on non-suicidal self-injury we’re not going to go into that a lot
but they may use substances they may binge eat they may oversleep they may
use distraction or suppression avoid situations or engage in constant
reassurance seeking or checking tell me I’m okay tell me it’s okay in the short-term some of those
behaviors may not be completely bad but in the long-term you know constantly
needing someone to reassure you that you’re okay
reassure you that you’re safe is not a healthy place to be because guess what
those people aren’t always going to be there we want to encourage people to
develop their own distress tolerance skills so when they feel dysphoric they
can choose behaviors that are helpful one of the first activities is urged
surfing urges are generally intense for twenty to thirty minutes sometimes less
every time people have an urge we want to encourage them to think I have a
choice and surfing the urge means opening themselves up to the urge
doesn’t mean getting consumed in it or fighting it and pushing it away it just
means accepting okay it is I feel like I want to use I feel like I want to drink
I feel like I want to put my fist through the wall experience the feeling
with acceptance and non judgement and being sensitively aware that it’s there
it’s just okay thinking about other urges that we have if you feed them if
you keep thinking about it if you keep focusing on it then it’s probably going
to continue on if you ignore it or distract yourself once you have
acknowledged it then you have a better chance and I’ve used the bee metaphor
before obviously this is not true if you are deathly allergic to bees but if you
are not allergic to bees think of distress like a bee and it lands on your
arm you can let that be sit there it’s not going to hurt you you can let an
urge sit there in your mind it’s not going to hurt you eventually the bee is
going to get bored or realize that you don’t have any sugar for it and it’s
gonna fly away same thing with urges eventually it’s
just going to dissipate and you’ll focus on other things but if you swat it the B
you’re likely gonna get stung and that’s gonna hurt and it’s gonna kill the bee
but it’s not gonna be a pleasant situation and it’s gonna end up causing
you more distress same thing with other urges when you go out and drink or give
in to whatever urge it is a lot of times it’s going to end up causing you a
little bit more distress thinking of those urges like bees and I like bees so
that’s especially the big fuzzy teddy bear lickin ones the bumble bees but
encouraging people to use a metaphor that works for them some people use
clouds you know how you can lay on your back and you can just watch the clouds
morph into different shapes and then slowly float off into the distance well
same thing with our urges you know our urges present and then they morph and go
away or obviously you can think of a battle think about a wave stop skills it
are other tools that we can use for distress tolerance the first thing to do
with a stop skill is stop go figure take a step back and unhook and that’s
what we’ve talked about earlier becoming that observer instead of being stuck in
the moment becoming that observer of what’s going on what your thoughts and
feelings are unhooking from that I am observing that I feel anxious I am
observing that I’m having these thoughts pretend you’re a scientist looking at
this or pretend you’re somebody watching a television show observe what’s going
on and then proceed proceed mindfully when we unhook it’s easier to make more mindful decisions encourage people
to think about their options when something happens what are the options
and you can do this if in group you can break the group up into four little
groups and each group gets a segment so something happens that causes you
distress group a identifies what are the options that can help the person reach
their goals of recovery and happiness in dealing with this situation group B what
are the alternate thoughts that they could have that could help them feel
empowered and self compassionate Group C what are your options that may stop the
suffering right away in the short term but don’t do anything to solve the big
problem and probably maintain the distress and Group D what are the
thoughts and feelings that you might be having in response to this situation
that’s in that are increasing your distress or that you’re holding on to
that are increasing your distress go through several different scenarios with
each of these when people are having urges when they’re feeling depressed
have them give an example of something that made them anxious or angry and go
through this four quadrant thing and encourage people to develop a menu of
options it doesn’t mean they have to choose the toward behaviors but it helps
them see they do have options from the last activity the one we just talked
about had the group used the results from what are your options that may stop
suffering in the short-term but maintain the distress to answer the following
questions what are the benefits to acting on impulsive urges so maybe they
say I would go you know have a glass of wine okay what are the benefits to
acting on that impulsive urge and what are the drawbacks to acting on it if
something makes you angry having a glass of wine is probably not going to resolve
it in the long term it’s probably gonna still be there when that glass of wine
is empty for each identified behavior identify an
alternate more helpful behavior so what are the benefits – and you’re looking at
those toward behaviors now what are the benefits – journaling what are the
benefits – calling my sponsor what are the drawbacks to journaling or calling
my sponsor so we’re kind of having them do a decisional balance exercise here
but encouraging people to really start getting mindful and analytical about
their menu of options tip skills and this is something that Linehan talks
about temperature intense exercise paced breathing and paired muscular relaxation
when people are feeling distressed sometimes they are they feel stuck they
feel caught in a whirlwind of those emotions and in order to change their
focus they need to be sort of jolted out of it temperature is good ice cubes
one of my favorites because people can hold ice cubes and you’re not going to
think about much else if you’ve ever had a sprained ankle and had to soak your
foot in ice or something you know you’re not thinking about much else during
those first few minutes and that can help people get into a better mind space
because well be well they’re focused on the coldness of the ice their adrenaline
is going down a little bit and being redirected towards a pain sensation
versus an emotional distress people can get into sauna I don’t like this one as
much because a lot of times people focus on you know they’re distressed while
they’re in the sauna but it’s not as immediate as the ice they can go outside
and just feel the Sun on their face or take a cold shower intense exercise is
you know doing 20 push-ups or 20 sit-ups or if you’ve ever if you remember back
in high school when we used to have to do wall sits you lean against the wall
and slide down until your legs your thighs are parallel to the ground and
you hold it for a minute and that is really uncomfortable after
about 15 seconds intense exercise especially the wall sets are something
even adolescents can do at school you know go to the bathroom go into a
bathroom stall and do a wall sit for a second in order to regroup encourage
people to identify tip skills that they can use anywhere you know where they
spend the most amount of time paced breathing encouraging them to breathe in
for for hold for for out for for that will trigger the rest and digest
function that will slow the heart rate that will release some of the HPA axis
activation and the belly breathing is awesome if they want to pair it with
that so breathing in for four and feeling the belly expand and holding for
four and then breathing out for four feeling the belly contract and the
tension or whatever it is exhale with the air you know you can use some guided
imagery with it and paired muscular relaxation the active muscle relaxation
is paired with a verbal cue like go figure relax when people are stressed
you know encouraging them to start from the head and work towards their toes and
notice tension tense those muscles and relax them notice the difference do that
three times and every time they relax their muscle they say
relax there are lots of scripts on YouTube for kube progressive muscular
relaxation or paired muscular relaxation so I’m not going to spend a lot of time
on that right now think about and I used to do this with my students because they
were a little skeptical that you could pair muscle relaxation with just a
verbal cue so you could say relax and a person
would you know start to relax but I would start the class I would walk in
and I would put my stuff down on the desk and I would say everybody clear
your desk we’re gonna have a quiz well guess what happened to well 99% of them
they started feeling anxious and I said tada one word quiz triggered
your stress response and now you’re tense all over you can do the same thing
with the relaxation response it’s not just a one-way street you can trigger
yourself or condition yourself to respond with relaxation to certain cues encourage people and this goes to Linna
hands mnemonics of accept and improve engage in actin activities have clients
they can make a collage they can make a list they need to have it down somewhere
out of their head because when they’re in distress they’re not going to
brainstorm okay what were those Pleasant activities that I like to do that help
me no that’s not where their head is when they’re in distress they need to
have a cheat sheet of some sort have them identify at least three in each
area if they can three pleasant activities that they can do in order to
help them step out of the moment for the moment when I get upset about
something if I’m home a lot of times I will go outside and I will work in the
garden for thirty minutes until I can clear my head let that adrenaline bleed
off and then I can focus on it more logically gardening is you know one of
my hobbies that I enjoy doing encourage people to identify at least three things
that they enjoy doing contributing what can they do to help out it can be
volunteering somewhere it can be going outside around your office and picking
up trash to make it look better it can be you know dusting the lobby whatever
it is that’s contributing helping others in order to improve your little slice of
the world comparisons you can compare yourself to people who are not doing as
well you can compare yourself to how you’re doing now versus how you were a
time though you were doing worse I like comparisons a little bit because
I also like using it to compare yourself to other people that you admire what is
going well for you and and you know comparing how that thing works it’s not
my favorite intervention but it is one of them but that is there in the in the
mnemonic opposite emotions encourage people to do things that make them happy
doing things that make them happy give them a belly laugh that is going to
trigger the release of endorphins and serotonin that will help rebalance some
of those glutamate and norepinephrine and excitatory neurons what is it that
they enjoy doing when I would get stressed where I used to work in Florida
I love squirrels and I would go out and I always kept peanuts in my desk and I
would go out and I would feed the squirrels you know it was just something
that made me happy because I liked watching them in their little tiny hands
eating eating the peanuts you can go on YouTube you can go on Pinterest find
something that makes you happy pushing away and that is as simple as
pushing thoughts away saying I’m not going to think about this right now you
know I have her the the image of her going lalalalala whatever it is that
helps you push away that thought and say it’s not that I’m going to not deal with
it at all it’s that I’m not going to deal with it right now if you get angry
at your boss for example and you are enraged about some new policy okay well
you’re enraged probably not the best time to go approach your boss so it’s
important to explore think ways to push it away to give
yourself a break so you’re not going in there in full flight or flight mode
you’re going in there in your wise mind mode to state your concerns or state
your objections you want to be able to handle it you want to be able to figure
out how to deal with it but doing it in the middle of full-on fight or flight is
usually not the best reaction encourage people to think about something totally
different for things they see three things they hear two things they smell
and one thing they can feel you know typical grounding think about things you
used to do on long car trips well this is for maybe for older people because
now the internet and tablets are so ubiquitous but we used to look at
billboards and we would find the letters of the alphabet in billboards or we
would look for green cars you know I grew up in the 80s there wasn’t a whole
lot to amuse yourself on a long car trip or what do you think about when you
cannot sleep hopefully it’s not thinking about
stresses you know I typically when I can’t sleep I think about designing my
garden for the spring you know that focuses on something that makes me happy
it gets me so I’m not focusing on what’s stressing me out self-soothing people can do a body scan
meditation and focus on focusing on relaxation is really important self
soothing uses the five senses sight smell hearing touch and taste what can
they do in order to self-soothe in any of these areas one of my favorite
pictures is this one it’s a little hamster in a sweater is that not the
cutest thing you’ve ever seen so that is a sight that I enjoy seeing it always
makes me smile smells I happen to like roses so if you smell roses or essential
oil of rose so you don’t have to keep fresh roses in your office all the time
or hearing the birds sing or feeling from getting a massage and if you can’t
afford to get a person massaging you you can get
one of those shiatsu back massagers you know sometimes any port in a storm will
work and then taste y’all know I love my coffee so that’s the one that’s up there
encouraging people to identify three things for each of the five senses that
they can have in sort of their emergency coping kit what can you do if you get
distressed and some of these things like I said they can keep with them in a
coping kit they can keep with them in their purse or in a box in their trunk
in their car like essential oils or make sure they have a playlist on their
tablet that they can listen to music that makes them happy you know there are
a variety of things that people can bring with them so no matter where they
are they have tools to tolerate the distress imagery improving the moment
encourage people to use imagery envision a safe space you know if they are
stressed out and they’re not in a dangerous situation of course but if
they’re stressed out sometimes it helps to go to their happy place what does
that place look like for me it’s in the woods with a babbling brook and a log
cabin and deer and you know snow white you know that’s kind of my little happy
place but encourage them to use all of their senses when they’re thinking about
it what is what does it smell like and not just one smell you know using those
senses again what are two or three things they smell what do they hear two
or three things they hear I can hear the brook I can hear the birds chirping I
can hear the wind rustling through the leaves have them make it as vivid of an
experience as possible what do they see instead of saying I see trees you know I
see an oak tree and I see leaves on the ground and I see little fish swimming in
the in the brook whatever it is haven’t have them imagine another imagery not
the same one have them imagine successfully dealing with whatever the
situation is if they have to go have a talk with their boss
or talk with their significant other or they are waiting on test results from
the doctor have them envision successfully dealing with whatever it is
that’s causing them their distress they can imagine a force field that goes
around them and protects them from anger or anxiety they can imagine having a
little coach fairy godmother angel Jiminy Cricket whoever they want to call
it on their shoulder that is there to protect them and is going to help guide
them through this challenging situation they can imagine their feelings and
thoughts as clouds in the sky and seeing those distressful tots thoughts fly away
or they can imagine their thoughts as an unstoppable train and they can envision
that train just bulleting through and going on meaning is the second one and
improve the moment encourage people to change how they think about their self
in their situation instead of focusing on what they don’t have or what they
can’t do or what they don’t have control over focusing on what they do have what
they can do and what they do have control over in that situation re
restructuring and seeing problems as challenges and opportunities and it
takes a while to get this way but when people can start seeing it that way then
it’s less overwhelming they don’t see a barrier they see an obstacle and you
know we all ran obstacle courses when we were in junior high school you know they
see an obstacle obstacles you can get around you either go over or around or
under or through or whatever but an obstacle is not something that’s going
to permanently stop you you just have to use your creativity to circumvent it
some people can use prayer and if they believe in a higher power that’s great
otherwise they can use meditation that’s fine to you anything that they can do to
help them feel more ground funded and centered in the universe they
can practice relaxation skills whatever that looks like for them one thing in
the moment encouraged them to focus on one thing that they’re doing right now
like sitting in the chair you know focus on how that chair feels does it have
good lumbar support is it soft are you sitting on something hard are you
uncomfortable you know generally that’s not something I have people focus on
unless they’re sitting in a really comfortable chair because I don’t want
to increase their distress but if you’re driving encourage people when they’re
driving to focus on driving oh my gosh that is a new concept there focus on the
cars around you the cars in front of you the birds on the power line the Sun as
it comes in through the driver’s window focus on experiencing the moment as
you’re driving instead of thinking about who ticked you off at work or what
you’ve got to do when you get home a lot of times when people focus on things
that upset them when they’re driving they tend to increase their speed which
can cause you know some legal problems which is another reason why focusing on
what you’re doing when you’re driving is also helpful and as I said weeding is
something else you can do if you remember for some of us when we were
little we had those little paddles that had the ball and in order to bounce that
little ball on that little paddle you really did have to focus on what you
were doing you couldn’t pay attention to anything else that was going on isn’t
actually an activity you can still get those things that people can do if
they’re feeling distressed encourage people to take a mental vacation or a
short break or just leave stress at work and that work-life balance you know you
may not call it a vacation but it is important for you to be able to turn it
off so to speak and to take a vacation encourage people to think about work or
whatever the distress is like a television set like a program
they’re watching and they got it DVR’d they can come back and pick up where
they left off but for right now they’re gonna turn off the TV and take a little
mental break from whatever’s going on and finally encouragement encourage
people to be their own best friend think about you know what would they tell
their best friend if their best friend were having this situation right now
well okay tell yourself that okay don’t hold yourself to a higher standard
or be harder on yourself than you would to be anybody else create your own
mental coach and your own mental best friend to encourage you so you don’t
have to rely on everybody else now it’s great if you can reach out to others and
get some encouragement not everybody has that luxury that’s something they may
need to develop I’m just talking about in the moment right now if they’re
experiencing distress at 2:00 in the morning you know where are they gonna
get encouragement from radical acceptance and reality acceptance is
important a complete and total acceptance of the facts of reality and
emphasis on the word facts and we all have our own phenomenological reality
our own interpretation of what’s going on but it’s important for people to be
able to identify the facts of the situation and say to themselves some
variation of okay it is what it is when I went into labor with my son I was 28
weeks pregnant I did not want to be going into labor at that point you know
it was not time to have my baby and I was a little bit upset about that
happening but it was what it was the fact was he was coming and there was
nothing they were able to do to stop it so radically accepting it instead of
getting you know angry about it and you know trying to stop it
you know nothing they did was going to stop it so it was a matter of accepting
that this is what’s going on right now so you’ve got to figure
out how are you gonna deal with it you can’t change it how are you gonna deal
with it which move to turning the mind and mentally looking to the other side
is this something that I would have wanted or would have chosen you know
lots of thoughts go on when you have a premature infant you can focus on those
or you can turn your mind and focus on what else is going on you know he my son
was lucky enough to not have to be on a respirator and he didn’t have anything
you know terribly wrong with him when he was born even though he was only 28
weeks I was grateful that he was surviving I could be upset that I wasn’t
so pregnant but I was grateful that he was surviving so trying to find that
silver lining so to speak turning your mind and accepting yeah
this bad stuff exists over here you know he’s at risk for neurodevelopmental
disorders and all this other stuff and he’s doing fine right now and accepting
the good with the bad encouraging people to see emotions
differently remembering that fear and anger kick in when there’s a threat and
sadness kicks in when you lose something important to you in some way if you
didn’t feel sadness then nothing would be important sadness is part of that
grief process recognizing that fear anger sadness these dysphoric emotions
are your body’s Way of telling you something there might be a threat fear
and anger or you may have lost something important or maybe you did lose
something important okay with fear and anger just like that fire alarm or the
dog poop you get up and you check and you see if there is a fire or if
somebody did poop in the dining room and if there is a problem you handle it if
there isn’t a problem then you choose your next step
sadness generally when we feel it you know it Clues us in that we lost
something in or that we feel hopeless or helpless
about something and the key with sadness is to evaluate which parts of the
situation we are helpless over and which parts of the situation are hopeless if
somebody dies you’re gonna feel sad you are helpless to bring them back you
cannot bring them back to life however what parts of the situation do you have
control over you have control over what you do with their memories you have
control over you know other things encouraging people to see emotions as
indicators you know what we do and what we feel speaks to us unpleasant emotions
are important to survival rather than something to be feared and avoided at
all costs when we have these unpleasant emotions it’s our body going hey I want
to survive so you better check it out to see if there’s a problem that’s all and
we have the ability to use biofeedback to use distress tolerance skills to use
a variety of tools and techniques to turn down the volume or you know reset
that HPA axis our threat response system if there’s no problem but it I would
rather be have a false alarm than not be alerted when there is a
problem willingness versus willfulness when we talk about reality acceptance
will furnace will fullness forgets ignores or actively tries to change
master or direct or control or manipulate what is your trying to change
the facts of the situation you’ve got cancer it is terminal and you’re trying
to wilfully change it and say no I don’t I’m gonna go to three different doctors
I’m going to get another opinion this this can’t be true
willingness is surrendering to a process in which one is already a part accepting
okay I had this diagnosis it sucks I don’t
like it however I’m a part of this process right now what is the next best
option for me and we all know about donkeys being or supposedly being very
willful but they’re actually very smart and our donkeys you know our neighbors
have seen lots of things of us trying to get our donkeys to move around the
property but once I learned that generally when they’re being resistant
it means they’re afraid they don’t know what’s coming next or they’re
anticipating something painful or unpleasant then it was easier to
manipulate them basically but it was helping them feel safe and feel like
they were empowered to change or to protect themself in a
process in which they were already apart half smiling and willing hands this is
another Linehan technique emotions are partially controlled by facial
expressions half smiling with lips slightly upturned enhanced unclenched
palms up and fingers relaxed is going to trigger the body to think hey we might
not be in such a bad mood after all try walking around even for 15 minutes
looking like you’re ticked off at the world and you’re hating life and looking
at the ground see how you feel and they’ve actually done studies people got
their PhD studying but the impact of body language on our actual emotional
perception and they found that there is a significant impact encouraging people
and in substance abuse we call fake it till you make it but encouraging people
to use this half smile and willing hands doesn’t mean that I love it it means
that I’m accepting it it is what it is encourage people to be mindful of
current thoughts and recognize that thoughts are just neural firing in the
brain and not necessarily facts about the world and they will come and fade
and encourage them to be aware of what those thoughts are telling them because
they might be leading them in the wrong direction just like a unscrupulous
used-car salesman may be trying to convince you that this is the car for
you your mind your thoughts may not be actually a hundred percent accurate and
you need to check the facts additional tools a clear mind the addicted mind is
governed by addictive behaviors the addictive mind is often one that wants
to that is acts impulsively and wants to make the pain go away right now and
wants to have whatever it wants right now it tends to be very guided very much
by impulses and urges the clean mind is what we often see when people are in
this freight phase of what we call a pink cloud and they forget that relapse
is possible they are clean they’ve gotten the substance out of their system
for a certain period of time their Energy’s coming back they’re starting to
feel happy again and they’re like woohoo I’m recovered I’ve got this thing kicked
no more problems unfortunately ultimately if they don’t
pay attention to their emotions then they may be on a relapse relapse path
clear mine is not engaging in addictive or unhealthy behaviors but remains aware
that relapse is possible with a clean mind it’s not paying attention to the
logic side that says you know you might you might fall into that trap again a
clear mind integrates it’s kind of like the wise mind if you will in addiction
it integrates feelings emotions and recognizes the possibility of relapse
burning bridges and building new ones and involves actively eliminating
triggers and vulnerabilities when we are experiencing distress if you are you
know afraid of needles and you hate doctors and yada yada
you know actively eliminating triggers you don’t want to be seeing paying
attention to that jar of tongue depressors and cotton balls and alcohol
swabs that you know they use before they give you a shot you want to avoid paying
attention to those triggers as much as possible for our animals you know I hate
taking them to the vet because they go there and they know the smell and you
know it’s it’s a lots of negative associations so we have a vet because we
live on a farm we have a vet that comes out to the house and it’s a lot less
stressful for the animals and by virtue it’s a lot less distressful for me find
physical and emotional sensations and create mental images that compete with
the addiction or the mood issue and we talked about this earlier identifying
opposite emotions and opposite sensations that will help you feel a
little bit better even if you’re depressed maybe smelling bergamont or
rosemary will help you feel a little bit better I’m not gonna say it’s gonna make
you giddy as a schoolgirl because it’s not but it can trigger some olfactory
memories that might help you feel better alternate rebellion means finding
alternate ways to act out which are safer harm reduction you know instead of
having an entire chocolate cake have keeping pieces of chocolate in the
freezer so when you’re really just craving that chocolate you can have a
piece when you are well that’s an example for that sublimation using that
energy to do something that is more positive that’s one of those Freudian
defense mechanisms right there have this energy right now I am really
angry and I want to put my fist through the wall what can I do that is more
positive I can get my toothbrush out and clean the baseboards that’s what I do
but use that energy for something positive since you got it ramped up
might as well use it and loud music is another way of alternate rebellion not
for too long don’t want to burst the eardrums yada yada yada but some of us
really enjoy spending a few moments where we are just immersed in the music
important questions no distress tolerance techniques are going to work
for every person all the time encouraging people to identify the ones
that work for them and developing their own distress tolerance toolkit with each
one that they try they need to ask themselves how does this make me feel
how does this impact my feelings in the moment and how does it affect how I
handle the problem does it help me basically get a clearer mind so I can
choose behaviors that are going to help me
behave more authentically behave in ways that I want to behave instead of
behaving in ways that are on autopilot sometimes emotions thoughts or urges
reappear it’s important to notice them without negative judgment tolerate the
distress and problem-solve kind of like mrs. Kravitz on bewitched you know she
just kept coming back prepare people for this grief it may come back you may have
these little bursts of grief even two three years later making sure that
they’re aware of that and they’re ready to handle it instead of going I can’t
believe I’m feeling this way again just oh well emotion you know I’ve got my
little mrs. Kravitz back what am I gonna do what’s clients are mindfully aware of
their thoughts sensations and urges and willing to accept the moment they need
to skills to tolerate the distress once they’re willing to say okay I don’t need
to fight I don’t need to be afraid of my anger or my anxiety but they need skills
once they’re sitting there with it they got to figure out what to do with it
help clients develop a menu of options which they can select from when they’re
in crisis and remind them that they feel how they feel and to accept it
non-judgmentally help them tolerate the distress until the intense emotions
subside and they can get into their wise mind and choose from their behavioral
options that will help them move towards their goals between writing notes filing insurance
claims and scheduling with clients it can be hard to stay organized that’s why
I recommend therapy notes they’re easy to use platform lets you manage your
practice securely and efficiently visit therapy notes com2 get two free months
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