Distress Tolerance | DBT Skills for Depression Anger & Anxiety Relief

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@Allce.com Counselortoolbox. I'd like to welcome everybody to today's presentation on distress tolerance. I AM your host, Dr. Donnelly 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 going to 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 going to 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 going to 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 going to 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 and 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. One of my mentors said that change change causes crisis and crisis causes change. And that has 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 going to do it, so I'm going to 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 counseling. 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 dysph, 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 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 and commitment therapy, urges often are 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, 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 a lot of times, fight or flight, they are going to have those excitatory responses, they are going to have the stress response, increased breathing, increased heart rate, sweaty palms, whatever. Just recognizing that and recognizing, recognizing it for what it is, recognizing it as a stress response and saying, okay, my body is gearing up to fight or flee should there be a problem. 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 may be I have to have that or I'm going, 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 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 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 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 helpless, or feeling anxious that maybe you'll never get better, or feeling guilty because you don't have the energy to do the things with your kids that you want. Encouraging people to identify what's going on in the present moment. What are 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 not feel like they have the energy to do 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 nonjudgmentally. There's the key. Oneself and the situation. That's the other key. Nonjudgmental 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 hopefully people have lists of 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 watched on the news, it is what it is. Okay? Now, taking all that into consideration, once we get into our wise mind, 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? 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, yeah, 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 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 error, 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 that other people need to validate your feelings? You know, why is it that you need to prove how bad it is to somebody? 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 manipulative 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 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 of retail therapy. None of those are going to generally solve the problem in the long term. They may. It's an away 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 going to go on forever. I'm stupid or unacceptable for feeling this way. I'm going to 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 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 urge surfing. Urges are generally intense for 20 to 30 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 judgment 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 going to fly away. Same thing with urges. Eventually it's just going to dissipate and you'll focus on other things. But if you swatted the bee, you're likely going to get stung and that's going to hurt and it's going to kill the bee, but it's not going to be a pleasant situation and it's going to 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 licking ones, the bumbly 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 about think about a wave. Stop skills are other tools that we can use for distress tolerance. The first thing to do with the 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 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 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 the situation that are increasing your distress or that you're holding onto 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 quadrants 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, have the group use 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? 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 going to 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 to and you're looking at those toward behaviors now. What are the benefits to journaling? What are the benefits to 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 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 while the, while 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 in a sauna. I don't like this one as much because a lot of times people focus on their distress 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 doing 20 push ups or 20 sit ups, or 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 sits, 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 four, hold for four, out for four. That will trigger the rest and digest function, that will slow the heart rate, that will release some of the HPA axis activation. 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 the tension or whatever it is, exhale with the air. You can use some guided imagery with it. Paired muscular relaxation, the act of muscle relaxation is paired with a verbal cue like go figure relax when people are stressed, 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 cued progressive muscular relaxation or paired muscular relaxation. 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 going to 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 Linehan's mnemonics of accept and improve. Engage in pleasant 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, 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 30 minutes until I can clear my head, let that adrenaline bleed off and then I can focus on it more logically. Gardening is 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 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 you know, comparing how that thing works. It's not my favorite intervention, but it's One of them 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 neurochemicals. 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 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 image of her going la la, la la la. 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 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. Four things they see, three things they hear, two things they smell, and one thing they can feel. 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. 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. I typically when I can't sleep, I think about designing my garden for the spring that focuses on something that makes me happy. 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 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 go 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. 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 does it smell like? And not just one smell. 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. 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 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 in. Improve the moment. Encourage people to change how they think about their self and 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. 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. 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 too. Anything that they can do to help them feel more grounded and centered in the universe, they can practice relaxation skills, whatever that looks like for them. One thing in the moment. Encourage 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 and work and that work, life balance. 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 going to 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 in the morning, you know, where are they going to 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, 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 common, 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 going to deal with it? You can't change it. How are you going to deal with it? Which moved to turning the mind and mentally looking to the other side. Is this something that I would have wanted or would have chosen? 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. Or 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 still 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 clues us in that we lost something important 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 of the situation are hopeless. If somebody dies, you're going to 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. 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 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, willfulness. Willfulness. Forgets, ignores, or actively tries to change. Master or direct or control or manipulate. What is you're trying to change the facts of the situation. You've got cancer, it is terminal, and you're trying to willfully change it and say, no, I don't. I'm going to go to three different doctors. I'm going to get another opinion. 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 themselves in a process in which they were already a part. Half smiling and willing hands. This is another Linehan technique. Emotions are partially controlled by facial expressions. Half smiling with lips slightly upturned and hands 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 PhDs studying the impact of body language on our actual emotional perception. And they found that there is a significant impact. Encouraging people in substance abuse. We call Fake It Till youl Make It. But encouraging people to use this half smile and willing hands doesn't mean that I love means that I'm accepting 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 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 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 is 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 path. Clear mind 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 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 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 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 bergamot or rosemary will help you feel a little bit better. I'm not going to say it's going to 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 of 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. So I 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 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 going to do? Once clients are mindfully aware of their thoughts, sensations and urges and willing to accept the moment, they need 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 TherapyNotes. Their easy to use platform lets you manage your practice securely and efficiently. Visit therapynotes.com to get two free months of TherapyNotes by just using the promo code CEU when you sign up for a free trial at therapynotes.com. If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@allce.com or getting your agency to sponsor an episode. A direct link to the on demand CEUs for this podcast is at allce.com/podcastce. That's allce. Com podcastce. To sponsor an episode of Counselor Toolbox and reach over 50,000 clinicians per week, go to allce.com sponsor. Thank you.