 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome you to dialectical behavior therapy techniques, Distress Tolerance. Now if you remember last Tuesday, we went through emotion regulation and basically talking about the fact that people who benefit from DBT skills are often people who have emotional dysregulation issues. That is, they tend to get more upset than say the average person. They tend to require longer to de-escalate than again the average person. And they have difficulty regulating their emotions in general. And I put average in quotes because what is average? And in my mind, it kind of depends on where you're starting from and we'll take a look at that in a minute. But today we're going to move on to distress tolerance. So we've already helped the clients understand what emotional dysregulation is and identify some of their vulnerabilities. So they are not as already under a low grade of stress. They can kind of empty their inbox, if you will. So we're going to define the goals of distress tolerance, discuss why some clients don't choose distress tolerance. They choose to be distressed and explore a variety of distress tolerance and reality acceptance skills, including stop pros and cons, tip accepts, self soothing, improve the moment, radical acceptance, turning the mind and many more. So think about your day. And I mean, I know today's Thursday. Imagine yourself on a Monday, because Monday is the day that can really set some people off. Would you rather start the day walking in and looking at a full inbox and going, oh, and that doesn't even begin to touch what's going to come my way yet today? Or would you rather come in to an empty inbox and go, okay, you know, I'm ready for whatever you got to throw at me. I don't already have to juggle 17 other things. Emotional dysregulation and vulnerabilities. This person already has vulnerabilities, whether it's stuff at work, or they've got stuff going on at home or with their kids or they didn't sleep well. Whatever the case is, if they've already got some stressors building up, those are things that their body and their mind are kind of paying attention to. Their stress level is already up, if you will. So it's going to be more difficult for them to figure out, okay, I'm balancing all these other things and trying to deal with them. Now you throw another apple in while I'm juggling. How do I keep everything in the air? The goal of distress tolerance is to accept and find meaning for and tolerate distress, realizing that, you know, some days we're going to walk in and we're going to be starting with a full inbox. Some days we might not, but it doesn't mean that distress isn't going to come our way. Now, thinking about that inbox example, if you start out with a full inbox and somebody brings you another project, what's your reaction? I know mine is really, really. If I start with an empty inbox and somebody brings me the same project, I'm like, okay, cool. I can handle that. I got plenty, plenty of energy, plenty of time. Stick with that metaphor throughout this class, if you will. Pain and distress are part of life. Well, let's go back to find meaning for and tolerate distress. When people get upset or overwhelmed, I mean, walking into that inbox and going, wow, I still have a lot to do. I can get frustrated. I can get overwhelmed. I can get anxious. I can get those feelings. And if I hold on to them and nurture them and think about how overwhelmed I am or fight them and go, well, I shouldn't feel that way. Even worse, it doesn't do anything. So accepting it and going, yeah, that's a pretty overwhelming pile of work I got to handle. So what am I going to do about it? Finding meaning for it? Well, if I've got a full inbox, that means I've probably got good job security today. So that's one way of finding meaning or making lemonade. And how do I tolerate it? Well, I can look at it and just start kind of letting my eyes get big and drooling on myself going, I have no idea how I'm going to get this done. Or I can step back and go, well, let's take the first thing off the top and start working on that. Or first thing off the bottom, whatever my plan is and get to working on it in order to tolerate the distress, recognizing that it's there. You know, I can see there's a lot of stuff to do. But dwelling on it isn't going to change anything. Recognizing that pain and distress are part of life and refusing to accept this leads to suffering telling myself I shouldn't feel overwhelmed by this, or I shouldn't be angry about this. Well, I am. So if I am, I am what I am. I'll do my Popeye impression for the day. Sorry. If I try to fight it, then I end up in a battle with myself and feeling angry about the fact that I'm angry or feeling frustrated about the fact that I can't control my own emotions or whatever it is. So just accepting how I feel takes that struggle away, takes that argument away between myself and my own little Jiminy Cricket or whoever it is that's trying to tell me how I should feel. Any attempts at change will produce distress. Therefore, distress tolerance skills are necessary. Wow. Here's, here's a point. Change causes crisis and crisis causes change. You know I've said this a dozen times if I've said it once. When we try to change, we're upsetting the apple cart. We like homeostasis as humans, you know, our bodies do our minds do our society does. When we try to change, then it causes a little bit of imbalance, which is a crisis. Now it can be a little crisis. It doesn't have to be much, or it can be a huge crisis, depending on what the change is. But whether you're trying to get healthier, go on a diet, not swear as much. Any change you're trying to make is going to cause a crisis. That means it's going to require energy. It's going to require you to pay attention and give it a little bit of energy. That's what crisis is. That's what stress is. Remember back to stress 101, there's you stress and distress. Well, both of them have the word stress in them. All that means is our body is requiring energy from us. So a good stress could be exercise, food digestion, you know, preparing for course, whatever it is. Distress, obviously there's a whole other list of things you can get into. Same kind of thing can be said for a crisis. There's a good crisis. There's something that you want to do, you want to change. It doesn't mean it's not going to take energy. And crisis causes change. When there is something unpleasant that happens, when there is a crisis that you didn't actually intend to precipitate, then you're probably going to change in order to get that homeostasis back, to get that balance back. Either way, even if you're not dealing with somebody with emotional dysregulation, everybody can benefit from distressed tolerance skills. Because every once in a while, it's my belief that everyone is going to encounter a situation in which their coping skills just aren't quite there. There's enough of a crisis that they're just like, okay, what do I do now? Distressed tolerance is a natural progression from mindfulness. You become aware of the fact that you are distressed. Now what do you do? I mean, the emotional dysregulation and mindfulness teaches you to be aware of your vulnerabilities, and be aware of how you're feeling, your physical sensations, your emotions. Now that you're aware of all that, what do you do with it? Well, first is to accept non-judgmentally oneself and the situation. And this is a tough one for most people. Accepting non-judgmentally how you feel, what your reaction is, it is what it is. And the situation, as it is right now in the present moment, it is what it is. Now you can change it in the future, you can't change the past, and the present is the present. That's what it is. So not trying to change the situation, your feelings, thoughts or urges in the right now and tell yourself, I shouldn't feel this way. Your feelings are natural reactions to situations. It's your body talent trying to tell you something. It's trying to give you good information. So take that information and figure out what to do with it. Distress tolerance means surviving crises and accepting life as it is in the moment. Tolerance and acceptance of reality don't equate with approval, though. So you can encounter a situation and it can really be miserable. It doesn't mean you have to go, okay, well this is just going to be miserable for a while. It doesn't mean you have to approve of it. It doesn't mean you have to sit there and wallow in it. You can't be changed. So you've got to decide how are you going to use your energy, but it doesn't necessarily mean that you have to approve or like it. You just have to accept it. Some people so want others to understand how bad it is. They focus on that instead of surviving the situation. Have you ever had a client who was talking to you and, you know, people just didn't understand how bad their depression was or how much it hurt inside or how out of control they felt. So they would act out and they would try to show them demonstratively through self injury or some other form of behavior, how bad it was. Look what you made me do. When working with clients with co-occurring disorders, sometimes clients will talk about drinking at someone, not drinking to escape the pain, but drinking at someone. You made me so angry. You made me relapse. You made it so bad that I couldn't stay clean and sober. What are the short term gains of proving how bad it is or acting out. It controls other people's behavior. You can try to make them feel guilty. You can try to make them come back. You can try to make them care for you. Whatever your goals are, probably those goals have been rewarded in the past in some way, or you wouldn't still be engaging in this behavior. It can also allow or precipitate the situation where you have to go to the hospital and you get attention or get a break. Getting attention from doctors, getting attention from other people about you're in the hospital. I didn't realize how bad it was. So the short term gains of acting out on emotional dysregulation can be really rewarding. If the person is feeling alone, if they're feeling isolated, if they're feeling like people aren't paying attention or listening, then those behaviors can inadvertently be rewarded. The long term benefits to this. There really aren't many. You know, I would say they're none, but I'm sure there are some somewhere. A lot of the clients that we work with who have emotional dysregulation issues can't get to the big picture. They are just doing their best to tread water in the moment and survive now, survive the short term. So thinking about tolerating this for the short term and what are the benefits for the long term, just not even something they can conceptualize because they're in so much pain, they're in so much distress. Have clients remember a time that they acted out to try to get someone to see how bad it was and ask them what were the results, whether they drank at somebody, they ate at somebody, they self injured, whatever the case may be. And talk about the pros and cons. And there are pros. We can't just say, well, there's no benefit to doing that. Well, yeah, there are, because we always choose as humans living organisms, we choose the most rewarding response, given the situation. So if they're choosing that behavior over distress tolerance, we've got to say what's more rewarding, what are they getting out of that? What's reinforcing that behavior? That distress tolerance skills aren't. So how can you make a crisis worse yelling at someone using alcohol or drugs? So lashing out lashing in retail therapy, eating too much, complaining so much that people just don't want to talk to you. They're just like, Oh, that person, bless their heart, they are struggling, they are suffering, but I just don't have the energy to handle that today. Or giving up on solving the crisis altogether and just kind of laying down and going, well, my life is just going to be miserable forever. And there are no doubt, when you are already stressed out and you are at the point of emotional dysregulation, all of these can sound in the moment very tempting, because it would make the pain go away temporarily or it would allow you to just go, I can't do anything and not feel like you had to fight or flee anymore. But is that where you want to be? Hopefully the answer for most of our clients is no. So what do we do? Well, let's start with the stress intolerant thoughts. What thoughts are you having that are telling you you cannot handle this? I can't stand it. Well, yeah. Think about a time you have been really upset. It has just been palpable or really, really scared, anxious about something that was going to happen. It can feel unbearable. It can feel like you can't stand it. And yeah, I would say I hate this feeling too. I don't think there are very many people who like feeling dysphoric or distressed. Do we have to stop it right now? What happens if we don't stop it? I must get rid of it. Eventually, yes. What happens if you don't stop it right now? I can't cope with this feeling. I might challenge clients. You know, one of you had feelings like this before and how have you coped? Because most people, this is not their first rodeo. They've had other experiences of dysphoria and they have survived. Now, maybe it was through drinking or retail therapy or one of those things we talked about earlier. The take home message, though, is they wanted to live. They wanted to survive and they did. So let's build on that. What did you do? And let's see if we can find a healthier kind of alternative that meets the same need. I'll lose control. Some people do feel like if they have one more thing come their way, they are just going to melt down. And that's, you know, a realistic feeling for a lot of our clients. Again, looking at other times where it has felt just overwhelming. Did they lose control? How did they prevent themselves from losing control? And what does losing control look like to you? When you say you're going to lose control, what are you afraid is going to happen? Are you afraid you're going to cry? Are you going to afraid you're going to need to ask for help? What is it that losing control looks like to you? I'll go crazy. Again, tell me what that looks like. What does it mean you're going to go crazy? And we can talk about the symptoms. We can talk about how that manifests and what to do with it. This feeling will keep going on forever. If I tolerate it, if I don't stop it right now, it's going to go on forever. We might, again, look at some of those feelings. When you've had them before, did they stop eventually? What would happen if you tried to tolerate it for a short period of time? And this is where we might talk about the wave and we'll get to the wave in a little while. But we might talk about the wave and how feelings come in and urges come in, they crest, and they dissipate over 20 to 30 minutes. So what would happen if you tolerated this feeling for 20 or 30 minutes? And if it still is as intense or worse, let's take a different tactic. What would happen? It's wrong to feel this way. So in my practice, and obviously you're going to have your own approaches to this, I firmly believe that the way people feel is very accurate and on point for the experiences that they've had leading up until now and the knowledge that they have right now. So their body is saying, there's a threat. We need to do something or you are powerless and you feel helpless. So then they feel depression. But we talk about what would be bringing on these thoughts. Why would your body be telling you this? It's stupid and unacceptable. I wonder where that came from. That's my first question. Who says, if you think it's stupid, I'm wondering, you know, where did you hear that from? Where did you get the idea that feeling scared or angry about this is stupid? And they may have some very legitimate answers. Maybe they're getting angry over, you know, they have a road rage issue and getting angry at somebody and screaming at them while they drive by. Is it helpful? No. Is it stupid to get angry if somebody has, you know, tailgated you and been unkind and then, you know, put you in a position where you felt like you were out of control? Not necessarily. That's your body going, I think there's a threat. Now we can talk about whether that was a threat or not. But in the moment, that's how you felt and that was kind of correct. I would also ask them if your child, your little sister, your best friend, depending on the client, came to you and told you that they had this situation and this is how they felt. Would you look at them and go, well, that's stupid. 99 times out of 100 or more. People will say, no, of course I wouldn't tell them it's stupid. Okay, so what would you tell them instead? How would you help them deal with this situation? Same thing with its weak, it's bad and it's dangerous. These feelings are your feelings. They're there for a reason. Can you tolerate them? You know, the intensity can feel overwhelming. That's true. So we're going to learn some skills in order to help figure out how to deal with it. And we're going to have an emergency plan. However, my guess is for every single one of our clients, there have been times in their past that they have felt overwhelming emotions and they tolerated it. They existed, they survived or they wouldn't be here now. So I want to build on those strengths and I want them to see that they are very strong people. Avoidance behaviors, which also come out with the stress. Maybe you don't lash out and make things worse, but you can use alcohol or drugs to numb the pain, to escape the pain, binge eating again, sleeping. Just going, you know what, I can't deal and crawling back under the covers, pulling them up over your head and not getting up for two or three days. That's avoidance. You know, you're not dealing with the situation and like an open wound that you don't clean out whatever situations causing this distress is probably just going to get worse. Distraction and suppression, trying to distract yourself from it and push it down, pretend like it doesn't exist. This always reminds me of a little kid who's not supposed to play with matches and they're in a room and they're playing with matches like little kids are known to do to, you know, do things they're not supposed to do. Mom and dad walks in and they take the lit match and they put it behind their back and they're trying to distract mom and dad from what they've been doing. Well that lit match is continuing to burn down towards their fingers. So the pain is becoming excruciating. Kind of what happens when we try to distract and suppress sometimes. There's a time for distraction. If the feelings are just so overwhelming, but using this as a constant coping skill, not just as a temporary stop gap until you can get into your wise mind is problematic. Avoiding situations that could cause you distress. Well, again, there's a time and a place. If I am already stressed out. Am I going to go unless I absolutely have to? Am I going to go shopping at the mall at the busiest time of the week? Probably not because lots and lots of people going around just kind of stresses me out. So I would avoid that during that period when I was already vulnerable, but I can't avoid every stressful situation. So there are some situations people have to learn how to deal with. Interference seeking or checking is kind of another avoidance behavior. You're avoiding feeling bad. You're avoiding feeling scared by constantly checking and making sure it's done right over preparing for things. Seeking not one, not two, but maybe six people's input on something. And self injury. Kind of going along with alcohol or drugs and we talked about that on Tuesday. Self injury is a way of exerting some control and avoiding the emotional pain for or trading in, if you will, the emotional pain for a physical pain that is more controllable. So urge surfing. That's intense emotional distress. They just got a phone call that they found out that one of their dear family members is terminally ill. And oh my gosh, you know, that feels like kicked him in the gut. Helping them realize, okay, let's identify go back to that emotion regulation. What are your feelings? What are your thoughts? What are your emotional physical sensations? And what are your urges? A lot of our clients their urges are probably in the self destructive or avoidance realm like we've just talked about probably going to make it worse, or at least not make it any better. So what do we do. Every time you have an urge think I have a choice. Now, taking it after that, and actually not acting on that urge takes practice. I have a choice. So if clients can even get to this point the first few times. And before they do something that is sort of their knee jerk reaction if they can stop and think okay I have a choice. Now they may stop there and go I can't remember what that choice is, but I've got a choice. That's progress. Not perfection, but it's progress. And then we can work on okay why did you choose your short term resolution instead of looking for the behavior that would help you more in the long term. Help them understand this metaphor of surfing the urge by opening yourself up to the urge, which is really terrifying. Most of our clients want to lock in and keep the urge out. They want to put a fortress around themselves. That's probably another metaphor for that. But we really want them in this metaphor to open up and let, let the urge come and go. This doesn't mean you have to consume yourself with it, which feels horrible or fight it and push it away. What you do is experience the feeling of the urge with acceptance, non judgment, and be aware that it's there. Think of yourself floating out in the ocean, you know, 30 or 40 feet offshore. Maybe yards. I'm not good with distance. Anyway, out there enough where you can get caught in a wave. The wave comes in now you can fight it and you can get like completely covered in the water and you can gasp for air and thrash around like you're drowning. Or you can relax and you'll float to the top and it will deposit you on the shore, which sounds easier, which sounds more preferable in the long run. Helping clients realize that our urges are kind of like waves. There's a trigger and you don't have urges right then and then all of a sudden the trigger happens and you quickly gather steam until this wave peaks. And then you start cresting and coming out your wise mind when you are not overly emotional when you are not driven by that adrenaline rush going we have to make this stop threat threat threat warning. Okay, when you're in that kind of alarm phase, you're not going to think clearly. So we want to help people figure out where they are on the wave. And if they're feeling the adrenaline rush, they're hearing their heartbeat in their ears. They've got tunnel vision, whatever their symptoms are. Help them recognize. Well, cool. That means I'm kind of at the top of the wave and it's going to start going away now. So they start going away and then they can start using their distress tolerance skills and their wise mind. So what do we do, we stop stop skills include hey stopping. This is the hardest part in my experience working with clients is getting them to be able to pause between the triggering event and the action. If you remember back to basic cognitive behavioral you have the ABCs, there's the activating event and the consequence. Something happens, you get upset, but there's those automatic beliefs in between that you almost don't notice because they happen so automatically. Well, we need to help people stop between the A and the C so they can figure out what those beliefs are and then decide what to do. Same sort of thing we're talking about here. Stop. When you get up stressed, when you get up stressed. Wow, when you get upset, figure out how you can help yourself stop or pause. And take a step back unhook as we talked about before. From those emotions, you are not your emotions become a fly on the wall become a lab technician. Imagine yourself in a lab coat stepping back with the board and just observing what's going on your thoughts, your physical sensations your urges. Observe and proceed mindfully. So if you remember back to the act matrix and this isn't obviously the whole matrix. They have their goals and values over here this is where they want to be in a month, three months, six months, what's important to you I mean really important to you not necessarily just escaping this pain right now. What are you trying to get to what are you trying to achieve. And then distress and stuff for suffering so when they take a step back and they stop. And they observe, then they can say, what are the options that can help you reach your goals. What things can I do. What alternate thoughts could you have that can help you feel empowered to reach your goals and get through this situation instead of, I can't stand this. I can't tolerate it. I have to make it stop right now. What can you tell yourself what thoughts can you have. I encourage clients to write, write these down and have them on their phone have them easily available. So when they do get distressed they can look at them when they are in the midst of a crisis at first, at least. This is not the time to start brainstorming well what positive thoughts could I have. They need to have something there. You also want to identify what are your options that may stop the suffering in the short term, but maintain the distress addiction self harm retail therapy any of those behaviors that people do to make the suffering stop right now. The short term solution which may not be conducive to the long term goals. And what thoughts and feelings are you having that are increasing your distress. I can't do it. This is awful. All those thoughts that we went through earlier. You can have people work through this. Once they've worked through it. Guess what time is passed. And when time passes adrenaline goes down if they get into their kind of observational scientific mind that emotional mind takes a backseat. So then they can step back and go. Alright, these are my options sorted them into the four categories. I'm going to choose to do another activity we can have them do is the pros and cons. What are the benefits and we talked about this in different ways in different classes. If you go to motivational interviewing this is your decisional balance exercise. In here we call it pros and cons. Same basic thing. What are the benefits to acting on the impulsive urges. There are benefits so they wouldn't do them. So let's put them out there. Let's not pretend they don't exist. What are the drawbacks to acting on impulsive urges. Okay. What are the benefits to insert the skill and it, whether it's the pros and cons or doing the act matrix or any of the other tools we talk about, they're going to be benefits and drawbacks and that's okay. And obviously the drawbacks to this particular skill, one of the drawbacks is almost always going to be, it doesn't provide immediate relief. It's okay. We can talk about, well if it doesn't provide immediate relief what are we going to do about it. This is one of those activities that you can put four flip chart papers around the room and have people go through and fill out. When you talk about acting on impulsive urges, you can either just do it in general, or you can be specific if you're doing a substance abuse group or if you're doing a self harm group or whatever kind of group you're doing. And it can give the group the chance to brainstorm together the benefits and drawbacks. Remember in the end you want to come back and draw it all together for your group and highlight the benefits to the new skill, the drawbacks to the impulsive behaviors. I also want to talk about how to achieve the same benefits, if you will, as acting on the impulsive urges. That is, how do we tolerate this distress in the short term. We need to figure out how to help clients have faith and self confidence and the empowered empowerment to believe they can get through it. And then what are the drawbacks to the new skill we've got to address that too. It's kind of like starting to eat healthy if you don't like any green vegetables that may be a drawback to eating healthy is like, oh, I'm going to have to eat those Brussels sprouts. So how do we address that how do we make it less unpleasant, you know, brussel sprouts drought drenched in butter and garlic takes away some of their health value but can make them more tolerable. So what is it that you can do to make this new skill, especially until it comes to full strength until the person is really proficient with it. What can you do to help them make this new skill more rewarding and more appealing tip skills temperature intense exercise paced breathing and paired muscle relaxation. So temperature, do something to change the temperature either take a really cold shower, or a really warm shower and I caution clients, this does not mean hot enough to scold yourself, because we don't want to encourage them to engage in self injurious behaviors. But a stark change in temperature can kind of jolt you out of a particular emotional state, because again, your mind goes from this emotional distress to, Okay, this is really unpleasant. Getting into a cold pool in the middle of summer so you know, cold is all relative it's like 68 or 70 degrees. Are you really focusing on what you got to do at work or are you focusing on oh my gosh this is really really cold gives your brain chance to tone down the emotion as emotional responses to this distress. You can also hold ice cubes. This is easier to do. I mean you can do it at work you can do it wherever grab a couple ice cubes go back to your office or whatever. Whatever you do, and hold on to them. I can tell you the pain, you know I've had to ice my ankles and stuff before. Carpal tunnel I've had to ice my hands. It can be intense and you're not focusing on much of anything but alright I've got to keep my hand in this for 20 minutes I can do this. People either have negative self talk about Oh this really hurts this is awful, or they will have more positive self talk like I can do this kind of stinks at the moment, but I've done it before and I know the pain will subside in five or 10 minutes. The same way they talk themselves through an ice bath with their hands is the same way they can talk themselves through emotional upset. Intense exercise if they're medically cleared for it can also help them get their heart rate up and focus on something else. It can be somewhat cathartic as well. Paced breathing. When you are stressed when you are under extreme distress. Your heart rate increases your breathing increases. So if you slow down your breathing, you trick your brain and your brain goes Oh, I guess the threats not there anymore. So it starts sending out the all clear. And then muscle relaxation. The active muscle relaxation is paired with a verbal queue. When I used to teach progressive muscle muscle relaxation in to a college class, I would walk into class that morning. And I would say okay everybody I want you to clear your desk we're going to have a quiz. And the immediate reaction of the people in the room. That's what I use for the rest of the day and I said, you know, I would let them all do it and have a little panic moment. And because I'm kind that way. And then I would say, just kidding. But what I want you to take away from that is do you see how much power that word or that phrase had to you when I said pop quiz. It caused you to have a stress reaction, or some of you. Just like you can pair something to make you have a stress reaction, you can also pair something to help you have a relaxation reaction. So if you pair muscle relaxation with a queue like release, calm down, breathe, whatever word queue you want to use whatever but verbal queue you want to use. Then we start getting stressed, you maybe driving in the car on the highway, you can say, okay breathe, and you breathe out, and you can actually your body actually responds with a calming, all clear sort of response. You may have to do it a few times, but your body will respond to that queue. So positive arousal. And this is another fun group activity. What things, what words, what phrases can people say to you that make you have a positive response. Or sounds, for example, a baby laughing, I'll be in the middle of a restaurant and if I hear a baby laughing automatically I have a smile on my face and I'm looking around going where's the baby. Same thing with dogs barking and just about anything like that. But all of those are positive arousal cues for me. They make me happy. Now unpleasant arousal would be something like telling somebody to clear, clear your desks, it's quiz time, or your spouse or your best friend calling you up on the phone and going, we need to talk. For most people when you hear that phrase, it's like, okay about what? Because if it's good, it's never prefaced with we need to talk. Let me tell you what happened today. So think about the difference between unpleasant arousal and positive arousal. Help your clients identify things that already exist in their environment and that already exist in their mind that appeared paired with a relaxation response. But you can also help them learn progressive muscular relaxation that is paired with a verbal queue and there are all kinds of scripts for that online. Distract with the wise mind accepts. And you know, I got a little overzealous with pictures this time. Do something pleasant, some sort of a pleasant activity if you are under distress or under stress, if you're distressed, try doing something not distressful. You can't be miserable and happy at the same time. So, you know, maybe go out on a walk, go out on a hike, go surf boarding or whatever that is. Contribute. Sometimes just getting out of your own head and giving back to the community. If you want to think of it as karma, however you want to think about it, helps distract you from your own stuff and you start focusing on planting trees for Arbor Day or volunteering or whatever it is you're doing to contribute. Draw comparisons. And this one can work, but it can also backfire. Compare yourself to someone who's not doing as well as you are and go, you know what? I was over there last week or last month, but I'm here now. I've made this much progress. So it's not necessarily perfection, but I have made progress. Emotions act the opposite. If you are not feeling well, if you're feeling depressed, try doing something that makes you laugh. Push away thoughts. If you're having negative thoughts come in or negative emotions come in, push them out of your head. Tell them, I don't have time for this right now. Or tell them, I'm not going to think about you right now. Or as the lady in the picture saying, la, la, la, la, la, I can't hear you. Or think about something totally different. For example, four things you can see, three things you can hear, two things you can smell, and one thing you can feel. And feeling can be temperature. It can be touch. You can even feel whatever shirt you're wearing or whatever the feel the texture of the cloth. Another thing you could ask people, if they're trying to think about something different, what did you do when you were a kid and you used to go on long car trips? May stop having the same effect in, you know, five or 10 years, but at least when I was a kid, we didn't have DVDs in the car. They didn't even have DVDs, but I digress. We used to look at road signs and, you know, find all the yellow cars or there were all kinds of little games that our parents would play with us in order to keep us from asking every five minutes. Are we there yet? Are we there yet? What kind of things did your parents use to distract you in the moment? Self soothing, doing a body scan meditation, laying down or sitting comfortably in a chair and doing a body scan from top to bottom or bottom to top. It doesn't matter. What are your, what are you feeling physically? What are you thinking? What are you, what are you physical sensations? What are you feeling? What are your urges? Just kind of go through and go, okay. And notice. That's all you're doing is noticing. But through that, it helps give your brain time to send out the all clear because when you're doing this, generally your, your breathing slows down, your heart rate starts to slow down, and you start to actually relax. Self soothing using the five senses, sight, anything that can help you calm down or feel better with sight, whether it's reading your Bible or, you know, I like hamsters and sweaters. I mean, how can you not smile when you see a hamster in a sweater? But that's one of my favorites. Smells. Roses may not be your thing, but find something that you can smell. Aromatherapy is great for some people. Doesn't do a thing for others. Have people experiment though. And it may not even be aromatherapy. Maybe it's the smell of their grandmother's perfume or something that makes them feel calm. Hearing. Here we've got the little bird that could help you self soothe. Some people like to put on music. What sounds help soothe you when you're feeling depressed when you're feeling angry when you're feeling anxious? Touch. Massage is always a good thing. And you don't have to go out and get an expensive massage. You know, you can massage your own neck. Not nearly as relaxing sometimes, but it can help because you're focusing on getting out the knots. You're focusing on, you know, whatever that is and not necessarily the emotional distress. And taste. And this, I work with a lot of clients who have eating disorders. So I try to avoid encouraging self soothing through eating, but certain tastes and certain times that it can be useful. Coffee, for example, decaf organic, you know, you can make it kind of healthy for some people can be very soothing or it can at least help them get into the moment because they like the smell of it. They like the feel of the warm cup. They like, you know, you can do a whole mindfulness, mindfulness exercise on drinking coffee. What we want to help people do is just tolerate figure out how to get through that 20 or 30 minutes until their emotional reaction and their urges dissipate and they can get into their wise mind. Improve the moment imagery, imagine a safe place, wherever you feel safe, if it's a fortress, if it's an igloo, what is your safe place look like this is a great art therapy activity. Imagine successfully dealing with this situation, whatever it is you anticipate is coming or that you're in in the midst of take a moment and imagine successfully dealing with this. Pretend you've got a force field or imagine you've got a force field around you protecting you from the negative stuff, or protecting you from maybe you're around somebody who is critical or negative or not helpful. Imagine yourself surrounded by a loving force field. Imagine a coach kind of on your shoulder going you got this, you can do this keep going push a little harder. I had some coaches push me really hard when I was younger and you know I thought I wasn't going to make it I thought I was going to fall out, but I didn't. They knew better than I did how strong I was. Some people like to envision it as a fairy godmother on the on their shoulder going, you've got this and I'll help you. I don't do a good fairy godmother imitation or an angel, whatever imagery works for the person to help them feel like they've got support and to help cheer them on and keep them going. Imagine feelings and thoughts as clouds in the sky. If you've ever laid back on the on the ground and just watch the clouds pass. You know this is anger, anger is going by. This is sadness sadness going by. Or letting go of balloons and watching them float away. You can have a red balloon that represents anger. Imagine just seeing it seeing yourself letting it go and watching it float away. Please don't do it in real life not good for the environment yada yada yada, but it's great for imagery or an unstoppable train. This express train is going through. And if you try to step on the tracks to go wait a minute. I want to get on what's going to happen. You're going to be squished. So you can't stop this unstoppable train you just let it go by and see it coming. Here comes the anger train and there it went. Meaning change how you think about yourself and your situation instead of feeling weak and powerless and stupid and all those other negative thoughts that we talked about earlier. Thinking about yourself as powerful and smart and able to survive this and strong and whatever other positive adjectives you can think of. And the situation making meaning out of it or making lemonade finding the silver lining. What could be one positive thing you could draw out of this prayer, depending on, you know, your religious philosophy your spiritual philosophy. This is an option. And relaxation, just hey, relaxing, letting yourself just be calm doing something that is relaxing to you like stretching or yoga. One thing in the moment focus on what you're doing right now, like sitting in a chair, which you're probably doing right now. So you could focus on that moment focus on what it feels like to sit in the chair. What does the chair feel like. What do your legs feel like you know you can see how you could take this and work, work on the imagery for two or three minutes at least. If you were like me when you were little. Again dating myself. We had that we get those little paddle balls. And if you were trying to do one of those little paddle balls, you had you couldn't focus on anything else because it was really hard to keep that little sucker going. One thing in the moment. And do I advocate for this now. Sure, if that helps you have your client get a little paddle ball or a yo yo and do that for a second. So I'm really thriving focusing on one thing in the moment noticing the birds on the power lines and whatever's going on around you instead of thinking about making dinner when you get home. For me, I go out and I weed, because it seems like they just show up to mock me. I'll go out and I'll have just weeded the garden and they're going to be six more weeds out there the next day. So, going out and focusing on that, believe it or not is just enough consuming weeds only weeds and not the flowers that you're focused on that one thing in the moment. Take a mental vacation. Just go to your happy place. Take a short break. It doesn't necessarily have to be, you know, an hour or two hours. Maybe it's 10 minutes to walk around the building. It doesn't work and this is easier said than done, but if you can leave the majority of work at work and set boundaries. So when you're home, you can balance it. You're going to feel a lot more energized and encouragement, be your own best friend and create a mental coach, somebody that is there to push you a little bit, but also to go you got this. And the one that's in the locker room with you after if you don't have a good game that day who says, you know what, let's figure out what we can do better next time but overall it was a good game. Reality radical acceptance means complete and total acceptance of the facts of the reality. This is a difficult one for people to kind of wrap their heads around it means accepting it is what it is. I have my clients say that and just sit with that for a minute and tell me what that means to them. The other thing they can do is turn their mind mentally looking to the other side. So if they're having this frustrated helpless depressed useless horrible thought feeling thing going on. I say imagine turning the other cheek, or looking to the other side. What do you see on the positive side. What is the opposite of what you are thinking and feeling right now. Say emotions differently. Remember 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. These negative or dysphoric or unhelpful or well they are helpful unpleasant emotions are important to survival. So then instead of fearing them and avoiding them at all costs when they come notice them pay attention go okay need to be a little alert figure out what's going on and let them go. Instead of beating yourself up for not being happy 100% of the time. Willingness versus willfulness willfulness forgets ignores or actively tries to change master direct control or manipulate what is. They have many donkeys and their rescues and they were not I mean they were just breeders for 23 years. So they weren't used to being in a barn they weren't used to having their hoofs pick they definitely weren't used to being on lead. So this is kind of what they were like at first we could push them we could pull them they were going to dig in they were going to be as willful as all get out. Willingness is surrendering to a process in which one is already a part. So once they learned that we weren't going to hurt them they started becoming less fearful and this was all fear fear driven behavior back here. Once they figured out that we weren't trying to hurt them they became became more fearful fear less less fearful and more a part of the process and said okay. If you think I can do this I'll try it I'll try it once and if something bad happens you can bet I'm not going to do it again. So helping people explore the difference between willingness to try willingness to accept versus willfulness and going no I won't. And what's underlying that willfulness and my guess is it's almost always going to come down to fear of some sort. So half smiling and willing hands emotions are partially controlled by facial expressions. So half smiling means having your mouth kind of relaxed with your lips slightly upturned hands are unclenched palms up fingers relax. So just take a second while I keep talking and sit like that in your chair sit back kind of turn your palms up and just relax and see what that does for your mood versus having a frowny face and tense fists. Mindfulness of current thoughts, recognize that thoughts are just neural firing in the brain and not facts about the world. Allow them to come and fade. I sometimes use the analogy of think of think of your thoughts like a salesman. Your thoughts want you to believe something it may not be the truth, but a salesman wants you to believe something because they want to make a sale. So do we need to pay attention to every salesman, or can we let them come give us their pitch and then let them walk away. Additional tools, clear mind, the addicted mind is governed by addictive behaviors. So sometimes we use dbt skills distress tolerance skills for things other than borderline personality disorder one would be addiction. So we want to think how is the addicted mind similar to the emotional mind. Well, the addicted mind is very impulsive. The addicted mind is basically the one that kicks in when someone gets emotionally dysphoric. It kicks in when that emotional dysregulation starts because the addicted mind says I can't handle this. I can't I will go crazy if I feel one more bad thing. The clean mind is like something like we refer to as the pink cloud in addiction recovery. The clean mind forgets that relapse is possible. They go I got this licked. It's no problem. I won't have any more problems. I am recovered. So the clean mind is similar to the rational mind because it misses some of the possibilities in there. It's overconfident. The clear mind is not engaging in the addictive behaviors. It's accepting and tolerating unpleasant emotions, but it does remain aware that relapse is possible. So it's integrating the fact that yes, I know those behaviors still exist somewhere in the back of my mind. I know the tools to do the next right thing and to maintain my recovery, but I know that there is a possibility at some point that these other behaviors in my addicted mind will be triggered again. So I've got to be mindful and aware of how I'm feeling. Burning bridges and building new means actively eliminating triggers and vulnerabilities. Try not to leave work with an inbox pile this high where you can't even see it on the screen. Try to eliminate as many underlying vulnerabilities as possible. Find physical and emotional sensations and create mental images that compete with the addiction. So if the addiction made you feel good, which, you know, it takes away the pain, what physical and emotional sensations that are healthy and helpful? Can you use to help you feel less pain? What mental images can you use to help you self soothe? Alternate rebellion would be finding alternative ways to act out which are safer sort of a harm reduction approach. So sublimation, taking that anger and instead of putting your fist through the wall, maybe going outside and digging a hole for the rose bush, you're going to plant in the spring. Or listening to really loud music, not for long, don't want to burst the eardrums, cause hearing problems, but for some people that helps kind of jar them out of the emotional pain they're feeling. Important questions though, for distress tolerance, any activity, how does this technique make you feel? How does it impact your feelings in the moment? And how does it affect how you handle the problem? And the other one I would add on in here, once you chose your response, how did it affect every other area of your life after that? So whenever clients use a distress tolerance technique, we want to ask them these things to help them figure out and help us help them figure out which tools are going to be the strongest for them. Remember, there can be emotional comebacks, sometimes thoughts and emotions and urges reappear, just kind of like Gladys Kravitz from Bewitched. You turn around and you look out the window and oh, here she comes again. Notice that they're coming without negative judgment, tolerate the distress and problem solve. After my dog Kenny was killed, there was a long period there where I wasn't just completely overwhelmed with despair all the time. You know, I'd have good periods, but then something would trigger it and that emotion would come back again. And I'd have a little cry and I'd pick myself back up and go back at it. But understanding that sometimes you got to go through it a couple of times and these emotions will come back and that's okay. Once clients are mindfully aware of their thoughts, sensations and urges and willing to accept the moment, then we need to help them figure out how to tolerate the moment. Help clients develop a menu of options which they can select from when they're in crisis, not just one thing, at least three. You know, when you're feeling like you want to self harm, go drink, fill in the blank, what can you do? What three things could you do? Remind them that they feel how they feel and our goal is to help them tolerate the distress until the intense emotions subside and they can get into their wise mind. Because once they can get past that adrenaline rush, then they can start sorting through their options and figuring out which behavioral or cognitive response is going to get them closer to their ultimate goals and how to do that. Are there any questions? Like I said, as soon as I end the presentation, I will get the links to those books that I like. They are not part of the class. They are just resources. If you really like DBT, they happen to be my favorite DBT resources out of the ones I've looked at. If you find others, please share. You know, obviously I haven't read every book out there on DBT, so I love to have new resources to share. Have an absolutely amazing weekend, everybody, and I will see you next week. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. 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