DBT Distress Tolerance Skills - Mental Health Countsmentalhealthcounts.net/wp-content/uploads/2013/07/...strategy to get unstuck when you are very distressed DBT Distress Tolerance

Kate Comtois, PhD, MPHCHAMMP/HarborviewUniversity of Washington

Goals of distress tolerance skillsGoals of distress tolerance skills

Teaching the SkillsTeaching the Skills•Distraction•Self Soothing•IMPROVE the moment•Pros and Cons

Clinical applicationsClinical applications•For clients•For yourself

DBT Distress Tolerance Skills 5/13/2010

1 of 19

A crisis is when you have aserious problem but youcan’t solve it (at least not

now).

In a crisis, there is a pressureto solve the problem and it is

difficult to stop trying.

In a crisis, emotions are highso the problem is distressingand having high emotionsgenerally makes things

worse.

A crisis is short term.• If it is happening all thetime, it isn’t a crisis, its’your life!

If yes, SOLVE IT

•Stick with it, don’ttake your eye offthe ball, and dowhat it takes.

•Stick with it, don’ttake your eye offthe ball, and dowhat it takes.

If no (or not right now), STOPtrying to solve it

•Trying to solve something youcan’t will often make it worseand send your emotionsthrough the roof.

•Focus on distress toleranceskills during an unsolved crisis.

•Trying to solve something youcan’t will often make it worseand send your emotionsthrough the roof.

•Focus on distress toleranceskills during an unsolved crisis.

These skills taught in thisThese skills taught in thiswebcast are designedjust for an unsolved

crisis.


2 of 19

Clientsface many stressors

• Housing• Money• Drugs and alcohol• Dangerous neighborhoods orbus lines

• Trouble finding and keepingwork

• Long waits for social services• Medical problems and chronicpain

• Housing• Money• Drugs and alcohol• Dangerous neighborhoods orbus lines

• Trouble finding and keepingwork

• Long waits for social services• Medical problems and chronicpain

Cliniciansface many stressors

• Large caseloads• Difficult clients• Hearing many traumatic stories• Inability to help their clients• Lack of time or resources tohelp their clients

• Frustrating interactions withsocial services

• Unhelpful rules or regulations• Paperwork

• Large caseloads• Difficult clients• Hearing many traumatic stories• Inability to help their clients• Lack of time or resources tohelp their clients

• Frustrating interactions withsocial services

• Unhelpful rules or regulations• Paperwork

Tolerating distress is notsolving the problem.

•There are other skillsfor problem solving.

•There are other skillsfor problem solving.

Remember

•Don’t hit your head ona brick wall by trying tosolve a crisis that can’tbe solved now.

•Figure out another wayto solve the problem.

•Then practice distresstolerance until thatother way can work.

•Don’t hit your head ona brick wall by trying tosolve a crisis that can’tbe solved now.

•Figure out another wayto solve the problem.

•Then practice distresstolerance until thatother way can work.


3 of 19

Tolerating distress is notremoving – or sometimeseven reducing – distress.

• There are other skills forreducing emotions.

• There are other skills forreducing emotions.

Don’t expect distresstolerance skills to make

you “feel better”.

• The fact is that you oftenmay feel better, but that isnot the purpose of the skill.

• The skills are so you won’tmake the situation worse.

• If the skills prevent the crisisgetting worse but don’tmake you feel better,DON’T STOP! If you do,things may get worse.

• The fact is that you oftenmay feel better, but that isnot the purpose of the skill.

• The skills are so you won’tmake the situation worse.

• If the skills prevent the crisisgetting worse but don’tmake you feel better,DON’T STOP! If you do,things may get worse.

How canyou make a

crisisworse?

Yelling atsomeone

Using drugsor alcohol

“Retailtherapy” withmoney youcan’t affordto spend

Eating toomuch

Complainingso much folksdon’t want totalk to you

Giving upon solvingthe crisisaltogether


4 of 19

you survive as wellas you can be and

“live to fight anotherday” on your crisis.

So, if you usedistress tolerance

skills,

the more competentand confident you

will become.

The more you learnto tolerate a crisiswithout making it

worse,

So what are the DistressTolerance skillsSo what are the DistressTolerance skills

•Distract•Self Soothe•IMPROVE the moment•Pros and Cons


5 of 19

Remember,wise mindACCEPTS

ActivitiesActivities

ContributingContributing

ComparisonsComparisons

opposite Emotionsopposite Emotions

Pushing awayPushing away

ThoughtsThoughts

SensationsSensations

Use an activity thatfits the moment orwhat you would be

doing if youweren’t distressed

Use an activity thatfits the moment orwhat you would be

doing if youweren’t distressed

Sports or exerciseSports or exercise Hobbies or usingyour talents

Hobbies or usingyour talents

Be with otherpeople and DON’Ttalk about the crisis

Be with otherpeople and DON’Ttalk about the crisis

Watch a movieWatch a movie Go to the zoo,park, beach

Go to the zoo,park, beach

ActivitiesActivities


6 of 19

Usually moredistractingthan an

activity foryourself

Usually moredistractingthan an

activity foryourself

Bake someonecookies

Bake someonecookies

Listen tosomeoneelse’s

problems

Listen tosomeoneelse’s

problems

Writesomeone

who is lonelya letter

Writesomeone

who is lonelya letter

VolunteerVolunteer

Contributing isdoing an

activity thatprimarily

serves others

Get attention of thecrisis but thinking about

other crises that areworse than yours

Someone or people whoare suffering more than

you

Get attention of thecrisis but thinking about

other crises that areworse than yours

Someone or people whoare suffering more than

you

A time in your life whenyou were doing worseRemember – your pain isstill valid but put it on acontinuum from easiestto hardest to bear andfocus attention on theharder

A time in your life whenyou were doing worseRemember – your pain isstill valid but put it on acontinuum from easiestto hardest to bear andfocus attention on theharder


7 of 19

Figure out an emotiondifferent from the negative

one you are feeling and try andbring it on

•If angry, watch a comedy•If scared, watch someonedaring

•If sad, listen to upbeat music

•If angry, watch a comedy•If scared, watch someonedaring

•If sad, listen to upbeat music

When we aredistressed, oneor two negative

emotionsdominate the

scene

Imagineputting it on ashelf, in atime releasesafe, inanother room

Imagine aLucite wallbetween youand theproblem soyou may beaware of itbut you arecut off

Imagine the“volume” ofthe problembeing turneddown

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


8 of 19

The idea is to fill your brain with otherthoughts, so there is no room for the crisis

•Sing song lyrics you don’t quite remember•Do the times tables to a number you haveto calculate

•Decide what profession everyone on thebus does

•Imagine decorating your future home

•Sing song lyrics you don’t quite remember•Do the times tables to a number you haveto calculate

•Decide what profession everyone on thebus does

•Imagine decorating your future home

Mobilize your body and it will bringyour mind and emotions with it

•Put your face in ice water or holdice

•Run up and down stairs•Take cold shower•If you are inside got outside or ifyou are outside go inside

•Put your face in ice water or holdice

•Run up and down stairs•Take cold shower•If you are inside got outside or ifyou are outside go inside

This isTHE BESTstrategy toget unstuckwhen you are

verydistressed


9 of 19

What would you do if you lived witha loved one going through a crisis?

How would you soothe them?

That is what you want to do foryourself

Don’t make a situation harder bybeing more uncomfortable thanrequired

For instance, don’t wear tight shoes to the dentist

Vision Decorate your space, gosomewhere inspiring

Decorate your space, gosomewhere inspiring

Sound Music, soothing voices, naturesounds

Music, soothing voices, naturesounds

Smell Cooking, lavender, the beachCooking, lavender, the beach

Touch Comfortable clothes, petanimal, foot massage

Comfortable clothes, petanimal, foot massage

Taste Favorite food, hard candy ormint, good cup of coffee

Favorite food, hard candy ormint, good cup of coffee


10 of 19

Skills toaccept painand reducesuffering

Imagery

Meaning

Prayer

Relaxation

One thing in the moment

Vacation

Encouragement

Happya beach, ahike, withfriends

Happya beach, ahike, withfriends

Safeplace far

away, placewith locks

Safeplace far

away, placewith locks

Relieflike when

the crisis willbe solved

Relieflike when

the crisis willbe solved

Relaxedon a warm,comfortable

couch

Relaxedon a warm,comfortable

couch

Picture aplace you

feel


11 of 19

What can this crisisor tolerating thiscrisis do for you?What will you get

out of this?

What can this crisisor tolerating thiscrisis do for you?What will you get

out of this?

What are your corebeliefs or religious

traditions?

What are your corebeliefs or religious

traditions?

“What doesn’t killyou makes you

stronger”

“What doesn’t killyou makes you

stronger”

“God doesn’t giveme more than I can

handle”

“God doesn’t giveme more than I can

handle”

“This too shallpass”

“This too shallpass”

Examples

Serenity Prayer

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

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

Ancient Tibetan Buddhist meditation

Use and connect to the religious or spiritualtraditions that are meaningful to you


12 of 19

Progressive relaxation•Tighten each part of your body fully for 5seconds and then completely relax it

•Start at toes and work through full body

Progressive relaxation•Tighten each part of your body fully for 5seconds and then completely relax it

•Start at toes and work through full body

Walk, yoga, other exercise thatrelaxes your musclesWalk, yoga, other exercise thatrelaxes your muscles

The goalis to

reducesuffering

byremovingphysicalstress

from thebody

Bring all of your attention to what ishappening right in this momentBring all of your attention to what ishappening right in this moment

Let go of thoughts about the past andfutureLet go of thoughts about the past andfuture

Describe (in your mind, out loud, inwriting) what you notice in this momentto bring your attention just to now

Describe (in your mind, out loud, inwriting) what you notice in this momentto bring your attention just to now

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

the future


13 of 19

Take a small vacation totolerate the distress

•Don’t talk to anyone for anhour

•Go to bed and forget the restof the day

•Decide everyone can dowithout you for a while

•Get take out rather than cook

•Don’t talk to anyone for anhour

•Go to bed and forget the restof the day

•Decide everyone can dowithout you for a while

•Get take out rather than cook

Key, as with all vacations, isplan it ahead of time andhave a “return ticket”

•Otherwise you are runningaway!

•Otherwise you are runningaway!

A vacation is when you deliberately step awayfrom your life to do something more relaxing, fun,

or peaceful

A vacation is when you deliberately step awayfrom your life to do something more relaxing, fun,

or peaceful

Be your owncheerleader•“I can do it”•“Only 3 more days… 2more…1 more…”

•“I have been through worseand I can do this too”

Similar to positive self talk

Be your owncheerleader•“I can do it”•“Only 3 more days… 2more…1 more…”

•“I have been through worseand I can do this too”

Similar to positive self talk

Goal is not tobe “Pollyanna”about yourtroubles butencourageyourself tostick with itand tell

yourself youwill succeed


14 of 19

Pros Cons

Making it worse by:____________

Tolerating distressby:____________

Pros Cons

Making it worse by:getting drunk

get to relaxwon’t have tothink about it

won’t be able tofunctiontomorrow whenhave to call guyback

Tolerating distressby:self soothing

get somerelaxationwill be clearmindedtomorrow

will be worried allnightprobably won’tsleep


15 of 19

Pros Cons

Making it worse by:just go through themotions

don’t have tofocus when tireddon’t get myhopes up

self fulfillingprophesyperson will thinkyou don’t care

Tolerating distressby:IMPROVE withmeaning, prayer,and encouragement

feel proud of thequality of myworkhave hopetreatment morelikely to work

takes a lot ofeffortmay bedisappointed(again)

Do with clientor colleagueor friend

Do with clientor colleagueor friend

Afterwards,copy the Consof making it

worse and thePros of

toleratingdistress onto

one list

Afterwards,copy the Consof making it

worse and thePros of

toleratingdistress onto

one list

Keep thelist whereyou need it

most!

Keep thelist whereyou need it

most!

If you are at your darkest moment, you will not be able tosee the pros and cons at all clearly

If you are at your darkest moment, you will not be able tosee the pros and cons at all clearly


16 of 19

• If you have the urge to die, ironing is probably not goingto help!

• If you have the urge to die, ironing is probably not goingto help!

Make sure the distress tolerance skill is closeto the intensity of the distress

•Distracting with Sensations is a great way to get startedbut doesn’t last; so if crisis is long, pair with Activities orContributing

•Distracting with Thoughts lasts for minutes to maybe anhour – good for the bus, traffic, staff meetings, or theline at the DMV

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

•Distracting with Sensations is a great way to get startedbut doesn’t last; so if crisis is long, pair with Activities orContributing

•Distracting with Thoughts lasts for minutes to maybe anhour – good for the bus, traffic, staff meetings, or theline at the DMV

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

Make sure the timing of the skill matchesthe situation


17 of 19

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

•Take too many vacations, you don’t get anything done•Distracting by watching a DVD TV series or readingnovels can take over your life

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

•Take too many vacations, you don’t get anything done•Distracting by watching a DVD TV series or readingnovels can take over your life

Any Distress Tolerance skills overused canmake things worse

•Often people see distraction getting your mind off it asthe only way to cope when you can’t do anything aboutthe problem

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

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

•Often people see distraction getting your mind off it asthe only way to cope when you can’t do anything aboutthe problem

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

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

Avoid Distraction when it is avoidance

Do each skillon purpose(even if it issomething

you do all thetime)

Practice eachskill till you

are good at it

Challengeyourself touse the skillswhen yourdistress is

high

Observe howyou go aboutusing the skill

Observewhat you dowhen the skilldoesn’t work

This iswhat tocoach

clients touse


18 of 19

Thank you.


19 of 19

Documents

DBT Distress Tolerance Skills - Mental Health Countsmentalhealthcounts.net/wp-content/uploads/2013/07/...strategy to get unstuck when you are very distressed DBT Distress Tolerance