dbt distress tolerance skills
TRANSCRIPT
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.
DBT Distress Tolerance Skills 5/13/2010
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.
DBT Distress Tolerance Skills 5/13/2010
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
DBT Distress Tolerance Skills 5/13/2010
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
DBT Distress Tolerance Skills 5/13/2010
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
DBT Distress Tolerance Skills 5/13/2010
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
DBT Distress Tolerance Skills 5/13/2010
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
DBT Distress Tolerance Skills 5/13/2010
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
DBT Distress Tolerance Skills 5/13/2010
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
DBT Distress Tolerance Skills 5/13/2010
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
DBT Distress Tolerance Skills 5/13/2010
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
DBT Distress Tolerance Skills 5/13/2010
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
DBT Distress Tolerance Skills 5/13/2010
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
DBT Distress Tolerance Skills 5/13/2010
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
DBT Distress Tolerance Skills 5/13/2010
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
DBT Distress Tolerance Skills 5/13/2010
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
DBT Distress Tolerance Skills 5/13/2010
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
DBT Distress Tolerance Skills 5/13/2010
18 of 19
Thank you.
DBT Distress Tolerance Skills 5/13/2010
19 of 19