7/17/19 DBT Distress Tolerance Skills - CSPAR · 7/30/2019 · Make sure the distress tolerance...
Transcript of 7/17/19 DBT Distress Tolerance Skills - CSPAR · 7/30/2019 · Make sure the distress tolerance...
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DBTDistressToleranceSkills:HelpingtheClientsThroughtheToughTimes(andYourself)
ClaraDoctolero,PsyDEi Resources,LLCandSeattlePsychStudio,LLC
[email protected],2019
*slidesadaptedfromDrs.Comtois,Korsland,andFleck
Overview
Goalsofdistresstoleranceskills
TeachingtheSkills• CrisisSurvival• RealityAcceptance
Clinicalapplications• Forclients• Foryourself
WhatisaCrisis?
Acrisisiswhenyouhaveaseriousproblembutyoucan’tsolveit(atleastnotnow).
Inacrisis,thereisapressure tosolvethe
problemanditisdifficulttostoptrying.
Inacrisis,emotionsarehighsotheproblemisdistressingandhavinghighemotions
generallymakesthingsworse.
Acrisisisshort-term.ü Ifitishappeningallthe
time,itisn’tacrisis,its’yourlife!
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Distresstoleranceskillsarefor…
Clientsfacemanystressors
ü Housingü Moneyü Drugsandalcoholü Dangerousneighborhoodsor
buslinesü Troublefindingandkeeping
workü Longwaitsforsocialservicesü Medicalproblemsandchronic
pain
Cliniciansfacemanystressors
ü Largecaseloadsü Difficultclientsü Hearingmanytraumaticstoriesü Inabilitytohelptheirclientsü Lackoftimeorresourcesto
helptheirclientsü Frustratinginteractionswith
socialservicesü Unhelpfulrulesorregulationsü Paperwork
CanyouSolvetheCrisis?
Ifyes,SOLVEIT
ü Stick with it, don’t take your eye off the ball, and do what it takes.
Ifno(ornotrightnow),STOPtryingtosolveit
ü Trying to solve something you can’t will often make it worse and send your emotions through the roof.
ü Focus on distress tolerance skills during an unsolved crisis.
Theseskillstaughtinthislecturearedesignedjustforanunsolved crisis.
Distresstoleranceissurvivingwithoutmakingthesituationworse.
Toleratingdistressisnotremoving– orsometimesevenreducing– distress.
ü Thereareotherskillsforreducingemotionsandproblem-solving.
Don’texpectdistresstoleranceskillstomakeyou
“feelbetter”.
ü The fact is that you often may feel better, but that is not the purpose of the skill.
ü The skills are so you won’t make the situation worse.
ü If the skills prevent the crisis getting worse but don’t make you feel better, DON’T STOP! If you do, things may get worse.
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Howcanyoumakea
crisisworse?
Yellingatsomeone
Usingdrugsoralcohol
“Retail therapy”with
money you can’t afford
to spendEatingtoomuch
Complaining so much folks
don’t want to talk to you
Givinguponsolvingthe
crisisaltogether
DistressToleranceskills:
•STOP(new2015)•ProsandCons•TIP•Distract•Self-Soothe•IMPROVEthemoment
STOP•Stop•Takeastepback•Observe•ProceedMindfully
-Whenimpulsivityandemotionmindtakeover-Whenyoudon’thavetimetouseyourskills-Tohelpyoustayincontrol
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Pros Cons
Making it worse by:____________
Tolerating distress by:____________
ProsandCons
Pros Cons
Making it worse by:getting drunk
-get to relax-won’t have to think about it
-won’t be able to function tomorrow when have to call guy back
Tolerating distress by: self-soothing
-get some relaxation-will be clear minded tomorrow
-will be worried all night-probably won’t sleep
Scenario:10pmSunnightandyoufoundanevictionnoticeonyourdoor
Pros Cons
Making it worse by:just go through the motions
-don’t have to focus when tired-don’t get my hopes up
-self-fulfilling prophesy-person will think you don’t care
Tolerating distress by:IMPROVE with meaning, prayer, and encouragement
-feel proud of the quality of my work-have hope-treatment more likely to work
-takes a lot of effort-may be disappointed (again)
Scenario:Thursafternoonandyouhaveanewreferralalotlikelast3whodropped
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DoProsandConsatyourbestmomentandmakelistfordarkestmoment.
Dowithclientorcolleagueor
friend
Afterwards,copytheConsofmakingitworseandthe
Prosoftolerating
distressontoonelist
Keepthelistwhereyouneedit
most!
Ifyouareatyourdarkestmoment,youwillnotbeabletoseetheprosandconsatallclearly
TIP• TippingtheTemperatureofyourfacewithcoldwater
• MammalianDiveReflex• https://www.youtube.com/watch?v=JkhGeHLzHJ8
•Intenseaerobicexercise•Pacedbreathing•Pairedmusclerelaxation
Distractionisdeliberatelyturningyourattentionawayfromthecrisis.
Activities
Contributing
Comparisons
oppositeEmotions
Pushingaway
Thoughts
Sensations
Remember,WiseMindACCEPTS
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Distractingwith...
Useanactivitythatfitsthemomentorwhatyouwouldbe
doingifyouweren’tdistressed
Sportsorexercise Hobbiesorusingyourtalents
BewithotherpeopleandDON’Ttalkaboutthecrisis
Watchamovie Gotothezoo,park,beach
Activities
Distractingby
Usuallymoredistracting
thananactivityforyourself
Bakesomeonecookies
Listen to someone
else’s problems
Writesomeonewhoislonelyaletter
Volunteer
Contributingisdoingan
activitythatprimarily
servesothers
DistractingbyComparisons
Get attention of the crisis but thinking about
other crises that are worse than yours
Someone or people who are suffering more than
you
A time in your life when you were doing worseRemember – your pain is still valid but put it on a continuum from easiest to hardest to bear and focus attention on the harder
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DistractingbyEmotions
Figureoutanemotiondifferentfromthenegativeoneyouarefeelingandtryandbringiton
• Ifangry,watchacomedy• Ifscared,watchsomeonedaring
• Ifsad,listentoupbeatmusic
Whenwearedistressed,oneortwonegative
emotionsdominatethe
scene
DistractingbyPushingAway
Imagineputtingitonashelf,inatime-releasesafe,inanotherroom
ImagineaLucitewallbetweenyouandtheproblemsoyoumaybeawareofitbutyouarecutoff
Imagine the “volume” of the problem being turned down
This means deciding that something cannot be dealt with now and putting it out of your mind
DistractingwithThoughts
Theideaistofillyourbrainwithotherthoughts,sothereisnoroomforthecrisis
• Singsonglyricsyoudon’tquiteremember•Dothetimestablestoanumberyouhavetocalculate•Decidewhatprofessioneveryoneonthebusdoes• Imaginedecoratingyourfuturehome
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DistractingwithSensations
Mobilizeyourbodyanditwillbringyourmindandemotionswithit
• Putyourfaceinicewaterorholdice
• Runupanddownstairs• Takecoldshower• Ifyouareinsidegotoutsideorifyouareoutsidegoinside
ThisisTHEBESTstrategytogetunstuckwhenyouare
verydistressed
Self-Soothe withFiveSenses
Vision Decorateyourspace,gosomewhereinspiring
Sound Music,soothingvoices,naturesounds
Smell Cooking,lavender,thebeach
Touch Comfortableclothes,petanimal,footmassage
Taste Favoritefood,hardcandyormint,goodcupofcoffee
Self-SOOTHEKIT§ Trytoincludethingsthatsootheall5senses.§ Useanycontainerthatworksforyou.Ifthecontainerissomehowspecialormeanssomethingpersonaltoyou,allthebetter.
§ Ifsomethingistoobigforwhatevercontaineryoudecidetostoreyourthingsin,considerputtingsomethingsmallbutsymbolicinitsplace.
§ Keepyourkitsomewherewhereyoucanseeitwhenyou’reupset.Itdoesyounogoodifyoucan’tfinditeasilywhenyouneedit.
§ TakethetimetomakeitspecialandpersonalTOYOU.Andfeelfreetoaddtoandrevisityourkitonceinawhiletoremindyouit’sthereandwhatwonderfultreasuresyouputinit.
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Skillstoacceptpainandreducesuffering
Imagery
Meaning
Prayer
Relaxation
Onethinginthemoment
Vacation
Encouragement
Imagery
Happyabeach,ahike,withfriends
Safeplacefar
away,placewithlocks
Relieflikewhen
thecrisiswillbesolved
Relaxedonawarm,comfortable
couch
Pictureaplaceyou
feel
Meaning
Whatcanthiscrisisortoleratingthiscrisisdoforyou?Whatwillyou
getoutofthis?
Whatareyourcorebeliefsorreligious
traditions?
“What doesn’t kill you makes you
stronger”
“God doesn’t give me more than I can
handle”“This too shall pass”
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Prayer
ExamplesSerenity 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
Useandconnecttothereligiousorspiritualtraditionsthataremeaningfultoyou
Relaxation
Progressiverelaxation• Tighteneachpartofyourbodyfullyfor5secondsandthencompletelyrelaxit
• Startattoesandworkthroughfullbody
Walk,yoga,otherexercisethatrelaxesyourmuscles
Thegoalistoreducesufferingbyremovingphysical
stressfromthebody
OnethingintheMoment
Bringallofyourattentiontowhatishappeningrightinthismoment
Letgoofthoughtsaboutthepastandfuture
Describe(inyourmind,outloud,inwriting)whatyounoticeinthismomenttobringyourattentionjusttonow
A lot of distressis not in the present – it is in the past or is anticipated for
the future
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Vacation
Takeasmallvacationtotoleratethedistress
• Don’t talk to anyone for an hour
• Go to bed and forget the rest of the day
• Decide everyone can do without you for a while
• Get take out rather than cook
Key,aswithallvacations,isplanitaheadoftimeandhavea“return
ticket”
••Otherwiseyouarerunningaway!
Avacationiswhenyoudeliberatelystepawayfromyourlifetodosomethingmorerelaxing,fun,or
peaceful
Encouragement
Beyourowncheerleader• “Icandoit”• “Only3moredays…2more…1more…”
• “IhavebeenthroughworseandIcandothistoo”
Similartopositiveself-talk
Goalisnottobe“Pollyanna”aboutyourtroublesbutencourage
yourselftostickwithitandtellyourselfyouwillsucceed
SothosearetheDBTDistressToleranceskills.
Notnewideas–justconceptualizedandorganizedinsystematicway.
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FewTips
ü Ifyouhavetheurgetodie,ironingisprobablynotgoingtohelp!
Makesurethedistresstoleranceskillisclosetotheintensityofthedistress
ü Distracting with Sensations is a great way to get started but doesn’t last; so if crisis is long, pair with Activities or Contributing
ü Distracting with Thoughts lasts for minutes to maybe an hour – good for the bus, traffic, staff meetings, or the line at the DMV
ü Take a “vacation” for as long as time allows
Makesurethetimingoftheskillmatchesthesituation
FewTips
• Soothing by taste is not a good idea if you are a compulsive eater or are gaining weight
• Take too many vacations, you don’t get anything done• Distracting by watching a DVD TV series or reading
novels can take over your life
AnyDistressToleranceskillsoverusedcanmakethingsworse
• Often people see distraction - getting your mind off it - as the only way to cope when you can’t do anything about the problem
• Sometimes you need to stay with the problem such as staying in class or on the worksite or with your children (or with your clients)
• Be sure to learn Self-Soothing and IMPROVE as much as Distract for this
AvoidDistractionwhenitisavoidance
PracticeDBTDistressToleranceskills
Doeachskillonpurpose(even
ifitissomethingyoudoallthetime)
Practiceeachskilltillyouaregoodatit
Challengeyourselftousetheskillswhenyourdistressis
high
Observehowyougoaboutusingtheskill
Observewhatyoudowhen
theskilldoesn’twork
Thisiswhattocoach
clientstouse
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And,mostofall,practicethemwhenyourdistressishighsoyoucantolerateyourcrises
too…
RealityAcceptanceSkills• “Theseareskillsforacceptingyourlifeasitisinthemoment.Theyareparticularlyusefulwhenyouarelivingalifethatisnotthelifeyouwant.”MML
• Goals:• Reduceyoursuffering• Increaseyoursenseoffreedom
TheRealityAcceptanceSkills:üRadicalAcceptanceüTurningtheMindüWillingnessüHalf-smilingüWillinghandsüAllowingthemind:Mindfulnessofcurrentthoughts
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RealityAcceptanceSkills
• Whathastobeaccepted?1. Realityiswhatitis2. Everyone’sfuturehaslimitations3. EverythingintheUniversehasacause4. Lifecanbeworthlivingevenwhenitcontainspain
RealityAcceptanceSkills
• Whyacceptreality?• Rejectingordenyingrealitydoesn’tchangereality• Changingrealityrequiresfirstacceptingreality• Paincannotbeavoided• Rejectingrealityturnspainintosuffering• Acceptingrealitycanbringfreedom• Acceptingmayleadtosadness,butdeepcalmusuallyfollows• Thepathoutofhellisthroughmisery
RadicalAcceptance
• IsNOT:• Itisnotapproval• Itisnotcompassionorlove• Itisnotpassivity,givingup,orgivingin• Itisnotagainstchange
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PracticingRadicalAcceptance:StepbyStep
1. Observethatyouarequestioningorfightingreality2. Remindyourselfthattherealityisjustasitis3. Considercausesofrealityyouneedtoaccept4. Practiceacceptingwiththewholeself(Mind,Body,and
Spirit)5. Practiceoppositeaction6. Copeahead7. AttendtoBodySensations8. AllowDisappointment,Sadness,orGrieftoarisewithinYou9. Acknowledgethatlifecanbeworthlivingevenwhenthereis
pain10. DoPros/Cons
TurningtheMind
• Choosingtoaccept…yes,thisisachoice• Steps:
1.Observethatyouarenolongeraccepting2.Makeaninnercommitmenttoacceptrealityasitis3.Doitagain,overandover4.Developaplanforcatchingyourselfwhenyoudriftoutofacceptance
Willingness
• versusWillfulness• HowtogofromWillfultoWilling
1.Observethewillfulness2.Radicallyacceptthewillfulness3.TurntheMind4.TryHalf-smilingandaWillingPosture5.Ask,“What’stheThreat?”
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Half-smileandWillingHands• Half-smilingisawayofacceptingrealitywithyourbody
1. Relaxyourface…startingwiththeforeheadandgoingdownyourfacetothelowerjaw.2. Then,witharelaxedface,turnyourlipsjustslightlyupatthecorners,onlyuntilyoufeelit.
• Willinghandsisanotherwayofacceptingrealitywithyourbody…agoodwaytoregulateanger.
1. Handsuncleanched2. Palmsup3. Fingersrelaxed
AllowingtheMind:MindfulnessofCurrentThoughts• Thisisnoticingandradicallyacceptingourthoughts• Thisischangingourrelationshipwithourthoughts• Thegoalisnotamindemptyofthoughts
1. Observeyourthoughts2. Adoptacuriousmindaboutyourthoughts3. Rememberthatyouarenotyourthoughts4. Trynottoblockorsuppressthoughts