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Dialectical Behavior Therapy Techniques
Distress Tolerance
Presented by: Dr. Dawn-Elise Snipes  Executive Director, AllCEUs
Podcast Host: Counselor Toolbox & Happiness isn’t Brain Surgery with Doc Snipes
President: Recovery and Resilience International
~    Define goals of distress tolerance
~    Discuss why some clients do not choose distress tolerance
~    Explore a variety of Distress Tolerance and Reality Acceptance Skills including
~    STOP
~    Pros and Cons
~    TIP
~    Self Soothing
~    IMPROVE the Moment
~    Radical Acceptance
~    Turning the Mind

Goals of Distress Tolerance
~    The goal of distress tolerance is to accept, find meaning for and tolerate distress
~    Pain and distress are part of life.  Refusing to accept this leads to suffering
~    Any attempts at change will produce distress, therefore distress tolerance skills are necessary

Change causes crisis and crisis causes change
Distress Tolerance
~    Distress tolerance is a natural progression from mindfulness
~    Accepting, nonjudgmentally, oneself and the situation
~    Not trying to change the situation, your feelings, thoughts or urges
~    Distress tolerance means surviving crises, accepting life as it is in the moment.

Tolerance and acceptance of reality do not equate with approval
Proving How Bad It Is
~    Sometimes people so want others to understand how bad it is they focus on that instead of surviving the situation
~    Short Term Gains  (Look what you made me do)
~    Controlling another’s behavior
~    Going to the hospital and getting attention/break
~    Long Term Benefits
~    ??

~    Have clients remember a time they acted out to try to get someone to see how bad it was.  What were the results?

Distress Intolerance Thoughts
~    I can’t stand this
~    It’s unbearable
~    I hate this feeling
~    I must stop this feeling
~    I must get rid of it
~    Take it away
~    I can’t cope with this feeling
~    I will lose control
~    I’ll go crazy
~    This feeling will keep going on forever
~    It is wrong to feel this way
~    It’s stupid and unacceptable
~    It’s weak
~    It’s bad
~    It’s dangerous

Avoidance Behaviors
Urge Surfing
~    Urges are generally intense for 20-30 minutes
~¬†¬† ¬†Every time you have an urge think, ‚ÄúI have a choice!‚ÄĚ
~    Surf the urge by opening yourself up to the urge. This doesn’t mean that you consume yourself in it (which feels horrible) or fight it and push it away. What you do is experience the feeling of the urge with acceptance, non-judgement, and be sensitively aware that it is there.
STOP Skills
~    Stop
~    Take a step back
~    Observe
~    Proceed Mindfully
Pros and Cons
~    What are the benefits to acting on impulsive urges?
~    What are the drawbacks to acting on impulsive urges?
~    What are the benefits to  __[insert the skill] __
~    What are the drawbacks to  __[insert the skill] __

TIP Skills
~    Temperature
~    Intense Exercise
~    Paced Breathing
~    Paired Muscle Relaxation
~    The act of muscle relaxation is paired with a verbal cue
~    What reactions do you have that are paired with verbal cues?

Distract with Wise Mind ACCEPTS
~    Activities (pleasant)
~    Contributing
~    Comparisons
~    Emotions (opposite)
~    Pushing Away
~    Think about something totally different
~    4       3     2    1
~    Body Scan Meditation
~    Self-Soothing Using the 5 Senses
~    Sight
~    Smell
~    Hearing
~    Touch
~    Taste
IMPROVE the Moment
~    Imagery
~    Safe place
~    Successfully dealing with this
~    A force field
~    A coach/fairy godmother/angel
~    Feelings and thoughts are clouds in the sky
~    An unstoppable train
~    Meaning
~    Changing how you think about yourself and your situation
~    Make lemonade.  Find the silver lining.
~    Prayer
~    Relaxation

IMPROVE the Moment
~    One thing in the Moment
~    Focus on one thing you are doing right now
~    Sitting in a chair
~    Driving
~    Weeding
~    Vacation
~    Mental vacation
~    Take a short break
~    Leave stress at work
~    Encouragement
~    Be your best friend
~    Create a mental coach

Reality Acceptance
~    Radical Acceptance
~    Complete and total acceptance of the facts of reality
~    Turning the mind
~    Mentally looking to the other side
Reality Acceptance
~    Seeing Emotions Differently
~    Fear and anger kick in when there is a threat
~    Sadness kicks in when you lose something important to you in some way, If you didn’t feel sadness when these things occurred, it would mean that nothing was important.

Negative emotions are important to survival, rather than something to be feared and avoided at all costs

Reality Acceptance
~    Willingness vs. Willfulness
~    Willfulness forgets, ignores or actively tries to change, master, direct, control or manipulate what is
~    Willingness is a surrendering to a process in which one is already a part

Reality Acceptance
~    Half Smiling and Willing Hands
~    Emotions are partially controlled by facial expressions.
~    Half smiling with lips slightly upturned
~    Hands are unclenched, palms up, fingers relaxed
~    Mindfulness of current thoughts
~    Recognize that thoughts are just neural firing in the brain, not facts about the world
~    Allow the thoughts to come and fade
Additional Tools
~    Clear Mind
~    Addicted Mind is governed by addictive behaviors
~    How is addicted mind similar to the emotional mind?
~    Clean Mind (Pink Cloud) forgets that relapse is possible
~    How is the clean mind similar to the rational mind?
~    Clear mind is not engaging in addictive behaviors but remains aware that relapse is possible.
~    How is the clear mind similar to the wise mind?
Additional Tools
~    Burning Bridges and Building New
~    Actively eliminating triggers/vulnerabilities
~    Finding physical and emotional sensations and creating mental images that compete with the addiction
~    Alternate Rebellion
~    Finding alternative ways to act out which are safer
~    Harm reduction
~    Sublimation
~    Loud music

Important Questions
~    How does [this technique] make you feel?
~    How does it impact your feelings in the moment?
~    How does it affect how you handle the problem?
Emotional Comebacks
~    Sometimes emotions, thoughts, urges reappear
~    Notice them without negative judgement.
~    Deal tolerate the distress
~    Problem solve
~    Once clients are mindfully aware of their thoughts, sensations and urges and willing to accept the moment, they need skills to tolerate that distress
~    Help clients develop a menu of options which they can select from when they are in crisis.
~    They feel how they feel
~    Tolerating the distress until the intense emotions subside and they can get into their wise mind.


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