Tolerating the distress

Sometimes I have to be intentional and deliberate with the use of DBT skills. Yesterday my day turned from ‘Improve the moment’ and self care plans, to crisis mode, and I had to go with Distress Tolerance.

After graduating from a Dialectical Behaviour Therapy (DBT) course, I find coping with life a little easier but I can become complacent with using the skills I learnt. I zealously applied them to overcoming Borderline Personality Disorder (BPD), but this form of treatment is showing such promising success in the areas of eating disorders too! My ED recovery is based in DBT.

Yesterday I was not complacent. I was aware fairly early that I was in ‘crisis mode’. My definition of crisis used to be around events or circumstances. The word crisis I would use to describe something traumatic happening, like a death or traumatic injury. My crisis is now defined around how I feel about any event. If my reaction is with turbulent emotion then I am in ‘crisis mode’. It validates my reality instead of dictating how I ‘should’ feel about something.

Something happened yesterday that was highly stressful and triggering. I can accept that I feel very strongly about this issue and dealing with it required me to 1) be aware of how I was feeling
2) apply the skills that were most appropriate

I could hear one of my therapist’s voices in my head (wise mind) linking a similar distress and it allowed me to acknowledge and accept the reality of the moment.

Distress tolerance (DT) is what I needed. DT involves skills to get through this moment, to tolerate it, without making things worse. It’s not about changing how you feel (though that can happen), it’s aim lies in making it through this initial period, doing things that will not bring harm.

It’s skill is based in wise mind ACCEPTS.
This ACCEPTS acronym stands for the distraction techniques you can draw from in ‘crisis mode’. Being in crisis mode it’s highly unlikely you can come up with ideas right then. The emotion is too high, so I recommend you personalize your own list at a time when you are sailing, or at least not in the firing zone on the battle field. Make it portable. Your phone is ideal to hold your weaponry of skills. It was the thing I turned to when I needed some ideas.

ACTIVITIES
Things you can DO to distract you. I used eating the meal I had yet to start. Face booking and housework. This one is easy to use. Surely anyone can find a game app they could get lost in!! EXERCISE is my biggest go to, but I have to be careful not to overuse it.

CONTRIBUTIONS
This is something you can do that gives to something or someone else. Could be charitable or encouraging a friend, making something for someone else,… Something that you can input that has a positive affect on others. I contribute to a Facebook group, sharing experiences or hope and encouragement… so I worked on that which inevitably helped me to focus on employing my skills.

COMPARISONS
When I originally heard this one, I cringed. I’m trying to steer away from comparing myself to others… Isn’t this going against my goals? However it is more directed at comparing for sake of gratitude, perhaps seeing the silver lining. So I become grateful for what I have, where I live, and who I have in my world to share that with. I compare my ability to cope in a positive way to how I would have coped a year ago.

EMOTIONS (opposite or different ones)
When I’m really sad, a good one for this is reading Damn You Auto Correct entries I have not been able to read these without tear spitting laughter!!
Music is always good as long as it isn’t perpetuating the emotion you are feeling.

PUSHING AWAY
This is about pushing thoughts away to think about at a more appropriate time when you have more wise mind to draw from. I visualize putting those thoughts in a box and putting them on a shelf. Aware they are still there to deal with later and not to let that box collect dust. Just postponing for looking at when I am not highly emotional.

THOUGHTS
Replacing negative or harming thoughts with others. I pick encouraging myself. ‘I can’t do this’ with ‘You can do this, you have done it before’. ‘This will never get better’ or ‘I can’t stand this’ to ‘it does get better, I have ridden this urge out before’

SENSATIONS
Using your senses to get an intense and/or physical reaction that is not self harming.
I didn’t need to call on this one yesterday as the urges weren’t intense and after scrolling through my list and doing all the above, my distress had lessened and could move on to use other skills. One of my favorites in this category when my distress is at its highest is pushing a full sized ice pack in my face. It’s like putting your face in a bucket of ice! Induces a divers reflex and an icy pain that won’t leave a mark or have permanence. Shocks me that much that it’s impossible to think of the distress and it’s causes. Other ones I use on the less intense scale are gentle touches on the arm or tickling feathers across my skin.

It takes time, but it works. It’s frustrating that I have to clear out the day to use these, like I am not coping, but in fact this is coping. Just coping in a more skillful and positive way than alternatives I have used in the past.

The practice was worth it. The distress has lessened.

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2 responses to “Tolerating the distress

  1. This is very insightful! I am working with a client suffering from BPD (she is on the very HIGH end of the spectrum and has basically been resistant to previous treatment. She is also older (mid fifties) and obviously pretty set in her ways. I LOVE, LOVE DBT, and have read up extensively on it, but I’m finding it really hard to actually execute the interventions with her, simply because of her fragility and low sense of self and others.

    I just had a few questions and you can answer them if you like. If they’re too personal, just ignore me!
    1. Did you have a therapist tell you that you had BPD or was it something you figured out on your own? My client doesn’t actually know she has this diagnosis (she is a transfer case).
    2. How did you start with DBT? Did you use a workbook/worksheets outside of session?
    3. Do you have any advice for a therapist working with this population? I really am fascinated by personality disorders in general, and I find it disheartening that treatment tends to STILL be rather ineffective or limited at best.
    4. When you need to vent (as my client often does), does your therapist allow you to do this for the entire session, or do you have more of a sense of structure?

    Thanks in advance for any and all answers. This would really help! I’m so glad that treatment has been working well for you!!! 😀

    • You’re welcome! I love DBT too, it’s so practical!!
      1) both. I originally was dx with GAD with co morbid panic disorder, then bipolar 2 disorder, before ending with BPD. The variety of ED’s has been present since I was 14. It was quite weird as the BPD kind of developed. The core of BPD I have always had but the criteria symptoms gradually became worse till I fit the BPD description. It was after I ended up in a psych unit for the first time that the bipolar didn’t make sense due to my presentation. It was during an in depth interview that they were becoming puzzled and I had suspected from my own research that this might be the explanation, so I asked ‘do you think I might have BPD?’ And he said that was the next place he was going. I was referred on to a centre that specializes in the program and is doing a study comparing DBT and conversational model. That assessment came up with mild BPD.
      2) I started with an individual therapist and prepared me for group therapy who supplied the workbook. 12 months of group and I’m still seeing my individual.
      3) my advice would be to be validating. That the behaviors makes sense but at the same time trying to get them to come up with why change would be preferable for them. It’s such a dance the approach in treating BPD. It needs to be multi pronged. Working on skills, core issues, and self worth to find the place of stability and motivation. Why change when you have a sense of hopelessness? Why stop self harm when you believe you deserve it? Once you have a good idea of the issues it will probably become more clear how to draw on the art of therapy. I a perfectionist (as is my therapist) so we tend to focus on change all the time. At the moment it’s not very effective and she is being quite hard where I need a little gentleness. Gentleness and firmness are both required. I would suggest using DBT in your own life for a while. Looking at life in a dialectical way and You would be using the skills anyway but putting yourself in the experience would create a depth of understanding and ultimately be helpful treating BPD.
      4) during DBT our sessions had definite structure they had to follow. I filled out a diary Card daily on my smartphone through an app which is brilliant, and emailed it to her once week. I would never have complied with paper. https://itunes.apple.com/au/app/dbt-diary-card-skills-coach/id479013889?mt=8
      The session followed 1) self harm and suicidal behaviors. 2) therapy interfering behaviors 3) I can’t remember the terms but it was about general life well being. This is where my therapy lives now and 4) sorry I can’t remember this either!
      Now my sessions are more about what I want to talk about and can vent and we use DBT Skills to problem solve. The motivation to get to these issues was that we had to get past the first 2 interventions. Of course if the issues were related and needed talking about to get past the self harm then we would talk about it as much as needed for her to work out the intervention. But I remember several times her writing on the whiteboard the structure and where were at and we will get further down the list when the self harm dropped. Because if there was self harm during the week we would start with a chain analysis to work out why and where to use skills next time.
      Hope this helps. good luck. Remember this is difficult to treat and your client is in pain. I admire your care and passion for therapy and I’m sure your journey will be a successful one. Xo

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