“Crisis” is the term used in DBT, but some people find themselves struggling to identify if they are actually in “crisis” or not. Here is a way to break it down and consider the value of using this set of skills. They are actually helpful to anyone who has ever struggled with painful or difficult life situations.
Category: Distress Tolerance
How To Survive Painful Life Situations
- Accept that pain will come your way. The more you pretend that pain is not there, the worse it will get.
- Write down a scenario in which you imagine coping well.
- Let go of what you can not control. Stop doing what you can not do.
- Rehearse acting according to your values and believing you did the best you could despite the circumstances.
- Don’t avoid doing things that are a little bit hard just because you are suffering; approach tasks that give you a sense of accomplishment.
- Increase your connections with other people. Pain allows us to be vulnerable, soften our stance, and let others in. Bearing pain is easier when we are not alone.
- Find people in your life and express appreciation to them openly.
- Are your actions effective? Do what is needed to get through the situation. Don’t do something that will make it worse.
- Assume that you are not the only one who is suffering.
- Contribute, help out, help others solve their problems; find ways to make other people’s lives easier.
- Do one thing to nourish your body and your soul.
- Write yourself a compassionate letter in which you acknowledge the pain and difficulties you are facing.
- Find one thing someone else can do to lighten your load and see if they would be willing to do it.
- Find three things a day that you are grateful for and share them with someone else.
- Stop comparing, judging, or evaluating your emotions.
What It Means To Be Sad
Sadness is one of those ordinary, human, connecting, important emotions. Lately I’ve been reflecting on how sadness is expressed in families, what is communicated about sadness, and what happens when people can’t acknowledge sadness.
Sadness is related to loss, and every person at some point in their life goes through loss when change occurs. Graduating from school, having a baby, getting married, moving, and getting a new job are all examples of changes that could generate sadness. Even when better things might be coming along, there is generally a loss of familiarity, old routine, social environment, and schedule. The loss of predictability takes up energy and attention that can be unsettling and even overwhelming.
In many families and cultures sadness is considered something that is problematic, and is often talked about with disdain, contempt, or pity. Sadness has been equated with being pathetic, not having a backbone, being weak, or being worthy of ridicule. When is the last time you used the word sadness in your vocabulary, and how did you use it? Was sadness used in a way that enhanced a connection with another person, or was it a disguise or judgement about how another person should express themselves? Do you get embarrassed when others cry or express sadness? Do you try to shut down their feelings, fix the problem, or ignore the emotion? Or was your verbalizing sadness an open invitation for a person to share openly, feel deeply, express themselves better, or to be understood?
The lack of acknowledgement of sadness can result in disconnect, alienation, confusing about one’s emotions or feelings, or even anger. Expressing or experiencing distress related to loss is an expression of vulnerability; a need to band together with the people we care about, a way to bring community together. Ridiculing, berating, or scapegoating people because they struggle with grief only makes it worse.
Grief is one of those things that has its own timetable, and can show up at unexpected times. There is no right way to go about it, and everyone has their own process to work through. I can’t tell you how many people I talk to each week that are fearful of showing or expressing emotion in public, and avoid being in public because they might become anxious or upset. It seems unfortunate to me that so much of our culture is shaming those that express or identify sadness. So many people think that no one else feels the way they feel, and this often inhibits expression or discussion of what people are missing the most. People frequently start apologizing to me for crying, and some have suggested that if they cry they deserve be locked up in a psychiatric hospital or “the looney bin.” Others inform me they spend a great deal of energy suppressing, inhibiting, ignoring, or distracting themselves from how they feel.
In some cases, sadness can take up residence in a person’s life and become depression. The open expression of sadness is generally one of connection and deep support, whereas the behaviors of depression can reduce connection with others; such as irritability, low frustration tolerance, complaining, expressions of hopelessness, or threats to give up.
A normative expression of sadness is generally moving, touching, and connecting. Consider what movies or music you may have seen or heard that have moved you deeply, and if sadness was part of that process. Consider what brings about sadness in your life, and how/ in what ways are you able to share it? What losses have you endured or gone through? In what ways have you been inhibited from expressing or sharing the pain of what happened? In what ways can you honor or acknowledge your own sadness; even if no one else can do it for you?
What are Dialectics and Dialectical Behavioral Therapy Skills?
What is Dialectics?
Dialectics is based on the idea that two opposing concepts can both be equally true. One truth does not trump or rule out another, which undercuts the dichotomy of a “I am right you are wrong” type of relationship. A common dialectic is that you are perfect as you are (acceptance), and that in order for things to turn out differently in your life, you need to do things differently (change). One is not more true than the other, and one truth does not rule out the other truth. Sometimes people need acceptance, and sometimes people need to be challenged. Both belonging and growth are an inherent part of being in relationship.
Dialectics challenges the idea that one person is always “right”, because when you take into account diversity of perspective, other truths often arise. Being “right” often fails to take into account effective communication and the value of the relationship. Experience and emotions get ignored. A set agenda of being “right” often gets people stuck in a very rigid, dichotomous, black and white, non-dialectical stance. Dialectics are important in that sometimes you can find the one thing you have in common with your enemy instead of focusing in ways you are different. Relationships exist in context of conflicting truths, yet relationships are the glue that carries us through life.
What are the four Dialectical Behavior Therapy Skills?
DBT is a complex treatment that has confusing origins in terms of how it was developed and who it was for, and has been tailored to a wide range of populations and settings. The DBT skills are universally applicable materials that help people with extreme and painful emotions, intolerable life situations, and relationships. The four skills sets are as follows:
Core Mindfulness: Mindfulness is a skill that helps people focus attention, regulate arousal, calm the brain, quiet the mind, and settle in. Being mindful is a way to steady and anchor oneself in order to observe quietly and not “react” to what is going on. It is inherent in all of the other skills in that it requires a steady, quiet, secure stance in the face of demanding life situations. It takes spaciousness to know what is going in with your body, your self-experience, your wants and desires, and your life. If you don’t pause the moment and check in with yourself, it is easier to get “caught up” in the banging and thrashing of what life throws in your direction. Mindfulness can be a spiritual practice of quiet contemplation, a way to press the pause button, and way to regroup. Core mindfulness skills taught from the DBT material include skills of observing and describing without judgement. Other traditions, spiritual practices, health care services, and therapies teach mindfulness, so it is not “new” nor is it confined to just DBT skills; its roots are actually in Zen Buddhism. There are multiple ways of accessing mindfulness including mindfulness based programs, meditation groups, trainings, and apps. DBT groups are known for implementing a mindful practice or exercise in every group, and like many spiritual traditions are simply considered part of a daily practice.
Emotion Regulation: This is a set of skills that helps people to observe and describe what they feel (you can see the overlap with mindfulness) in order to help regulate arousal, understand what they feel, and know the reasons why they feel the way they feel. Skills cover ways to reduce emotional suffering through mindfulness and opposite action, and ways to reduce vulnerability to emotional suffering. Skills are quite complex and take practice, feedback, and validation. Since emotions can be tricky, elusive, (and just plain unbearable at times) the emotion regulation content is not something you could “quick learn” and be done with it. Sometimes people are not always aware of how or what they feel in general, and there is nothing pathological about this. It is a process! Knowing oneself and knowing one’s emotions is a lifelong task not subjected to any particular type of disorder, and does not end just because you have had a first exposure to all of the skill content. That is why working together on ways to regulate arousal given varying life circumstances can best be done over time in small group settings that promote cohesion and intimacy.
Distress Tolerance: In order to regulate emotional arousal, finding ways to endure the “I-can’t-stand-it-itis” of painful and extreme emotions is critical. Surviving painful life circumstances well means doing so in a way where people do not lose self-respect, forget their values, give up what is important to them, or react in such a way that makes things worse. Sitting in the fire and not reacting is often harder than picking a fight, poking the fire, making others suffer in order to prove a point, exacerbating pain to let others know how bad things are, undermining a person where it hurts, forcing the university to prove its point, perseverating on being “right”, asking “why me”, or engaging in self-defeating or relationship destroying behaviors. Being willing to tolerate the unknown, be zen with the universe, stop fighting reality, and do what works is skillful practice. We all want things to do our way or to turn out for the best. In reality, a lot of people are suffering a great deal and need everything they can to survive well. Distress tolerance skills encompass not only change strategies (if you can do one thing make it better, why wouldn’t you?), but acceptance and willingness skills. Anyone who has successfully undergone any type of exposure treatment for anxiety knows that the benefit to tolerating anxiety is a decrease in overall anxiety. There is an inherent truth that reality is easier to face once you stop fighting it, thus freeing you up to do what is needed to effectively solve problems.
Interpersonal effectiveness: True to the concept of the dialectical philosophy of DBT, it is better to be effective than it is to be right. The interpersonal skill content encourages readers to identify objectives in situations (what exactly it is you want or don’t want), how the relationship may be impacted, and if self-respect is at stake. Balancing the three helps people to look at natural barriers and consequences of interacting, and enables readers to problem solve the cost/ benefit of ignoring each. For instance, you can ask for what you want at the expense of the relationship, or you can give into a relationship but sacrifice self-respect. The balancing act of relationships is an ongoing challenge for everyone, and some give and take is part of how people stick together, find intimacy, and keep people close. Interpersonal skills also include ways to get out of or decrease contact with toxic or unwanted relationships, set limits, say no, and to identify barriers to doing so. Direct rehearsal in terms of “what to say and how to say it” benefits group members in that they can try out and receive feedback in both verbal and non-verbal forms.
A book of all the DBT skills is available for purchase via this link: https://tinyurl.com/y2qad6sk
Here is a short video of me on YouTube with an overview of the skills: What Are the DBT Skills? DBT Skills with DrReneeHoekstra
What to do in a mental health crisis: What are your options?
The following options are adapted from Marsha Linehan’s DBT Skills Training Handouts and Worksheets (see link under books I recommend on my website) page 10.
Solve the problem if now is a good time to solve it. Most people who avoid solving their problems end up avoiding their problems. When people avoid problems, problems tend to build up or become even worse. It is not a good feeling to know you are avoiding a problem, and solving problems is a practical and understandable path towards reducing distress. Skill building, practice, rehearsal, obtaining feedback, breaking things down into steps, evaluating the effectiveness of the steps, and challenging yourself slightly are all ways to approach problems. Emotional problems generally get us to take action or are telling us to do something about it. Consider this statement: Everything is as it should be unless or until something is done to fix or change it. In other words, don’t sit on your hands if you have some responsibly to speak up or do something about it.
If now is NOT a good time to solve it, don’t make it worse. Now may not be a good time to solve it because extreme emotions get in the way or extreme emotions make your attempts at problem solving ineffective. In this case you may need to work on regulating your moods, which can entail identifying your feelings, figuring out what the threat is or the trigger that sets you off, looking at how you interpret the incident, and coming up with a more adaptive means of interpreting and responding to the event. As Lori Gottlieb reminds us in her recent book, Maybe You Should Talk To Someone. And (of course), skills from the Dialectical Behavioral Therapy Handouts and Homework worksheets could be of assistance.
If you could do one tiny thing to make the current situation better, what might it be? Sometimes treating yourself or someone else with kindness, gently avoiding the situation for the time being, doing something to shift gears (self-soothing, exercising, activities, engaging your brain or body differently, or focusing on something or someone else for a while) can make you feel better. People who can’t do anything about a painful life situation generally want to ease their experience. Finding compassion for oneself generally generates an easier time of things, rather than critical self-blame or self-defeating behaviors.
Focusing on accepting and/ or tolerating what you can’t control. Resisting reality, throwing up one’s arms in defeat, doing something to make the situation worse, or staying miserable when there is something you could do to feel better about the situation generally don’t get people unstuck. Acceptance is a hard task and does not necessarily mean approval or passivity. It just means a willingness to bear with the uncertainty or difficulty of what you’re going through.
Is Your Anxiety The problem? Why Getting Rid Of Your Anxiety Isn’t The Answer:
When people start to have anxiety problems they usually believe that anxiety itself is a problem. When anxiety becomes the focus of attention people overlook the actual fear or fears that create anxiety in the first place. The problem with this is that it often fails to activate problem solving, because the anxiety creates distractions from addressing the actual situation that is being avoided. People can successfully avoid treatment for panic by focusing on being anxious about being anxious, which ironically tends to generate more panic and amplify the belief that anxiety is indeed the problem. In some circumstances, because people have tried to get rid of their anxiety unsuccessfully, they believe that nothing can be done for their anxiety. Sometimes people get angry when anxiety treatments are presented as options, because they don’t want to be invalidated for their efforts to get rid of anxiety.
People have anxiety about all sorts of things: Losing people they love, sickness or illness, death; threats of losing power, status, money; being in situations that threaten physical integrity or safety, being humiliated or shamed in public, being verbally attacked, being fired, or loss. In a given situation coping well with these situations means incorporating some degree of acceptance, acknowledgement, and sadness. It also might activate problem solving, fixing, or making changes to prevent these things from happening in the future. This is what normal people do in normal situations, and creates understandable, realistic, and adaptive ways of coping. Community supports, problem solving, religious institutions, family, and other means of coming together helps people to naturally solve painful life circumstances and problems.
People that have a lot of problems with anxiety generally tend to have problems identifying and responding to the actual thing that makes them anxious. If you are afraid of having conflict, and then you tend to avoid people when conflict is present, and then you have anxiety because you have conflict, and then you blame your anxiety, and then you try to get treatment for your anxiety, you can create ways to avoid addressing the actual problem. For example, treating anxiety with relaxation techniques without actually looking at what it is about the conflict, exactly, that is making you so anxious evades problem solving. When “the problem” becomes “the anxiety” most people’s solutions are to get rid of how they feel, not to figure out how to deal with conflict. If you could figure out how to respond to conflict adaptively, chances are your anxiety will naturally go down.
You can’t address emotional problems by failing to identify the thing that evokes the emotion in the first place. Here are some brief questions to help you figure out your anxiety:
What is it about this situation that you are actually afraid of? What is the actual threat?
What is the realistic likelihood of this actually happening?
If you had to approach what you are afraid of, what uncomfortable sensations, emotions, or experiences would you have to be willing to tolerate?
If what you are afraid of is actually happening, how would you approach this situation effectively?
What is one adaptive, problem solving step that you could take?
What can you do to validate the pain or difficulty of this situation to yourself?
Tolerating Uncertainty in Uncertain Times: Values, Anxiety, And Willingness In The Era Of The Coronavirus
In this pandemic, many people’s lives have been disrupted in ways they never imagined. People are struggling with losses, lack of structure, difficulty with motivation, changes in schedule, computer fatigue, lack of ability to control things, feeling restricted and limited in what they can do, and being told what to do by governmental authorities. Anxiety prevails when times are uncertain, time frames are not set, and no one knows what it will mean for “things to go back to normal.” People usually cope better when they have a clear answer as to when the stress and restrictions will end; as they can predict and control how long they will have to tolerate what may not feel tolerable. The not knowing is the challenge.
Sitting with uncertainty is often a major part of adaptive coping. Often when people feel out of control they behave in ways that produce an illusion of having more control, including trying to be more controlling themselves. Anxiety behavior tends to be restricting, rigid, and inflexible. Some pick fights with people they love. Some try to micro-manage the people around them. Some yell, lash out, or escalate. Some people withdraw, sleep, or restrict their interactions with others. Some stop reaching out to friends or people they love. Some avoid getting things done or move forward. Some drink alcohol or use marijuana in excess. Others cope by antagonism or rebellion, externalizing blame to authority figures who can’t make this end, either.
In an era of a pandemic, there is no immediate quick fix. No one knows what will happen, who will contract the virus, and who will be taken by the virus. No one can cheat death. Here are some things to keep in mind in the era of uncertainty:
-Anxiety behaviors are not a way to obtain certainty. People often have their own “personal fix” of what they do when they are stressed. Some of this has some sense of normalcy and is not harmful, such as sleeping a bit more or eating more chocolate. However, some anxiety behaviors have hurtful outcomes. What is your anxiety behavior when stressed, and does it actually control the outcome of when the pandemic will “end”?
-Be willing to accept the discomfort of uncertainty. In the face of uncertainty, people have found ways to cope well. Find the ways in which people are coping well and see what you can do to manage stress and anxiety without making it worse. Reach out and ask what other people are doing with boredom, fatigue, work-life changes, and other related stressors. Find the news, heroes, and people who have survived great life challenges well. Once you accept what you can not control, your anxiety may not disappear but it will go down. Trying to control what you can not control makes it worse.
-Keep in mind your values. What is important to and who is important to you and why? What does this tell you about your spiritual values, who/ what to trust, and who you rely on when you are having a hard time? A willingness to yield control often means finding more trust in community. People are rediscovering lost values as limits are being placed on them, and finding new ways and means of connecting to family and loved ones. Keep asking and looking people for the silver lining, the unseen benefit, or the ways that people are enhancing their sense of connection.
-Do your part. If you have something to offer at this time, consider the benefit or value of what you can do for others. Often contributing is a way to distract from our own anxiety and involves universal benefit. Donate to a food drive, reach out to neighbors, do errands for someone who is quarantined, pick up trash in a nearby park or bike path, give blood, make masks, cook or bake for family members, repair something that is broken, join a neighborhood volunteer task force, or start online Zoom socials.
Why Your Psych Meds Aren’t Working- A Bitter Pill To Swallow?
Psychiatric meds actually do work, and they very well may be working. Psychiatric medications have helped numerous people with many different things, including nightmares, anxiety, symptoms of bulimia, public speaking, mood regulation, paranoid thoughts, and depression.
However, there is one thing that medications will never do, and that is get rid of emotions. Emotions are hard wired, biologically adaptive responses to situations that help people survive. They give people important information about threatening situations and painful circumstances. The allow people to know what matters, what to hold close, what to pursue, what risks to take, and what to avoid. Without emotions we would not have important information about ourselves, our circumstances, our environment, and other people.
People have tried numerous and unsuccessful things to get rid of emotions. This might include drinking, drug use, numbing out, hurting oneself, picking fights, avoiding, sleeping, dominating a conversation, being coercive, smoking marijuana, or being violent. The simple truth is, emotions can’t be eliminated. If they are temporarily eliminated, they come back.
Some people don’t like their emotions because their emotions show up when other people tell them what to do, how to think, how to feel, or how to react. Thus they minimize or inhibit their emotions in these situations because they are trying super hard to fit in, avoid conflict, live up to someone’s standards, please a parent, or survive in their environment. However, this can lead to a very unhappy life and can be very painful.
Sometimes people are very sensitive to emotions, thus they tend to have strong reactions to things that may, to others, not seem like that big of a deal. While this can lead to bigger, out-of-control emotional problems, it is also important to learn how to discern when a threat is actually a threat, vs. when a person develops a fear or phobia about something that is not a threat.
Emotions are often related to eccentric, atypical, or problematic behavior. If you have a behavior that you are trying to stop doing, just consider if not doing that behavior brings up any discomfort, anxiety, or restlessness for you. Asking people to stop doing behaviors such as self-harm, drinking, escalating an argument, threatening suicide, doing a behavior excessively or repetitively, or picking a fight is quite hard. The benefits if these behaviors can sometimes include getting a point across, expressing an emotion, getting taken seriously, reducing anxiety, or getting another to be validating or affirming. Sometimes significant others don’t react at all until another person escalates or flips out, which makes the problem behavior even harder to stop. (After all, it worked!).
If you think your psych meds aren’t working it may be worth asking yourself: What feelings do you have that are intolerable? What do you think your feelings might be telling you? What feelings do you try to ignore? What feelings are trying to get your attention? How willing are you to bear with some of the discomfort of what is going on for you? If you honored your feelings and what they were telling you, what sort of action would you take?
Understanding, naming, managing, and controlling moods are a lot of work. Thankfully, there is are services available that are focused on doing just that- and aren’t focused on dosages or prescriptions. While meds do wonders for people- they are not, thank goodness, the only way of helping a person solve emotional problems. In fact, the entire basis of the group services that I provide help people with all of this- managing mood, understanding emotions, listening to one’s wisdom, and taking necessary steps to tolerate feelings better. Getting rid of what you feel is just not an effective long term strategy for solving emotional problems.
“There Is No Good Reason To Feel The Way I Feel”
Is this something you find yourself saying? This is something people frequently tell me. Unfortunately a lot of people think this is true. When people think it is true, they often stop trying to figure out the significance of how emotions show up in their life. People will say their emotions come out of the blue, show up for no reason, don’t make any sense, and even create problems in their lives that they wish they didn’t have to deal with.
I actually don’t think that people have no good reasons for feeling they way they feel. In fact, I think reasons are there, but people are often not aware of them. My belief is that emotions show up for a reason, and are important and critical to our existence. However, because emotions can be nebulous, hard to pinpoint, and often elusive; they are sometimes hard to understand and even identify.
All emotions have certain functions. Functions work to serve a purpose or accomplish a task. Functions of emotions include communication, validation, or action. The emotion of sadness, for instance, is an invitation to figure out what is important, grieve losses, search for what is missing, or acknowledge how important something was in our life. Without sadness we would not know what matters, who we love, or what is missing. Sadness gives us important information about all of these things.
Primary emotions are emotions that we have about certain situations, persons, or events in our lives. They are what shows up when stuff happens. They provide valuable information that, if ignored, can create even more problems. Secondary emotions when people have emotions about emotions. For instance, if you feel angry that you are sad, ashamed that you are distressed, or embarrassed that something angers you, you are experiencing a secondary emotion. Secondary emotions generally cause more problems for people because they are ways to judge (or not accept) a primary emotion. When we work really hard to inhibit, hide, minimize, or judge what we feel in the first place, we can create even more problems for ourselves. Sometimes people focus on secondary emotions as a way to avoid focusing on primary emotions. (“If I talk about how angry I am, you won’t really get how much I am hurting.”)
The key point is that people who learn to accept and even value their primary emotions generally have less distress than those who go out of their way to inhibit, hide, or suppress what they feel. If we treat our emotions as useful and valuable means to provide information about ourselves and our environment, the task of addressing emotional pain will be easier. Getting rid of emotional pain because it is uncomfortable doesn’t teach us to be open, present, and accepting of our emotions. While this may seem counter-intuitive, having less shame about how we feel helps us solve the problems of life a bit more easier. (“I am upset because something happened” vs. “Because I am upset I am ashamed, then angry at myself for being ashamed, then guilty for snapping at people because I was angry, then humiliated for how I handled this. Because I have no good reason to be upset.”)
Here are some tips to help you work on your emotions:
- Treat your emotions as useful
- Approach how you feel with curiosity, not judgment
- Assume your emotions are trying to give you important information
- Be willing to experience the intensity and painfulness of emotions
- Observe any action urges that come along with emotions
- Pay attention to how you feel about things more closely
- Be aware that low levels of distress is still stress, and that minimizing it can sometimes result in a blow up later on
Depressed? Anxious? Here’s What You Can Gain and Obtain
Most people who have more than their fair share of depression and anxiety are often seeking ways to decrease depressive and anxiety symptoms. In other words, they want to not be depressed and not have significant anxiety. If the symptoms are extreme or significant the person may start to avoid a lot of things, such as getting out of bed and going to places to that prompt panic attacks. Lifestyles can become restricted and the person may stop going to events or venues where they have the feelings they don’t want. Medications might be pursued, evaluated, and re-evaluated to see if they “work” or they “don’t work”.
If you are a depressed or anxious person, it might be worth considering what it is that you want more of, you would like to have, or what you value in your life. Instead of thinking what do I want to avoid start thinking about what you want to have more of in your life. What is it that would make your life more fulfilling, more engaging, more interesting, more desirable, or more alive? What is actually important to you? Sometimes people are so focused on what they are trying to get rid of they stop pursuing what they want.
Figuring out what you want more of ties in to your values, your energy, and your time. Are you sacrificing what is important to you because you are avoiding negative feelings? Have you stopped seeking activities that give you pleasure, fulfillment, obligation, a sense of contribution, or the opportunity to enhance an important relationship? If depression and anxiety interfere, this is a good time to evaluate what you might have to tolerate to go after more of what you want.
Sometimes, if people have more of what they want, their buffer against depression and anxiety can be tolerated more naturally. Some people get panic attacks at work, but because their job is important to them, they find a way to bear with them. Sometimes people get depressed when important things are lost, but because they have other important and meaningful activities in their life, the depression is bearable.
People who have fulfilled lives often have a wide range of things that give them pleasure, provide a sense of work/ mastery, invest in important relationships, and find new relationships when important ones end. Diversity and stability of the good things can help people shore up more resources when things go south and important jobs and relationships end.