Distraction. ACCEPTS, Distress Tolerance

Everyone loves progression right? Well I know I do in any case. Today in group we finally moved onto the next module: DISTRESS TOERANCE. Again, this is a nice inoffensive, non triggering topic. This time round anyway. Last time I found it hard to accept that these skills won’t solve all my problems straight away, as in right now! But rather they are designed to help you to bear pain skilfully without making the situation any worse. (Marsha Linehan 1993)

This set of skills is for when in the throes of an emotional crisis. When the problem can’t be solved, or if it can, maybe it is simply not the right time to solve it in that moment. It may not be the right environment to try to solve the problem either; for example, I am not skilled enough yet to stay emotionally regulated around my family during disagreements, so for now, using the DISTRESS TOLERANCE skills is the best solution for me. When I am in a food crisis, where I am trying really hard not to binge or purge, then being at home or around food is most defiantly the worst environment to be in, so some skills might not be as effective. And parallel to that, sometimes I can’t get away from situations involving food; this is when I find DISTRESS TOLERANCE skills really help. I like to think that my cue to use the distress tolerance is when I reach my complex skill breakdown point. It is also a way for me to find wise mind and calm the moment so I can try a solution focused skill like OPPOSITE ACTION, because it’s really important to not spend all my time self soothing or distracting! I would never get anything done!

What I picked up from today’s group is that PREPERATION is the key for these skills to REALLY work, and to allow myself to gain maximum benefit from them. We are always being told to practise the skills in less emotionally intensive situations so as we are familiar with them when we really need them when deregulated. So that is the aim of this post. To put together a list of distraction ideas based on the skill WISE MIND ACCEPTS.

DISTRACTION for CRISES SURVIAL is not the same as ‘zoning off’ when a problem CAN be solved, like staying in bed watching Disney films and avoiding the real world for days on end. That will just make it worse! WISE MIND ACCEPTS is for when you have to tolerate the situation in a way that is not harmful to yourself or others.

WISE MIND ACCEPTS stands for:

A – Activities

C – Contributing

C – Comparisons

E – Emotions

P – Push Away

S – Sensations

These are some of my own ideas; things which I know will help me during a crisis. Again, it is a work in progress and as always I would love to hear all your suggestions.

Activities Throw self into the moment.

·         Reading books – Silly novels, short stories about unimportant topics, Sci-Fi, Harry Potter. NO non-fiction. Magazines, trashy or glossy! Read recovery Blogs, Karyn Hall, Audio Books

·         Exercise - Get active, something intensive which demands focus and attention. Zumba class, Yoga.

·         Hobbies – Music, learn a new song on the guitar. Art and crafts. Writing, blogging. 

·         Mental activities – Memrise.com. Word games, scrabble on phone, Memorize a poem or prayer. Write a poem or short story.

·         Cleaning – Bedroom, Kitchen, Bathroom, Make-up, Wardrobe, Cooking, Washing

·         Events – Go see a movie, a play, a show, a lecture. The Silent Room, Meditation class. Google entertainment.ie, Hospital lectures.

·         Friends – Meet up, text, call, chat, email….. But DO NOT talk about crisis.
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Contributing - Focus on something/someone other than yourself.

·         Volunteer time, Hospital, Church,

·         Do something nice for another person. Bake, cook, send letter/card

·         Surprise someone, pay for coffee, buy something

·         Send nice text, Email, facebook

·          Smile at shop assistant, people on the street.

·         Give money to charity, buy food for homeless person

·         Visit Nana, Granny, Someone who is sick

·         Say prayers for the well – being of others

Comparison – Remember, it could always be worse

·         Compare myself to myself this time last year, a few months ago, even a few weeks ago!

·         Compare myself to others in my situations who are coping worse than me.

·         Compare myself to the rest of my family who have the same condition who are not accepting and coping with the disorder.

·         Be thankful for what I have

Emotions – Create opposite emotions to the one you are experiencing.

·         Music – create ‘happy’ playlist, ‘upbeat’ playlist, ‘relaxing’ playlist

·         Movies – Disney, Comedies, Period Dramas, Scary films

·         Comedy show

·         Read romantic books, thrillers

·         Read inspirational stories or poems

Push Away – Allow yourself a break from the emotion/thought

·         Mentally leave the situation, go to another ‘room’ in your mind

·         Give it to God box

·         Do a guided visualisation on Youtube

Thoughts – Focus mind on thoughts, Take a mental ‘Time-Out’

·         Count to ten

·         Count your breath

·         Visualise STOP! Sign

·         Look around, observe the things around you, and name them.

·         Say the same thing over and over in your mind. Breathe in WISE breathe out MIND. Over and over

Sensations – Interrupt physiological action urges with something intense which will not harm

·         Have a very hot or cold shower. Alternate between the two

·         Hold ice, eat frozen fruit

·         Go swimming, use the steam room

·         Suck on a lemon/lime

·         Snap a rubber band on your wrist

I cannot stress the importance of being prepared ahead of a crisis, and also it’s so important to find what works for you. It took me a really long time to figure out that these things work for me.

The Raging River of Emotion

My intricate network of defective nerves carrying the equally faulty transmitters must have decided to jolt its self back into action today. I sat for a while in the chilly spring sunshine before my weekly ‘me-time’. It really is such a delight to have a whole hour where I can simply talk about me, and I know that my therapist will give me her full, exclusive attention. That sounds conceited, I know, but I don’t care. I have spent too long neglecting my own turbulent mind.  I thought about how privileged I really am while I sat on an ugly and uncomfortable plastic bench outside the treatment centre. ‘I have someone who gives me time to talk and helps me to become a better person; I have a confidant, a sounding board.’ Then it struck me; ‘I have never given myself so freely and truthfully to anyone before and I have never felt such empathy from another human being in my life.’ It feels peculiar, both excellent and shocking at the same time, for I feel extraordinarily exposed and vulnerable having another person on this earth know my secrets, yet relieved that I don’t have to bear the weight of them alone anymore.

We have an idiosyncratic relationship, in so far as I would never choose to disclose such prized and feared confidences to this woman if I knew her casually. To be honest I don’t know if before DBT I would have been able to tolerate her mannerisms. She is quirky and a bit disorganized. Actually she reminds me of my mother; extremely caring yet frustratingly scatty. I got the feeling that I also annoyed her (but of course that could be BPD thinking!). She seemed to resent how little progress I was making despite how well read up I was on the DBT material.

Before we had even met last summer, I had read Marsha’s Training Manual, and shimmed her major body of work: Cognitive-Behavioral Treatment of Borderline Personality Disorder. 1993. I am an intelligent woman when I want to be, and I like to be primed and set to tackle a problem when I feel able. I am always able to read. So for the year between getting my diagnosis and accessing the right treatment to treat it, I read everything I could get my arduous little eyes on. I spent hours scouring the internet for reliable sources of information and weaving together the best comprehension I could grasp outside of a Clinical Psychology Doctorate. Luckily I still had my University student library admittance which afforded me full access online to both the British and American Medical Journals. I also had a good grounding in mental health from my years studying Occupational Therapy.

Now all that stood before me was to somehow turn my culvert of knowledge into tangible skills. And annoyingly, I couldn’t do it alone. She was the bridge I needed (but didn’t want to have to rely on) to pass over the violent river safely. Battling the raging currents of emotion alone was not working anymore, but I couldn’t see that. I fought for weeks not only against my emotions, but against this woman who said she knew a better way across and wanted to help me get there. I didn’t believe her. She couldn’t understand my internal conflict, no-one could.

At first I thought she came across patronizing, one of the many things which annoy me about her. Yet, as the weeks wore on, I realized she was merely reciting little Marsha-isims. “How can you create a life worth living, if you are not willing to participate in the therapy?” And every time I would be self critical or chastise myself for my transgressions, she would pipe up and bluntly cut across me; “That’s a judgment!!!” So for a while I stopped talking, I stopped telling her anything and I continued down my white watered river of destruction!

Now that I am a few months down the watercourse, the rapids are less frequent and some tributaries of support have joined my journey towards the sea of recovery. The emotions are still there as is the water in the river, but I have more energy to swim back and survey the journey as the intensity of the emotions have subsided and the volume of support has grown.

Even though we still don’t always see eye to eye, I am now at peace with my therapist and the service as a whole. I can see how far I have come, and how far I still have to go, but like the river, it only really flows in one direction… towards the sea. I guess my route has simply taken a small meander along that path. 

WILLINGNESS to get over this bump and OPPOSITE ACTION TO ENVY

Although I would like to think I am calm, rational and a judicious person when it comes to taking an objective standpoint about transgressions in my own life, simply put, these skills is severely lacking from my toolbox. I find it very hard to push aside the judgements which paralyse me and turn my thoughts into narrow, dichotomous lines which only have two end points.

As I mentioned in the last few posts, my emotions have been amplified to way out of manageable levels this past week.  All this lead to me equating many of these emotions as facts; hence I felt had to act on the emotion. The feelings almost felt like they have a mind of their own, and that I was a vessel for them to carry out their action urges. At the time I felt I had no control, but I am not trying to evade responsibility for how I treated my therapist, as I know I could have been more skilful. I could have used OPPOSITE action to my anger, or even HALF SMILE. In reflection, I see that it could have been a perfect week to also practise DISSTRESS TOLERANCE and RADICAL ACCEPTANCE.

Yesterday morning I received a letter stating that a course I had been waiting to get onto for many months had been cancelled due to lack of funding. When I first saw the letter I was super excited, as I thought it was a start date. I had been advised to hold off going to university by my team for another year until I finished DBT and instead attend this collage as it operates under recovery ethics. It seemed a perfect transitory step for me. I decided to do something creative and less academic, so picked a photography course. I really was looking forward to it. 

Now I am so disappointed that my heart literally hurts. I am so afraid; I feel I have nothing really left to look forward to now.

I went to check in with the community nurse a few hours after getting this terrible news. And I am really so very grateful and abashed to admit that he was not the invalidating type I was expecting. In truth, he sat with me for about 45 mins and listened intently to what I had to say. We came up with a plan in order to help problem solve the solution, and jointly agreed that the best outcome would be for me to attend a crisis resolution based therapy group for 8 – 10 days. It came with a warning that I would have to be willing to work at finding solutions to my problems and not to abandon self responsibility. It seems fair, if like a lot of hard work, but I am up for the challenge. I really am so appreciative for how great that nurse was. I really needed his objectivity in that moment. 

I felt calmer and more in control after the meeting, and was much more willing to stay with my family for the night, I tried not to see it as a suicide watch, but as an opportunity to spend quality time with them. I went to see my sister and her husband who are expecting a baby and are in full blown 'nesting' mode. They are buying my family home off my mother, and have done a beautiful job of renovating it and putting their own stamp on the house. I noticed that I had been avoiding seeing the house as I felt great envy towards my elder sister, who has such a perfect life and gets to have everything I want and more, and on top of that gets to have the house I grew up in, the only place I called home. I am afraid I might never fall pregnant again, so am also reluctant to talk to her about the baby and envious of her ability to carry a child. I (quite skilfully in my opinion) figured out that I was experiencing ENVY which really did not fit the facts of the situation

I put on my DBT SKILLS hat and tried to use OPPOSITE ACTION. I knew that the prompting event to the ENVY was that I was being reminded about all the things I really want but can't have. A stable home, a family, nice things.....

My HOT thoughts where:

• 'I will never have what my sister has'
• 'I am such a failure'
• My sister is more successful than I will ever be'
• 'I am inferior to my sister'
• 'My parents think she is the better sibling'
• 'life has treated my so unfairly

The biological changes and bodily experiences I felt with the envy was a slight pain in the pit of my stomach and I was extremely anxious and noticed I was feeling resentment towards my sister and her husband   I began to ruminate about how unfair I felt the situation was and how much of a failure I felt I was. My attention was very narrow and I could barely even talk to them. I OBSERVED how much I had avoided seeing my sister and the house, which had undergone so much renovation that I nearly didn't recognize it! I hadn't even offered to help with painting or decorating because I had been festering in my envy.

Although it is ok to feel envy when others have what you want, the problem here lies with the intensity of which I felt the emotion. I had checked the facts and become conscious that I had not been there to help my sister due to an out of control emotion.

I mindfully asked myself what my assumptions, belies and thoughts were about my sister buying the house and having a baby. I then tried to challenge the hot thoughts which popped up. Here is how I tried to turn the judgments into facts;

• ‘My sister is 7 years older than me, is married and in a good position to raise a child’
•   My sister and her husband have worked very hard to get everything they have and deserve it all
•    I also have many very wonderfully things. I live in a fantastic location and have so many beautiful things. Someday, with hard work, I will also have a house to live in, but for now, recover and health are my greatest assets.
• It is a very good solution to the present economic recession as my sister would not have been able to buy a house like this without help from the family
•   My sister’s children will get to grow up in the same wonderful house and we did
• I am not a failure because I am not the same as my sister, I have other attributes which make me a successful and competent person

My goal is to have a positive and functioning relationship with my sister and brother-in-law, I love them and love the bump too! So my anger and resentment to them was making me avoid them and not nurture and develop a healthy bond with them. That is the main reason that the envy needed to be challenged.

In the moment I made sure to count all my blessings and avoided exaggerating my deprivations, Marsha states that to go ALL THE WAY I must imagine that it makes sense for my sister to have all this, as she has worked hard and deserved it all.

Finally I changed my emotions by changing by behaviors and posture. I unclenched my hands and relaxed my stomach and used HALF SMILE.

I now feel my envy is more in proportion to the situation. I’m not going to lie, it’s still there, but now I feel motivated to work as hard as my sister so I can have what she has. That means I can’t just throw my hands up in the air and moan about how unfair life is, I have to get off my ass and go get it for myself!

I’m really sorry this is so long and thank you so much for taking the time to read this. 

 

Why do we need emotions anyway?

Before fully engaging in therapy, I honestly thought that if I could just 'turn off' my emotions, then all would be fine. This is seemingly a very common request with BPD sufferers according to my group facilitator. Greenberg and Paivio (1997) capture nicely the generally agreed upon functions of emotions, which are that they;

1. Prompt and organize us for action
1. Give us important information about whats going on in a given situation
2. Are for motivating
3. Are for communicating to others
4. Are fundamentally adaptive

So I now realize that my emotions are like a motion-detection or warning system telling me that something is happening that I should know about. Another important lesson I have resonantly grasped is that my emotions never last forever, even though some may last longer than others and I tend to be more sensitive than my peers to emotional stimuli. It also depends on my current level of skillfulness in handling emotion and other factors such as sleep, health, stress, and support.

As Marsha Linehan explains so wonderfully in her book; 

'Emotions are like tides of the ocean, they ebb and flow, they come and go; they're transitory.'

When I forget this simple piece of advise, I am more inclined to act impulsively when in the throws of an intense emotion. But when I can tell myself calmly in the heat of the moment 'This too will pass' I am so much more able to open up a variety of options and not feel so helpless.

When emotions do what they are supposed to do, they are called PRIMARY EMOTION. They are unlearned and fundamental to human functioning. When you hear a loud noise, you jump, you feel afraid. Its a perfectly normal response. They are helpful. 

The problem lies in what are called SECONDARY EMOTIONS. These are complicated, non adaptive patterns of emotions about emotion. You feel shame for jumping and feeling afraid at the loud noise. 

When I learned about the different levels of emotion, I felt relived. It all started to make sense. I had never understood why I felt such random emotions in reaction to a situation. My secondary emotions were very often generated and intensified by judgments I had about how I was supposed to feel rather than how I actually felt.

My 'Judgement' Counter

The best thing I did to help me OBSERVE the judgments which lead to SECONDARY EMOTION was to get a counter. I found one in my local knitting shop, and its actually a stitch/row counter. A tally counter can also be used. I carry it in my pocket and click it every time I realize I am having a judgement. I observed how critical I can be of myself when i catch my reflection and I noticed how cruel I am with my self talk.

Try it out for yourself. I bet you will be surprised at the results of you judgement monitoring.

Shameful Emotions

"Please not again!"

Today , being Tuesday, it was once again time for my weekly dose of skills training. I have grown to quite like our little routine of learning, and even though some of the other service users do my head in, I am finding myself more tolerant of their perceived annoyances. I am genuinely interested in how they are getting on with their skill use, even when the unrelenting crisis's overtake our sessions (which happens nearly every week!) I am overcome with empathy and understanding for them rather than intolerance and frustration. I like to take this as a sign of progression on my part, as I am not as wrapped up in my own internal suffering as I have been in the past. 

We are still on EMOTION REGULATION and have finished the first goal of UNDERSTANDING and NAMING EMOTIONS. We got given this massive set of notes on the topic of describing emotions and to be honest I didn't read it all, I've had much too much of a crap week for reading such patronizing handouts. I just flicked through it and stumbled across a very adequate-to-me section on SHAME. Its my primary emotion. My weakness. My downfall.

Shame is recognized as a powerful, painful and potentially dangerous emotion,- especially for those who don’t understand its origins or know how to manage it. Unlike guilt, which is the feeling of doing something wrong, shame is the feeling of being something wrong. When I experiences shame, I feel there is something basically wrong with me. I constantly compare some aspect of myself or behavior to a standard and nearly always feel like I do not live up to that standard. Guilt can be positive, it’s a response of psychologically healthy individuals who realize they have done something wrong. It helps them act more positively, more responsibly, often to correct what they've done. But shame is not productive, shame tends to direct individuals into destructive behaviors. When we focus on what we did wrong, we can correct it; but when we’re convinced that we are wrong as a result of shame, our whole sense of self is eroded.

Shame is the substructure for SELF-INVALIDATION I feel. It feeds the drive to 'pile misery on-top of misery' as Marsha would say! When I feel shame, I believe myself unlovable, that I do not live up to expectation, that I am a failure, unworthy of life. With these thoughts circulating around my head, it becomes a good deal easier to contemplate and justify the destructiveness of self harm. Yes I know I have not referred to my ED as self harm before, but in reality, it is, I need to stop telling myself otherwise.

I actively avoid intimacy with others and have only superficial relationships most of the time, which always deteriorate in times of stress. Isolation and loneliness are serious consequences of my shame. Self-condemning attitudes and negative self-talk reinforce the shame and ultimately lead to self-loathing and self-sabotaging ED behavior.

So much goes into expelling the energy of SHAME. The expressions and actions of my shame control my life most days. It could be hiding the after shocks of a binge, or avoiding others, terrified they know about my Bulimia. I often find myself avoiding myself too, switching off, dissociating from my shame, ignoring my emotion.. This shutting down effects me greatly. I spend hours sitting in front of a screen, looking at moving pictures but not taking anything in, lying for hours, not washing, not eating, not peeing, just fighting to push away the shame. 

It upset me to realize this SHAME hold so much power over me. But some glimmer of hope was illuminated during the teaching part of today session when we learned about challenging negative thoughts with the basic CBT model and also the DBT skill of OPPOSITE ACTION.

The idea of exposing myself to the horrible feeling of shame scares me to my core. But the main thing I must remember is that OPPOSITE ACTION is only for when the emotion does not fit the fact. So my challenge this week is to figure out a transgression for which I feel I could practice this skill, engage in behavior which sets off shame over and over. I must also go ALL THE WAY by not apologizing or trying to make up, and change my body posture to look innocent, maintain eye contact and keep my voice steady and clear.

Some ideas I might try;

• Leave a dirty plate in the kitchen overnight.
• Return an item to a shop.
• Ask for help from a friend or family member.

Opposite Action

I am not in the mood for being social tonight. In fact,  I am damn grouchy. So what does DBT tell us to do? (cue validating and reassuring voice...) OPPOSITE ACTION. If I am to apply a rational mind to this skill, I can see how it can be useful, but at the same time my emotion mind is yelling at me that it is just another 'get on with it' statement disguised as a skill! But hay, I will try try anything once!

First things first. Identify which primary emotion I am actively avoiding. I don't think I am angry, or sad. Both are normally too intense for OPPOSITE ACTION just yet. Yes it must be fear. I am afraid of life today.

OK, so how do I apply OPPOSITE ACTION? Marsha tells us to approach our fear and do things which gives a sense of mastery over the situation. I was asked to the movies tonight, so in the spirit of making myself feel good and practicing DBT, even though I feel like crying, hiding under the covers and not coming out for a week, I smile and accept the invitation. OH NO! NOW I actually HAVE to go.

First things first. I must do something to give myself some control over the situation. So being the girl that I am, I spend an hour washing blow-drying, straightening and preening my hair. I put on my face and feel somewhat more able to deal with the world.

During the movie, I try to go ALL-THE-WAY with the OPPOSITE ACTION. I MINDFULLY PARTICIPATE in the story line of the movie, I OBSERVE the palpitations of fear which are causing me to breakout in waves of nauseating and sweaty tremors. I am in full blown panic at this stage and all I want is to run away, to flee the movie theater and be alone.

Instead I count slowly to ten and concentrate on my breathing, and try to once again bring my attention back to the story. Finally the movie ends, and although it wasn't easy and it was far from enjoyable, at least I went, and I didn't engage in any destructive behaviors!