Distress Tolerance Skills from DBT

DBT means Dialectical Behavioral Therapy. Read about it here.

These are practical skills to get you through difficult times. I like to keep things like this posted on my refrigerator or somewhere else I can see it often until I get into the habit of using the skills consistently and incorporating them into my daily life. I’ve added to, adapted, and tweaked this version from DBT Skills Training Handouts and Worksheets by Marsha M. Linehan.

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The history so far

…Or herstory, as it were.

 

TW: sui ideation, hospitalization, incest mention (not graphic)

My name is Molly DuMars, and I’m the founder of Reimagining Recovery. I’m writing this on September 23rd, 2018 and I feel a little silly talking about the “history” of something that was only properly conceived a few months ago. Although I will say, that this idea has had a pretty lengthy incubation period; that period is in fact the sum of my experiences in recovery.

One of the many events that cumulated in this conception was my most recent hospitalization for suicidal ideation 5 months ago. Once again I had found myself at a point of desperation. This was my 5th or 6th hospitalization (they blur together in a haze of slowly-sipped instant bouillon and Sharkzilla marathons interspersed with crying spells and art therapy). Once again, going to the hospital enabled me to stabilize, grow, and feel like I was getting somewhat of a fresh start. When I began to trust myself enough to be alone, I was discharged.

As for my plan after discharge, I kept running into the same exasperating decision: Go to mental health or addiction treatment for my outpatient care? Very few integrative options exist, certainly in my price range. I had briefly lapsed on my drug of choice, alcohol, but my crisis had precipitated before the idea of drinking even entered my mind. Several triggers converged at once and my PTSD symptoms became beyond my control. I learned in retrospect that I was also in the middle of a hypomanic and dissociative episode. My trauma, my bipolar, and my addictions are one inextricable ball of twine, and my experience isn’t unique in that: More and more, dual diagnosis is beginning to be seen as the rule rather than the exception.

Hence, why I have opted to do away with the whole addiction/mental health dichotomy and offer classes, groups, and discussions about issues that affect everyone, practical coping and grounding skills that anyone can use, regardless of their diagnoses or lack thereof. I believe that humans all have the same needs, at core. One can get them met in constructive, or destructive ways. Many of us have unfortunately learned a lot of destructive methods, but not for lack of alternatives. The knowledge has just been out of reach. That’s why this project is essentially about accessibility and inclusion for people at all stages in their journeys.

But I digress– After I was discharged, I opted to go to Providence’s intensive outpatient program (IOP). They do wonderful work there, and where I used to be a tinge ashamed, I now proudly say I have graduated not once, but FIVE times. And I learned new lessons and cemented old ones each time– lessons about topics like distress tolerance, mindfulness, myths and realities of mental illness, radical acceptance, sleep hygiene and other self care basics, and so much more. During one particular class about enforcing boundaries, I wondered “Why doesn’t everyone learn this stuff in school?”

I’m sure I wasn’t the first to ask that. But, I’ve always felt constrained by schools and academia. When I was 16 I decided to Unschool myself and “dropped out” and into lifelong learning. I have always been an autodidact, the type of person that listens to lectures in their free time. It never feels like a chore, because I’m passionate about learning. Once you begin to feed your curiosity, it grows, and the rest comes naturally. So I’m wanting to bring some of the things I’ve learned through that journey back to the recovery community: First, the joy of teaching oneself new things; Second, the joy of sharing that knowledge with others.

Another lesson from this quest for knowledge, is the freedom of not having to choose a specialty, the freedom of not being bound by “discipline”. A cross-disciplinary approach is helpful, but to truly approach understanding of complex systems (for instance the small matter of everything that constitutes the human experience) it’s more effective to transcend disciplines entirely. When you’re free to follow your curiosity wherever it takes you, I’ve learned that you can achieve a more nuanced understanding of any issue.

Another experience of mine that informs my ideas on the project and my vision for it is my year of teaching English in a “small town” of 5 million in China. It wasn’t something I had really planned on, in fact it would have been inconceivable that I’d go back much less move there a couple months prior. It’s too long of a story to go into here, but I was barely eking out an existence in Sydney, Australia, juggling my time between working at a small grocery store and moonlighting as a cello-wielding busker when my then-boyfriend’s online poker buddy in China said their school was hiring and they’d pay for our flights. Thus we were faced with a decision: Admit defeat and cut our trip short, become homeless, or make a rather drastic detour?

So, there I was thrust into the world of English pedagogy abroad. I had to learn how to teach people from age 10 to 90 and quick. It actually came surprisingly easily to me. After all, I was fluent, I grew up in and amongst the matrices of this complex, beautiful language– I knew the subject matter well, I just had to learn how to relate the material. Luckily, the school I worked for made it as easy as possible for teachers to step right in and start teaching– all you had to do was pull a lesson plan out of the filing cabinet, look it over, add your own twist if you had some extra time, and go to class. The students did most of the work. Most of the time you were just soliciting responses, asking the right questions. The point was to give the students room to talk. This brought to mind what I had heard of the Socratic method, and I started experimenting with those concepts with my more advanced students. I was also introduced to a wide range of teaching and learning styles. Most of all, it taught me that everyone has the potential to be a natural teacher, if you give them a solid template and set a good example.

My own struggle with Alcohol Use Disorder, again, informs this project;  I’ve tried, lapsed, and relapsed many times. I did get decent periods of sobriety racked up, but kept repeating the same patterns eventually. I now look back on how I managed to accumulate the time and successes I have, and I realized I was unknowingly practicing dialectical abstinence.

The idea behind dialectics is that two seemingly opposite truths can both have and contain, well, truth. My aunt once commented, “Isn’t that just growing up?” and I admit she has a point, but not everyone had that learning opportunity, especially in the case of developmental trauma. In this case, dialectical abstinence is the idea that harm reduction and complete abstinence both have benefit. The idea is to practice harm reduction while you are making your ultimate journey to sobriety (whatever that means to you), as you gain the coping skills that enable you to make the transition.

Traditional support groups tend to shy away from harm reduction. How many of us believe in abstinence-only sex education in high schools? It doesn’t work and it’s not realistic. The same is true in recovery. It is an act of radical acceptance to acknowledge that recovery is f*cking hard. Recovery is not linear. Recovery takes time, and it’s a continuous process. We are going to make mistakes, and rather than wallow in shame, it is more effective and helpful to accept rather than reject reality as it is.

To touch on another main influence: I want to take a different kind of detour now, and it’s a twisty one. Flash forward to my hospital stay again. I had finally gotten the courage to ask an actual doctor something I had wondered about for years– How had the specifics of my earliest traumas impacted my development? (TW for the footnote below)* Specifically, how had a substance that was given to me without my knowledge affected my brain development? He told me– and I might have taken this a lot differently if he hadn’t been the first psychiatrists there to sit down and truly listen to me without judgement or an agenda– that he thinks I’m probably THE expert on that one. It was validating, actually. He was also the first person in a white coat to tell me they would change my diagnosis to C-PTSD if only the APA would catch up and put it in the diagnostic manual (which it sounds like they will soon). It was empowering also– I am my own expert. We all are the experts at our own lives, because no one else has ever had to live them.

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*(TW r***, incest) Flash back to 8 years old– I think? I think that’s about when my dad started drugging me so that he could more easily molest me in the wee hours of the mornings before he would go to work. Sometimes I think he drugged me first so that he could convince himself he was doing less harm, but even that’s probably giving him too much credit… I’m sure it was just to more thoroughly silence me.

This project is also me speaking out against oppression in all forms. My dad’s actions cannot be neatly separated from the rape culture we inhabit. The personal is political, and especially with relation to trauma. Recovery to me also means examining the structures that lead to a chain of events that cumulated in homelessness. poverty, self-destruction, addiction, and how these intersections interacted in my lived experience. As is often the case, understanding the factors that led up to my  addiction contextualized my experience in a way that enabled me to shed shame, which is toxic to recovery.

Running list of class ideas

  • Locating Emotions in the Body
  • Living with Dual Diagnoses 
  • The Legacy of Trauma: Intro to Epigenetics 
  • The Gut-Brain Axis
  • Transformative Storytelling: Rewriting Your Personal Narrative
  • Spotting and Combating Black and White Thinking 
  • Creating a Sensory Kit for Grounding 
  • Coping with the Complex Trauma of Intersectional Oppression 
  • Navigating OHP 
  • Understanding the Fight/Flight/Freeze/Fawn Response
  • Establishing everyday rituals
  • Introduction to kratom for alcohol and opiate cessation , depression, anxiety, and chronic pain
  • Personal harm reduction strategies
  • Societal harm reduction interventions
  • The science of mindfulness
  • Mindfulness for trauma survivors
  • The embodied mind
  • Spotting and combating cognitive distortions
  • Nonviolent communication for intimate relationships
  • Combating stigma, med shaming, and other mental health and addiction myths
  • Introduction to trauma release exercises (TRE)
  •  Introduction to tapping (EFT)
  • Distress tolerance strategies from DBT
  • The Sinclair Method for alcohol reduction
  • Cost benefit analysis for problematic behaviors
  • Naming and giving voice to your emotions
  • The many benefits of CBD (not a sales pitch!)
  • The paralysis of analysis
  • Adult ADHD & ADD
  • Making a gratitude journal
  • Your chosen family tree: Building a network of support
  • Setting and enforcing boundaries in the real world
  • Tips for choosing a therapist
  • Breathing technique for stress, anxiety, and panic
  • Put down the phone: Combating technology addictions
  • Trump Traumas: Coping with political burnout
  • Creating a culture of enthusiastic consent, in the bedroom and out
  • Volunteering, service, and activism as self care
  • Trauma and the brain
  • How to be an ally to victims of domestic abuse
  • Processing grief
  • Bibliotherapy: Reading to Heal
  • (Trying to) overcome your perfectionism
  • Recognizing, understanding, and healing from narcissistic abuse
  • Flashback management
  • Relapse triggers and prevention plans
  • Unraveling self-defeating beliefs
  • Standing up for yourself: Assertiveness 101
  • Discovering your inherent resiliency
  • Crash course on human neurobiology
  • It is what it is: Living a life of radical acceptance
  • Seeing progress: Methods of habit tracking
  • Chair and bed yoga and stretching
  • Exercise and the depressed brain: solutions for the real world
  • Understanding stages of change
  • Nutrition for improved mental health
  • Herbal allies for depression, anxiety, and insomnia
  • Coping with and recovering from social anxiety
  • Coming out of isolation: Practical methods of reaching out
  • Taking a life stress inventory
  • When you can’t decide: How to write a declaration for mental health treatment
  • Goal mapping and planning
  • Maintaining motivation
  • Is self medication inherently harmful?
  • Making a safety plan for suicidal ideation
  • Life lessons from the Stoics
  • Questioning the cult of happiness
  • Letting go of toxic shame
  • Owning up: Atonement and making amends with intact boundaries and self respect
  • The complexities of complex PTSD and developmental trauma
  • Neurodiversity and the mad pride movement
  • What to expect in a mental health hospitalization
  • Living with Bipolar
  • Tips for having fun and socializing sober
  • Coping with burnout for Activists
  • Introduction to EMDR (Eye Movement Desensitization and Reprocessing): Is it right for me?
  • Lessons from Positive Psychology
  • Fostering your innate creativity
  • Quieting your inner critic
  • Patterns of codependency
  • Codependent or Interdependent? Examining similarities and differences
  • The Power of Vulnerability and the work of Brene Brown
  • Introduction to the autism spectrum
  • Everyday consequences of the war on drugs
  • Radical Self Care: A critique of the commodification of wellness
  • A trauma-informed critique of AA aka It’s okay to hold resentments against your abuser!
  • Learning about your learning style
  • Getting things done: Setting realistic goals and breaking tasks down
  • Supporting your partner, friend, or family member in recovery, while honoring your own needs
  • Taking and ACE (Adverse Childhood Experiences) Inventory
  • Addiction as an attachment disorder
  • Listening to your heart: Understanding emotions as manifestations of needs
  • What peer support can and can’t do: When to seek professional help
  • How to spot projection in yourself and others
  • Reprogramming our inherent negative bias
  • You can’t please everyone: Giving fewer fucks about what others think of you
  • How to spot and counter gaslighting
  • Who decides what “sober” is? Medicinal marijuana, therapeutic ketamine, mindful use of kratom and other psychotropic drugs
  • Getting past your past” vs. “Integrating your past”
  • Suffering as a spectrum: The traumas of everyday life
  • Cutting ties: Letting go of toxic relationships
  • Germinating a beginner’s mindset
  • On Autopilot: Breaking free of the Default Mode Network
  • Understanding your lizard brain
  • Crash course on childhood development
  • De-fusing with your thoughts and emotions
  • The map is not the territory: Separating your self from your diagnoses and shedding unhelpful labels
  • Hope for the best, Prepare for the worst: Coping ahead of hard times
  • Understanding the vagus nerve
  • Propagating loving-kindness
  • Reciprocity and getting your needs met in relationships
  • Styles of anger expression
  • Creating your own meditation practice
  • The allures and pitfalls of dating in early recovery
  • Creating a culture of consent in the recovery community: How to avoid 13th stepping and unbalanced power dynamics
  • How to make friends as an adult
  • What Myers-Briggs tests can and can’t tell you about yourself
  • Quick and dirty tips for resisting urges
  • Dealing with dismissiveness and people who just don’t understand mental health and addiction
  • Practicing Practice: Establishing a new routine
  • How to say “NO” to anything
  • Creating a Hierarchy of Values (HOV)
  • CES and neurostimulators for mood and sleep: Research and testimonials
  • Navigating the terrain and exploring the unique joys of non-monogamy in a safe and loving context
  • Apocalypse someday maybe: Halting catastrophization
  • Nature immersion for mental wellness
  • Love languages 101
  • Understanding your attachment style
  • Who will help the helpers?
  • Radical self care for compassionate people
  • Planning your coming-out (as queer, as mad, mentally ill, aspy, whatever)
  • Coping with the challenges of invisible disabilities
  • Confronting ableism in work and life
  • Coping with nightmares
  • Honoring and listening to your anger in a healthy way
  • Recovering from toxic gender roles
  • Getting the help you deserve: Being your own advocate in recovery
  • Planning ahead for a hospitalization: Medical releases, phone trees, and making plans for pets, bills, and loved ones
  • Exercise for mental health: Practical resources
  • Financial recovery crash course
  • Everyday practices for cultivating gratitude
  • Peaceful Co-habitation: Living with roommates and parents
  • Managing expectations for a more satisfying life
  • Adjusting to life as an immigrant: Practical resources, coping with xenophobia, and retaining your cultural identity
  • Coping with phobias
  • Observing the self: Recognizing patterns of mania, depression, and anxiety
  • Escaping abuse: How to make a safety plan and get a restraining order
  • The Upward Spiral: How building a sense of agency can snowball confidence
  • Applying for disability
  • Living a life of radical honesty
  • Practical local resources round-table
  • Medical cannabis and a crash course on terpenes
  • Unlearning unhealthy and obsolete coping mechanisms- Processing and methods
  • The therapy of creativity
  • Everyday practices for better brain health
  • The Politics of Experience: Lessons from R.D. Laing
  • The Pathology of normalcy: Understanding the work of Erich Fromm
  • The history of mental health treatment
  • Media resources Roundtable (podcasts, TED talks, youtube channels, message boards, etc.)
  • Breaking free from sugar addictions
  • Living with seasonal affective disorder (SAD)
  • Understanding and healing from adrenal fatigue
  • Rebuilding trust appropriately
  • Progressive muscle relaxation for anxiety and insomnia
  • The physiology of trauma
  • Spotting red flags and manipulative tactics in dating
  • The power of words: The psychological impact of racist, sexist, homophobic, xenophobic, and other divisive language
  • What to expect from detox/withdrawal and when to seek help\
  • Healing from toxic relationships
  • Forgiveness as self-care
  • Facing the opiate crisis
  • Dopamine and the biology of addictions
  • Surviving PAWS (Post acute withdrawal syndrome)
  • Nutrition for active drinkers
  • Understanding trauma bonding
  • The challenges and joys of being a highly empathetic person
  • The physical manifestations of depression and anxiety
  • Strategies for defying suicidal ideation
  • Self pity versus self compassion
  • Throwing a wrench in your own self sabotage
  • Integrating the rational and the emotional: Cultivating Wise Mind (DBT)
  • Pros and cons of ECT (electro-convulsive therapy) and TMS (Transcranial magnetic stimulation)
  • Caring for your childhood self/inner child
  • Finding a service animal for your unique needs
  • Living well with learning disabilities
  • Identifying enabling behavior in yourself and others
  • Coping with chronic pain and ambiguous diagnoses
  • Willfulness vs. Willingness
  • Fighting complacency and maintaining motivation
  • Introduction to the cognitive model: Thoughts, feelings, behaviors
  • Living with social anxiety
  • Distress tolerance strategies from DBT (Dialectical Behavior Therapy)
  • Active listening: How-to and demonstration
  • Strategies for overcoming procrastination
  • Understanding cycles of abuse
  • Practicing and insisting on enthusiastic consent (A trauma-informed perspective)
  • Creating a list of activities for distraction, laughter, mindfulness, and fun
  • Affirmations for everyone (including the self-loathing): Making believable statements
  • Debunking the myth of “rock bottom”
  • Secular spirituality
  • Alternate rebellion from DBT
  • The ABCs of ACT (Acceptance and Commitment Therapy)
  • Introduction to Jungian analysis
  • Holistic approaches to mental wellness
  • Guided imagery practices for stress and anxiety
  • Creating a container for difficult emotions
  • What kind of bodywork is right for me?
  • Spotting and overcoming barriers to recovery
  • Peaceful cohabitation with roommates and parents
  • Chain analysis for problematic behaviors
  • Healthy Self-soothing 101
  • Which treatment modality is right for me?
  • On being a human animal
  • Hormones and human behavior
  • Stressed out: the effects of cortisol
  • Woo or true: spotting pseudoscience
  • Staying within your window of tolerance
  • Self-acupressure for emotional wellbeing
  • Breaking the silence: Demystifying the suicidal impulse
  • Recognizing and halting emotional flashbacks
  • Neuroscience and free will: Real world implications
  • Understanding and harnessing heart rate variability (HRV)
  • Creating a sense of safety in uncertainty and life
  • Balancing your left and right brain thinking
  • The science of willpower and impulsivity
  • Body positivity 101
  • The problem with good intentions
  • Moving towards vs. moving away from
  • What you need to know about trauma bonding
  • Crisis as opportunity
  • Embarking on self-crit with self-compassion: finding comfort in discomfort
  • Getting the most out of individual therapy
  • Dialectics and holding space for multiple truths
  • Deprogramming from internalized oppression (racism, homophobia, misogyny, ableism, etc)
  • Growing up too soon: healing from parentification
  • Spoon theory 101
  • Sitting with uncertainty and change

Adulting is hard

I feel compelled to share a snippet of my morning, just because I don’t think many of us have good role models for this kind of thing and I’m doing my best putting the lessons I’m learning into practice, so I think it might be helpful to someone.

Yesterday I tried scheduling in time to think about certain things. Like, Molly: at 4 o’clock, think about what’s worrying you for an hour and what you can do about it. This is supposed to help you minimize rumination and excessive worrying throughout the day.

It didn’t go as planned, I just thought about the thing all day. I tried bringing my attention back to my breath and the rich sensory world we are always inhabiting, as often as we forget.

Time to try a radical acceptance approach: Molly: you’re getting sick and you haven’t been sleeping well and you’re probably thinking it’s your fault for not trying hard enough. Go ahead and think those things, but recognize how utterly wrong those thoughts are.

No, not wrong:

First, that’s labeling, a type of cognitive distortion that leads to reckless decision making and a warped sense of reality. It’s also black-and-white thinking. sorting every experience, thought, and person as Right or Wrong.

Secondly, that is an example of personalization, the faulty idea that you have more control of things than you do. Remember, this can also manifest as you feeling solely responsible for other’s wellness or misery.

Third, you are trying hard enough. You are trying hard enough. You are trying hard enough. You are trying hard enough etc. Etc. Try to remind yourself throughout the day. And don’t be hard on yourself if it slips your mind. It takes lots of repetition to overcome our inherent human negative bias. You are new to your practice.

Fourth, you are sick. Stop being in denial about it.

All that (and a lot more) before I got my morning coffee. Truthfully, the third realization came to me at my first sip…

No wonder I’m tired.