Skills to Prevent Relapse
Part 1/2: Mindfulness and Distress Tolerance
What is Dialectical Behavior Therapy?
Dialectical behavior therapy, more commonly known as DBT, is a type of therapy that was originally created to help people with borderline personality disorder, a personality disturbance that is so difficult to work with that some mental health professionals actually consider it untreatable.
Although treatment of borderline personality disorder was its original purpose, the domain of DBT has expanded greatly as it has been demonstrated to result in good outcomes in many other mental health conditions, such as eating disorders and anxiety disorders.
How can DBT Prevent A Relapse?
DBT is comprised of a number of skills. These skills can be divided into four main categories, which are called modules: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.
The skills DBT teaches are essentially “common sense.” However, it is focused practice and application of these skills that makes this such an effective therapy. Traditionally, DBT is delivered in an intense format that includes group counseling, individual therapy, skills training, and DBT diary cards, but it’s generally accepted that anyone – even people without a mental health problem – can benefit from simply learning about and practicing DBT skills.
In short: The goal of DBT is to help a person cope with unpleasant emotions and address difficulties in a wise and effective manner. Specifically, DBT can help people cope with urges to drink, find joy in healthy alternatives to drinking, and lead an overall more meaningful and stable life free of addiction.
MODULE 1: MINDFULNESS
Mindfulness is considered the foundation of DBT. It is through awareness and acceptance of the present moment that one is able to change a reflexive, ineffective emotional response. The goal is to learn to nonjudgmentally “sit with” unpleasant sensations without acting on the urge to drink or engage in other “problem behaviors.”
Practicing meditation — or even simply practicing being mindfully aware throughout the day — is a good way to strengthen mindfulness skills. However, DBT offers some specific skill suggestions for the mindfulness module. There are three “What” skills (Observe, Describe, and Participate) and three “How” skills (Nonjudgmentally, One-Mindfully, and Effectively).
This skill reminds us to be aware of our surroundings. It is easy to get lost in one’s own head while trying to fight down an urge to drink. Using the Observe skill means saying to ourselves, “Okay, I notice that I’m really craving a drink right now. I also notice that I’m getting wrapped up in my own thoughts. Turning my awareness outward, I notice that I’m sitting on a comfortable couch. I feel the warm fur of the cat on my lap, and I hear purring as I pet this cat’s soft, warm body.”
(See what happened there? The craving was observed and fully accepted – not denied or avoided. This left the mind free to turn its attention outward and fully observe and experience what else is present.)
This skill is essentially the result of using the observe skill. After observing, we describe, in great sensory detail, exactly what we are noticing. Just the facts — no judgments or opinions.
When we use the Participate skill, we surrender ourselves fully to the activity in which we are participating. We focus all of our attention on the present moment, refusing to be distracted by any other thoughts, emotions, or sensations.
This is the first “How” skill. It has been mentioned in the earlier descriptions of skills, but it is worth mentioning again: When being mindful, it is important to fully and willingly accept reality – without judgment. Again: Mindfulness involves focusing on just the facts.
When we use the Nonjudgmentally skill, we think “I notice that I am craving alcohol” rather than “Oh, s**t, I’m craving alcohol again!” Maintaining a nonjudgmental state of mind helps us to approach problems from a clearheaded perspective and prevents us from beating ourselves up over things – like cravings – that we can’t control.
Using this skill means focusing on one thing at a time. This keeps us from getting overwhelmed and/or distracted by emotional “interrupting” thoughts.
Simply put, this skill is about “doing what works.” Through mindfulness, we become unbiasedly aware of what is effective and what is not. We apply the Effectively skill to that knowledge, and we end up acting in a way that keeps us from succumbing to the desire for alcohol.
MODULE 2: DISTRESS TOLERANCE
Distress tolerance is about making it through unpleasant short-term emotions or situations. It is an “in the moment” lifeline that we turn to when the present moment feels unbearable and we are unable to use the mindfulness skills above to accept it and act in an effective manner. The distress tolerance skills include the following: ACCEPTS, Self-Soothe, IMPROVE the Moment, Pros and Cons, Radical Acceptance, Turning the Mind, and Willingness.
ACCEPTS is an acronym for a set of skills that can be used to provide a temporary distraction.
- A = Activities (use an activity as a distraction)
- C = Contribute (volunteer or do something useful)
- C = Comparisons (“Is this really the worst thing in the world?”)
- E = Emotions (do something that will elicit an emotion opposite to the current unbearable emotion)
- P = Push Away (temporarily avoid the distressing stimulus and think about something else)
- T = Thoughts (simply focus your attention on different, unrelated thoughts
- S = Sensations (expose yourself to intense sensations, such as a pleasant scent or a hot bath, as a distraction)
Self-soothing means doing something kind for yourself that makes you feel loved, soothed, and cared for. In essence, the soothing of the self soothes the distress that is being experienced. Some examples: Complimenting yourself, listening to music, stretching….
IMPROVE the Moment
IMPROVE is another acronym that suggests ways to relax when feeling distressed.
- I = Imagery (imagine pleasant, relaxing scenes)
- M = Meaning (determine the purpose or usefulness of what you are feeling)
- P = Prayer
- R = Relaxation (relax and breathe deeply – or do anything else you find relaxing)
- O = One Thing at a Time (if life seems overwhelming, just focus on getting through one moment at a time)
- V = Vacation (take a “mental vacation” from your problems)
- E = Encouragement (support yourself with positive words)
Pros and Cons
This skill can be used to logically determine the best course of action in a distressing situation. For example, when considering going to the liquor store to buy some alcohol, it might be a good idea to write a pros and cons list (which will help make it clear that the best decision is NOT to go, of course!).
Radically accepting something is like saying, “It is the way it is…and there’s nothing I can do to change it…so why fight it??” Radical Acceptance helps us avoid toxic rumination and instead focus on the areas of our life that we do have control over.
Again, the goal is to avoid toxic rumination. When we Turn the Mind, we gently remind ourselves that we have already Radically Accepted reality, and we re-focus our thoughts on a more productive topic. This decreases distress.
It’s hard to Radically Accept something we dislike — such as the fact that sobriety is needed to live a meaningful life. The Willingness skill tells us that, like it or not, we have to stop resisting. The best way forward is to embrace the truth and radically accept the present reality.
See Part Two of this article for more! There are still two more DBT modules to learn about!