Moving from mindfulness to the distress tolerance module, Jackie spent significant time discussing these skills, as the hierarchy dictates working on life-threatening behaviors first.
With addressing Jackie’s suicidal ideation and self-injuring urges being her first treatment plan goal, it was beneficial to build a safety plan for her to use if they became unmanageable. She didn’t experience them to such an intensity that there were concerns for her safety, but it was good for her to think about what activities she could do for distraction, who she could access for support, and which resources could manage those thoughts and urges.
The safety plan led Jackie to recognize what she was already doing to manage self-injurious behaviors and suicidal ideation, and that activities like reading, watching TV, schoolwork, or light stretching were good distractors. It also helped her acknowledge who she could trust, like her boyfriend or a work confidant, to keep her mind off them.
Building a safety plan together aided both client and therapist to build awareness of triggers. These included negative self-judgments, being continuously judged by her mother, feeling overwhelmed by responsibilities, and being in significant physical pain.
The Thermometer Metaphor
Distress tolerance skills were introduced using the metaphor of a thermometer, for understanding when to use certain skills. At higher levels of distress, Jackie was coached to use crisis survival skills like TIPPs, ACCEPTS, self-soothe, pros and cons, or IMPROVE the moment. At lower levels she could use acceptance, willing thinking, or turning the mind, to foster a different approach to distress.
This metaphor gave Jackie a framework for choosing skills more effectively. She found TIPP, grounding, deep breathing, and radical acceptance skills to be the most beneficial in managing distress and not making her situation worse. This module was arguably the most important for her second goal of engaging in self-care and stress management techniques.
A stress management skills plan was also developed with Jackie, to help her judge which skills to use when she noticed her stress at certain levels. So when she sat down at her desk and gave a number to her stress, she knew exactly how to respond.
When at an 8 or 9, she knew to walk outside in the cold air or hold an ice cube to the back of her neck, practicing the TIPP skill of changing body temperature to manage distress. At a 3 or 4, she would do deep breathing and grounding exercises at her desk or on her couch at home to manage rumination, irritability, or low energy. The exercises Jackie found helpful for frustration and rumination were square breathing and double exhalation breathing.
- Square breathing is breathing in for four seconds, holding that breath for four seconds, breathing out for four, and holding that for four. Repeat the process for a minute or two.
- Double exhalation breathing is breathing out for twice as long as breathing in. If you breathe in for five seconds, breathe out for 10, and so on. This calms the nervous system, redirects attention from the mind to the body, and decreases stress in the moment.
Pros and Cons
Examining the pros and cons of engaging in stress management behaviors was helpful to Jackie in achieving her second goal as well, comparing the benefits and ramifications of using skills against those of engaging in treatment-interfering behaviors. Jackie was asked to set up a board to list pros and cons, then examine how these played out over the short and long term. It’s up to the client what those periods of time mean for them.
Jackie once created a pros and cons list when faced with the decision of doing laundry after a long time of not having done it: good things about doing it or not, bad things about doing it or not. The short term was deemed by her to be a few days to a week. Needless to say, the hygienic and practical considerations of not doing laundry for a month were very motivating.
Also valuable was pairing pros and cons with examining how Jackie’s behavioral choices might interact with her values. When creating a list, she would ask herself which behaviors aligned most with those values. Being the “overachiever” she was, this was often enough to crush woefulness, low motivation, or fear that might arise, allowing her to take action.