While the distress tolerance module was helpful and important for Jackie to learn, the emotion regulation skills were vital to managing and reducing her depression. The emotion regulation module is devoted to helping clients learn how to reduce sensitivity to emotions and vulnerability to stress. This was, of course, Jackie’s second goal.
Three particular principles from that module were targeted for Jackie: stress management, increasing feelings of competency, and increasing behavioral activation to help her manage depression and achieve her treatment goals. These skills also aided Jackie in working toward her first treatment goal of managing safety concerns and suicidal ideation.
Because of her depression, efforts to care for her mother, and balancing different needs at work, Jackie was pulled in many directions and her self-care routine waned over time. She worked hard to implement skills of sleep hygiene, adapted exercise, and effective eating to minimize vulnerability to stress, reactivity to emotions, and to reduce her depression.
- Jackie was given psychoeducation on sleep hygiene, including a sleep routine. She had to turn the TV off at least an hour before bed, stop all schoolwork by 10 p.m., and spend at least four to five nights a week in her own home. These strategies allowed her to relax her body and mind. Over time she experienced less night waking and got back to pre-depression levels of six to seven hours sleep a night, waking up feeling rested.
- Jackie spoke with her primary care physician about exercises that wouldn’t cause pain. Taking walks, stretching, and swimming helped Jackie to feel like she was supporting her body as well as rebuilding a sense of achievement. This was tricky, though, requiring her to practice nonjudgmental stance, not comparing her current self with her past self.
- In addition to eating junk food, using the drive-through a lot because it was fast and easy, Jackie would forget to eat because she was attending to stressors or felt uninterested in food. This led her to feel more “hangry”, or hungry-angry. She would then feel more stress, pushing her into avoidance behaviors like ignoring schoolwork and texts, or lashing out at people around her. So improving her approach to food was important.
The Five C’s
Jackie also worked on suicidal ideation through the build mastery skill, engaging in activities to build “the five C’s”: competency, capability, confidence, creativity, and control. A list was created of activities for feeling more urgency and empowerment, reducing worthlessness, and gathering evidence to counter negative self-judgments about being stupid or inept.
This included brushing her teeth, paying bills, doing laundry, painting, completing projects at school and work, and cooking for herself. At the same time, Jackie remained mindful and aware of ineffective judgments that might arise from overachieving in those areas.
Jackie called this the adulting skill because it let her feel like a responsible person, capable of caring for herself. If Jackie’s suicidal ideation had caused despair or anguish, the opposite action to emotion (O2E) skill would have been important. It is also valuable in other ways, so was made integral to Jackie’s repertoire along with building positive experiences (BPE).
BPE and O2E
- Jackie said during intake that it had been a long time since she felt enjoyment or amusement. For BPE, she spent a session making a list of activities that sparked pleasure, enjoyment, calm, excitement, fun, or even just neutrality. This started small, with Jackie taking a few moments each morning to make her favorite flavor of coffee. This was really important for her. Given her level of depression, jumping right into something big like planning a vacation seemed unfeasible. Breaking down stress in small ways but in multiple locations in her life reduced the intensity of her depression, increased behavioral activation, and helped her feel excited about future events again.
- For the O2E skill, Jackie used mindfulness to notice judgments leading to apathy and low motivation, noted emotions, then chose a behavior that was opposite to lethargy or indifference. Making herself paint for two minutes was often enough to get her moving and induce positivity upon which to build better emotions or tackle more difficult tasks.
Utilizing the build mastery skill was important for meeting Jackie’s first goal, inducing a sense of competency and capability. This same skill was beneficial for her third goal of managing negative self-judgments. By actively engaging in behaviors contributing to feelings of empowerment, Jackie could refute her negative self-judgments and build self-respect.
Similarly, when self-judgments produced emotions like worthlessness, futility, or insignificance, behaviors that acted opposite to those emotions were very helpful. For example, Jackie felt incapable of completing a school assignment because her judgments told her she was incompetent. Rather than avoiding schoolwork and failing the assignment, Jackie cleaned her entire kitchen.
Feeling wonderful about her newly organized kitchen, but mindful of the black-and-white thinking she approached that situation with, Jackie was able to write her entire paper in one sitting. (Though she received a grade of B+, which obviously she wasn’t pleased with).
O2E and Communication
Jackie would grow fearful of setting boundaries with her mother and asserting herself with her partner. While Jackie’s fourth goal of improving interpersonal communication wasn’t directly linked to skills from the emotion regulation module, she found O2E helpful when establishing boundaries, practicing assertiveness, and fostering relationships.
This skill helped her to recognize her fears, accept them, then act in a way that reflected confidence and poise within her values in her relationships. It also helped her to push away emotions like depression, apathy, low motivation, and urges to isolate, aiding her efforts to build friendships with colleagues at work and in her studies.