Distress Tolerance

This video gives a brief review of psychoeducation around the fight/flight/freeze response and how that influences the brain/amygdala.

Symptoms of both depression and anxiety can trigger these physiological fight/flight/freeze responses and contributes to significant distress. In this workshop today we will be focusing on learning skills that can help reduce distress in these instances. We call these skills “distress tolerance” skills. Distress tolerance is the ability to tolerate intense emotional distress when you (1) cannot solve the problem that’s causing it right away, AND (2) want to avoid making things worse by doing something impulsive. 

In the attached packet, you will find a number of skills we will review today to help with both anxiety and depression. We encourage you to keep an open-mind when reviewing these skills, but also want to validate that perhaps not every skill will be effective for each individual and your challenge is practicing these skills and finding which ones work for you.All of these skills take practice (even as the facilitator,I am not “perfect” at utilizing these skills and need to continually practice them in my own life as well). The skills discussed in today’s distress tolerance workshop are to utilize primarily in crisis situations, to calm yourself down when you feel so emotionally overwhelmed that you’re unable to think straight;(not necessarily every time one experiences low-levels of distress).

The handouts begin by introducing skills to utilize when you are in crisis (when you are experiencing a panic,for example). The handouts also provide more long-term skills that can be effective at reducing your emotional pain and suffering. With practice and repeated use, these long-term skills can lower your amygdala response over time.

Welcome to the second module of the Retrain your Brain workshop series. This workshop will cover distress tolerance skills and is a part of a four-part series. The other workshops are emotional awareness, cognitive appraisal and behavioral change. We really encourage students to watch all four modules to get the most out of it. Throughout this presentation I will be referencing handouts and worksheets and you will find those linked below. Please reach out to CAPS at 919-966-3658 if you need further support.

As you may have seen in the videos about why we experience anxiety and depression and how does anxiety and depression work in the brain, you know that symptoms of both depression and anxiety can trigger the physiological fight, flight or freeze responses and contribute to significant distress. In this workshop today we will be focusing on learning skills that can help reduce distress in these instances. We call these skills distress tolerance skills.

Distress tolerance is the ability to tolerate intense emotional distress when you: 1. cannot solve the problem that's causing it right away and 2. want to avoid making things worse by doing something impulsive. In the packet of handouts that I'll be sharing on my screen you will find a number of skills we will review today to help with both anxiety and depression. We encourage you to keep an open mind when reviewing these skills but also want to validate that perhaps not every skill will be effective for each individual and your challenge is to practice these skills and find which ones work for you.

All of these skills take practice. Even me, as the facilitator, am not perfect at utilizing these skills and find the need to constantly practice them in my own life.

The skills discussed in today's distress tolerance workshop are utilized primarily in crisis situations to help calm yourself down when you feel so emotionally overwhelmed that you're unable to think straight. We'll begin by introducing skills to utilize when you are in crisis or when you're experiencing a panic, for example, so to kind of help put out the fire. We'll end this workshop by also introducing more long-term skills that can be effective at reducing your emotional pain and suffering over time. With practice and repeated use these long-term skills can lower your amygdala response over time.

So the first skill is the Stop skill. Depression and anxiety tend to contribute to a "clogging of the brain" and make us spend a lot of time ruminating about the past or the future. It's very normal that when you're in a crisis you'll spend a lot of time ruminating and experiencing distressing thoughts. Spending too much time ruminating and thinking about this distress is only going to contribute to increased levels of distress. Imagine if you had a scab. It's not going to heal and it'll continue to bleed if you continue to touch and pick at it. It's helpful to notice the scab but not spend time continuously analyzing and picking at the scab.

I want you to know that the Stop skill is difficult to use and even for me as a facilitator it takes a lot of practice, but it's helpful to use when you first notice yourself starting to spin out of control emotionally, as it helps you focus on the present experience of your body rather than spending time cognitively ruminating about the past or present crisis situation. So give me a chance to share my screen and then we'll go over one of the first pieces. This here is the Stop skill. So of course the "s" stands for Stop. Imagine yourself slamming on the brakes at a stop sign or hitting the pause button. This gives you an opportunity to take a step back and a deep breath and once you do that, gives you the opportunity to notice what's going on in both inside and outside of you. What's the situation? What are you thinking and feeling right then in that moment? And what are others saying and doing? After you've been able to stop take a step back and observe, you then now have an opportunity to proceed mindfully. And that starts with thinking about what your emotion is telling you to do. And then whether it's telling you to avoid the situation, or to get angry, and then you want to determine what your goals are in this situation and which actions will make it better or worse for you. So that's something to keep in mind as you as you try to utilize that Stop skill.

The next skill is the TIPP skill. The TIPP skill involves changing your body's physical chemistry to reduce emotional suffering, especially when you're trying to use the stop skill, but it's feeling ineffective to use. These TIPP skills entail some breathing and physical exercises so if you have a pre-existing heart condition please consult your physician before attempting these TIPP skills.

The "t" in TIPP is going to be for temperature so the purpose of this is to bring your body temperature down quickly by splashing your face with cold water or sticking your head or your hand in the freezer or even holding an ice cube or a ziploc bag with ice or cold packed to your face, your eyes and cheeks. And you can carry ice in your water bottle for this. This initiates the human dive response. This turns off the fight flight or freeze response of your sympathetic nervous system which is activated when you're intensely distressed. So this brings down the intensity of your emotional arousal and kind of jars you out of feeling overwhelmed.

The "I" in the TIPP skill refers to intense exercise. So that can look like running in place or doing jumping jacks, climbing several flight of stairs, or putting on some music and dancing. So this is used to help calm you down by burning off some of the nervous energy associated with the fight-or-flight response. It also helps to clear your brain and can be especially helpful when you're experiencing emotions that are overwhelming and you feel numb. This can make you start feeling sensation in your body again.

The first "p" in TIPP refers to paced breathing, and we'll go into that with this with the next skill around square breathing. So I'll spend more time on that there.

But the second "p" in TIPP is for progressive muscle relaxation. So the idea is that you can't be tense and relaxed at the same time so the purpose of this is to fully tense each muscle group in your body starting with your feet to your forehead and tensing that and then releasing it after five or ten seconds so that the tension is released in those areas. There are guided progressive muscle relaxation meditations that you can find doing a quick google search or on youtube and this also can be a excellent exercise to help with falling asleep. So moving on to square breathing. I really like this exercise because you can do this where and people don't necessarily know what you're doing. You can utilize it whenever you're feeling stressed out and it gives you an opportunity to help reduce some of the stress that you're feeling in those moments. So for instance if you have a presentation that you're about to do or or talk or something like that um and you're feeling nervous you can utilize this right before you're about to do your talk to help calm yourself down. It's something that I actually use as well. So just like the utilizing cold water, square breathing helps to communicate to your amygdala and your nervous system that you're not in any current danger. This flips off the fight, flight or freeze response and activates rest and digest. It's physiologically impossible to panic if you're doing this correctly. Now this is also going to take some time to master but I think it's important to try to do that so there's two parts to this: slowing down the pace of your breathing and then breathing from your belly and not your chest.

So what I'm going to do is I'm going to lead us through this and I like to do it three times three squares so that we really feel the full effect of it. So on the count of three, you can do it with me. We're going to breathe in for four seconds, hold it for four seconds and breathe out for four seconds and hold it for four seconds. And we're going do that three times. One two three - breathe in: one two three four. Hold it one two three four. Breathe out one two three four Hold it five six seven eight Breathe in one two three four one two three four. Breathe out one two three four five six seven eight Breathe in one two three four Hold it one two three four. Breathe out one two three four five six seven eight.

Wow. Even after doing that I actually felt myself starting off fast but then slowing it down as I went into it so I'm being more intentional about slowing down the pace of my breathing and the counting. I feel like the counting as well really helped to keep me on track with that and so I just want you to know that this skill takes a lot of practice but it's something that you can do at any point in time in the day and you can do it multiple times a day so that's another reason I really like that skill.

On to self-soothing. Self-soothing gives you an opportunity to take a break, to nurture yourself with sensory experiences. This break helps to soothe your nervous system and brings down your arousal level in addition to distracting you from your distress. Things that have been helpful for me have been listening to music. I really enjoy it. I really enjoy listening to soothing artists as well, for instance Shade or Erykah Badu. And then in terms of taste, one thing one thing I like to do is on the weekends, I wake up and cook me a big breakfast and I love the smell of onions and green peppers in a buttered skillet. I mean I can smell it now. It is really a wonderful feeling, and then I know it's going to taste so good too. And so it's also with touch. You can never go wrong with a nice massage and comfortable lounge clothes. That's something that I really enjoy as well. So those things I think are ways that i engage in self-soothing myself.

The next piece is going to be distraction. Distraction actually helps to change the channel and give you some time and distance from emotional suffering, as this helps to decrease you from ruminating about what is bothering you and allows you to focus on the present moment. The categories for distraction - there's a couple of different categories and a way to remember these skills is the phrase "Wise Mind ACCEPTS." So the "A" is going to be for Activities. You can look at this list you'll be able to find this in the link to be able to determine which of these skills that you actually use and then which ones you want to incorporate. The next is going to be Contributing and then Emotions, Pushing away thoughts, and then Sensations. Some of my favorites include - let's see here - focusing on a task that I need to get done. Reading books - I definitely like that. Exercising - riding my bike. Also contributing - you know doing something thoughtful for someone else. It's always helpful. So those are just a couple of things that I find helpful for me. With that being said that concludes the section of skills for the short term. So the section of skills that we just covered focuses on putting fires out. This next section is going to focus on stress tolerance skills for the long term or preventing the risk of fire starting in the first place. Repeated daily practice of the following long-term skills helps lower your amygdala response because it gives your brain an opportunity to strengthen these newly created associations.

And you can remember these skills of taking care of your by your mind and taking care of your body as PLEASE skills. Physical - treat physical illness. Take care of your body. See a doctor when necessary and take your prescribed medications. The "E" is going to be for balanced eating. The "A" is going to be for avoiding mood altering substances. We know how those can negatively affect our our mind and our brain and as well as our mood, and also can create dependence. And that's not something that we're looking for. Getting balanced sleep. Making sure you're not sleeping too little or too much. And one important thing about this is to to be consistent in your sleep and sleeping habits. So that can be very helpful so whatever is the earliest time that you get up throughout the week, that might be the time that you need to get up each and every day, as well as finding a consistent time to to fall to go to sleep - I mean prepare yourself for sleep, so um that can definitely help with regulating that sleep hygiene. Then the last thing here is going to be getting exercise. While there's not a specific handout around the benefits of long-term exercise practice, research supports that regular 20 minutes of exercise, multiple times a week reduces your vulnerability to emotional suffering.

The next handout is going to be related to food and your mood. The first thing you want to do is observe how certain foods affect your mood both negatively and positively. You can see these negative examples here: soda and sugary snacks which might make you feel tired and irritable. Caffeine might make you feel jittery and more anxious and interfere with your sleep. So these are negative examples there are also positive examples. Complex carbohydrates and fiber gives you slow and steady energy. Proteins also provide your body with steady energy that helps you stay active and strong both physically and mentally. You can see how fruits and vegetables provide you with energy and boost your health. You can see how there are positive things around food as well that can impact your mood. The second thing you want to do is notice whether you're eating too much or too little. Imagine if you're going for a long drive in your car, if the car isn't well maintained and doesn't have enough fuel, the car will fail and not function effectively. Same thing with your body. Now, I understand that proper nutrition as a college student is very difficult to maintain or figure out. But with continued effort and proper nutrition, it can have an extremely positive impact on your overall well-being. And although you may not be able to make big changes, the key is to start small. For example, cut down on processed foods and add more fresh foods. Add more fruits and vegetables to meals and have them for snacks. There's little things that you can do to help develop healthier habits when it comes to food and impacting your mood. The last thing you want to do is notice the effects of eating well on your mood. How do you feel after? What do your energy levels look like? I want to make you aware that Campus Health has a clinical nutritionist that you can utilize so if you're looking for tips of how to develop healthy eating patterns that might be a really good resource for you so I just wanted to mention that as well. And please read over this for homework after this after our session. I know I'm going through it kind of fast and I know that you'll have access to this worksheet right here so I want you to be able to utilize that and kind of read over this stuff on your own time.

The next piece is going to be about sleep which we talked about earlier. So of course you know being in college sleep hygiene is difficult to focus on given social schedules and studying for exams, increased phone usage and looking at screens before we go to sleep, sharing dorms with a roommate - You know all these different kind of things that impact our ability to focus on sleep. However it is extremely important to to have good sleep hygiene. It can make you feel energized and just improve your mood throughout the day. So what I'm going do is I'm going read off of this sheet here and so there are 12 tips. And the first thing is to stick to a schedule. Wake up at the same time. Go to sleep around the same time and that's going to help with getting your body ready and prepared and tired when you need to go to sleep and energize when you're when you want to be up. You want to establish a bedtime routine. Shutting off the screens. Getting into your pajamas. Those kind of things - reducing the light. Not stimulating your mind in that way. Third piece is don't eat or drink a lot before bed. Give yourself time before you lay down to finish eating and drinking because you don't want those things to interrupt your ability to fall asleep. Four is avoid caffeine and nicotine - both of these are stimulants and it can keep you awake. Exercise. Exercise is important because it helps to tire us out. But you don't want to do it late at night. You want to make sure that you're doing that in the morning or in the afternoon because if you do it late at night, it can actually stimulate you and keep you from falling asleep as well. The next thing is to keep your room cool. The next piece is sleep primarily at night. Daytime naps steal hours from your nighttime sleep so limit daytime sleep to less than one hour no later than 3 p.m. I have been a victim of this plenty of times and it doesn't feel good and I'm speaking from experience on that one. So I try to minimize the naps that's been helpful with getting to sleep on time so and being able to kind of stay asleep throughout the night that's helpful when I minimize the naps. Keep it dark and quiet and no screens. Looking at screens is very stimulating and that can definitely interrupt with our ability to fall asleep. The next piece is to use your bed only for sleep. I know there's it's tempting to engage in watching TV from the bed and reading in the bed, but if you use your bed only for sleep that kind of trains your body to associate getting into bed with falling asleep and that's what you're aiming for with that. So the next is take a shower before you get to bed. That can help you relax tense muscles and that's always helpful. Don't rely on sleeping pills. If they are prescribed to you use them only under a doctor's close supervision. Make sure the pills won't interact with other medications. But if you engage in the other pieces that are helpful for sleep hygiene then you minimize your need to kind of use sleeping pills. And if you're lying there and you're lying there, tell yourself, "It's okay. You'll fall asleep eventually." But if you're lying there for an extended amount of time the best thing might be to get up and get out of the bed until you feel sleepy. The next piece is going to be the pleasant events checklist and so I understand that as a student we can be very busy with work and school and oftentimes when we're we are busy the activities that bring us joy and help our mental health are usually the first ones to go and to be crossed off our list.

So I'm challenging you right now, as homework, just whenever you have time to read through this list and to begin regular practice of intentionally adding activities from this list that bring joy into your schedules throughout the week. Everyone is different, and it's your task to discover what pleasant activities resonate with you. There's a lot of different things on here. This this list is very extensive. I'm just glancing at it right now and I can see so many things that I don't do and then there's also many things that I do as well. This a pretty extensive list but there's always more that you can add so if it's not covered on that and that's something that you enjoy doing please add that to your schedule. And I know some people like to pick one day to set aside for doing things that they like to do and use the other days to focus on things that need to get done and I think that is a way that sets you up for burnout. So I found it very effective and beneficial to engage in at least one thing even if it's small right - one thing per day that I have something that is fulfilling for me and that I enjoy doing each and every day. It doesn't have to be big and it doesn't have to take a lot of time but I find that I'm more fulfilled when I'm able to engage in something that I want to do each and every day rather than waiting and pushing it off until one day out of a seven day week.

The last thing that I kind of want to go over is to encourage you to create a self-care kit. In times of crisis and panic it can be very difficult to think clearly and it may be difficult to come up with a self-care plan in that moment. So it's helpful to write down this plan when you're not in crisis so it's readily available for you if a crisis does occur. Once you fill this out, please take a picture of it and send it to yourself or email it to yourself or something so that you can have it in that time when you may need it. That's something that you can do in your spare time is to create this list. We discuss skills to use for crisis situation and skills to help minimize emotional vulnerability over time, and so your homework is to engage in activities that bring you joy throughout the week and to complete the self-care kit. As a reminder to get the most out of the Retrain your Brain workshop series it's important to watch the other modules, and so with that being said have a great rest of your day and take care.