Tips, Ideas & Recommendations in CBT Treatment

Distress tolerance is one of the four core skills taught in dialectical behavior therapy (DBT). DBT is a type of therapy that helps people learn to manage their emotions and behaviors in a healthy way. Distress tolerance skills are especially helpful for people who experience intense or frequent negative emotions.
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One of the most well-known distress tolerance skills is ACCEPTS. ACCEPTS is an acronym for the following skills:

• Activities: Engaging in activities that you enjoy and find distracting, such as going for a walk, listening to music, or spending time with loved ones.
• Contributing: Doing something nice for someone else, such as volunteering, running an errand for a friend, or simply offering a listening ear.
• Comparisons: Reminding yourself that everyone experiences difficult emotions and that your situation is not unique or hopeless.
• Emotions: Allowing yourself to feel your emotions, even if they are unpleasant. Trying to suppress or avoid your emotions will only make them worse in the long run.
• Pushing away: Putting the situation that is causing you distress on hold for a while, so that you can come back to it later with a clearer head.
• Thoughts: Distinguishing between helpful and unhelpful thoughts. Challenging unhelpful thoughts can help you to reduce your distress.
• Sensations: Focusing on your physical sensations, such as the feeling of the wind on your skin or the taste of food in your mouth. This can help to ground you in the present moment and take your mind off of your negative emotions.

How to use ACCEPTS
To use ACCEPTS, simply go through the acronym and choose the skills that are most likely to be helpful for you in that moment. For example, if you are feeling overwhelmed by anxiety, you might try the following:

• Activities: Go for a walk, listen to calming music, or do some deep breathing exercises.
• Contributing: Call a friend or family member and offer to listen to them talk about their day.
• Comparisons: Remind yourself that everyone experiences anxiety from time to time and that your feelings are valid. You're doing better than many other people.
• Emotions: Allow yourself to feel your anxiety, even if it is uncomfortable. Trying to suppress or avoid your anxiety will only make it worse in the long run.
• Pushing away: If you are feeling particularly overwhelmed, you might try putting the situation that is causing you anxiety on hold for a while. You can come back to it later when you are feeling calmer.
• Thoughts: Challenge any unhelpful thoughts that you are having about yourself or the situation. For example, if you are thinking "I'm a failure," you could challenge that thought by asking yourself if there is any evidence to support it.
• Sensations: Focus on your physical sensations, such as the feeling of your feet on the ground or the sound of your breath. This can help to ground you in the present moment and take your mind off of your anxiety.

It is important to note that there is no one-size-fits-all approach to using ACCEPTS. What works for one person may not work for another. The best way to find out which skills are most helpful for you is to experiment and see what works best.
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Tips for using ACCEPTS
Here are a few tips for using ACCEPTS effectively:

• Be creative. There are many different ways to implement each of the ACCEPTS skills. For example, if you are not sure what activities to do to distract yourself, you can try making a list of things that you enjoy doing and then choosing something from the list.
• Be patient. It takes time and practice to learn how to use ACCEPTS effectively. Don't get discouraged if you don't see results immediately.
• Be kind to yourself. Everyone experiences difficult emotions from time to time. It's important to be patient and understanding with yourself when you are feeling distressed.

ACCEPTS is a powerful set of skills that can help you to manage distress in a healthy way. It is important to note that ACCEPTS is not a magic bullet. It will not eliminate all of your negative emotions. However, it can help you to cope with them in a more effective way. If you are struggling to manage your emotions, talk to a mental health professional about learning ACCEPTS and other distress tolerance skills.

Emotions are an integral part of our lives, influencing our thoughts, behaviors, and overall well-being. However, for many of us, managing intense emotions can be a challenging task. Dialectical Behavior Therapy (DBT), developed originally by Dr. Marsha Linehan, offers a comprehensive set of skills to help individuals regulate their emotions effectively. One of these essential skills is TIPP, an acronym that stands for Temperature, Intense Exercise, Paced Breathing, and Paired Muscle Relaxation.
 
How do TIPP skills work?
TIPP skills work by changing your body's physical response to stress. When you are feeling stressed or overwhelmed, your body goes into "fight or flight" mode. This is a natural response that helps you to deal with danger, but it can also be uncomfortable and make it difficult to think clearly.

TIPP skills can help to calm your body down and bring it back to a more relaxed state. This can make it easier to manage your emotions and cope with the situation at hand.

How to use TIPP skills

Temperature
One of the easiest ways to use TIPP skills is to change your body temperature. This can be done by splashing cold water on your face, holding an ice pack to your neck, or taking a cold shower. Changing your body temperature can help to activate the parasympathetic nervous system, which is responsible for the "rest and digest" response.

Intense exercise
Another way to use TIPP skills is to do some form of intense exercise. This could be anything from running or biking to doing jumping jacks or push-ups. Intense exercise releases endorphins, which have mood-boosting effects. It can also help to burn off excess energy and tension.

Paced breathing
Paced breathing is a simple but effective way to calm down your body and mind. To do paced breathing, simply sit or lie down in a comfortable position and focus on your breath. Breathe in slowly and deeply through your nose, and exhale slowly through your mouth. Try to keep your breathing even and regular.

Progressive muscle relaxation
Progressive muscle relaxation is a technique that involves tensing and relaxing different muscle groups in your body. This can help to release tension and promote relaxation. To do progressive muscle relaxation, start by tensing and relaxing the muscles in your toes. Then, move up your body, tensing and relaxing the muscles in your legs, stomach, chest, arms, neck, and face.

How to use TIPP skills in everyday life
TIPP skills can be used in a variety of situations, including:

• When you are feeling stressed or overwhelmed
• When you are having a panic attack
• When you are feeling angry or upset
• When you are trying to cope with a difficult situation
  
  

It is important to practice using TIPP skills when you are not feeling stressed so that you can use them effectively when you need them.

Here are some tips for using TIPP skills in everyday life:

• Identify your triggers. What are the things that typically make you feel stressed or overwhelmed? Once you know your triggers, you can start to practice using TIPP skills when you are exposed to them.
• Have a plan. Decide which TIPP skills you are going to use in different situations. For example, you might decide to splash cold water on your face if you start to feel anxious in a social situation.
• Be patient. It takes time and practice to learn how to use TIPP skills effectively. Don't get discouraged if you don't see results immediately. Just keep practicing and you will eventually get the hang of it.
  
  

If you are struggling to use TIPP skills on your own, consider working with a therapist who is trained in evidence-based therapies. They can help you to learn how to use TIPP skills effectively and develop a distress tolerance plan.

Self-care is "in." At work, with friends, and even at home, we often hear about and proclaim the benefits of self-care. Popular self-care ideas range from a hot bath or a manicure to a fancy spa treatment or a vacation in Hawaii. All of those activities are useful and effective ways to take a break or disconnect from everyday life. 

However, if you catch yourself yearning for that break all the time, that may be a sign that the life you've built is not the life you need. If you need to escape from reality at regular intervals, your reality may be misaligned with your values.

In this thought-provoking article, author Brianna Wiest advocates for taking care of yourself every day, not by pampering and withdrawing from your routine but by including healthy and responsible choices in it.

"If you find yourself having to regularly indulge in consumer self-care, it’s because you are disconnected from actual self-care, which has very little to do with “treating yourself” and a whole lot do with parenting yourself and making choices for your long-term wellness."

If you're looking to take better care of yourself, start by taking inventory of the values that matter to you and then assessing how well your life is aligned against them. If you need support going through that analysis, find a good therapist who can serve as a sounding board.

​Anxiety and fear are quite different. To illustrate the difference I normally share a concrete example. Let's say I open my front door and there is a wild tiger right there. I will be terribly afraid. There is a clear and imminent danger I can pinpoint, thus leading to the fear. However, if I step out of my front door, hear a noise or see some movement in the grass, and think that there might be a tiger in there somewhere, odds are I will be feeling quite anxious. I think there might be a threat somewhere, only I cannot see it. I can imagine it.
 
Anxiety is a response to perceived threats that come to us either in the form of thoughts (a story) or images. Because we don’t like the feeling of anxiety, we often avoid thinking about those threats and try to block out the troublesome images. This helps reduce the anxiety in the immediate short-term. But long-term, it is still there. That pesky feeling of foreboding, a tightness in your chest, a lump in your throat.  If it’s in your head and it has a negative emotional valence, it will come back at some point. That makes sense, right? I’s your brain trying to keep you safe by reminding you often of the dangers around you.
 
How can you conquer that anxiety? There are several methods in cognitive behavioral therapy (CBT) for anxiety treatment. The most effective one is exposure therapy. This is an approach where, figuratively,  you get out of the house, go to where the noises and movement in the grass are, look behind the bushes, and find out that there isn’t a tiger there after all – it’s a kitty cat. To get to this liberating a-ha moment, we do need the courage to be willing to face the tiger.
 
For some types of anxiety such as driving or public speaking, we can actually go out there and do exposure exercises in real life relatively simply. But other times, if our fears involve imagined situations and outcomes that we can’t replicate in the real world, then we have to use the tool of ‘imaginal exposure.’ Imaginal exposure, as the name suggests, involves immersing ourselves in this worst-case scenario fear of how things can turn out badly. For example, if I am constantly anxious about having a deadly disease, I can enter a mental world where that actually happens. If I am concerned about my children having a terrible accident, I can make that true in my head.

​Imaginal exposure scripts are short stories that we can write laying out what would happen if our worst fears came true. We add what happens in the immediate aftermath and what happens over the long run. These scripts are usually sad and dark because, well, our anxieties are sad and dark. Once an anxiety-provoking imaginal exposure script is written, exposure therapy involves reading that script over and over and over, several times a day for several days, recording the level of distress that it brings up. The objective is to get you habituated to the facts and feelings in the script.  After reading a story a few hundred times, it gets boring. Boring is the opposite of anxiety-provoking. Boring is good.
 
Of course, you’ll be well served to have a therapist support you through this unpleasant but highly effective and necessary process. Any well-trained CBT therapist should be able to hold your hand and help you feel safe and cared for as you go face your tigers. Happy hunting!

Dr. Kristi Neff is one of the pioneers in the study of self-compassion as a tool for psychological wellbeing. There are many definitions of self-compassion out there, but hers hinges on three tenets:

1) Self-kindness vs. judgment
Self-compassion involves being kind and understanding to ourselves, just as we would be to a friend or loved one. It means treating ourselves with the same compassion we would treat others when we are going through a difficult time.

2) Common humanity
Self-compassion is not about being selfish or self-indulgent. It is about recognizing that we are all human beings who make mistakes, and that we all experience pain and suffering. When we are self-compassionate, we are able to accept ourselves with all of our flaws and imperfections. We are also able to be more understanding of our own limitations and to forgive ourselves for our mistakes.

3) Mindfulness  
Mindfulness is the basic human ability to be fully present, aware of where we are and what we're doing, and not overly reactive or overwhelmed by what's going on around us. It entails paying attention to the present moment without judgment. When we are mindful, we observe thoughts and feelings from a distance, without getting caught up in them. This allows us to be aware of our thoughts and feelings while making choices about how to respond to them, without exaggerating or suppressing them.

There are many benefits to self-compassion. Studies have shown that self-compassion can lead to:

• Improved mental and physical health
• Reduced stress and anxiety
• Increased resilience
• Improved self-esteem
• Increased happiness and well-being

There are equally many ways to cultivate self-compassion. You can start by being kind and accepting to yourself, practicing mindfulness and loving-kindness meditations, spending time with people who are supportive and kind, and engaging in activities that help you feel good about yourself. You can also practice self-compassion through guided audio exercises such as this one:

Let's say you have an important work deadline coming up, or an important meeting, or a job interview. You'll likely be a bit stressed about it, right? That's understandable - and useful! A reasonable amount of stress shows that we care about these critical tasks and can actually help us prepare better for them. However, every now and then, that stress gets out of hand...instead of encouraging us to be ready for the challenge, the stress mounts so high that it makes that challenge seem completely unattainable.

In the early 1900s, psychology researchers Robert Yerkes and John Dodson developed an empirical curve that illustrates our performance levels on a task relative to the stress levels present in that situation. It is easy to understand if you think about it in terms of a test at school. If there is no stress at all, we won't really prepare for the test, and might show up on the exam day without having done any studying. A good amount of worry and stress will encourage us to prepare for the test by reading the book chapters and doing the practice exercises, once...or maybe twice. An amount of stress beyond that might lead us to re-read all those chapters and re-do the practice exercises a few too many times, to the point where we may be too tired by the time the test comes along to get the best grades. And if we are really, really scared of the test, telling ourselves that it's way too difficult and we will never get a good grade on it, we may just throw our hands up in the air and not study for it at all. We may give up before we start, out of panic, exhaustion, and fear.

So, some stress is good. Too little or too much may lead to subpar performance. The question is how to modulate the stress to get it to the level that is good for you. There are many answers there, ranging from relaxation exercises to worry break and mindfulness moments to reappraising the importance and threat of the situations ahead. In TEAM-CBT, we have some great tools that can help with all of those!

A client recently shared with me a video of actor Will Smith talking about the fear that he felt before he was scheduled to go on a skydiving trip. That prompted a discussion around the difference between fear and anxiety. 

To my way of thinking, fear is to anxiety as concrete is to imagined, actual is to forecast, or today is to tomorrow. From a cognitive standpoint, fear pertains to a real, tangible, identifiable, and often immediate source of danger. For example, if a lion is standing in front of me, I will be afraid (not anxious!). If I am about to jump out of a plane, standing by the open door at 3,000 feet, I will be afraid (not anxious!). On the other hand, anxiety applies to situations where I perceive a potential for danger. I have not yet seen the lion, but I think that the lion may be lurking close by. Or coming for me at any time. Or just feeling hungry. I worry about something that has not happened yet and may never happen, But then, it could conceivably happen. 

In psychotherapy, we may address both fears and anxiety using Cognitive Behavior Therapy. Problematic fears often come up in the context of phobias (e.g., fear of flying or driving across bridges). Clinically-relevant anxiety tends to manifest itself in the form of excessive worrying, tension, restlessness, over-sensitivity and hypervigilance.  Both feelings trigger our "fight or flight" response mechanism, which I will describe in more details in my next blog post.  The treatment of choice most often involves Exposure Therapy, an evidence-based intervention in which the client learns how to gradually expose themselves to stimuli that they fear, with a lot of support and guidance from the therapist.

In the meantime, here is Will Smith talking about his "fears," which actually pertain to both anxiety and fear. Enjoy!

Cognitive behavioral therapy (CBT) tends to operate within a much more short-term, focused model of psychological intervention that aims to reduce current symptoms, address specific problems, and build skills that the client can take with him/her after treatment ends. Hence, treatment length is usually measured in weeks or months, rather than years or decades.

​Indeed, there is ample research evidence that response to psychotherapy follows a 'negatively accelerated' curve where more and more effort is required to achieve smaller and smaller changes (that is called a log-normal curve for the math geeks out there). Dr. Ken Howard was the first to analyze this correlation and posit markers for response to psychotherapy according to dosage. Here is his original article.

The original dose-effect study was run in 1986, based on psychodynamic or interpersonal treatment only, with the following findings:
* About 15% of patients improve before the first session of therapy 
* 50% of patients typically improve at 8 sessions
* 75% of patients typically improve at 26 sessions
* 85% of patients typically improve at 52 sessions

It is possible that modern psychological techniques have accelerated that theoretical curve in the past 30 years. In practice, however, there are many factors influencing the right dose of psychotherapy for each client, including diagnosis, acuity, readiness to change, social circumstances, and frequency of treatment (more regular treatment is  shown to be more effective).  But what we can glean from the data above is that longer and longer treatment periods may indeed offer diminishing gains at increasing levels of effort. 

With CBT, you and your therapist will have powerful tools for change readily available. The specific length of psychotherapy treatment will vary for each person and each presenting problem. But with commitment and focus in the context of a true partnership, CBT can lead to fast and meaningful change.

Empathy is a fundamental ingredient of any psychotherapy treatment. It is so important in TEAM-CBT that it gets its own letter in the acronym: The 'E' in TEAM actually refers to the phase of treatment when offering and receiving empathy is the main goal. In my experience, it is a necessary - although most often not sufficient - element for successful therapy.

Through empathy, the therapist attempts to develop a deeper understanding of the client's idiosyncratic experiences in certain situations. That hinges on the therapist's ability to put themselves in the place of the client, reflecting the client's thought processes and feelings, acknowledging the client's strengths and struggles, and sharing, in a professional manner, the impact that these aspects have had on them, the therapist. With clear communication and a genuine desire to connect, empathy builds a sense of shared experience that allows the therapeutic alliance to flourish.

Empathy is not sympathy, though.  Empathy is a process where two people meet at the same level. In sympathy, one 'stronger' player attempts to rescue the 'weaker' one, often times by minimizing their experience in a well-meaning maneuver to quickly sweep away negative feelings.   Renowned researcher Dr. Brene Brown has developed a short video that illustrates this distinction. It's well worth three minutes of your time: