As clients develop the skill to observe, accept, and choose (O+A+C) when responding to emotion, they are learning distress tolerance and beginning to change the belief that they can’t stand pain. The emotional distress that they have habitually run from or acted on may seem less overwhelming now. They have seen the pain, they have observed emotions that once felt “too hot to handle.” And they’re able to locate the moment of choice—when they can choose to act or not act on emotion-driven urges.
But emotion efficacy is more than believing one has the ability to face and endure pain, or act on values instead of emotion. It also means knowing that one has the skills to cope with pain. For example, when emotional distress shows up as a sudden urge, and the pain hits, there’s an instantaneous appraisal: “Do I have the ability to withstand this? Do I know what it takes to live with this emotion?” The answers to these questions come at a point of decision when the client chooses acceptance versus avoidance.
EET Skill Objective: Observe + Accept + Choose mindful coping (relaxation/self-soothing)
Mindful coping, as with all key EET components, begins with the practice of mindful acceptance. Clients observe and “surf” a strong emotion. The exposure practice is brief—usually five minutes or less—and gives clients the opportunity to strengthen beliefs that they can experience difficult emotions without running.
As with previous O+A+C exercises, the object is to watch and not act on emotional pain and urges. However, mindful coping requires a second phase to the O+A+C process. Once the exposure is terminated, the focus shifts to a specific coping strategy. Now the client copes down distress until some downregulation is achieved.
Just as with values-based action, clients will use mindful coping skills in the face of emotional triggers in the moment of choice. The sequence is similar to choosing a VBA:
Mindful coping will help build the emotion efficacy muscle and, in particular, develop the skills necessary to hold—and not avoid—pain as well as to downregulate it.
Emotion coping strategies are usually taught in the relatively comfortable environment of a therapist’s office or DBT group meeting. The clients rehearse the coping process and may promptly forget it when facing the exigencies of an emotional storm. The difficulty of retrieving skills learned in a relaxed state—while aroused—is explained by state-dependent learning research (Szymanski & O’Donohue, 1995). These studies suggest that knowledge or skills learned in a specific state are harder to remember in a different one. Mindful coping solves this problem by inducing emotional arousal through imaginal exposure before practicing coping. The clients are thus placed in the same emotionally triggered state in which they will need to use the coping skills in vivo.
The second advantage of mindful coping is that it affords repeated practice opportunities across multiple contexts. Craske and colleagues have shown that exposure works best when the avoided stimulus is encountered in many environments and contexts (Craske, Treanor, Conway, Zbozinek & Vervliet, 2014). The same can be said for exposure plus coping. Imaginal exposure creates opportunities to practice coping skills in the face of varied emotions and triggering situations.
The steps to introduce mindful coping include the rationale for using this coping strategy, along with a brief description of the five EET mindful coping skills: relaxation and self-soothing (this chapter), coping thoughts and radical acceptance (chapter 8), and distraction and time-out (chapter 9).
What follows are the steps for guiding a mindful coping skills practice, along with a sample dialogue.
Therapist: Today we’re going to start something new—mindful coping. It will be added onto the emotion exposure you’ve already been doing—so after each exposure you will use these new coping skills to reduce distress.
Here’s why this will help. Mindful coping skills will give you more confidence and security that you can deal with emotions—no matter how big. They’ll strengthen your feeling of efficacy—the sense that you have what it takes to face any emotional storm. You’ll get lots of practice coping in an emotionally aroused state, which will help you remember these skills when you get emotionally triggered out in the world.
Client: What are the coping skills? What am I supposed to learn?
Therapist: There are five of them. First, you’ll learn basic relaxation skills—deep breathing, relaxing muscles, and so forth. Then self-soothing, which are calming experiences—like listening to peaceful sounds or music, looking at something beautiful, smelling a lovely fragrance. Things like that.
We’ll work on relaxation and self-soothing today. Later, we’ll develop some coping thoughts to calm you as well as distraction strategies to give you more distance from upsetting emotions. So far, so good?
Client: Sure, okay.
Therapist: Mindful coping is pretty simple. We’ll do an exposure, as usual, to something that was recently upsetting. You’ll keep watching the scene till the emotion is moderately strong—5 or 6 SUDS. Then we’ll stop the exposure and begin mindful coping till the emotion quiets a little bit. We’ll practice with both relaxation and self-soothing to see how each of them works for you.
The protocol for using mindful coping is the same using all five skills that are covered in chapters 7 through 9. The steps for O+A+C + mindful coping are as follows:
Now let’s look at the two mindful coping skills covered in this chapter: relaxation and self-soothing.
Key relaxation skills taught in EET are diaphragmatic breathing, relaxation without tension, cue-controlled breathing, and the five-senses exercise.
Cue words can include relaxing colors (golden light, sea blue), places associated with peace (Tuolumne Meadows, Shenandoah National Park), commands (“relax now”), or spiritual mantras (om). Whatever cue word is chosen, by noting it at the moment of relaxation the cue becomes associated with and begins to trigger muscle release (see the Mindful Coping Through Relaxation handout). Once relaxation without tension is mastered, the procedure can be shortened to focus on a single muscle group, or even a specific tense muscle, as needed during mindful coping practice.
The following sample script can be a model when your clients are ready to be introduced to using the mindful coping skill of relaxation.
In the following example of mindful coping, the client has chosen a recent fight with her sister for the exposure.
Therapist: As you close your eyes, bring up the scene where you had a fight with your sister. You’re in the restaurant—Salute. See the configuration of tables, the room; hear the murmurs of conversation and click of silverware. Feel the texture of the tablecloth under your hands. Now see your sister across from you, notice how she’s dressed. Hear her voice—she’s telling you that you’ve neglected her. Just watch the scene and listen to what she says… What are your SUDS?
Client: A 3 or 4.
Therapist: Stay with it. Watch her across from you. Listen to her words… See if you can accept the feelings. Try to make room for them… Just allow whatever you feel as you listen to her talk. What are your SUDS?
Client: Around 5.
Therapist: Okay. Notice the action urge. Your emotion is pushing you to say something harsh. Just watch the urge, the moment you must choose.
Client: I feel like telling her she’s worthless and walking out.
Therapist: Yes, notice the urge. And that you can choose to do that or not. Keep listening to what she says… What are your SUDS?
Client: A 6.
Therapist: Good. Let go of this image now. It’s time for mindful coping. What relaxation exercise would feel best at this moment?
Client: A deep breath [takes several diaphragmatic breaths].
Therapist: Any tense places in your body?
Client: My shoulders.
Therapist: Can you use your breath and the cue word to relax away tension in your shoulders… ? Where are your SUDS?
Therapist: What would help now?
Client: I’d like to try the five senses.
Therapist: Good. Notice what you hear. If thoughts interrupt, just go back to listening. Notice anything you can smell…notice your sense of touch… Now focus on what you see…notice anything you can taste… Where are your SUDS?
Client: A 3.
Therapist: The emotion is softening, less intense. What was that experience like?
Client: It’s very different to observe my anger and the urge to blow up. To just allow it, rather than have to do something. Breathing away the stress in my shoulders worked the best. Using the five senses is okay, but I don’t think it would work that well in real life. We’ll see, I guess.
The following handout (also in Appendix C and online at http://www.newharbinger.com/34039) can be given to your clients to assist them in practicing the mindful coping skill of relaxation outside of session.
Mindful Coping Through Relaxation
When a powerful emotion has been triggered and you are suddenly facing your moment of choice, a mindful coping skill can help downregulate your emotions before you decide on a values-based action. Practice these relaxation techniques daily so that you can rely on them in your moment of choice.
Diaphragmatic Breathing
Place one hand on your abdomen, just above the belt line, and the other on your chest.
Take a slow, deep breath into the abdomen. The hand on the abdomen should move but not the hand on the chest.
If you are having difficulty pushing the breath into your abdomen (and the hand on your chest is moving), you can do one of two things:
Practice 15 diaphragmatic breaths three times a day.
Relaxation Without Tension
Choose a cue word. Identify a word or phrase that you associate with relaxation. This could be a color (golden light, sea blue), a place that calms you (Tuolumne, Shenandoah), a command (relax now), or a spiritual mantra (om, peace on earth, I let go). This cue word will become associated with, and soon trigger, deep relaxation.
Observe a muscle group (see next paragraph) and notice any tension. Take a deep, diaphragmatic breath. At the top of the breath, say to yourself the cue word. Now, as you exhale, relax away any tension in the target muscle group. Do this process twice with each muscle group, in any order.
The five muscle groups you will relax are:
Practice this skill three times a day.
Cue-Controlled Breathing
Use the same cue word you established with Relaxation Without Tension.
Take a deep, diaphragmatic breath. At the top of the breath, say to yourself the cue word. Now, as you exhale, relax away any tension throughout your body at once. Let your body slump forward slightly as you exhale and release all tension.
Take 15 cue-controlled breaths three times a day to practice this new skill.
Five-Senses Exercise
For 30 seconds, focus on every sound you can hear: voices, traffic noise, machinery noise such as the hum of an air conditioner, sounds of movement, sounds your body makes. Try to keep your attention fully on these sounds. If your mind wanders, gently bring it back to focusing on what you hear.
For 30 seconds focus on what you can smell: fragrances, odors, scents from your own body or the environment. Try to keep attention on what you smell; return to this focus when your mind wanders.
For 30 seconds focus on your sense of touch, including temperature and texture, noticing the pressure where your body touches the floor or chair. Return to your sense of touch when your mind wanders.
For 30 seconds focus on visual sensations, observing color and shapes, and noticing the objects in your environment. When you get distracted, bring your attention back to what you see.
For 30 seconds focus on your sense of taste. What residual tastes do you notice in your mouth—bitter, sweet, sour, salty? Are there more subtle tastes? If you get distracted, bring your attention back to taste.
Practice this exercise twice daily as a way to focus attention away from negative thoughts and onto present-moment experience.
Used extensively in dialectical behavior therapy, self-soothing exercises facilitate calming physical experiences for each of the five senses. Clients are encouraged to find and test self-soothing practices focused on sight, sound, taste, smell, and touch, including ones they can do at home and ones appropriate for public places.
The worksheet that follows can be given to clients to help them discover new methods of self-soothing as a way to mindfully cope in the moment of choice.
Mindful Coping Through Self-Soothing
This worksheet will help you identify some ways to soothe yourself using each of your five senses.
Sense of Smell
Using your sense of smell can activate specific thoughts, memories, or sensations that can be calming. If you identify smells that make you feel good in advance, you will be prepared to use them when triggered. Following are some examples, and feel free to add your own ideas:
Sense of Sight
Sight is an important sense for humans in that a large portion of our brain is devoted to what we see. What we look at can have powerful effects on our emotions, for better or for worse. If you identify images that make you feel good in advance, you will be prepared to use them when upset. Following are some examples, and a place for you to add your own ideas:
Sense of Hearing
Certain sounds can be very soothing. For example, everyone has his or her own tastes or preferences in music. By identifying in advance songs or sounds you know are soothing for you, you will be prepared to use them to help calm down. Following are some examples, and a place for you to add your own ideas:
Sense of Taste
Our tongues have distinct regions on them that use taste buds to differentiate flavors and tastes of food. These sensations can also trigger memories and feelings. By identifying tastes you know are soothing for you in advance, you will be prepared to use them to deal with upsets. Following are some examples, and a place for you to add your own ideas:
Sense of Touch
Our skin is the largest organ in the body, and it’s completely covered with nerves that carry sensations to our brain. This makes skin a powerful emotional messenger. By identifying tactile sensations you know are soothing for you in advance, you will be prepared to use them to quiet your emotions. Following are some examples, and a place for you to add your own ideas:
This worksheet, and all the worksheets in this book, is available in appendix C and for download at http://www.newharbinger.com/34039.
The client has downloaded and been practicing a “relaxing sounds” app. She has brought with her a photo of a meadow where she camped in the high Sierras, along with a small bar of soap with a fragrance of violets. In session, the client has just completed an imaginal exposure to a scene in which her son had refused help with his homework and told her to leave him alone. The exposure lasted five minutes, and the client has reached 5 on the SUDS scale.
Therapist: Let’s shift now. Let go of the scene. What self-soothing technique would you like to start with?
Client: Smelling violets. [Smells the soap bar for a minute] Reminds me of my father’s nursery—the hothouse in back. I loved being in there.
Therapist: Where are your SUDS?
Client: I don’t know…4 maybe.
Therapist: Want to add anything else?
Client: I’ll look at the meadow. And I have the sound of a brook. [Plays it on her phone and takes a deep breath] That’s nice…
Therapist: I can see you’re feeling a little more peaceful. Where are your SUDS now?
Client: A 3, or a little less.
Therapist: Good. What was that like for you?
Client: The fragrance and the sound helped most. I can get lost in it, kind of drift away.
Therapist: Could you experiment with some of these self-soothing strategies during the week?
Client: Yeah. I have earphones. And I can keep the soap and the picture with me.
After practicing exposure with relaxation and self-soothing, prepare clients to use mindful coping outside of session. Start by identifying some of the likely situations when clients could get triggered. Emphasize the importance of responding initially with O+A+C. Observing and accepting remains the first, and most important, response to any painful emotion. Then clients must choose: values-based action versus emotion-driven urges.
Only after a period of O+A+C should the clients consider coping responses. Coping, at this point, is limited to relaxation and self-soothing, and clients are encouraged to choose among those available responses mindfully. This means making a best choice—mindfully and intuitively—based on what’s happening in the triggering situation. First, clients practice mindful acceptance, and then they choose additional coping strategies, as needed—until the emotional storm begins to subside.
Ultimately, the choice of whether to use coping strategies at all is a mindful one. Many clients will use them sparingly, and only in situations when they are feeling overwhelmed. They make the choice by staying aware of the moment and the risk of emotion-driven behavior. If the risk is high, mindful coping will give clients a sense of efficacy—that they can successfully ride the wave.
Following is a synopsis of content covered in chapter 7: