The next mindful coping skills in EET are coping thoughts and radical acceptance. Both skills have to do with the way we think about the triggering event and the emotions that go with it. As one of the four contributing components of an emotion, thoughts are powerful forces in creating and maintaining emotion.
As we have discussed in previous chapters, emotions follow whatever the brain is registering as “true.” If thought content is a result of threatening stimuli, emotions may manifest as tense sensations; feelings of fear, anxiety, and dread; and the urge to fight, freeze, or flee in some way. Or if thought content is a result of pleasurable stimuli, emotions may manifest as relaxed sensations; feelings of joy, contentment, and confidence; and the urge to engage. If clients struggle with automatic negative thoughts, replacing those thoughts with coping thoughts or practicing radical acceptance can help them increase distress tolerance and regulate their emotions by downshifting emotion.
EET Skill Objective: Observe + Accept + Choose mindful coping (coping thoughts/radical acceptance)
Automatic negative thoughts are often made up of judgment or danger thoughts about the self and/or the self in relationship to the world. Frequently, these thoughts reflect a person’s maladaptive core beliefs organized around schemas, which contribute to and maintain distressing emotions (Rafaeli, Bernstein & Young, 2011). Coping thoughts are simply personalized, strength-based declarations about resiliency, history, or perspective that shifts the client’s attention to help effectively navigate the difficult emotion.
Distinct from some other interventions that use coping strategies to increase emotion regulation and distress tolerance, all coping skills in EET are taught to be used mindfully. Similarly, coping thoughts are used differently than in other treatment interventions. Coping thoughts are taught as a mindful skill because they are used only after clients observe and accept their emotional experience. For example, after clients have practiced mindful acceptance and have located the moment of choice, they may choose to use coping thoughts to support them in decreasing distress.
In order to use coping thoughts, it’s important to “cope ahead” by having some preselected cognitions in response to different triggers. To select effective coping thoughts, you’ll work with your clients to identify common automatic negative thoughts they have in response to triggers and then come up with coping thoughts that can be used to replace them.
Following is a step-by-step guide to help clients recognize automatic negative thoughts and replace them with coping thoughts.
Use the following steps to introduce your clients to coping thoughts:
For example, if a client’s automatic negative thought is “I’ll never be good enough,” an effective coping thought might be “I always try my best.” However, an example of an ineffective coping thought might be “I am the best,” which may not be true, depending on the context, and may actually reinforce the negative automatic thought if the client doesn’t believe it.
You’ll want to do a reality check with your clients for each coping thought, asking your clients questions to ensure that they are creating coping thoughts that will be effective. Ask them, “Is that statement true for you?” or “Is that realistic?” Once your clients have created a coping thought for this situation, guide them through completing the worksheet by recording a few more triggering situations, automatic thoughts, and coping thoughts. Give clients the Client Coping Thoughts handout so they can record the coping sequence.
Following is a handout on coping thoughts you can give to clients to help them understand this skill, and a blank worksheet for clients on which to log their triggers, automatic thoughts, and coping thoughts. (Both are available in reproducible format in Appendix C, and for download at the website for this book.) To help them understand this exercise, a filled-out sample of the second worksheet is also provided for clients.
Coping thoughts can be used when you are facing a difficult emotion. They may be especially helpful after you’ve practiced observing and accepting the difficult emotion, and you’re still struggling with specific ruminations, or a repetitive automatic thought is fueling your emotion wave.
You now know that your emotions will follow whatever you pay attention to. If you’re triggered, you’re likely to have negative automatic thoughts. One way to tolerate the distress and shift your emotion is to replace the negative automatic thought with a coping thought. The key with a coping thought is that you believe it to be true and realistic. If you don’t believe the thought, it’s unlikely to be effective.
Following are some examples of coping thoughts:
Replacing Automatic Thoughts with Coping Thoughts
Use this worksheet to record specific triggers, the automatic thoughts that go with them, and alternative coping thoughts with which you can replace them.
Trigger |
Automatic Thought |
Coping Thought |
1. |
1. |
1. |
2. |
2. |
2. |
3. |
3. |
3. |
4. |
4. |
4. |
5. |
5. |
5. |
(Client Sample)
Trigger |
Automatic Thought |
Coping Thought |
1. Turning in a project to my boss. |
1. My work isn’t as good as it should be. |
1. I’m doing my best, which is all I can do. |
2. Being at a party with people I don’t know. |
2. If I don’t say the right thing at this party, people are going to think I’m a loser. |
2. I can have this thought without acting on it. |
3. My wife comes home and goes straight to the bedroom. |
3. My wife doesn’t love me anymore. |
3. My defectiveness schema is talking, but I’m not listening. |
4. Anytime… |
4. Something’s wrong with me. |
4. I have strengths and weaknesses, just like everybody else. |
5. My boss doesn’t talk to me at the office-wide lunch. |
5. My boss doesn’t like me. |
5. It’s not my job to be liked. It’s my job to do my job. |
Therapist: Now that you’ve completed the Coping Thoughts worksheet, let’s do an exposure exercise to practice using the coping thoughts we’ve developed for one of the triggering situations and an automatic negative thought.
Client: Okay. Which one should I choose?
Therapist: Just take a look at what you have there, and choose a situation that you predict will be somewhere around a 5 or 6 on the SUDS scale, with 1 being no distress and 10 being the worst distress you can imagine.
Client: [Pauses] Well, I think when my wife comes home and goes straight to the bedroom.
Therapist: Okay. And how distressing do you predict that scene will be for you?
Client: I would say a 6.
Therapist: Okay, good. Let’s take a few minutes to get into that scene. Just close your eyes and I’ll talk you through it.
Client: Okay [closes eyes].
Therapist: Imagine the last time your wife came home and went to the bedroom. Put yourself in the physical location you were in. Try to remember what you were doing. Remember what you can see around you, what you can hear, anything you can sense. Can you see yourself there, and are you feeling the emotion?
Client: Yes.
Therapist: Okay. Where do you feel the emotion in your body?
Client: I have a tight feeling in my stomach.
Therapist: Okay, let’s start with that. See if you can allow that sensation to just be there, without judging it, without reacting to it, and instead opening and softening to it.
Client: [Pauses] Yeah, I’m trying.
Therapist: You might imagine that instead of avoiding the sensation, you are leaning into it…
Client: Okay.
Therapist: Just notice if the sensation is changing or staying the same; notice what size and shape it is…whether there’s a temperature to it.
Client: Yeah. It’s hard and tight, about the size of a baseball. It’s not moving. I don’t feel any temperature.
Therapist: Has it changed since you’ve been observing it?
Client: It’s a little less intense now.
Therapist: Okay, good. Can you identify a feeling that goes with the sensation?
Client: Uh, maybe fear? I feel afraid.
Therapist: So there’s a tight sensation in your stomach, and the feeling that goes with it is fear?
Client: Yeah.
Therapist: Okay. And is there an urge to do something or not do something?
Client: Well, I don’t want to talk to her… I think I’m scared I’ll see that she really doesn’t want to talk to me. The urge is also to shut my office door…to hide out.
Therapist: Okay. Just see if you can sit with that urge to not talk to her, and also the urge to shut the door and hide. Notice what it’s like to allow that urge to be there.
Client: It feels terrible.
Therapist: Okay, can you allow it to feel terrible…? Just make space for it to be exactly as it is?
Client: Yeah. I just wish it would change.
Therapist: Sure—it feels terrible and it makes sense you’d rather not feel that. See if you can stay with this and instead allow the feeling, and be curious about it for a few moments longer.
Client: Okay. Hmm.
Therapist: What came up for you?
Client: Well, it got a little less terrible as soon as I just accepted that it felt terrible.
Therapist: When you stopped avoiding or resisting, the emotion wave went down?
Client: Yeah.
Therapist: Okay. Let’s now think about the negative automatic thought that comes up for you in this situation.
Client: That “My wife doesn’t love me anymore.”
Therapist: Your SUDS?
Therapist: Okay, let’s shut off the scene with your wife now and work on coping thoughts. What’s the coping thought that might help you most?
Client: I guess that I don’t have to listen to my defectiveness schema?
Therapist: Okay. So you can just say, “I’m having the thought that she doesn’t really love me anymore,” and then say your coping thought.
Client: Okay. “My defectiveness schema is talking, but I don’t have to listen.”
Therapist: How is that working for you?
Client: Well, it takes my attention off of the fear. And…it makes me question whether it’s true that she doesn’t love me anymore.
Therapist: Okay. Stay with it for a moment, just saying it to yourself a few times. [Waits 45 seconds] What’s showing up for you now?
Client: Well, I feel better…
Therapist: Your SUDS dropped?
Client: Yeah. I was up to almost 7, and then once I said the coping thought I dropped to about a 4.
Therapist: So the thought that it’s your defectiveness belief talking and not the absolute truth was helpful?
Client: Yes. I’m actually surprised how much the feeling of fear changed… It’s like my whole perspective changed…
Therapist: Great. Let’s try a second coping thought now. What do you think might most help now?
Client: Hmm. Maybe that “My emotions aren’t the truth”?
Therapist: Okay, your emotions aren’t the truth. So try saying that to yourself a few times silently.
Client: Okay…
Therapist: [Waits twenty seconds or so] So are you thinking differently about the trigger?
Client: Yeah… I’m thinking that maybe she went to her room because she wants to change clothes and have a few moments to herself. Since she works as a nurse when she’s at her job, she’s with people nonstop, so maybe she just needs a little time-out. Maybe it has nothing to do with me.
Therapist: Great. So that thought helped you look at this differently?
Client: Yes, it helped to just allow the emotion, and then using the coping thought definitely helped too.
Therapist: Good. So let’s just check in again. Where is your SUDS level in this moment?
Client: It’s around a 2.
Therapist: Okay, great. Let’s wrap up the exercise, take a deep breath, and let it out slowly as you open your eyes and come back to the room.
Radical acceptance is a key component of dialectical behavior therapy, which was developed by Marsha Linehan (1993). It is the practice of accepting the reality of things exactly as they are without resisting or trying to change them. To grasp the concept of radical acceptance, it can be helpful to understand what it is and what it isn’t: Radical acceptance is a complete and total embracing of an unchangeable reality. Radical acceptance is not approval, passivity, forgiveness, compassion, or love.
By practicing radical acceptance of a triggering situation, event, or memory, clients learn to be mindful while downregulating emotion. Clients will find that they have more freedom to choose how they respond. Radical acceptance can be a difficult skill to choose when life is painful, disappointing, or scary; it’s the opposite of what most of us want to do when things are different than what we would hope.
It’s important to note that radical acceptance is distinct from mindful acceptance. Radical acceptance means accepting the unchangeable reality of “what is”; mindful acceptance means accepting one’s emotional experience.
Following is a handout you can use to help your clients understand radical acceptance.
What It Is
Part of successfully navigating intense emotions is knowing when it’s time to try to improve your situation and when it’s time to accept it. Radical acceptance is another mindful coping skill that allows you to accept “what is” and stop suffering from rejecting the reality in front of you. We have a choice in every moment: to reject the reality of what is or to accept it. The choice we make will determine whether we continue to suffer or create space for something else to exist.
Our natural response to distressing emotions is to fight against the reality that we think caused them. In doing this, we can make ourselves and others miserable. Choosing radical acceptance—to accept “what is”—is a huge shift for most people. It feels like the opposite of what your emotions urge you to do when you encounter pain.
What It’s Not
Radical acceptance does not mean you like or condone what happened. It just means that you accept the reality that it happened. In other words, some situations in life are simply unjust or unfair. In other situations, you may share responsibility for what happened. Either way, just because you accept that it happened doesn’t mean you’re condoning it.
The more you practice radical acceptance, the easier it will become to stop resisting what you cannot change.
Following are a few examples of radical acceptance:
Radical acceptance requires a willingness to look at things differently. Sometimes our disappointments and moments of frustration were preventable. We can also practice radical acceptance by accepting what we might have done differently, and taking responsibility for how we didn’t. For example, could you have prevented being late to an appointment, forgetting to do work assignments, or behaving in a way that was less than stellar? Moreover, could you have prevented lying to hurt someone or allowing yourself to be motivated by hate? Many times we have culpability in “what is.” Accepting that is key to practicing radical acceptance.
While the outcomes of these situations may have serious consequences, they can also be opportunities for growth if you can view them as moments of learning. Often people who struggle with intense emotions believe that life is something that “happens” to them, instead of recognizing their own power in creating their experience.
The good news is that if we have responsibility in the things happening, we also have the power to make different choices—choices that can alleviate suffering and bring us closer to living the life we want in accordance with our values.
It’s not unusual for clients to struggle with understanding radical acceptance, especially if the situation they are struggling to accept was traumatic. Following is a sample therapist-client dialogue of how you can talk to you clients about radical acceptance. The Radical Acceptance worksheet at the end of this chapter is another tool to help your clients understand and practice this skill.
Therapist: Have you heard of radical acceptance?
Client: Um, I think so. Is it a Buddhist thing?
Therapist: I believe it is something that Buddhists practice, but we are using it here as a mindful coping skill.
Client: I see. So what’s radical about it?
Therapist: Good question. The radical part of radical acceptance refers to how complete and total the acceptance is. In other words, you don’t just partly accept the reality of what is—you fully accept that what exists is unchangeable.
Client: Okay…
Therapist: So let’s use an example of something you’ve been struggling with, or wish would change, but that you can’t change. You can use the worksheet, starting with the section “Assessing the situation.”
Client: I guess the fact that I have chronic pain, and no matter what I do, I can’t seem to get rid of it.
Therapist: Okay, great example. Because you have done everything in your power, right? You exercise, eat healthy, and get plenty of sleep just like your doctor has told you to?
Client: Yep. And I still hurt every day [eyes well up].
Therapist: Yeah. This is an ongoing challenge for you.
Client: Uh-huh.
Therapist: So let’s continue with the worksheet. What’s next?
Client: [Looks at the worksheet] So the situation is my pain… I’m not really sure that any past events led to the situation because the doctor doesn’t really know why I hurt.
Therapist: Okay. What’s next?
Client: [Continuing with the worksheet] I don’t think I or anyone else played a role in my pain. I really don’t have much control over it, and what control I do have I’m already taking.
Therapist: That’s right. You’re already doing all the things your doctor says can help the pain.
Client: And I can’t control the fact that it still hurts every day.
Therapist: Right.
Client: [Continuing with the worksheet] So my response to the pain at first was to be really depressed. I just thought about all the things I can’t do anymore because it makes the pain worse. And I was really mad.
Therapist: Who were you mad at?
Client: I don’t know… God? My parents for giving me these genes?
Therapist: Okay. And how did that affect your thoughts and feelings?
Client: Gosh, I ended up miserable and depressed! I just went round and round with it. I mean, now it’s better because I at least accept I have the pain, but I still haven’t accepted what I can’t do…like running for example.
Therapist: Good point. You’ve accepted it halfway, but not all the way?
Client: Yeah.
Therapist: And how is that affecting you?
Client: I’m still pretty down about it. I mean, I just never really liked any other exercise. Nothing else gives me that feeling of being so…free.
Therapist: I get it. And how does being down affect you and your life?
Client: Well, I haven’t been exercising at all because I’m down, so I’ve gained weight…and can’t really fit into my favorite clothes now. And it makes me not want to go out with my friends because I’m self-conscious about how I look. And now my friends are frustrated with me that I don’t want to hang out like I used to.
Therapist: So it’s really affecting you to not be able to radically accept the limitations that come with your pain?
Client: Yeah. It really is.
Therapist: What would it look like if you applied radical acceptance to the reality that you have chronic pain.
Client: Yeah…it’s got to be better than this.
Therapist: Okay. So using the worksheet, let’s walk through what they might look like.
Client: Okay.
Therapist: When you think about your pain, can you connect to the resistance you have about how it limits your activity?
Client: Oh, yeah!
Therapist: Okay. So move on to step 2.
Client: Okay. So I know how to do mindful acceptance…should I just talk through it right now?
Therapist: Exactly. Go ahead and close your eyes, if it’s helpful, and just notice each component of the emotion that goes with that resistance. Tell me what you’re experiencing as you practice observing and accepting.
Client: All right… So the first thing I notice is a tightness in my chest and throat. So I’m just noticing that sensation…trying to allow it.
Therapist: Great. Just make room for it and observe whether it changes or shifts, whether it has any temperature to it.
Client: Yeah, there’s no temperature, but it got less strong as soon as I started making room for it.
Therapist: Great. What else are you aware of?
Client: I’m having the thought that this isn’t fair!
Therapist: Okay. Can you just acknowledge that thought, and try to let it go?
Client: Yeah…but now I’m angry.
Therapist: Okay, let’s stay with that for a moment.
Client: Yeah… [Starts to cry a little] I’m just so, so…disappointed.
Therapist: Yeah. Not being able to run has been a huge adjustment for you.
Client: Yeah. It feels so unfair…there’s the thought again.
Therapist: So see if you can allow the anger and the disappointment, and also acknowledge the thought and let it go…
Client: Okay [still sniffling].
Therapist: Just stay with that for a moment…allowing and letting the thought go.
Client: [After thirty seconds] Okay… I’m feeling less angry, but I have the urge to keep thinking about how unfair this is.
Therapist: The thought just keeps coming up over and over again?
Client: Yeah.
Therapist: Okay. Let’s move into choosing radical acceptance. First, just practice letting go of the resistance. Continue to allow the emotion while also trying to let go of any rejection of the reality that you can’t run. Let me know what’s coming up.
Client: All right…so I am not going to resist that I have pain that keeps me from running, and I’m going to tell myself that I can’t change that?
Therapist: Exactly. No resisting. If you start to notice your mind, body, feelings, or urges are resisting, try to radically accept it by telling yourself that the reality of not being able to run is unchangeable, and just watch your emotion.
Client: Okay. I’m feeling the anger still, so I’m going to tell myself that the facts are that I have chronic pain that keeps me from running, and it can’t be any other way, because it just is this way.
Therapist: Good work… What’s it like when you tell yourself that?
Client: Well [exasperated sigh], it actually makes it seem senseless for me to be angry.
Therapist: Why’s that?
Client: Well, it makes it so clear that it’s not going to do anything but ruin my life. And as long as I’m angry, I’m disappointed and depressed, and then I don’t do anything I want.
Therapist: Okay. So it seems like it makes more sense not to continue feeling angry and disappointed about not being able to run, because you can’t change that?
Client: It’s just keeping me stuck.
Therapist: And what’s happening to the emotion?
Client: It’s shifted…and now I have the urge to figure out what I can do so I don’t stay heavy and so I feel like going out again.
Therapist: Okay, great. So it seems like you’re focusing on what you can control and are letting go of what you can’t?
Client: Yeah. Can we talk about that?
Therapist: Sure!
Think of a situation you have no control over, but about which you struggle to accept. Then answer the following questions:
Describe briefly the distressing situation:
What past events led to the situation?
What role, if any, did you play in creating the situation?
What roles, if any, did others play in the situation?
What do you have control of in this situation?
What do you not have control of in this situation?
What was your response to this situation?
How did your response affect your own thoughts and feelings?
How did your response affect the thoughts and feelings of others?
How could you have changed your response to this situation so that it led to less suffering for yourself and others?
How could the situation have occurred differently if you had chosen to radically accept the situation?
How to Practice Radical Acceptance
Once you’ve identified the situation and have a clear understanding of it, you can use these steps to practice radical acceptance during imaginal exposure or when you get upset.
As with all skills, it takes time and practice to master them. Remind your clients that the more they practice using coping thoughts and radical acceptance when they get triggered, the easier these skills will be—and the more relief they will bring.
Following is a synopsis of content covered in chapter 8: