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第七章：放松与自我安抚

第7章

放松与自我安抚

随着来访发展出在应对情绪时观察、接受和选择（O+A+C）的技能，他们正在学习忍受痛苦，并开始改变“自己无法承受痛苦”的信念。那些他们习惯性逃避或采取行动的情绪困扰现在可能显得不那么难以承受了。他们已经看到了痛苦，观察到了曾经感觉“太难以处理”的情绪。并且他们能够找到选择时刻——即当他们可以选择是否根据情绪驱动的冲动行事的时候。

但情绪效能不仅仅是相信自己有能力面对和忍受痛苦，或者基于价值观而不是情绪采取行动。它还意味着知道一个人有应对痛苦的技能。例如，当情感痛苦以突然的冲动形式出现，痛苦袭来时，会有一个即时评估：“我是否有能力承受这个？我知道如何与这种情绪共存吗？”这些问题的答案出现在来访选择接受而非回避的那个决策点上。

EET技能目标：

  • 观察 + 接受 + 选择
  • 正念应对
  • （放松/自我安抚）

正念应对

正念应对，就像所有关键的EET组成部分一样，始于正念接受的实践。来访观察并“驾驭”强烈的情绪。暴露练习是短暂的——通常不超过五分钟——这为来访提供了机会，增强他们可以体验困难情绪而不逃避的信念。正如之前的O+A+C练习一样，目的是观察而不是对情绪痛苦和冲动采取行动。然而，正念应对要求在O+A+C过程中加入第二阶段。一旦暴露结束，重点就转移到特定的应对策略上。现在来访将通过某种方式减少痛苦，直到达到一定程度的调节。

就像基于价值观的行动一样，来访将在选择时刻面对情绪触发时使用正念应对技巧。其过程类似于选择VBA：

  • 注意到痛苦的情绪，包括感受、想法和身体感觉的成分；
  • 观察并接受行为冲动；
  • 认识到情绪如此强烈，以至于首先需要进行正念接受练习；
  • 选择一种正念应对技巧来调节情绪，然后选择基于价值观的行动。

正念应对有助于建立情绪效能，特别是发展必要的技能来忍受（而不是避免）痛苦，并调节它。

正念应对的优势

情绪应对策略通常是在治疗师办公室或DBT小组会议等相对舒适的环境中教授的。来访排练应对过程，但在面对情绪风暴的紧急情况时可能会迅速忘记。在放松状态下学到的知识或技能在被激发时难以回忆，这可以通过状态依赖学习研究解释（Szymanski & O'Donohue, 1995）。这些研究表明，在特定状态下学到的知识或技能在不同状态下更难记住。正念应对通过在练习应对之前通过想象暴露诱导情绪唤醒，解决了这个问题。因此，来访被置于与实际情境中需要使用应对技能时相同的情绪触发状态。

正念应对的第二个优势在于它提供了跨多个情境的重复练习机会。Craske及其同事的研究表明，当避免的刺激在多种环境和情境中遇到时，暴露疗法效果最佳（Craske, Treanor, Conway, Zbozinek & Vervliet, 2014）。对于暴露加应对也是如此。想象暴露为在面对各种情绪和触发情境时练习应对技能创造了机会。

向来访介绍正念应对

介绍正念应对的步骤包括使用这种应对策略的理由，以及简要描述五种EET正念应对技巧：放松与自我安抚（本章），应对思维与彻底接受（第8章），以及分心与暂停（第9章）。

正念应对技巧练习的步骤及示例对话

以下是引导正念应对技巧练习的步骤，以及一个示例对话。

第一步：引导来访进行简短的想象暴露

第二步：达到目标情绪唤醒水平（5-6 SUDS），然后终止暴露

第三步：开始正念接受，并识别选择时刻

第四步：开始正念应对（使用五种EET技能之一），直到痛苦有所减轻（SUDS）

治疗师-来访对话示例：介绍正念应对

治疗师：今天我们开始学习一些新的内容——正念应对。这将添加到你已经进行的情绪暴露练习中——每次暴露后，你将使用这些新的应对技巧来减少痛苦。

这样做有以下好处：正念应对技巧会让你更有信心和安全感，相信自己能够处理任何情绪，无论它们有多强烈。这些技巧会增强你的效能感——让你觉得有足够的能力面对任何情绪风暴。你会在情绪被激发的状态下进行大量练习，这将帮助你在现实生活中遇到情绪触发时记住这些技巧。

来访：这些应对技巧是什么？我需要学些什么？

治疗师：总共有五种技巧。首先，你会学习基本的放松技巧——深呼吸、肌肉放松等。接下来是自我安抚技巧，比如听平静的声音或音乐、看美丽的事物、闻令人愉悦的香气等。这些都是有助于平静的体验。

今天我们将重点放在放松和自我安抚上。之后，我们还会开发一些应对思维来帮助你平静下来，以及分心策略来让你与困扰的情绪保持距离。这样可以吗？

来访：好的，没问题。

治疗师：正念应对其实很简单。我们会像往常一样做一个暴露练习，选择最近让你感到不安的情境。你会继续观察这个场景，直到情绪达到中等强度——大约5或6 SUDS。然后我们会停止暴露，并开始正念应对，直到情绪稍微平息一些。我们将分别练习放松和自我安抚，看看哪种对你更有效。

O+A+C + 正念应对

使用正念应对的方案与第7章至第9章中涵盖的所有五种技能相同。O+A+C + 正念应对的步骤如下：

第一步：让来访在家练习一周新的正念应对练习。

第二步：在会话中，选择一个来访最近情绪被触发的情境。鼓励他们可视化该场景，注意视觉、听觉和动觉元素。

第三步：当来访“观看”场景时，定期检查SUDS。当SUDS达到5或6，或者经过五分钟时，结束暴露并进行最终的SUDS评分。

第四步：要求来访观察并接受出现的任何感觉、想法、情感和冲动。鼓励他们为情绪的各个部分“腾出空间”。

第五步：开始正念应对。指导来访完成整个过程。继续正念应对，直到SUDS有所下降（即使是很小的下降）。

第六步：与来访回顾结果——讨论哪些方法有效，哪些无效。

现在让我们来看看本章中介绍的两种正念应对技巧：放松和自我安抚。

正念应对中的放松技巧

EET中教授的关键放松技巧包括膈肌呼吸、无紧张放松、提示控制呼吸和五感练习。

膈肌呼吸

  • 定义：这是放松程序中的经典第一步。膈肌呼吸要求来访将一只手放在胸部，另一只手放在腰带线上方。然后指导他们缓慢而深地呼吸，使腹部的手移动，而胸部的手不动（参见《通过放松进行正念应对》手册）。
  • 重要性：
    • 膈肌呼吸有助于减缓心率，降低血压，并促进身体的放松。
    • 这种呼吸方式可以迅速缓解紧张和焦虑，帮助来访更好地集中注意力。
  • 具体实践：
    • 指导呼吸：引导来访深呼吸，注意腹部的起伏。
    • 反复练习：多次重复练习，直到来访能够自然地进行膈肌呼吸。

无紧张放松

  • 定义：这项技能要求来访专注于五个肌肉群：面部（额头和下巴）、颈部和肩膀、手臂和手、胸部、背部和腹部、腿部（臀部、大腿、小腿和脚）。来访被指导观察特定的肌肉群，注意任何紧张区域。然后深呼吸，在吸气顶点默念一个提示词，然后呼气时放松目标肌肉群的紧张。这个过程应该对每个肌肉群重复两次。
  • 重要性：
    • 无紧张放松有助于识别和释放身体各部位的紧张。
    • 通过与放松相关的提示词，来访可以在日常生活中更容易地实现放松。
  • 具体实践：
    • 选择提示词：提示词可以是放松的颜色（金色光线、海蓝色）、与平静相关的地方（图奥勒米草地、谢南多厄国家公园）、命令（“现在放松”）或精神咒语（om）。
    • 逐步放松：从一个肌肉群开始，逐步扩展到全身，最后可以在需要时专注于单个肌肉群或特定紧张的肌肉。

提示控制呼吸

  • 定义：由Ost（1987）开发，这是一种快速有效的放松程序。它将无紧张放松简化为一个单一序列：深呼吸，在吸气顶点默念提示词，然后在呼气时放松全身的紧张。目标是同时放松所有肌肉群。来访使用在无紧张放松过程中建立的相同提示词。每次练习会话中做五到十个提示控制呼吸（参见《通过放松进行正念应对》手册）。
  • 重要性：
    • 提示控制呼吸是一种快速的放松方法，可以在短时间内达到放松效果。
    • 通过反复练习，提示词可以成为一种触发放松反应的条件反射。
  • 具体实践：
    • 选择提示词：确保来访选择一个对他们有积极意义的提示词。
    • 练习频率：建议每天练习几次，以加强提示词与放松之间的关联。

五感练习

  • 定义：这种技术旨在让来访进入当下。它通过将注意力从负面想法转移到当前的感觉体验上来放松。来访被教导每种感觉花费三十秒，按照以下顺序观察：
    • 听觉体验：尝试注意到每一个听到的声音。
    • 嗅觉体验：观察来自自己身体或环境中的香气、气味。
    • 动觉体验：注意触觉，包括温度、质地或压力，感受身体接触地板或椅子的部分。
    • 视觉体验：观察颜色、形状和物体。
    • 味觉体验：识别并观察任何味道（参见《通过放松进行正念应对》手册）。
  • 重要性：
    • 五感练习有助于将来访的注意力从负面情绪转移到当下的感官体验上。
    • 通过这种方式，来访可以更有效地管理情绪，减少情绪困扰。
  • 具体实践：
    • 逐步引导：治疗师逐步引导来访逐一关注每一种感觉。
    • 持续练习：鼓励来访在日常生活中定期练习，以增强效果。

治疗师-来访对话示例：放松作为正念应对技巧

在以下正念应对的例子中，来访选择了最近与她姐姐的一次争吵作为暴露情境。

治疗师：今天我们来学习如何使用放松技巧来进行正念应对。我们已经进行了简短的想象暴露，现在你的情绪强度大约是5或6 SUDS。接下来，我们将开始放松练习。首先，我们来做一些膈肌呼吸。请把一只手放在胸部，另一只手放在腹部。慢慢地深呼吸，注意你的腹部随着呼吸起伏，而胸部尽量保持不动。让我们一起做几次这样的呼吸。

来访：好的，我试试。（来访跟随治疗师的指示进行膈肌呼吸）

治疗师：很好，现在我们来尝试无紧张放松。我们将从面部开始。请闭上眼睛，观察你的面部，特别是额头和下巴。注意是否有任何紧张。如果有，深深地吸一口气，在吸气顶点默念“放松”，然后慢慢呼气，同时放松这些部位。我们重复两次。

来访：（来访跟随治疗师的指示进行无紧张放松）

治疗师：很好。接下来，我们来做提示控制呼吸。请深呼吸，在吸气顶点默念“放松”，然后慢慢呼气，放松全身。我们做五次这样的呼吸。

来访：（来访跟随治疗师的指示进行提示控制呼吸）

治疗师：非常好。最后，我们来做五感练习。请依次关注你的听觉、嗅觉、动觉、视觉和味觉。每种感觉花30秒时间。现在，先从听觉开始。请注意你周围的声音。

来访：（来访跟随治疗师的指示进行五感练习）

治疗师：非常棒！现在请告诉我，经过这些练习后，你的SUDS评分是多少？

来访：我觉得现在大概是3或4分了。

治疗师：很好，我们成功地降低了你的情绪强度。请记住，这些放松技巧可以帮助你在实际情境中更好地应对情绪。我们下次继续练习。

治疗师-来访对话示例：放松作为正念应对技巧

治疗师：闭上眼睛，回想一下你和姐姐吵架的那个场景。你们在餐厅——Salute。看到桌子的布局、房间的样子；听到周围人们的低语声和餐具碰撞的声音。感受手下的桌布质地。现在看到对面的姐姐，注意她的穿着。听她说话——她在说你忽视了她。只是观察这个场景，听她说的话……你的SUDS评分是多少？

来访：3或4。

治疗师：继续保持。看着对面的她。听她的话……试着接受这些感觉。尽量为这些感觉腾出空间……只是允许自己在听她说话时感受到任何情绪。你的SUDS评分是多少？

来访：大约5。

治疗师：好的。注意冲动。你的情绪正在推动你说一些刻薄的话。只是观察这种冲动，这是你需要做出选择的时刻。

来访：我感觉想告诉她她一无是处，然后离开。

治疗师：是的，注意到这种冲动。你可以选择这样做或不这样做。继续听她说的话……你的SUDS评分是多少？

来访：6。

治疗师：很好。现在放下这个画面。是时候进行正念应对了。你觉得哪种放松练习现在最适合你？

来访：深呼吸 [做了几次膈肌呼吸]。

治疗师：身体有没有紧张的地方？

来访：我的肩膀。

治疗师：你能用呼吸和提示词来放松肩膀的紧张吗？……你的SUDS评分是多少？

来访：4或5。

治疗师：现在什么可以帮助你？

来访：我想试试五感练习。

治疗师：好的。注意你听到的声音。如果有思绪干扰，就回到听觉上。注意你能闻到的气味……注意你的触觉……现在集中注意力看……注意你能尝到的味道……你的SUDS评分是多少？

来访：3。

治疗师：情绪变得柔和，强度降低了。这次体验怎么样？

来访：观察我的愤怒和爆发的冲动非常不同。只是允许它存在，而不是必须采取行动。通过呼吸缓解肩膀的压力效果最好。使用五感练习还可以，但我觉得在现实生活中可能效果不会那么好。我们再看看吧。

通过放松进行正念应对的手册

当强烈的情绪被触发，而你突然面临选择的时刻时，正念应对技巧可以帮助你在决定基于价值观的行动之前调节情绪。每天练习这些放松技巧，以便在关键时刻能够依赖它们。

膈肌呼吸

  • 将一只手放在腹部，另一只手放在胸部。
  • 缓慢深呼吸，使腹部的手移动，而胸部的手不动。
  • 如果你难以将呼吸推入腹部（胸部的手在动），可以尝试以下两种方法之一：
    • 用手按住腹部，然后吸气，使呼吸将手推出。
    • 躺下，在腹部放一本电话簿。吸气时让电话簿上升。
  • 每天练习15次膈肌呼吸，分三次进行。

无紧张放松

  • 选择一个提示词。选择一个与放松相关的词语或短语。这可以是一种颜色（金色光线、海蓝色）、一个让你平静的地方（图奥勒米草地、谢南多厄国家公园）、一条命令（现在放松）或一句精神咒语（om、世界和平、我放手）。这个提示词会逐渐与深度放松联系起来，并最终触发放松。
  • 观察一个肌肉群（见下一段），并注意任何紧张。做一次深呼吸。在吸气顶点默念提示词。然后呼气时，放松目标肌肉群的紧张。对每个肌肉群重复两次，顺序不限。

通过放松进行正念应对的手册

你将放松的五个肌肉群是：

  • 面部（额头和下巴）
  • 颈部和肩膀
  • 手臂和手
  • 胸部、背部、腹部
  • 腿部（臀部、大腿、小腿、脚）

每天练习这项技能三次。

提示控制呼吸

  • 使用你在无紧张放松时建立的相同提示词。
  • 做一次深呼吸，吸气到顶点时默念提示词。然后在呼气时，一次性放松全身的所有紧张。呼气时让身体稍微前倾，释放所有紧张。
  • 每天做15次提示控制呼吸，分三次进行，以练习这项新技能。

五感练习

  • 听觉体验：30秒内专注于你能听到的每一个声音：人声、交通噪音、机器噪音（如空调的嗡嗡声）、移动的声音、身体发出的声音。尽量保持注意力完全集中在这些声音上。如果思绪游离，轻轻地将其带回到所听到的声音上。
  • 嗅觉体验：30秒内专注于你能闻到的味道：香气、气味、来自自己身体或环境中的味道。尽量保持注意力集中在所闻到的味道上；当思绪游离时，返回到这个焦点。
  • 触觉体验：30秒内专注于你的触觉，包括温度和质地，注意身体接触地板或椅子的压力。当思绪游离时，回到触觉上。
  • 视觉体验：30秒内专注于视觉感受，观察颜色和形状，并注意环境中的物体。当分心时，把注意力拉回到所看到的事物上。
  • 味觉体验：30秒内专注于味觉。注意口腔中残留的味道——苦、甜、酸、咸。是否有更微妙的味道？当分心时，把注意力拉回到味觉上。

每天练习两次这种练习，作为将注意力从负面想法转移到当下体验的一种方式。

通过自我安抚进行正念应对

在辩证行为疗法中广泛使用的自我安抚练习，可以帮助每个感官获得平静的生理体验。鼓励来访找到并测试针对视觉、听觉、味觉、嗅觉和触觉的自我安抚方法，包括可以在家中进行的方法以及适合公共场合的方法。

以下工作表可以提供给来访，帮助他们发现新的自我安抚方法，以便在选择时刻进行正念应对。

通过自我安抚进行正念应对

这份工作表将帮助你识别一些使用五种感官来安抚自己的方法。

嗅觉

  • 使用你的嗅觉可以激活特定的想法、记忆或感觉，从而带来平静。如果你提前识别出让你感觉良好的气味，那么在情绪触发时就可以准备好使用它们。以下是一些例子，你可以自由添加自己的想法：
    • 点燃你喜欢的香薰蜡烛或熏香。
    • 涂抹让你感到快乐、自信或性感的香油、香水或古龙水。
    • 在钱包、手提包或车里携带杂志上的香味卡片，或者自制的香味卡片。
    • 去一个你知道有令人愉悦气味的地方，比如面包店或咖啡馆。
    • 在公园里躺下，闻一闻草、花或其他户外的气味。
    • 拥抱一个让你感到平静的人。
    • 其他想法：

视觉

  • 视觉对人类非常重要，因为我们的大脑很大一部分都用于处理我们所看到的东西。我们所看的东西可以对我们的情绪产生强大的影响，无论是好是坏。如果你提前识别出让你感觉良好的图像，那么在情绪低落时就可以准备好使用它们。以下是一些例子，你可以添加自己的想法：
    • 在网上、杂志或书籍中挑选你喜欢的图片。制作一张拼贴画挂在墙上，设置为电脑屏幕保护程序，或者随身携带在钱包或手提包里，全天随时查看。

通过自我安抚进行正念应对

视觉

  • 找一个让你感到宁静的地方，比如公园、湖泊、博物馆或其他地标。或者拍一张那个地方的照片。
  • 在网上或书店找到一些你觉得放松的照片或画作，例如安塞尔·亚当斯的自然摄影作品。
  • 画一幅你喜欢的画。
  • 随身携带你爱的人、你觉得有吸引力的人或你钦佩的人的照片。
  • 其他想法：

听觉

某些声音可以非常舒缓。例如，每个人对音乐都有自己的品味或偏好。通过提前识别出你知道对你有舒缓作用的歌曲或声音，你将准备好在需要时使用它们来帮助自己平静下来。以下是一些例子，你可以添加自己的想法：

  • 听舒缓的音乐：古典音乐、歌剧、老歌、新世纪音乐、摩城音乐、爵士乐、情绪摇滚等，任何适合你的都可以。可能是纯音乐或带有人声的音乐。去iTunes上听各种音乐，找出能帮助你放松的音乐。寻找预先选定的放松和冥想合集。
  • 听有声书或CD。许多公共图书馆允许借阅有声书。尝试一些看看是否有助于你放松。你甚至不需要关注故事情节；有时仅仅听某人的声音就能让人放松。
  • 看电视或在电脑上观看节目。找一部无聊或平静的节目，不要选择刺激性的真人秀或会让你生气的新闻。保持音量较低。
  • 听温和的谈话类播客，如园艺或音乐节目。
  • 听白噪音、风扇声或声音机。白噪音是一种混合的声音，可以屏蔽其他分散注意力的声音。声音机记录了鸟鸣、瀑布、风声、雨声和海浪声等。许多人发现这些机器非常放松。
  • 听流水声或涓涓细流的声音。找到个人电子喷泉或公园或商场附近的喷泉。
  • 听放松或冥想练习。这些练习可以帮助你想象自己以不同方式放松。
  • 其他想法：

味觉

我们的舌头上有不同的区域，利用味蕾来区分食物的味道。这些感觉也可以触发记忆和情感。通过提前识别出你知道对你有舒缓作用的味道，你将准备好在情绪波动时使用它们。以下是一些例子，你可以添加自己的想法：

  • 享受你最喜欢的餐点。慢慢品尝，用心感受其中的各种味道。
  • 随身携带口香糖、薄荷糖、口腔喷雾或其他美味的小吃，在感到不安时品尝。
  • 吃一种对你来说具有安慰作用的食物。
  • 喝一些你觉得舒缓的饮料，如茶、咖啡或热巧克力。
  • 吮吸冰棍或冰块，特别是当你感到热的时候。
  • 找一块成熟的多汁水果，慢慢品尝。
  • 其他想法：

触觉

我们的皮肤是身体最大的器官，上面布满了传递感觉至大脑的神经。这使得皮肤成为强大的情感信使。通过提前识别出你知道对你有舒缓作用的触觉体验，你将准备好在需要时使用它们来平复情绪。以下是一些例子，你可以添加自己的想法：

  • 在花园里工作，触摸凉爽的土壤。
  • 口袋里携带柔软或天鹅绒质地的东西，在感到不安时触摸。
  • 洗热水澡或冷水澡，感受水在皮肤上的感觉。
  • 泡一个带有泡泡或香精油的温水澡。
  • 做按摩。如果你不喜欢脱衣服，可以选择如指压按摩这样的类型，只需穿着宽松的衣服即可。或者找一个座椅按摩，进行肩颈按摩。
  • 自我按摩。
  • 和宠物玩耍——无论是你的还是别人的。抚摸动物的毛发或皮肤可以提供舒缓的触觉体验。事实上，养宠物有许多健康益处，如降低血压、降低胆固醇水平和减少心脏病风险。如果你找不到宠物，可以去当地的动物收容所，那里可以与被救助的动物玩耍。

本章知识点阐述

知识点阐述

  1. 观察 + 接受 + 选择 (O+A+C)

    • 定义：一种帮助来访在面对情绪时进行自我调节的方法。
    • 重要性：
      • 来访学会观察自己的情绪反应，接受它们的存在，并在选择时刻做出基于价值观的决策。
      • 这种方法有助于提高情绪容忍度，减少情绪驱动的行为。
    • 具体实践：
      • 观察情绪：指导来访注意自己的情绪反应，包括感觉、想法、情感和冲动。
      • 接受情绪：鼓励来访接受情绪的存在，而不是试图控制或避免它们。
      • 选择行动：帮助来访在选择时刻做出基于价值观的决策，而不是情绪驱动的行为。

  2. 正念应对

    • 定义：一种结合正念接受和特定应对策略的技巧，用于减轻情绪痛苦。
    • 重要性：
      • 正念应对不仅帮助来访学会接受情绪，还提供了一种方法来调节和管理情绪。
      • 通过反复练习，来访可以在实际情境中更好地应用这些技能。
    • 具体实践：
      • 暴露练习：通过想象暴露让来访体验强烈的情绪，然后停止暴露。
      • 应对策略：引入特定的应对策略，如放松、自我安抚等，帮助来访调节情绪。

  3. 正念应对的优势

    • 定义：正念应对相较于传统的情绪应对策略具有的独特优势。
    • 重要性：
      • 正念应对通过在情绪激活状态下进行练习，解决了状态依赖学习的问题。
      • 提供了跨多个情境的重复练习机会，增强了技能的应用性和泛化性。
    • 具体实践：
      • 想象暴露：在练习应对之前通过想象暴露诱导情绪唤醒。
      • 多情境练习：在多种情境下练习应对技能，增强其适应性和有效性。

  4. 向来访介绍正念应对

    • 定义：向来访介绍正念应对的概念和具体技巧的过程。
    • 重要性：
      • 通过清晰的解释和示范，帮助来访理解正念应对的重要性及其应用方法。
      • 为来访提供具体的应对工具，以便在实际生活中有效管理情绪。
    • 具体实践：
      • 解释理由：向来访解释为什么使用正念应对是有益的。
      • 介绍技巧：详细说明每种正念应对技巧的具体内容和应用场景。
      • 实践指导：通过实际练习帮助来访掌握这些技巧，并在实际情境中应用。

通过以上知识点的阐述，我们可以看到正念应对不仅是一种有效的心理技术，还可以帮助来访在面对情绪困扰时更好地管理和调节情绪。希望这些信息能为您提供有价值的见解，并在实践中有所帮助。

知识点阐述

  1. 引导来访进行简短的想象暴露

    • 定义：通过想象暴露让来访体验近期引起情绪反应的情境。
    • 重要性：
      • 通过想象暴露，来访可以在安全的环境中模拟实际情境，从而更好地理解和处理情绪。
      • 想象暴露有助于来访逐渐适应和忍受情绪，提高情绪容忍度。
    • 具体实践：
      • 情景描述：要求来访提供详细的事件描述，包括触发因素、情绪反应和行为。
      • 情绪激活：通过详细想象，使来访的情绪达到中等强度（5-6 SUDS）。

  2. 达到目标情绪唤醒水平（5-6 SUDS），然后终止暴露

    • 定义：在来访情绪达到中等强度时终止暴露。
    • 重要性：
      • 中等强度的情绪唤醒水平有助于来访感受到情绪，但不至于过于强烈而难以承受。
      • 终止暴露的时间点很重要，过早或过晚都可能影响效果。
    • 具体实践：
      • 监测SUDS：定期检查来访的SUDS评分，确保达到5-6分。
      • 终止暴露：一旦达到目标SUDS评分，立即终止暴露。

  3. 开始正念接受，并识别选择时刻

    • 定义：在终止暴露后，来访开始正念接受，并识别选择时刻。
    • 重要性：
      • 正念接受帮助来访学会观察和接受情绪的存在，而不是试图控制或避免它们。
      • 识别选择时刻有助于来访意识到自己可以选择如何应对情绪。
    • 具体实践：
      • 观察情绪：指导来访注意自己的情绪反应，包括感觉、想法、情感和冲动。
      • 接受情绪：鼓励来访接受情绪的存在，为情绪腾出空间。

  4. 开始正念应对（使用五种EET技能之一），直到痛苦有所减轻（SUDS）

    • 定义：使用特定的正念应对技巧来减轻情绪痛苦。
    • 重要性：
      • 正念应对不仅帮助来访学会接受情绪，还提供了一种方法来调节和管理情绪。
      • 通过反复练习，来访可以在实际情境中更好地应用这些技能。
    • 具体实践：
      • 选择技巧：根据来访的具体情况选择合适的正念应对技巧。
      • 练习技巧：指导来访练习选定的技巧，直到情绪有所减轻。

  5. 给来访一周时间在家练习新的正念应对技巧

    • 定义：让来访在家中练习新学到的正念应对技巧。
    • 重要性：
      • 家庭练习有助于巩固所学技巧，提高来访在实际情境中的应用能力。
      • 通过持续练习，来访可以更好地掌握和内化这些技巧。
    • 具体实践：
      • 设定任务：明确告诉来访每天练习的内容和次数。
      • 反馈与调整：在下次会话中收集来访的反馈，根据需要调整练习计划。

  6. 在会话中选择一个近期情绪被触发的情境

    • 定义：在会话中选择一个来访最近经历的情绪触发情境。
    • 重要性：
      • 选择具体的事件有助于来访更好地理解和处理特定的情绪障碍。
      • 通过回顾实际发生的情境，来访可以更清晰地看到自己的行为模式。
    • 具体实践：
      • 事件描述：要求来访提供详细的事件描述，包括触发因素、情绪反应和行为。
      • 情绪识别：帮助来访识别和命名他们在该情境中体验到的情绪。

  7. 观察和接受任何感觉、想法、情感和冲动

    • 定义：来访观察并接受在暴露过程中出现的所有感觉、想法、情感和冲动。
    • 重要性：
      • 观察和接受情绪有助于来访更好地理解自己的情绪反应。
      • 通过接受情绪，来访可以减少对情绪的回避和抵抗。
    • 具体实践：
      • 观察情绪：指导来访注意自己的情绪反应，包括感觉、想法、情感和冲动。
      • 接受情绪：鼓励来访接受情绪的存在，为情绪腾出空间。

  8. 开始正念应对，直到SUDS有所下降

    • 定义：使用正念应对技巧，直到情绪有所减轻。
    • 重要性：
      • 正念应对技巧帮助来访学会管理和调节情绪。
      • 通过反复练习，来访可以在实际情境中更好地应用这些技巧。
    • 具体实践：
      • 选择技巧：根据来访的具体情况选择合适的正念应对技巧。
      • 练习技巧：指导来访练习选定的技巧，直到情绪有所减轻。

  9. 与来访回顾结果，讨论哪些方法有效，哪些无效

    • 定义：与来访一起回顾练习的结果，讨论哪些方法有效，哪些无效。
    • 重要性：
      • 回顾结果有助于来访更好地理解和巩固所学的知识。
      • 通过反思和总结，来访可以更好地认识到自己的进步和需要改进的地方。
    • 具体实践：
      • 回顾与讨论：与来访一起回顾练习过程，讨论他们的体验和感受。
      • 反思与总结：引导来访反思整个过程，总结他们的收获和下一步计划。

通过以上知识点的阐述，我们可以看到正念应对技巧不仅是一种有效的心理技术，还可以帮助来访在面对情绪困扰时更好地管理和调节情绪。希望这些信息能为您提供有价值的见解，并在实践中有所帮助。

知识点阐述

  1. 膈肌呼吸

    • 定义：通过深呼吸使腹部扩张，而不是胸部。
    • 重要性：
      • 帮助减缓心率，降低血压，促进身体放松。
      • 快速缓解紧张和焦虑，提高专注力。
    • 具体实践：
      • 指导呼吸：引导来访深呼吸，注意腹部的起伏。
      • 反复练习：多次重复练习，直到来访能够自然地进行膈肌呼吸。

  2. 无紧张放松

    • 定义：通过观察和放松特定肌肉群来减轻身体紧张。
    • 重要性：
      • 识别和释放身体各部位的紧张。
      • 通过与放松相关的提示词，来访可以在日常生活中更容易地实现放松。
    • 具体实践：
      • 选择提示词：提示词可以是放松的颜色、与平静相关的地方、命令或精神咒语。
      • 逐步放松：从一个肌肉群开始，逐步扩展到全身，最后可以在需要时专注于单个肌肉群或特定紧张的肌肉。

  3. 提示控制呼吸

    • 定义：通过深呼吸、默念提示词和放松全身来实现快速放松。
    • 重要性：
      • 是一种快速的放松方法，可以在短时间内达到放松效果。
      • 通过反复练习，提示词可以成为一种触发放松反应的条件反射。
    • 具体实践：
      • 选择提示词：确保来访选择一个对他们有积极意义的提示词。
      • 练习频率：建议每天练习几次，以加强提示词与放松之间的关联。

  4. 五感练习

    • 定义：通过关注当下的感官体验来转移注意力，从而放松。
    • 重要性：
      • 将来访的注意力从负面情绪转移到当下的感官体验上。
      • 通过这种方式，来访可以更有效地管理情绪，减少情绪困扰。
    • 具体实践：
      • 逐步引导：治疗师逐步引导来访逐一关注每一种感觉。
      • 持续练习：鼓励来访在日常生活中定期练习，以增强效果。

通过以上知识点的阐述，我们可以看到放松技巧不仅有助于来访在面对情绪困扰时更好地管理和调节情绪，还能提高他们的整体生活质量。希望这些信息能为您提供有价值的见解，并在实践中有所帮助。

知识点阐述

  1. 膈肌呼吸

    • 定义：通过深呼吸使腹部扩张，而不是胸部。
    • 重要性：
      • 帮助减缓心率，降低血压，促进身体放松。
      • 快速缓解紧张和焦虑，提高专注力。
    • 具体实践：
      • 指导呼吸：引导来访深呼吸，注意腹部的起伏。
      • 反复练习：多次重复练习，直到来访能够自然地进行膈肌呼吸。

  2. 无紧张放松

    • 定义：通过观察和放松特定肌肉群来减轻身体紧张。
    • 重要性：
      • 识别和释放身体各部位的紧张。
      • 通过与放松相关的提示词，来访可以在日常生活中更容易地实现放松。
    • 具体实践：
      • 选择提示词：提示词可以是放松的颜色、与平静相关的地方、命令或精神咒语。
      • 逐步放松：从一个肌肉群开始，逐步扩展到全身，最后可以在需要时专注于单个肌肉群或特定紧张的肌肉。

  3. 正念应对中的放松技巧

    • 定义：通过放松技巧来帮助来访在面对情绪困扰时更好地管理和调节情绪。
    • 重要性：
      • 放松技巧有助于降低情绪强度，提高情绪容忍度。
      • 通过反复练习，来访可以在实际情境中更有效地应用这些技巧。
    • 具体实践：
      • 膈肌呼吸：引导来访进行深呼吸，注意腹部的起伏。
      • 无紧张放松：指导来访观察并放松特定肌肉群。
      • 五感练习：引导来访关注当下的感官体验，转移注意力，从而放松。

  4. 五感练习

    • 定义：通过关注当下的感官体验来转移注意力，从而放松。
    • 重要性：
      • 将来访的注意力从负面情绪转移到当下的感官体验上。
      • 通过这种方式，来访可以更有效地管理情绪，减少情绪困扰。
    • 具体实践：
      • 逐步引导：治疗师逐步引导来访逐一关注每一种感觉。
      • 持续练习：鼓励来访在日常生活中定期练习，以增强效果。

通过以上知识点的阐述，我们可以看到放松技巧不仅有助于来访在面对情绪困扰时更好地管理和调节情绪，还能提高他们的整体生活质量。希望这些信息能为您提供有价值的见解，并在实践中有所帮助。

知识点阐述

  1. 放松肌肉群

    • 定义：通过放松五个主要肌肉群来减轻身体紧张。
    • 重要性：
      • 识别和释放身体各部位的紧张有助于整体放松。
      • 通过逐步放松，来访可以更好地管理身体的紧张和压力。
    • 具体实践：
      • 面部：额头和下巴
      • 颈部和肩膀
      • 手臂和手
      • 胸部、背部、腹部
      • 腿部：臀部、大腿、小腿、脚
      • 练习频率：每天三次，每次放松每个肌肉群两次。

  2. 提示控制呼吸

    • 定义：通过深呼吸、默念提示词和放松全身来实现快速放松。
    • 重要性：
      • 是一种快速有效的放松方法，可以在短时间内达到放松效果。
      • 通过反复练习，提示词可以成为一种触发放松反应的条件反射。
    • 具体实践：
      • 选择提示词：确保来访选择一个对他们有积极意义的提示词。
      • 练习频率：每天三次，每次15次提示控制呼吸。

  3. 五感练习

    • 定义：通过关注当下的感官体验来转移注意力，从而放松。
    • 重要性：
      • 将来访的注意力从负面情绪转移到当下的感官体验上。
      • 通过这种方式，来访可以更有效地管理情绪，减少情绪困扰。
    • 具体实践：
      • 听觉：30秒内专注听到的声音。
      • 嗅觉：30秒内专注闻到的气味。
      • 触觉：30秒内专注触觉体验。
      • 视觉：30秒内专注看到的颜色和形状。
      • 味觉：30秒内专注口腔中的味道。
      • 练习频率：每天两次。

  4. 自我安抚技巧

    • 定义：通过各种感官体验来安抚自己，帮助缓解情绪。
    • 重要性：
      • 自我安抚技巧可以帮助来访在情绪触发时找到平静。
      • 通过多种感官体验，来访可以更好地调节情绪，提高生活质量。
    • 具体实践：
      • 嗅觉：利用喜欢的气味来安抚自己。
      • 视觉：通过观看喜欢的图片来安抚自己。
      • 其他感官：包括听觉、味觉和触觉的自我安抚方法。

通过以上知识点的阐述，我们可以看到放松技巧和自我安抚技巧不仅有助于来访在面对情绪困扰时更好地管理和调节情绪，还能提高他们的整体生活质量。希望这些信息能为您提供有价值的见解，并在实践中有所帮助。

知识点阐述

  1. 视觉

    • 定义：通过视觉体验来达到放松和平静的效果。
    • 重要性：
      • 视觉体验可以直接影响我们的情绪状态。
      • 通过提前准备并使用视觉元素，可以在情绪波动时迅速找到平静。
    • 具体实践：
      • 寻找宁静的地方：选择一个让你感到放松的地方，并拍照留念。
      • 欣赏艺术作品：收集你喜欢的艺术作品，如照片或画作。
      • 创造艺术：绘画或创作一幅你喜欢的作品。
      • 随身携带喜欢的照片：携带你爱的人或你喜欢的人的照片。

  2. 听觉

    • 定义：通过听觉体验来达到放松和平静的效果。
    • 重要性：
      • 声音可以直接影响我们的情绪和心理状态。
      • 通过提前准备并使用特定的声音，可以在情绪波动时迅速找到平静。
    • 具体实践：
      • 听音乐：选择你喜欢的音乐类型，如古典音乐、自然声音等。
      • 听有声书：听有声书或故事，不一定需要关注内容，只是听声音就可以放松。
      • 听白噪音：使用白噪音机或自然界的声音，如鸟鸣、流水声等。
      • 听放松练习：进行放松或冥想练习，帮助你想象自己处于放松状态。

  3. 味觉

    • 定义：通过味觉体验来达到放松和平静的效果。
    • 重要性：
      • 味觉可以触发愉悦的记忆和情感。
      • 通过提前准备并使用特定的食物或饮料，可以在情绪波动时迅速找到平静。
    • 具体实践：
      • 享受美食：慢慢品尝你喜欢的食物，体会其中的各种味道。
      • 携带小零食：随身携带口香糖、薄荷糖等小零食，在需要时食用。
      • 喝舒缓饮料：喝一杯你喜欢的茶、咖啡或热巧克力。
      • 吃水果：慢慢品尝一块成熟的多汁水果。

  4. 触觉

    • 定义：通过触觉体验来达到放松和平静的效果。
    • 重要性：
      • 触觉可以直接影响我们的情绪和心理状态。
      • 通过提前准备并使用特定的触觉体验，可以在情绪波动时迅速找到平静。
    • 具体实践：
      • 接触自然：在花园里工作，触摸土壤。
      • 携带柔软物品：口袋里携带柔软或天鹅绒质地的物品，在需要时触摸。
      • 洗澡：洗热水澡或冷水澡，感受水在皮肤上的感觉。
      • 做按摩：进行专业按摩或自我按摩，放松肌肉。
      • 与宠物互动：抚摸宠物的毛发或皮肤，提供舒缓的触觉体验。

通过以上知识点的阐述，我们可以看到通过五种感官体验来进行自我安抚不仅有助于来访在面对情绪困扰时更好地管理和调节情绪，还能提高他们的整体生活质量。希望这些信息能为您提供有价值的见解，并在实践中有所帮助。

Chapter 7 Relaxation and Self-Soothing 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 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: Noticing painful emotion, including the components of feelings, thoughts, and sensations; observing and accepting the action urge; recognizing that the emotion is so powerful that they first need to practice mindful acceptance; and choosing a mindful coping skill to downregulate emotion before they choose a values-based action. 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. Advantages of Mindful Coping 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. Introducing Mindful Coping to Clients 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. Step 1: Lead clients into a brief imaginal exposure. Step 2: Achieve the target range for emotional arousal (5–6 SUDS), then terminate exposure. Step 3: Initiate mindful acceptance and identify the moment of choice. Step 4: Initiate mindful coping (using one of the five EET skills) until there is some reduction in distress (SUDS). Therapist-Client Dialogue Example: Introducing Mindful Coping 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. O+A+C + Mindful Coping 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:Step 1: Give clients a week to practice new mindful coping exercises at home. Step 2: In session, choose a recent situation when the clients were emotionally triggered. Encourage them to visualize the scene, paying attention to visual, auditory, and kinesthetic elements. Step 3: While the clients “watch” the scene, periodically check SUDS. When SUDS reach 5 or 6, or five minutes has elapsed, end the exposure and take a final SUDS rating. Step 4: Ask clients to observe and accept any sensations, thoughts, feelings, and urges that arise. Encourage them to “make room” for all parts of the emotion. Step 5: Begin mindful coping. Coach the clients through the process. Continue mindful coping until there is some (even a small) reduction in SUDS. Step 6: Review outcomes with the clients—go over what worked and what didn’t. Now let’s look at the two mindful coping skills covered in this chapter: relaxation and self-soothing. Mindful Coping with Relaxation Key relaxation skills taught in EET are diaphragmatic breathing, relaxation without tension, cue-controlled breathing, and the five-senses exercise. Diaphragmatic breathing. This is the classic first step in a relaxation program. Diaphragmatic breathing starts by having clients place one hand on their chest and the other just above the belt line. The clients are then instructed to breathe slowly and deeply, so the hand on the abdomen moves while the hand on the chest does not (see the Mindful Coping Through Relaxation handout).Relaxation without tension. This skill requires clients to focus on five muscle groups: face (forehead and jaw); neck and shoulders; arms and hands; chest, back, and abdomen; and legs (buttocks, thighs, calves, and feet). Clients are instructed to observe a specific muscle group, noting any area of tension. Then they take a deep breath, subvocally recite a cue word at the top of the breath, and then release the breath while relaxing away tension in the target muscle group. This process should be done twice with each muscle group. 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. Cue-controlled breathing. Developed by Ost (1987), this skill is a quick, effective relaxation procedure. It distills relaxation without tension to a single sequence: a deep breath, the subvocalized cue word at the top of the breath, and the release of breath while relaxing away tension throughout the body. The goal is to relax all muscle groups simultaneously. Clients use the same cue word established during relaxation without tension. They do five to ten cue-controlled breaths during each practice session (see the Mindful Coping Through Relaxation handout). The five senses. This technique is designed to induct clients into the present moment. It relaxes by moving attention from negative thoughts into a focus on current sensory experience. Clients are taught to spend thirty seconds on each sense, observing the following sequence:Auditory experience: trying to notice each sound in earshot Olfactory experience: observing fragrances, odors, and scents from clients’ own bodies or the environment Kinesthetic experience: noticing touch, including the sense of temperature, texture, or pressure where one’s body touches the floor or chair Visual experience: observing colors, shapes, and objects Gustatory experience: identifying and observing any kind of taste (see the Mindful Coping Through Relaxation handout) The following sample script can be a model when your clients are ready to be introduced to using the mindful coping skill of relaxation. Therapist-Client Dialogue Example: Relaxation as a Mindful Coping Skill 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. Tryto 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? Client: A 4 or 5. 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 dosomething. 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: • Press your hand into your abdomen, and then inhale so that the breath pushes your hand out. • Lie down and put a phone book over your abdomen. Breathe so that your inhale pushes the phone book up. 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: • Face (forehead and jaw) • Neck and shoulders • Arms and hands • Chest, back, abdomen • Legs (buttocks, thighs, calves, feet) 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. Mindful Coping with Self-Soothing 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: Burn scented candles or incense that you like.Wear scented oils, perfume, or cologne that makes you feel happy, confident, or sexy. Carry perfumed cards from magazines, or ones that you make, in your purse, wallet, or car. Go someplace where you know the scent is pleasing to you, such as a bakery or coffee shop. Lie down in a park where you can smell grass, flowers, or other outdoor smells. Buy flowers or find flowers in your neighborhood. Hug someone whose smell makes you feel calm. Other 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: Look online, through magazines, and in books to select pictures you like. Make a collage of them to hang on your wall, add as a screensaver on your computer, or keep with you in your purse or wallet to look at throughout the day. Find a physical place that’s soothing for you to look at, like a park, a lake, a museum, or other landmark. Or take a picture of that place. Go online or to the bookstore and find a collection of photographs or paintings that you find relaxing, such as the nature photographs by Ansel Adams. Draw or paint a picture that’s pleasing to you. Carry a picture of someone you love, someone you find attractive, or someone you admire. Other ideas: Sense of HearingCertain 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: Listen to soothing music: classical, opera, oldies, new age, Motown, jazz, emo, whatever works for you. It might be instrumental or music with singing. Go online to iTunes and listen to a variety of music to determine what helps you relax. Look for preselected compilations for relaxation and meditation. Listen to audiobooks or CDs. Many public libraries will let you check out audiobooks. Try some to see if they help you relax. You don’t even have to pay attention to the story line; sometimes just listening to the sound of someone’s voice can be relaxing. Watch TV or stream shows on your computer. Find a show that’s boring or sedate, not anything activating, like reality TV, or that would make you angry, like the news. Keep the volume at a low level. Listen to a gentle talk-show podcast, like a gardening or music show. Listen to white noise, a fan, or sound machine. White noise is a blend of sounds that blocks out other distracting sounds. A sound machine has recorded sounds such as birds, waterfalls, wind, rain, and waves. Many people find these machines very relaxing. Listen to the sounds of rushing or trickling water. Find a personal electronic water fountain or a nearby fountain in a park or a mall. Listen to a relaxation or meditation exercise. Exercises like these help you imagine yourself relaxing in different ways. Other 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:Enjoy your favorite meal. Eat it slowly and mindfully so you can savor all of its various flavors. Carry gum, mints, mouth spray, or other tasty treats with you to taste when you’re feeling upset. Eat a “comfort” food that’s soothing to you. Drink something you find soothing, such as tea, coffee, or hot chocolate. Suck on a popsicle or ice cube, especially if you’re feeling warm. Find a piece of ripe, juicy fruit and eat it slowly. Other 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: Work in the garden, touching the cool earth. Carry something soft or velvety in your pocket to touch when you’re upset. Take a hot or cold shower and observe the sensations of water on your skin. Take a warm bath with bubbles or scented oil. Get a massage. If you’re not comfortable taking your clothes off, look for massage types such as Shiatsu, which simply requires you to wear loose-fitting clothes. Or find a seated chair massage for a shoulder and neck rub. Massage yourself. Play with a pet—yours or someone else’s. Stroking an animal’s fur or skin can provide a soothing tactile experience. In fact, having a pet can have many health benefits, such as lower blood pressure, lower cholesterol levels, and reduced risk for heart disease. If youcan’t find a pet, visit your local animal shelter, where you can play with the rescued animals. Wear your most comfortable clothes, for instance a worn-in T-shirt, baggy sweats, and so on. Other ideas: This worksheet, and all the worksheets in this book, is available in appendix C and for download at http://www.newharbinger.com/34039. Therapist-Client Dialogue Example: Self-Soothing as a Mindful Coping Skill 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. Using Mindful Coping Outside Session 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. Summary Following is a synopsis of content covered in chapter 7:Distinct from coping skills that are used in other interventions, mindful coping skills are practiced only after the practice of mindful acceptance. This sets up coping skills to be used intentionally, consciously, and in a contextually adaptive manner. Mindful coping skills are for crisis situations when clients have become so emotionally flooded that they are unable to access values-based action and need to intentionally and mindfully downshift their emotion. The six mindful coping skills in EET include: relaxation, self-soothing, coping thoughts, radical acceptance, distraction, and time-out. Relaxation is a skill that can be used to downregulate emotion including all four components of emotion: thoughts, feelings, sensations, and urges. Self-soothing is a mindful coping skill that applies pleasurable experiences to each of the five senses in order to downregulate emotion using all four components of emotion. Mindful coping also helps clients recover enough to choose values-based action. The knowledge that clients can use mindful coping increases their emotion efficacy by contributing to their belief that they have the skills to recover when necessary.

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