第九章：分心与暂停

Chapter 9 Distraction and Time-Out The previous two chapters covered four mindful coping skills—relaxation, self-soothing, coping thoughts, and radical acceptance. The last two mindful coping skills clients will learn are distraction and time-out. As with all the mindful coping skills, distraction and time-out are not substitutes for mindful acceptance or values-based action. Rather, mindful coping is a choice that is only used when clients are still significantly emotionally dysregulated, even after practicing mindful acceptance and/or values-based action. You’ll want to keep emphasizing to clients that sometimes just practicing mindful acceptance or values-based action is all it takes to tolerate distress, regulate emotions, and move in the direction of one’s values. Mindful coping, on the other hand, is used when clients get emotionally overwhelmed, and are still in too much pain, even after choosing to mindfully accept the pain and/or choose a values-based action. EET Skill Objective: Observe + Accept + Choose mindful coping (distraction/time-out) Distraction Distraction follows the exposure of observing and accepting. In the moment of choice, distraction allows clients to shift attention away from stimuli that trigger emotion: provoking thoughts, sensations, and situations. Some theorists in the mindfulness and acceptance community view distraction as a form of avoidance and therefore discourage it. In EET, however, distraction is used mindfully—to intentionally shift attention to alternative present-moment experiences after observing and acceptingemotions. Because clients always begin with mindful acceptance, distraction is not used to avoid their experience but rather to mindfully regulate their emotions in an effective, contextually adaptive, and values-consistent manner. Moreover, distraction is taught as a skill to use only in crisis situations, as a last resort. For example, when clients are in danger of harming themselves or others, sometimes the best and only choice is to distract themselves from the urge to act on their emotions. The mindful coping protocol for distraction is the same as described in previous chapters. After reaching the target SUDS level (typically 5 to 7), clients practice one or more previously chosen distraction strategies. Ideally, they will have preselected techniques from each of the five distraction categories: Shifting attention to someone else. Here clients shift attention to those they care for, often making a specific plan to provide help or support. Thinking about values- based behavior can provide an effective alternative to triggering situations and cognitions. Shifting attention to something else. The goal of this technique is to use memory and imagination to create an alternative focus. Prayer, mantras, and passive forms of entertainment are also part of this mix. Focusing on productivity. While clients probably won’t practice this in your office, having a list of house- and self-care tasks can offer an effective response to emotional storms at home. Using alternatives to self-destructive behaviors. When clients struggle with emotion-driven urges that are dangerous or destructive, creating an alternative physical sensation is often the best distraction strategy (Linehan, 1993). Such approaches include holding an ice cube, screaming into a pillow, snapping a rubber band on the wrist, or even using a red marker or pen to draw on the body instead of cutting.Doing pleasurable activities. Pleasure sensations can rapidly shift mood and help clients downregulate. The list of pleasurable activities included in the Distraction Strategies handout is merely a conversation starter. You’ll need to make a more complete and customized list with your clients, and then choose some portable pleasures that you can use in the office. The following handout (also available at http://www.newharbinger.com/34049 and in Appendix C) will help clients identify mindful coping strategies to distract themselves when they have already tried to use mindful acceptance and/or values-based action and are still feeling triggered. Distraction Strategies The following handout will help you identify mindful coping ideas to distract yourself when you have already tried to use mindful acceptance and/or values-based action and are still feeling triggered. Pay Attention to Someone Else One effective way to shift your attention when you are emotionally triggered is to place your attention on someone else. Following are some examples of how you might do this, as well as a space for your own ideas: Call your friends and ask if they need help doing something, such as a chore, grocery shopping, or housecleaning. Ask any family members who live nearby if you can assist them with something: running errands, yard work, babysitting, walking the dog, etc. Call your local soup kitchen, homeless shelter, volunteer organization, or advocacy group and sign up to help. Bake cookies for a neighbor or coworker. Send a “just because” card to someone you haven’t talked to in a while. Write a thank-you email to someone who did something kind for you.Write a handwritten letter to someone who has changed your life for the better and tell him or her why. Make a list of people you admire and want to be like and write down why. People-watch. Go to a local store, shopping center, bookstore, or park and notice what other people do, how they dress. Listen to their conversations. Observe as many details about other people as you can. Play counting games while people-watching, for example, count the number of blue-eyed people versus brown-eyed people you see. Think about someone you care about. What do you imagine he or she is doing right now? Keep a picture of those you love in your wallet or purse. These people can range from family members to friends to public figures you admire. Look at the photo whenever you need comfort. Imagine having a healing, peaceful conversation with someone you deeply care about or admire. What would he or she say to you that would help you feel better? Imagine him or her saying this to you. Other ideas: Pay Attention to Something Else Our brains are amazing thinking machines. They produce millions of thoughts every day. Our emotions follow what we think about, and you can intentionally shift your thoughts when you’re triggered to decrease your emotional activation. Following are some examples of how you might do this, as well as a space for your own ideas: Pay attention to the natural world around you. Observe the flowers, trees, sky, and landscape as closely as possible. Observe any animals that are around. Listen to all the sounds around you. Or, if you live in a city without much nature, observe what you can see and hear. Keep a copy of your favorite prayer or saying with you. When you feel distressed, read it to yourself. Imagine the words calming and soothing you. Use imagery (such as white light coming down from the sky) to soothe you as you read the words.Walk around your neighborhood or a park and notice the scenery, the colors, the textures of your surroundings. Listen to music that’s pleasing to you. Also try listening to new music: from a different genre or from another country. Listen to an engaging audiobook. Close your eyes and really try to pay attention. Watch a TV show or movie you know will hold your attention and take your focus off yourself. Think about whether you would have written a different plot or ending. Learn a new language. Learn how to play a musical instrument. Write a letter to God or your higher power. Write in your journal. Other ideas: Be Productive Many people don’t schedule time to take care of themselves or their living environments. Doing tasks and chores can be an effective way to shift your attention away from your distress. Following are some examples, and a place for you to add your own ideas: Make a to-do list. Wash the dishes. Make phone calls to people with whom you are not angry and want to catch up with. Clear your room or house. Clean out your closet and donate old clothes. Redecorate a room in your house. Organize your books, files, drawers, etc. Make a plan of action for finding a job, or for finding a better job if you already have one.Make appointments with various people—doctor, dentist, optometrist, accountant, etc.—and arrive on time. Get a new hairstyle or haircut. Get a manicure or pedicure. Get a massage. Wash your car. Plan something: a party, event, your next vacation. Mow the lawn. Plant a garden, or do gardening work in your own space or in a community garden. Clean out your garage. Do homework or other work. Clean your bathtub and take a bath. Go grocery shopping and cook a nice dinner for yourself. Pay bills. Other ideas: Do a Pleasurable Activity Call or text a friend. Visit a friend or invite a friend to come over. Exercise: lift weights; do yoga, tai chi, or Pilates, or take classes to learn how; stretch your muscles; ride your bike; go swimming or hiking; play something you can do by yourself, such as basketball, bowling, handball, miniature golf, billiards. Get out of your house and go for a drive in your car, or ride public transportation. Plan a daytrip to somewhere you’ve always wanted to go. Sleep or take a nap. Eat something you really like.Cook your favorite meal. Watch TV or stream shows on the Internet. Go to a sporting event. Play video games. Join an Internet dating service. Create your own blog or website. Go shopping. Go to a bookstore and read. Go to your place of worship. Sing or learn how to sing. Take pictures. Join a club or attend a meet-up group. Make a movie or video with your phone. Go to a flower shop and smell your favorite flowers. Knit, crochet, or sew, or learn how. Make a scrapbook. Write a loving letter to yourself when you’re feeling good, and read it when you’re feeling upset. Draw or paint a picture, or learn how. Make a bucket list of things you want to do before you die. Make a list of 10 things you’re good at or that you like about yourself. Masturbate or have sex with someone you care about. Join a public-speaking group and write a speech. Pray or meditate. Other ideas:Alternatives to Self-Destructive Behaviors Some people who struggle with overwhelming emotions use self- destructive behaviors to temporarily relieve their distress. Instead of continuing to hurt yourself, consider using some tools to help shift your emotions rather than acting on them. Following are some examples, and a place for you to add your own ideas: Instead of hurting yourself, hold an ice cube in one hand and squeeze it. The sensation from the cold ice will be numbing and distracting. Write on yourself with a red felt-tip marker instead of cutting. Draw exactly where you would cut. Use red paint or nail polish to make it look like you’re bleeding. Then draw stitches with a black marker. If you need more distraction, squeeze an ice cube in the other hand at the same time. Snap a rubber band on your wrist each time you feel like hurting yourself. This is very painful, but it causes less permanent damage than cutting, burning, or otherwise mutilating yourself. Dig your fingernails into your arm without breaking the skin. Throw foam balls, rolled up socks, or pillows against the wall as hard as you can. Scream as loud as you can into a pillow or scream someplace where you won’t draw attention, like your car or at a loud concert. Cry. Sometimes people don’t cry because they’re afraid that if they start they’ll never stop. This never happens. In fact, the truth is that crying can make you feel better because it releases stress hormones. Other ideas: Mindful Coping with Distraction When you feel that your clients are ready to be introduced to skillful distraction, you can take the following steps: Step 1: Psychoeducation on distraction. Review the Before You Act, Distract handout with your clients. Emphasize that distraction isn’t about avoidingexperience—your clients have already faced their feelings during exposure. Distraction is merely a tool to increase behavioral choices—values-based behavior instead of emotion-driven urges. Highlight the way distraction works: Emotions mirror what we pay attention to. If we pay attention to people, things, or sensations that anger or upset us, our feelings will reflect that. And the intensity of those emotions can make it hard to act on our values. If we switch attention to something else, our feelings will reflect the new experience we’ve chosen. By shifting our attention to alternative present- moment experience, there are several potential benefits: • Clients will be less likely to be swept into destructive emotion-driven behaviors. • Clients will be more likely to be willing and able to act on values. • Clients will build their ability to tolerate distress. • Clients will learn that emotions subside if you observe and accept them. This is good news because it means we have some power over shifting our emotions by changing our attention. If possible, you’ll want to give both handouts—Distraction Strategies and Before You Act, Distract—to your clients as homework in the previous session so they can select one or more strategies they think will work for them. Step 2: Choosing distraction strategies. Talk with your clients to determine what distraction strategiesthey want to use in both their lives and the exposure practice. You’ll want to discuss them with your clients, being very specific about how they will be used. It’s also important to do a reality check about whether the strategies they’ve chosen will work for them in situations in which they imagine they might be needed. Step 3: Observe + Accept + Choose distraction. Select a recent emotionally triggering experience to use in imaginal exposure. Keep clients focused on the scene until arousal reaches 5 to 6 SUDS, or five minutes have elapsed. During exposure, coach clients to observe and accept all parts of the emotion, and make room for whatever shows up. Next, erase the scene and commence mindful coping with a distraction technique chosen by the clients. Support the clients to stay with the distraction, if effective, or choose another one. Check for SUDS both during the five or so minutes of mindful coping and at the end. A small reduction in SUDS is desirable but not necessary. Practicing mindful coping, even without a drop in distress, will still increase distress tolerance. Finally, talk to your clients about their experience to consolidate learning. The following dialogue sample can be used to guide you and your clients through the art of distraction as a mindful coping skill after clients have completed the Distraction Strategies worksheet. Therapist-Client Dialogue Example: Mindful Coping with Distraction Therapist: Let’s see what distraction strategies appeal to you [looks over the list to see which strategies the client checked]. You checked, “Do something for someone else.” Can you say more about that? Client: I’d like to pay attention to something else by planning my daughter’s birthday party. And I’d like to payattention to someone else by helping my brother with his disability claim. Therapist: Could you do either of those things here? Client: Sure. I have paper to make a list of things I’ll need for the party. And I brought the disability application papers. Therapist: Great. Did you choose any other distractions? Client: Yes. I brought a little peace meditation from Pema Chödrön. I also made a list of small chores I want to get done in the house—I think it would help if I tried to do something productive. ’Course, I can’t do that stuff here. Therapist: Very good. Anything else? Client: When I’m upset, I don’t really do anything to hurt myself, so I skipped over those ideas. In terms of being productive, I brought my needlepoint project. Therapist: What do you plan to make? Client: A pillow for the couch. Therapist: Any pleasurable activities? Client: Well, peaches are in season so I brought one to eat (pulls a peach out of her bag). Therapist: Perfect. You’ve got the idea. Could you choose two or three distraction strategies that we can practice right now? [The client chooses planning her daughter’s birthday party, the Pema Chödrön peace meditation, and eating a peach. Imaginal exposure focuses on feelings of hurt and anger at her father. After five minutes of exposure to the scene, and trying to make room for the feelings, the client is at a 4 on the SUDS scale. It’s a little low, but mindful coping proceeds anyway.] Therapist: Good. Let go of the scene now, and we’ll use distraction to shift your attention to something else.Which of the distraction strategies would feel best now? Just use your intuition. Client: I’ll try the peach [takes a few bites, piercing the juicy sweet flesh, letting the nectar caress her tongue and slide down the back of her throat, letting out a soft moan]. Therapist: Where are your SUDS? Client: Around 3. Therapist: Want to stick with eating the peach, or do something else? Client: I’ll read the Pema Chödrön meditation [looks for it, then settles in to read silently]… I like this, I’m gonna read it again [closes her eyes]… I can feel it. Therapist: Your SUDS? Client: A 2 or 2½. Therapist: Good. We’ll practice again in a minute. What was that like for you? Client: It was calming. I was already pretty over that thing with my father; I couldn’t get too worked up about it. The peach was good, but particularly the Pema Chödrön meditation helped me refocus and go somewhere else. [Folds her hands and looks at them] I can see how this helps. Use the following handout to help your clients understand when to use distraction as a mindful coping skill in the moment of choice. Before You Act, Distract Emotions mirror what we pay attention to. If we pay attention to people, things, or situations that anger or upset us, our feelings will reflect that. And the intensity of those emotions can make it hard to act on our values. If we switch attention to something else, our feelings will reflect the new experience we’ve chosen. We have the power to shift how we feel by shifting our attention. There are several benefits from using distraction:You’re less likely to be swept into destructive, emotion-driven behaviors. Your upset is likely to subside more quickly than if you act on your emotion. You’re more likely to feel able to act on your values. Avoiding Avoidance Sometimes it’s hard to tell if you’re using mindful coping to avoid your emotions or to move in the direction of your values. If you’re not sure, you can ask yourself this basic question: “Am I using this skill to move toward my values or to avoid my emotion?” Using distraction after you observe and accept your emotional experience can be a life- improving, values-consistent choice in situations when you’re getting overwhelmed and need to “downshift” an emotion wave. Mindful Coping with Distraction Follow these steps for mindful distraction: Step 1: Select a triggering event. Visualize an upsetting event until you are at the target level of arousal (usually 5 to 6 SUDS). Step 2: Observe and accept. Observe and accept the sensations, emotions, and urges that come up for at least 5 minutes. Make room for all the experience. Step 3: Choose distraction. Begin using a distraction technique of your choice for at least 5 minutes. You may also choose additional distraction strategies, if you want. Remember, if you experience a strong, painful emotion in the course of daily life, you can do one of two things: You can stay with the feeling, noticing the moment of choice, and responding with a values- based action. Or, if the pain is pushing you hard toward emotion- driven behavior and you can’t muster a values-based response, you can mindfully choose distraction (or any of the other mindful coping skills). Time-Out The last mindful coping skill is called time-out. When clients are in triggering environments or situations, sometimes thebest choice is to leave, or to take a “time-out.” This is particularly true if they are at risk of acting on emotion-driven urges that might damage a relationship or result in losing a job. Guide clients in coping ahead by helping them determine which situations they can safely walk away from and how to do it (i.e., a short script for exactly what to say, and how to handle resistance from the other person). The following handout will help clients identify when to take a time-out. Take a Time-Out Sometimes when you get emotionally triggered, the best thing you can do is leave, or take a “time-out.” If you find yourself in an extremely distressing situation with someone or something, and, after trying to practice mindful acceptance or enact a values-based action, you’re still very upset, it’s often best to distance yourself and shift your attention away from the trigger to a more positive present-moment experience. Try to remember that if you’re already overwhelmed by your emotions, it will be more difficult to resolve your problem in a healthy way. If you stay in the situation, you may make it worse than it is already. If you can put some distance between you and the situation, and give yourself time to calm your emotions, you can better think about what to do next. It may be helpful to rehearse doing this, or to write a short script ahead of time, so that you’ll know exactly how you want to excuse yourself from the situation. If you don’t feel you have time to excuse yourself, sometimes just walking away is the best you can do to keep from making a difficult situation worse. Mindful Coping with Time-Out Use the following steps to introduce your clients to the skill of time-out: Step 1: Psychoeducation on time-out. Review the Take a Time-Out handout with your clients. Emphasize that, in extreme cases, the best choice can be to put distance between the triggering person or situation. Asa tool, time-out gives clients a chance to increase behavioral choices—to enact values-based behavior instead of emotion-driven urges—by walking away from a situation before making it worse. Remind clients that they have some power over shifting their emotions by changing where they focus their attention. By shifting attention to a different present-moment experience, there are several potential benefits: • Clients will be less likely to be swept into destructive emotion-driven behaviors. • Clients will be more likely to be willing and able to act on values. • Clients will build their ability to tolerate distress. • Clients will learn that emotions subside if you observe and accept them. If possible, you’ll want to give the handout to your clients as homework in the previous session so they can select one or more strategies they think will work for them. Step 2: Choosing a time-out strategy. Talk with your clients to determine how they might excuse themselves from an overwhelming experience. Discuss how to walk away from a situation—what they would do and/or say—if necessary. Step 3: Observe + Accept + Choose time-out. Select a recent emotionally triggering experience to use in imaginal exposure. Keep clients focused on the scene until arousal reaches 5 to 6 SUDS, or five minutes have elapsed.During exposure, coach clients to observe and accept all parts of the emotion, and to make room for whatever shows up. Next, erase the scene and commence visualization of the time-out in the way the clients have planned it. Check for SUDS both during the five or so minutes of mindful coping and at the end. A small reduction in SUDS is desirable but not necessary. Practicing mindful coping, even without a drop in distress, will still increase distress tolerance. Finally, talk to your clients about their experience to consolidate learning. The following dialogue sample can be used to guide you and your clients through the art of time-out as a mindful coping skill. Therapist-Client Dialogue Example: Mindful Coping with Time-Out Therapist: You’ve come up with great ideas for how you might use distraction as a mindful coping skill, but what about a situation, like the one with your father, when you seem to get consistently hooked into a fight? Client: Yeah, I really have trouble with that. Therapist: Sometimes even after you practice mindful acceptance or try to do a values-based action, the emotions are still just too powerful not to get sucked in? Client: Yes. And sometimes I end up making the situation worse. Therapist: So that’s when you could take a time-out… Client: So how does that work? Therapist: To choose a time-out in the moment of choice, you would simply leave the situation. And you can improve your chances of successfully doing that with some planning. You can figure out how to leavea situation when you’re so triggered that you might act on emotion-driven urges. Client: Like the night he came home drunk and wanted to get into the whole situation around the divorce between him and my mom…? Therapist: Right. So let’s look at that. How could you have taken a time-out in that situation? Client: I could have told him I was too upset to have a conversation, and that I’d call him the next day. Therapist: Perfect. You’ve got the idea. You walk away from the situation and come back to it later when you feel that you’re not so emotionally triggered that you can’t practice mindful acceptance and values-based action. Client: Yeah, but what if he just keeps yelling at me? Therapist: What do you think you could do? Client: At that point, the best choice is probably just to leave. ’Cause I know nothing good can happen when he is drunk and angry like that. No matter how hard I try to be reasonable, or use mindful acceptance, he will just piss me off until I explode. Therapist: Right. That’s exactly the time to use a time-out. Now that your clients have practiced distraction and time- out using exposure, you will want to help them be clear about when to use distraction or time-out out of session. As a review, the criteria for using mindful coping are: When clients are in danger of losing behavioral control and engaging in destructive, emotion-driven responses. When clients are overwhelmed with pain and seem stuck in a deepening emotional crisis, even after practicing mindful acceptance. When clients are in too much pain to act on their values.Clients should be encouraged not to use distraction—or any other form of mindful coping—if: they haven’t first done exposure (O+A+C) and located their moment of choice, or the primary motivation is avoidance as opposed to having exhausted available choices (sitting with the feeling or acting on values). The following sample dialogue is one way you might approach this conversation. Therapist-Client Dialogue Example: Mindful Coping in Vivo The therapist explains to the client how to use mindful coping in daily life. Therapist: This week, when strong emotions come up, you have some new choices. The first thing is always to make room for the feeling—observe it and accept it. Then try to figure out what valued action you can choose, rather than actions driven by your emotions. Sometimes—often—that will be enough. But sometimes your feelings could be so strong that they seem overwhelming…maybe values-based action seems impossible and you’re about to do something harmful. That’s when mindful coping comes in. Client: Why only then? We’ve practiced it a lot, shouldn’t I use it whenever I’m upset? Therapist: Mindful coping is for situations when you’re so overwhelmed that you’re at risk of losing control. Otherwise, stay with observing, accepting, and choosing—O+A+C. Just allow the emotion, and then choose a values-based action. Client: So I only do mindful coping if I’m in total meltdown? Therapist: [Nodding] If you’re overwhelmed and in danger of doing something hurtful. Client: How am I supposed to figure that out? Therapist: Remember the work we did on being mindful of the moment of choice—the moment when you could do old, destructive behaviors or act on your values?That same mindful awareness can help you decide whether to use coping skills. Just watch what’s happening—can you think about what you value in this situation, or is that the last thing on your mind? Now make a mindful choice—if you’re overwhelmed and can’t act on your values, select a mindful coping strategy. Client: How? Therapist: See if you can make the choice intuitively—the strategy that would feel best right then. That’s another form of mindfulness. We could also make a list of the mindful coping strategies you’ve already practiced, and you could keep it with you. When you’re overwhelmed, you could look at it and see what would feel best for that moment. Summary Following is a synopsis of content covered in chapter 9: Distraction and time-out are mindful coping skills that can be used to shift attention and downregulate emotion. Shifting attention away from the triggering stimuli will downregulate emotion, giving clients more choices in how to respond. Neither distraction nor time-out is used as an avoidance strategy. Like all mindful coping skills— relaxation, self-soothing, coping thoughts, and radical acceptance—distraction or time-out is chosen mindfully, after observing and accepting the four parts of emotion. Distraction and time-out is only for use in “crisis” situations, when clients become flooded and are too emotionally triggered to continue mindful acceptance or to choose a values-based action.Distraction skills include: paying attention to someone or something else, shifting thought content, using productivity tasks or chores, and alternatives to self- destructive behaviors. Time-out is used in situations when leaving is the best way to prevent a difficult situation from becoming worse. Mindful coping using distraction and time-out is rehearsed through imaginal exposure and in vivo practice to enhance learning, recall, and retention.