When a client hits a roadblock in therapy, it’s sometimes because they’re actively trying to avoid stirring up (or even talking about) painful memories or emotions.
Now of course, it’s understandable why most clients skirt around painful topics to some extent . . .
. . . but as we know, it can also become a major impediment to healing.
And so, to restore therapeutic progress, we often need to help clients learn to tolerate distress so they can begin the critical work of unpacking difficult emotions.
In the video below, Christine Padesky, PhD walks through a titrated approach to help you do just that.
Click here for full transcript
It’s usually talking about some topic that they’ve been avoiding. It might be revealing something that happened to them. In the case of trauma, it might be talking about feeling depressed or anxious. In the case of someone with avoidant personality or an anxiety disorder. It might be talking about using a substance that the person’s highly dependent on or addicted to in the case of substance misuse. And what I tell them though is I say, “I’m going to propose that we talk about this for just 30 seconds and at the end of those 30 seconds, I’m going to work with you to distract and get away from it so that your distress doesn’t go beyond 30 seconds. Would you be willing to give that a try as an experiment to see what happens?” Now I set it up as a behavioral experiment and what that means is I ask them to predict.
I’ll say, “What do you predict will happen? What’s the worst you can imagine could happen if you talk about this or stay in this state of distress for 30 seconds? What’s the worst?” Now it’s interesting because sometimes people predict that they will literally start freaking out and going crazy. And if so, I asked what their images of that because it makes a difference whether they see it as a just kind of… or if they see it as, “Ah, I’m going crazy.” So I tried to get their image of what it is they think’s going to happen. Then we talk about what can we do to get them out of that state of distress and it’s often something very simple, like we’re going to talk about something. “What’s your favorite television show that you watched last night on television? Okay, we’re going to talk about that when we’re done.”
Because something has to be engaging enough to get their mind off the distress. So then we say, “Okay, let’s, let’s do this. I’m going to watch my clock 30 seconds, I’m going to stop you. Tell me what you can about this issue that seems too hot to touch.” And so then they’ll begin talking and usually, they do get distressed quite quickly in talking about the situation that they’ve been avoiding. And at 30 seconds promptly, I interrupt them. I say, “Okay, that’s 30 seconds. Let’s talk about that television show last night. I didn’t see that. What’s that about? Who are the characters?” And I ask them, pepper them with questions to get their mind engaged so they can trust me that I am in fact going to stop their distress at a certain point. After a minute or two I asked them, “Are you still feeling distressed?”
And if they say “No,”… if they say “Yes,” we’ll keep talking about television or something, but they usually say “no.” And then I’ll say, “Okay, let’s look at what happened. How high did your distress get from zero to 10 with zero being no distress, 10 being the most you’ve ever felt, and did that worst case scenario happen? Did you go crazy? Did you do something?” Sometimes their fear is about me, that I will judge them or be critical of them, that I appear judging or critical, and they’re usually a little bit surprised that it wasn’t as bad as they thought. And then I’ll say, “Now let’s review what the benefits would be if you could talk to me about this situation and then we’ll review benefits of facing distress” and then I’ll say, “Okay, let’s do a second experiment. How long do you want to do it for this time?”
“Do you think you could do one minute? Do you think he could manage one minute? What do you predict’s the worst that would happen?” We set it up as another experiment, do the same thing over and that usually goes pretty well and then I invite them to do it for two minutes and eventually we get to the point where I tell them, “Let’s just talk about distress without a time limit. You can stop whenever it feels too much for you” and that puts them in control and I find by the time we’ve done these little exercises and they trust me that I’m not going to want to plunge them into distress to the point where they fall apart, that I’m really going to be there for them and listening to them and that we are going to be trying to learn something from the distress, make links, understand what’s triggering them in the here and now related to this thing that perhaps is so distressing that they’d been hiding all these years.
And I find by the time I’ve done this, usually even just one session of these little mini experiments that then clients are quite able to tolerate the distress of talking about things in therapy
For more insights on helping clients work through emotional distress (from experts including Ron Siegel, PsyD; Janina Fisher, PhD; Shelly Harrell, PhD; Michael Yapko, PhD; and more) click here.
Now we’d like to hear from you. How have you approached distress tolerance in your clinical practice? Share your experiences in the comments below.
This wto as a great video with a specific technique/behavioral exercise to use in session. Thank you.
I have used the “tell the story” technique with EFT. Similar to the technique in the video, I set it up with an explanation of what we’re going to do, then I have them start with telling the story of the distressing situation from just a few minutes before it began and as soon as they start to feel a strong emotion (rating 5 or higher, or in their body), to tell me stop. At that point, I have them go through some rounds of EFT describing the image, sound, physical sensation (or smell, taste) at that stop moment (like a freeze frame of a movie) while tapping until the rating is down to a zero. Then I have them start over from beginning and see if they get past that first frame they stopped at without the distress until they say stop and we repeat the process. Until they are all the way thru to the part where they’re safe and there’s no distress. We repeat the story telling thru to the end (tapping the whole time) to make sure we got all the distressing “frames” neutralized.
A perfect adjunct to those with ADHD, stuck in Analysis Paralysis!
I find this a really good concept for helping look at difficult topics and how to broach them gently. I always reassure my clients by empowering them on how strong they are and what they have done well.
I use this when they have been looking at something difficult to go back to a time when they have done well and use aspects of how they went about dealing with something that had a positive outcome. I then ask if they can see a way of using this in moving forward with a difficult thought or problem they are experiencing in the here and now.
What triggered the thoughts what emotions they are feeling? I am still learning and going through my training so love learning what experienced practitioners have found helpful. Thank you.
Thank you for this opportunity to learn this approach. It surely will assist in building empathy and confidence in the relationship with clients who are distressed. Trust building is so important to this relationship.
Since a SE workshop a week ago, I started SE resourcing with clients before going to the difficult stuff. The 4 axes embodiment exercise has also been useful for this purpose.
Beautiful exercise! Thanks.
Helpful simple structure to follow to discharge and titrate distress, and build capacity and deepen practitioner-client relationship. The part I’d like to know more about is regarding other tools to work when the clients’ ability to return to regulation or utilize distraction is more limited, and they are overcome by distress and unable to co regulate?