The Dialectical Behavior Therapy Skills Workbook

The individual struggling with overwhelming emotions and DBT therapists will benefit significantly from

this workbook. McKay, Wood and Brantley have expanded and translated DBT Skills, making Linehan’s

iconic work on emotional skill building even more accessible and easy to apply to everyday life.

—Kate Northcott, MA, MFT, is a DBT therapist in private practice with

Mindfulness Therapy Associates and is director of New Perspectives Center

for Counseling, a non-profit counseling center, in San Francisco, CA

The Dialectical

Behavior Therapy

Skills Workbook

MATTHEW M

KAY, PH.D. • JEFFREY C. WOOD, PSY.D.

JEFFREY BRANTLEY, MD

Practical DBT Exercises for

Learning Mindfulness, Interpersonal

Effectiveness, Emotion Regulation

& Distress Tolerance

New Harbinger Publications, Inc.

Publisher’s Note

is publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It

is sold with the understanding that the publisher is not engaged in rendering psychological, nancial, legal, or other pro-

fessional services. If expert assistance or counseling is needed, the services of a competent professional should be sought.

Distributed in Canada by Raincoast Books

New Harbinger Publications, Inc.

5674 Shattuck Avenue

Oakland, CA 94609

www.newharbinger.com

Acquired by Catharine Sutker; Cover design by Amy Shoup;

Edited by Elisabeth Beller; Text design by Tracy Carlson

Library of Congress Cataloging-in-Publication Data

e dialectical behavior therapy skills workbook : practical DBT exercises for learning mindfulness, interpersonal

eectiveness, emotion regulation, and distress tolerance / Matthew McKay ... [et al.].

p. cm.

ISBN-13: 978-1-57224-513-6

ISBN-10: 1-57224-513-1

1. Dialectical behavior therapy--Problems, exercises, etc. I. McKay, Matthew.

RC489.B4D52 2007

616.89’142--dc22

2007013007

In memory of my mother, Louise Long LaBrash, who was always there for me in the hard times.

—Matthew McKay

To my students and clients at Fresno City College and Reedley College, 2005–2006, whose

strength, hope, and resilience inspired me while writing this book.

—Jeffrey C. Wood

This work is dedicated to all who struggle with intense and unpredictable emotions in their

inner and outer lives. May you find peace and happiness, and may all living beings benefit from

your efforts.

—Jeffrey Brantley

Contents

INTRODUCTION

Dialectical Behavior Therapy: An Overview of the Treatment .............1

CHAPTER 1

Basic Distress Tolerance Skills .....................................5

CHAPTER 2

Advanced Distress Tolerance Skills: Improve the Moment ..............31

CHAPTER

Basic Mindfulness Skills ..........................................63

CHAPTER 4

Advanced Mindfulness Skills ......................................85

CHAPTER 5

Exploring Mindfulness Further ....................................115

CHAPTER 6

Basic Emotion Regulation Skills. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121

CHAPTER 7

Advanced Emotion Regulation Skills ................................159

CHAPTER 8

Basic Interpersonal Effectiveness Skills ..............................181

vi The Dialectical Behavior Therapy Skills Workbook

CHAPTER 9

Advanced Interpersonal Effectiveness Skills ..........................199

CHAPTER 10

Putting It All Together ..........................................225

References ....................................................229

INTRODUCTION

Dialectical Behavior Therapy:

An Overview of the Treatment

Dialectical behavior therapy, developed by Marsha Linehan (1993a, 1993b), is extraordinarily

effective at helping people manage overwhelming emotions. Research shows that dialectical

behavior therapy strengthens a person’s ability to handle distress without losing control or acting

destructively.

A lot of people struggle with overwhelming emotions. It’s as if the knob is turned to maximum

volume on much of what they feel. When they get angry or sad or scared, it shows up as a big,

powerful wave that can sweep them off their feet.

If you’ve faced overwhelming emotions in your life, you know what we’re talking about. There

are days when your feelings hit you with the force of a tsunami. And when that happens, it makes

you—understandably—afraid to feel things because you don’t want to get swept away by your

emotions. The trouble is, the more you try to suppress or put a lid on your emotions, the more

overwhelming they can get. We’ll talk about that in chapters 6 and 7 on emotional regulation.

What’s important to know right now is that trying to stop your feelings doesn’t work.

There’s a fair amount of research to suggest that the likelihood of developing intense, over-

whelming emotions may be hardwired from birth. But it can also be greatly affected by trauma

or neglect during childhood. Trauma at critical points in our development can literally alter our

brain structure in ways that make us more vulnerable to intense, negative emotions. However, the

fact that a propensity to intense emotions is often rooted in genetics or trauma doesn’t mean the

problem can’t be overcome. Thousands of people have used the skills you’ll learn in this book to

achieve better emotional control. They have changed their lives—and you can too.

So what are these skills, and how will they help you? Dialectical behavior therapy teaches

four critically important skills that can both reduce the size of emotional waves and help you keep

your balance when those emotions overwhelm you.

2 The Dialectical Behavior Therapy Skills Workbook

1. Distress tolerance will help you cope better with painful events by building up your

resiliency and giving you new ways to soften the effects of upsetting circumstances.

2. Mindfulness will help you experience more fully the present moment while focusing

less on painful experiences from the past or frightening possibilities in the future.

Mindfulness will also give you tools to overcome habitual, negative judgments about

yourself and others.

3. Emotion regulation skills help you to recognize more clearly what you feel and then to

observe each emotion without getting overwhelmed by it. The goal is to modulate your

feelings without behaving in reactive, destructive ways.

4. Interpersonal effectiveness gives you new tools to express your beliefs and needs, set limits,

and negotiate solutions to problems—all while protecting your relationships and treating

others with respect.

This book is structured to make learning easier. Each of the key skills is covered in two chap-

ters—basic and advanced—except mindfulness, which has a third, more advanced chapter. The

basic skills chapters teach necessary concepts, identify the components of the new skill, and lead

you through initial steps for acquiring the skill. The advanced skills chapters take you through the

remaining components of the skill, building level by level. There will be examples to make each

step clear as well as assessments, exercises, and worksheets to help you practice each thing you

learn. Then in the final chapter, Putting It All Together, you’ll learn how to integrate all those

skills, in order to make them a regular part of your life.

The Dialectical Behavior Therapy Skills Workbook is written to make learning easy. The hard

part will be making the commitment to do the exercises and put your new skills into practice.

Nothing will change by just reading. The words on these pages will have no impact on your life

unless you implement—behaviorally—the new techniques and strategies you will learn here. So

now is a good time to think about why you are reading this book and what you want to change.

Right here, on this page, write down three ways you currently react to your emotions that you

want to change. In other words, what three things do you do when upset or overwhelmed that are

damaging—and that you are committed to replace with better ways to cope?

Dialectical Behavior Therapy: An Overview of the Treatment 3

WHO THIS BOOK IS FOR

There are two intended audiences for The Dialectical Behavior Therapy Skills Workbook. The first is

people who are in dialectical behavior therapy (either group or individual) and need a workbook to

help learn the four key skills. We also wrote this book so it could be used independently by anyone

who struggles with overwhelming feelings. All the tools are here to achieve significant changes in

your ability to control emotion. With that said, if you are reading this workbook on your own and

are having a hard time implementing the new skills, we strongly recommend seeking the services

of a qualified dialectical behavior therapist.

THERE IS HOPE

Life is hard. You already know that. But you are not stuck or helpless in your struggle with your

emotions. You can expect, if you really do the work to implement these skills, that how you react to

feelings will change. That’s because—regardless of genetics or early pain—the key skills you’ll learn

here can affect the outcome of every conflict and every upset and can literally alter the course of

your relationships. There is every reason to hope. All you have to do is turn the page and begin.

Then keep working at it.

CHAPTER 1

Basic Distress Tolerance Skills

DISTRESS TOLERANCE SKILLS: WHAT ARE THEY?

At some point in our lives, we all have to cope with distress and pain. Either it can be physical,

like a bee sting or a broken arm, or it can be emotional, like sadness or anger. In both cases, the

pain is often unavoidable and unpredictable. You can’t always anticipate when the bee will sting

you or when something will make you sad. Often, the best you can do is to use the coping skills

that you have and hope that they work.

But for some people, emotional and physical pain feels more intense and occurs more fre-

quently than it does for other people. Their distress comes on more quickly and feels like an

overwhelming tidal wave. Often, these situations feel like they’ll never end, and the people expe-

riencing them don’t know how to cope with the severity of their pain. For the purposes of this

book, we’ll call this problem overwhelming emotions. (But remember, emotional and physical pain

often occur together.)

People struggling with overwhelming emotions often deal with their pain in very unhealthy,

very unsuccessful ways because they don’t know what else to do. This is understandable. When a

person is in emotional pain, it’s hard to be rational and to think of a good solution. Nevertheless,

many of the coping strategies used by people with overwhelming emotions only serve to make their

problems worse.

Here’s a list of some common coping strategies used by people dealing with this problem.

Check () the ones that you use to cope with your stressful situations:

You spend a great deal of time thinking about past pains, mistakes, and problems.

You get anxious worrying about possible future pains, mistakes, and problems.

You isolate yourself from other people to avoid distressing situations.

6 The Dialectical Behavior Therapy Skills Workbook

You make yourself feel numb with alcohol or drugs.

You take your feelings out on other people by getting excessively angry at them or

trying to control them.

You engage in dangerous behaviors, such as cutting, hitting, picking at, or burning

yourself or pulling out your own hair.

You engage in unsafe sexual activities, such as having sex with strangers or having

frequent unprotected sex.

You avoid dealing with the causes of your problems, such as an abusive or

dysfunctional relationship.

You use food to punish or control yourself by eating too much, not eating at all, or

by throwing up what you do eat.

You attempt suicide or engage in high-risk activities, like reckless driving or taking

dangerous amounts of alcohol and drugs.

You avoid pleasant activities, such as social events and exercise, maybe because you

don’t think that you deserve to feel better.

You surrender to your pain and resign yourself to living a miserable and unfulfilling

life.

All of these strategies are paths to even deeper emotional pain, because even the strate-

gies that offer temporary relief will only cause you more suffering in the future. Use the Cost of

Self-Destructive Coping Strategies worksheet to see how. Note the strategies that you use as well

as their costs, and then include any additional costs that you can think of. At the end of the

worksheet, feel free to add any of your own strategies that aren’t included as well as their costs.

Basic Distress Tolerance Skills 7

THE COST OF SELF-DESTRUCTIVE COPING STRATEGIES

Self-Destructive Coping Strategy Possible Costs

1. You spend a great deal of time thinking

about past pain, mistakes, and problems.

Miss good things that might be happening

now and then regret missing those things,

too; depression about the past

Other:

2. You get anxious worrying about possible

future pain, mistakes, and problems.

Miss good things that might be happening

now; anxiety about the future

Other:

3. You isolate yourself to avoid possible

pain.

Spend more time alone and, as a result, feel

even more depressed

Other:

4. You use alcohol and drugs to numb

yourself.

Addiction; loss of money; work problems;

legal problems; relationship problems; health

consequences

Other:

5. You take your painful feelings out on

others.

Loss of friendships, romantic relationships,

and family members; other people avoid

you; loneliness; feel bad about hurting other

people; legal consequences of your actions

Other:

6. You engage in dangerous behaviors,

like cutting, pulling out hair, and

self-mutilation.

Possible death; infection; scarring;

disfigurement; shame; physical pain

Other:

8 The Dialectical Behavior Therapy Skills Workbook

7. You engage in unsafe sexual activity, like

unprotected sex or frequent sex with

strangers.

Sexually transmitted diseases, some life threaten-

ing; pregnancy; shame; embarrassment

Other:

8. You avoid dealing with the causes of

your problems.

Put up with destructive relationships; get

burned-out doing things for other people;

don’t get any of your own needs met;

depression

Other:

9. You eat too much, restrict what you eat,

or throw up what you eat.

Weight gain; anorexia; bulimia; health

consequences; medical treatment;

embarrassment; shame; depression

Other:

10. You have attempted suicide or engaged

in other nearly fatal activities.

Possible death; hospitalization;

embarrassment; shame; depression;

long-term medical complications

Other:

11. You avoid pleasant activities, like social

events and exercise.

Lack of enjoyment; lack of exercise;

depression; shame; isolation

Other:

12. You surrender to your pain and live an

unfulfilling life.

Lots of pain and distress; regrets about your

life; depression

Other:

13.

14.

Basic Distress Tolerance Skills 9

The costs of these self-destructive coping strategies are clear. All of them lead to your pain

being prolonged into long-term suffering. Remember, sometimes pain can’t be avoided, but many

times suffering can.

Take, for example, an argument between friends Maria and Sandra. For Maria, who doesn’t

have overwhelming emotions, the argument was initially painful. But after a few hours, she began

to realize that she and Sandra were both to blame for the argument. So by the next day, Maria

was no longer upset or mad at Sandra. But for Sandra, who struggles with overwhelming emo-

tions, the argument was replayed in her memory over and over again for three days. Each word

and gesture was remembered as an insult from Maria. So the next time Sandra saw Maria, three

days later, Sandra was still angry and she restarted the argument just where it had ended. Both

women experienced the initial pain of the argument, but only Sandra was suffering. Clearly, Sandra

carried her emotional pain with her for days, and it made her life more of a struggle. While we can’t

always control the pain in our lives, we can control the amount of suffering we have in response

to that pain.

To avoid this type of long-term suffering, chapters 1 and 2 will teach you distress tolerance

skills. These skills will help you endure and cope with your pain in a new, healthier way so that it

doesn’t lead to suffering. The new plan outlined in these two chapters will teach you to “distract,

relax, and cope.”

ABOUT THIS CHAPTER

The first distress tolerance skills you’ll learn in this chapter will help you distract yourself from the

situations that are causing you emotional pain. Distraction skills are important because (1) they

can temporarily stop you from thinking about your pain and, as a result, (2) they give you time to

find an appropriate coping response. Remember how Sandra carried her pain with her for three

days? She couldn’t stop thinking about her argument with Maria. Distraction can help you let go

of the pain by helping you think about something else. Distraction also buys you time so that your

emotions can settle down before you take action to deal with a distressing situation.

However, do not confuse distraction with avoidance. When you avoid a distressing situation,

you choose not to deal with it. But when you distract yourself from a distressing situation, you still

intend to deal with it in the future, when your emotions have calmed down to a tolerable level.

The second group of distress tolerance skills you’ll learn in this chapter are self- soothing

skills (Johnson, 1985; Linehan, 1993b). It’s often necessary to soothe yourself before you face the

cause of your distress because your emotions might be too “hot.” Many people with overwhelming

emotions panic when faced with an argument, rejection, failure, or other painful events. Before

you can address these problems with your new emotion regulation skills (chapters 6 and 7) or your

new interpersonal effectiveness skills (chapters 8 and 9), it’s often necessary to soothe yourself to

regain your strength. In situations like these, distress tolerance skills are similar to refilling the gas

in your car so that you can keep going. Self-soothing is meant to bring you some amount of peace

and relief from your pain so that you can figure out what you’re going to do next.

10 The Dialectical Behavior Therapy Skills Workbook

Self-soothing skills also serve another purpose. They’ll help you learn to treat yourself com-

passionately. Many people with overwhelming emotions have been abused or neglected as children.

As a result, they were taught more about how to hurt than to help themselves. The second purpose

of the self-soothing skills, therefore, is to teach you how to treat yourself kindly and lovingly.

HOW TO USE THIS CHAPTER

As you read the following groups of skills, mark the ones that are helpful to you. This will make

it easier to create a distraction plan for emergencies when you get to the end of this chapter. You’ll

also be shown how to create a list of relaxation skills to help soothe yourself, both at home and

when you’re away. Then, in the next chapter, you’ll learn more advanced distress tolerance skills.

RADICAL ACCEPTANCE

Increasing your ability to tolerate distress starts with a change in your attitude. You’re going to need

something called radical acceptance (Linehan, 1993a). This is a new way of looking at your life. In

the next chapter, you’ll be given some key questions to help you examine your experiences using

radical acceptance. But for now, it will be sufficient to cover this concept briefly.

Often, when a person is in pain, his or her first reaction is to get angry or upset or to blame

someone for causing the pain in the first place. But unfortunately, no matter who you blame for

your distress, your pain still exists and you continue to suffer. In fact, in some cases, the angrier

you get, the worse your pain will feel (Greenwood, Thurston, Rumble, Waters, & Keefe, 2003;

Kerns, Rosenberg, & Jacob, 1994).

Getting angry or upset over a situation also stops you from seeing what is really happening.

Have you ever heard the expression “being blinded by rage”? This often happens to people with

overwhelming emotions. Criticizing yourself all the time or being overly judgmental of a situation is

like wearing dark sunglasses indoors. By doing this, you’re missing the details and not seeing every-

thing as it really is. By getting angry and thinking that a situation should never have happened,

you’re missing the point that it did happen and that you have to deal with it.

Being overly critical about a situation prevents you from taking steps to change that situa-

tion. You can’t change the past. And if you spend your time fighting the past—wishfully thinking

that your anger will change the outcome of an event that has already happened—you’ll become

paralyzed and helpless. Then, nothing will improve.

So, to review—being overly judgmental of a situation or overly critical of yourself often leads

to more pain, missed details, and paralysis. Obviously, getting angry, upset, or critical doesn’t

improve a situation. So what else can you do?

The other option, which radical acceptance suggests, is to acknowledge your present situation,

whatever it is, without judging the events or criticizing yourself. Instead, try to recognize that your

present situation exists because of a long chain of events that began far in the past. For example,

Basic Distress Tolerance Skills 11

some time ago, you (or someone else) thought you needed help for the emotional pain you were

experiencing. So, a few days later, you went to the bookstore and bought this book. Then today

you thought about reading this chapter, and eventually you sat down, opened the book, and began

reading. Now, you are up to the words you see here. Denying this chain of events does nothing to

change what has already happened. Trying to fight this moment or say that it shouldn’t be only

leads to more suffering for you. Radical acceptance means looking at yourself and the situation

and seeing it as it really is.

Keep in mind that radical acceptance does not mean that you condone or agree with bad

behavior in others. But it does mean that you stop trying to change what’s happened by getting

angry and blaming the situation. For example, if you’re in an abusive relationship and you need to

get out, then get out. Don’t waste your time and continue to suffer by blaming yourself or the other

person. That won’t help you. Refocus your attention on what you can do now. This will allow you

to think more clearly and figure out a better way to cope with your suffering.

Radical Acceptance Coping Statements

To help you begin using radical acceptance, it’s often helpful to use a coping statement to

remind yourself. Below are a few examples and spaces to create your own. Check () the state-

ments that you would be willing to use to remind yourself that you should accept the present

moment and the chain of events that created it. Then, in the next exercise, you’ll begin using the

statements that you chose.

“This is the way it has to be.”

“All the events have led up to now.”

“I can’t change what’s already happened.”

“It’s no use fighting the past.”

“Fighting the past only blinds me to my present.”

“The present is the only moment I have control over.”

“It’s a waste of time to fight what’s already occurred.”

“The present moment is perfect, even if I don’t like what’s happening.”

“This moment is exactly as it should be, given what’s happened before it.”

“This moment is the result of over a million other decisions.”

Other ideas:

12 The Dialectical Behavior Therapy Skills Workbook

Exercise: Radical Acceptance

Now, using the coping statements that you checked, begin radically accepting different moments

in your life without judging them. Naturally, it will be difficult to accept very painful situations,

so start with smaller events. Here are some suggestions. Check () the ones you’re willing to do,

and add any of your own ideas. Then use your coping statements to radically accept the situation

without being judgmental or critical.

Read a controversial story in the newspaper without being judgmental about what has

occurred.

The next time you get caught in heavy traffic, wait without being critical.

Watch the world news on television without being critical of what’s happening.

Listen to a news story or a political commentary on the radio without being

judgmental.

Review a nonupsetting event that happened in your life many years ago, and use

radical acceptance to remember the event without judging it.

Other ideas:

DISTRACT YOURSELF FROM

SELF-DESTRUCTIVE BEHAVIORS

One of the most important purposes of dialectical behavior therapy is to help you stop engaging in

self-destructive behaviors, such as cutting, burning, scratching, and mutilating yourself (Linehan,

1993a). No one can deny the amount of pain you are in when you engage in one of these behaviors.

Some people with overwhelming emotions say that self-injury temporarily relieves them of some of

the pain they’re feeling. This might be true, but it’s also true that these actions can cause serious

permanent damage and even death if taken to an extreme.

Think about all the pain you’ve already been through in your life. Think about all the people

who have hurt you physically, sexually, emotionally, and verbally. Does it make sense to continue

hurting yourself even more in the present? Doesn’t it make more sense to start healing yourself

and your wounds? If you really want to recover from the pain you’ve already experienced, stopping

these self-destructive behaviors is the first step you should take. This can be very hard to do. You

might be addicted to the rush of natural painkillers called endorphins that are released when you

hurt yourself. However, these types of self-destructive actions are highly dangerous and certainly

deserve your best efforts to control them.

Basic Distress Tolerance Skills 13

Exercise: Distract Yourself from Self-Destructive Behaviors

Here are some safer actions that you can use to distract yourself from your self-destructive emotions

and thoughts. Check () the ones you’re willing to do, and then add any healthy, nonharming

activities that you can think of:

Instead of hurting yourself, hold an ice cube in one hand and squeeze it. The sensa-

tion from the cold ice is numbing and very 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 to make it even more distracting, 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 mutilat-

ing yourself.

Dig your fingernails into your arm without breaking the skin.

Draw faces of people you hate on balloons and then pop them.

Write letters to people you hate or to people who have hurt you. Tell them what they

did to you and tell them why you hate them. Then throw the letters away or save

them to read later.

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 some place where you won’t draw

the attention of other people, like at a loud concert or in your car.

Stick pins in a voodoo doll instead of hurting yourself. You can make a voodoo doll

with some rolled-up socks or a foam ball and some markers. Or you can buy a doll

in a store for the specific purpose of sticking pins in it. Buy one that’s soft and easy

to stick.

Cry. Sometimes people do other things instead of crying because they’re afraid that

if they start to cry 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 healthy, nonharming ideas:

14 The Dialectical Behavior Therapy Skills Workbook

Here’s an example of using alternative actions to distract your self-destructive emotions. Lucy

often cut herself when she felt upset or angry. She had dozens of scars on her wrists and forearms.

She wore long-sleeve shirts even in the hot summer because she was embarrassed when other

people saw what she had done to herself. But after getting some ideas from this workbook, she

made a distraction plan. So the next time she got angry with herself and felt like cutting, she

looked at her plan for alternative actions. She had written down the idea of drawing on herself

with a red marker. She drew a line exactly where she would have cut herself. She even used red

paint to make it look like she was bleeding. She carried the mark on her arm for the rest of the

day to remind herself how sad and overwhelmed she felt. But then, before she went to sleep, she

was able to erase the “scar” and “blood” from her arm, unlike the rest of the marks from her

permanent injuries.

DISTRACT YOURSELF WITH PLEASURABLE ACTIVITIES

Sometimes doing something that makes you feel good is the best way to distract yourself from

painful emotions. But remember, you don’t have to wait until you feel overwhelmed by painful

emotions in order to do one of these activities. It’s also helpful to engage in these types of activities

on a regular basis. In fact, you should try to do something pleasurable every day. Exercise is also

especially important because not only is it good for your overall physical health but it’s also been

shown to be an effective treatment for depression in some cases (Babyak et al., 2000). Plus, exer-

cise makes you feel good almost immediately by releasing natural painkillers in your body called

endorphins (the same painkillers that are released when you cut yourself).

Following is a list of over one hundred pleasurable activities you can use to distract yourself.

Basic Distress Tolerance Skills 15

Talk to a friend on the telephone.

Go out and visit a friend.

Invite a friend to come to your home.

Text message your friends.

Organize a party.

Exercise.

Lift weights.

Do yoga, tai chi, or Pilates, or take classes to

learn.

Stretch your muscles.

Go for a long walk in a park or someplace

else that’s peaceful.

Go outside and watch the clouds.

Go jog.

Ride your bike.

Go for a swim.

Go hiking.

Do something exciting, like surfing, rock

climbing, skiing, skydiving, motorcycle riding,

or kayaking, or go learn how to do one of

these things.

Go to your local playground and join a game

being played or watch a game.

Go play something you can do by yourself

if no one else is around, like basketball,

bowling, handball, miniature golf, billiards, or

hitting a tennis ball against the wall.

Get a massage; this can also help soothe your

emotions.

Get out of your house, even if you just sit

outside.

Go for a drive in your car or go for a ride on

public transportation.

Plan a trip to a place you’ve never been

before.

Sleep or take a nap.

Eat chocolate (it’s good for you!) or eat

something else you really like.

Eat your favorite ice cream.

Cook your favorite dish or meal.

Cook a recipe that you’ve never tried before.

Take a cooking class.

Go out for something to eat.

Go outside and play with your pet.

Go borrow a friend’s dog and take it to the

park.

Give your pet a bath.

Go outside and watch the birds and other

animals.

Find something funny to do, like reading the

Sunday comics.

Watch a funny movie (start collecting

funny movies to watch when you’re feeling

overwhelmed with pain).

Go to the movie theater and watch whatever’s

playing.

Watch television.

Listen to the radio.

Go to a sporting event, like a baseball or

football game.

Play a game with a friend.

Play solitaire.

Play video games.

Go online to chat.

Visit your favorite Web sites.

Visit crazy Web sites and start keeping a list

of them.

Create your own Web site.

Create your own online blog.

Join an Internet dating service.

Sell something you don’t want on the

Internet.

Buy something on the Internet.

Do a puzzle with a lot of pieces.

Call a crisis or suicide hotline and talk to

someone.

Go shopping.

Go get a haircut.

THE BIG LIST OF PLEASURABLE ACTIVITIES

Check () the ones you’re willing to do, and then add any activities that you can think of:

16 The Dialectical Behavior Therapy Skills Workbook

Go to a spa.

Go to a library.

Go to a bookstore and read.

Go to your favorite café for coffee or tea.

Visit a museum or local art gallery.

Go to the mall or the park and watch other

people; try to imagine what they’re thinking.

Pray or meditate.

Go to your church, synagogue, temple, or

other place of worship.

Join a group at your place of worship.

Write a letter to God.

Call a family member you haven’t spoken to

in a long time.

Learn a new language.

Sing or learn how to sing.

Play a musical instrument or learn how to

play one.

Write a song.

Listen to some upbeat, happy music (start

collecting happy songs for times when you’re

feeling overwhelmed).

Turn on some loud music and dance in your

room.

Memorize lines from your favorite movie, play,

or song.

Make a movie or video with your camcorder.

Take photographs.

Join a public-speaking group and write a

speech.

Participate in a local theater group.

Sing in a local choir.

Join a club.

Plant a garden.

Work outside.

Knit, crochet, or sew—or learn how to.

Make a scrapbook with pictures.

Paint your nails.

Change your hair color.

Take a bubble bath or shower.

Work on your car, truck, motorcycle, or bicycle.

college, adult school, or online.

Read your favorite book, magazine, paper, or

poem.

Read a trashy celebrity magazine.

Write a letter to a friend or family member.

Write things you like about yourself on a

picture of your body or draw them on a

photograph of yourself.

Write a poem, story, movie, or play about

your life or someone else’s life.

Write in your journal or diary about what

happened to you today.

Write a loving letter to yourself when you’re

feeling good and keep it with you to read

when you’re feeling upset.

Make a list of ten things you’re good at or

that you like about yourself when you’re

feeling good, and keep it with you to read

when you’re feeling upset.

Draw a picture.

Paint a picture with a brush or your fingers.

Masturbate.

Have sex with someone you care about.

Make a list of the people you admire and

want to be like—it can be anyone real or

fictional throughout history. Describe what

you admire about these people.

Write a story about the craziest, funniest, or

sexiest thing that has ever happened to you.

Make a list of ten things you would like to do

before you die.

Make a list of ten celebrities you would like to

be friends with and describe why.

Make a list of ten celebrities you would like to

have sex with and describe why.

Write a letter to someone who has made your

life better and tell them why. (You don’t have

to send the letter if you don’t want to.)

Create your own list of pleasurable activities.

Other ideas:

Basic Distress Tolerance Skills 17

Here’s an example of using pleasurable activities to distract yourself. Karen was feeling lonely

and had nothing to do. As she sat alone at home, she began to think about how lonely she’d been

her whole life and how she was hurt by her father when she was growing up. Very quickly, Karen

was overwhelmed with very painful emotions. In fact, the memories also triggered physical pain

in her shoulder. Karen began to cry and didn’t know what to do. Luckily, she remembered the

distraction plan she had created. Exercise had always been a powerful tool for Karen, so she went

for a long walk in the park while she listened to some of her favorite music. The activity didn’t

erase her memories or remove her pain completely, but the long walk did soothe her and prevent

her from being overwhelmed with sadness.

DISTRACT YOURSELF BY PAYING ATTENTION

TO SOMEONE ELSE

Another great way to distract yourself from pain is to put your attention on someone else. Here

are some examples. Check () the ones you’re willing to do, and then add any activities that you

can think of:

Do something for someone else. Call your friends and ask if they need help doing some-

thing, such as a chore, grocery shopping, or housecleaning. Ask your parents, grand-

parents, or siblings if you can help them with something. Tell them you’re feeling

bored and you’re looking for something to do. Call up someone you know and offer

to take them out to lunch. Go outside and give money to the first needy person you

see. If you can plan ahead for moments like these when you’re overwhelmed with

pain, call your local soup kitchen, homeless shelter, or volunteer organization. Plan to

participate in activities that help other people. Join a local political activities group,

environmental group, or other organization, and get involved helping other people.

Take your attention off yourself. Go to a local store, shopping center, bookstore, or park.

Just sit and watch other people or walk around among them. Watch what they do.

Observe how they dress. Listen to their conversations. Count the number of buttons

they’re wearing on their shirts. Observe as many details about these other people as

you can. Count the number of people with blue eyes versus the number of people with

brown eyes. When your thinking returns to your own pain, refocus on the details of

the people you’re watching.

Think of someone you care about. Keep a picture of them in your wallet or in your

purse. This could be your husband, wife, parent, boyfriend, girlfriend, children, or

friend, or it could be someone else you admire, such as Mother Teresa, Gandhi, Jesus,

the Dalai Lama, Ganesha, and so on. It could even be a movie star, an athlete, or

someone you’ve never met. Then, when you’re feeling distressed, take out the picture

and imagine a healing, peaceful conversation you would have with that person if you

18 The Dialectical Behavior Therapy Skills Workbook

could talk to them at that moment when you’re feeling hurt. What would they say to

you that would help make you feel better? Imagine them saying those words to you.

Other ideas:

Here’s an example of distracting yourself by paying attention to someone else. Louis got upset

by a fight he had with his boyfriend, Roger. Very quickly, Louis became overwhelmed by sadness

as he started to remember all the other fights he and Roger had had in the past. Louis went to his

desk, where he kept a picture of his mother. He sat down and started to talk to his mother as if

she were there with him. He asked for strength and guidance to handle the situation with Roger.

Then he imagined what she would say to him, and he started to feel better. Later, when he was

able to think more clearly, he returned to what he needed to do that day.

DISTRACT YOUR THOUGHTS

The human brain is a wonderful thought-producing machine. It turns out millions of thoughts

every day. Most of the time, this makes our lives much easier. But unfortunately, we can’t fully

control what our brain thinks about. Here’s an example. Imagine a picture of your favorite cartoon

character, such as Bugs Bunny, Snoopy, Superman, or whomever. Close your eyes and see the

character in vivid detail in your mind’s eye. Remember exactly what it looks like. Think about

the character for about fifteen seconds. Got it? Now, for the next thirty seconds do your best not

to think about the character. Try to block the character from your thoughts. But be honest with

yourself and notice how often the character pops into your thoughts. It’s impossible not to think

about the character. In fact, the harder you try not to think about it, the more power you give to

the image and the more your brain keeps bringing it into your thoughts. It’s almost as if the harder

you try to forget something, the harder your brain tries to remember it. This is why forcing yourself

to forget about something that happened to you is impossible. It’s also why you can’t simply force

yourself to get rid of emotions that you don’t want.

So, instead of trying to force yourself to forget a memory or thought, try to distract your

thoughts with other memories or creative images. Here are some examples. Check () the ones

you’re willing to do, and then add any activities that you can think of:

Remember events from your past that were pleasant, fun, or exciting. Try to remember

as many details as possible about these happy memories. What did you do? Who were

you with? What happened?

Basic Distress Tolerance Skills 19

Imagine sexual thoughts that make you excited. Create sexual fantasies involving you

and someone you know or someone you would like to know. Try to think of as many

details as possible. What happens that’s so exciting?

Look outside at the natural world around you. Observe the flowers, trees, sky, and

landscape as closely as you can. Observe any animals that are around. Listen to the

sounds that they make. Or if you live in a city without much nature around you, either

do your best to observe what you can or close your eyes and imagine a scene you’ve

observed in the past.

Imagine yourself as a hero or heroine correcting some past or future event in your life.

How would you do it? What would people say to you?

Imagine yourself getting praise from someone whose opinion matters to you. What

did you do? What does this person say to you? Why does this person’s opinion matter

to you?

Imagine your wildest fantasy coming true. What would it be? Who else would be

involved? What would you do afterwards?

Keep a copy of your favorite prayer or favorite saying with you. Then, when you feel

distressed, pull it out and read it to yourself. Imagine the words calming and soothing

you. Use imagery (such as a white light coming down from heaven or the universe)

that soothes you as you read the words.

Other ideas:

Here’s an example of using distracting thoughts. Joel was in a bad relationship that often

reminded him of the way he was treated by his mother. She was always criticizing him and telling

him he was wrong. When these memories overwhelmed him, Joel never knew what to do. Sometimes

he would just scream at his friends or whoever else was around. But after creating a distraction

plan, Joel thought of other ideas. The next time he had memories of his mother berating him, he

went to his bedroom to lie down. Then he started to imagine himself as a child confronting his

mother about her abusive language. He told her all the things he wished he could have said to her

years ago. He told her she was wrong and that she should stop criticizing him. Joel controlled the

details of the fantasy in the way he wished it could have happened years ago. Afterwards, he slowly

felt better. He had escaped the cycle of letting his painful emotions overwhelm him.

20 The Dialectical Behavior Therapy Skills Workbook

DISTRACT YOURSELF BY LEAVING

Sometimes the best thing that you can do is leave. If you’re in a very painful situation with someone

and you recognize that your emotions are going to overwhelm you and possibly make the situation

worse than it is already, then often it’s best to just leave. Remember, if you’re already overwhelmed

by your emotions, it will be harder for you to think of a healthy resolution to your problem. Maybe

it’s best to put some distance between you and the situation in order to give yourself time to calm

your emotions and think of what to do next. Just walk away if that’s the best you can do. It will

be better than adding fuel to the emotional fire.

Here’s an example of leaving to distract yourself. Anna was in a large department store shop-

ping for a blouse. She wanted one of the clerks to help her find her size, but the store clerk was

busy with other customers. Anna waited as long as she could and kept trying to get the clerk’s

attention, but nothing worked. Anna recognized that she was getting angry very quickly. She was

ready to tear the blouse in half. She didn’t know what else to do. In the past, she would have

stayed in the store and gotten angrier, but this time she remembered to leave. She walked out of

the store, did some shopping elsewhere, and returned to get the blouse later, when the store was

less crowded and when she was feeling more in control of her behaviors.

DISTRACT YOURSELF WITH TASKS AND CHORES

Strangely, many people don’t schedule enough time to take care of themselves or their living envi-

ronments. As a result, tasks and chores go uncompleted. Here, then, is the perfect opportunity to

do something to take care of yourself and your environment. The next time you’re in a situation

in which your emotions become too painful, temporarily distract yourself by engaging in one of

the following activities. Check () the ones you’re willing to do, and then add any activities that

you can think of:

Wash the dishes.

Make phone calls to people you haven’t spoken to recently but not someone you’re

angry with.

Clean your room or house, or go help a friend with their cleaning or gardening

project.

Clean out your closet and donate your old clothes.

Redecorate a room or at least the walls.

Organize your books, CDs, computer desktop, and so forth.

Make a plan for getting a job if you don’t already have one, or make a plan for finding

a better job.

Basic Distress Tolerance Skills 21

Go get a haircut.

Go get a manicure or pedicure, or both.

Go get a massage.

Wash your or someone else’s car.

Mow the lawn.

Clean your garage.

Wash the laundry.

Do your homework.

Do work that you’ve brought home from your job.

Polish your shoes.

Polish your jewelry.

Clean the bathtub and then take a bath.

Water your plants or work in the garden.

Cook dinner for yourself and some friends.

Pay the bills.

Go to a support meeting, like Narcotics Anonymous, Alcoholics Anonymous, or

Overeaters Anonymous.

Other ideas:

Here’s an example of using tasks and chores to distract yourself. Mike called his girlfriend

Michelle to go to a movie. Michelle had already made plans with her friends to do something else.

Mike felt incredibly rejected and abandoned. He started yelling at Michelle, who hung up on him.

This made Mike feel worse. He didn’t know what to do. Quickly, he began to feel light-headed and

confused, and his emotions became very angry. But this time, instead of calling Michelle back and

arguing, he opened his wallet and pulled out the distraction plan he had made (which you’ll also

create at the end of this chapter). He had written down “get a haircut,” so he walked a half mile

to his barber. Getting out of his house helped soothe his anger, and when he returned home, he

had cooled down enough to call Michelle back to see if she was busy the next day.

22 The Dialectical Behavior Therapy Skills Workbook

DISTRACT YOURSELF BY COUNTING

Counting is a simple skill that can really keep your mind busy and help you focus on something

other than your pain. Here are some examples. Check () the ones you’re willing to do, and then

add any activities that you can think of:

Count your breaths. Sit in a comfortable chair, put one hand on your belly, and take

slow, long breaths. Imagine breathing into your stomach instead of your lungs. Feel

your belly expand like a balloon with each inhalation. Start counting your breaths.

When you inevitably start thinking about whatever it is that’s causing you pain, return

your focus to counting.

Count anything else. If you’re too distracted by your emotions, simply count the sounds

that you’re hearing. This will take your attention outside of yourself. Or try counting the

number of cars that are passing by, the number of sensations that you’re feeling, or any-

thing else you can put a number on, such as the branches of a tree you’re looking at.

Count or subtract by increments of seven. For example, start with one hundred and

subtract seven. Now take that answer and subtract seven more. Keep going. This

activity will really distract you from your emotions because it requires extra attention

and concentration.

Other counting ideas:

Here’s an example of using counting to distract yourself. Dawn became upset when her mother

told her to help set the table for dinner. “She’s always telling me what to do,” Dawn thought. She

could feel her anger getting worse, so she went to her room and remembered that the last time this

happened, counting her breaths had helped soothe her emotions. She sat down and did it again.

After ten minutes, she felt calmer, so she went back to the dining room.

CREATE YOUR DISTRACTION PLAN

Now identify those distraction skills that you’re willing to use the next time you’re in a situation

that’s causing you pain and discomfort. These chosen skills will make up your distraction plan.

Remember, these are the first steps you will use in your plan to distract, relax, and cope. Write your

chosen distraction techniques below. When you’re done, write them down again on a 3 x 5 inch

note card or a sticky note to carry around with you in your wallet or purse. Then the next time

you’re in a distressing situation, you can pull out the card to remind yourself of your distraction

plan.

Basic Distress Tolerance Skills 23

MY DISTRACTION PLAN

10.

RELAX AND SOOTHE YOURSELF

Now that you’ve learned some healthy and effective ways to distract yourself when you become

overwhelmed by painful emotions, you’ll need to learn new ways to help soothe yourself (Johnson,

1985; Linehan, 1993b). Remember, these next skills will give you the second step in your plan to

distract, relax, and cope. The activities in this section will help you relax. Then, later in this book,

you’ll learn specific skills to cope with problematic situations. These will include emotion regula-

tion skills, mindfulness skills, and interpersonal effectiveness skills.

Learning to relax and soothe yourself is very important for many reasons. When you’re

relaxed, your body feels better. It also functions in a healthier way. In a state of relaxation, your

heart beats more slowly and your blood pressure is reduced. Your body is no longer in a state of

constant emergency, preparing to either confront a stressful situation or run away from it. As a

result, it’s easier for your brain to think of healthier ways to cope with your problems.

Included here are some simple relaxation and soothing activities that utilize your five senses

of smell, sight, hearing, taste, and touch. These activities are meant to bring you a small amount

of peace in your life. So if one of these activities doesn’t help you feel relaxed, or makes you feel

worse, don’t do it. Try something else. And remember, each one of us is different. For example,

some people will become more relaxed by listening to music and others will find that taking a hot

bubble bath works for them. As you explore this list, think about what works best for you and be

willing to try something new if it sounds exciting.

24 The Dialectical Behavior Therapy Skills Workbook

Self-Soothing Using Your Sense of Smell

Smell is a very powerful sense that can often trigger memories and make you feel a certain

way. Therefore, it’s very important that you identify smells that make you feel good, not bad. Here

are some ideas. Check () the ones you’re willing to do, and then add any activities that you can

think of:

Burn scented candles or incense in your room or house. Find a scent that’s pleasing

to you.

Wear scented oils, perfume, or cologne that makes you feel happy, confident, or

sexy.

Cut out perfumed cards from magazines and carry them with you in your handbag

or wallet.

Go someplace where the scent is pleasing to you, like a bakery or restaurant.

Bake your own food that has a pleasing smell, like chocolate chip cookies.

Lie down in your local park and smell the grass and outdoor smells.

Buy fresh-cut flowers or seek out flowers in your neighborhood.

Hug someone whose smell makes you feel calm.

Other ideas:

Self-Soothing Using Your Sense of Vision

Vision is very important to humans. In fact, a large portion of our brain is devoted solely to

our sense of sight. The things you look at can often have very powerful effects on you, for better

or for worse. That’s why it’s important to find images that have a very soothing effect on you. And

again, for each person, it comes down to individual taste and preference. Here are some ideas.

Check () the ones you’re willing to do, and then add any activities that you can think of:

Go through magazines and books to cut out pictures that you like. Make a collage of

them to hang on your wall or keep some of them with you in your handbag or wallet

to look at when you’re away from home.

Find a place that’s soothing for you to look at, like a park or a museum. Or find a

picture of a place that’s soothing for you to look at, like the Grand Canyon.

Basic Distress Tolerance Skills 25

Go to the bookstore and find a collection of photographs or paintings that you find

relaxing, such as the nature photographs of Ansel Adams.

Draw or paint your own picture that’s pleasing to you.

Carry a picture or photograph of someone you love, someone you find attractive, or

someone you admire.

Other ideas:

Self-Soothing Using Your Sense of Hearing

Certain sounds can soothe us. Listening to gentle music, for example, may be relaxing. In

fact, this entire chapter was written while listening to classical music. However, each one of us

has our own tastes. You have to find what works best for you. Use these examples to identify the

sounds that help you relax. Check () the ones you’re willing to do, and then add any activities

that you can think of:

Listen to soothing music. This can be classical, opera, oldies, new age, Motown, jazz,

Celtic, African, or anything else that works for you. It might be music with singing or

without. Go to a music store that lets you listen to music before you buy it, and listen

to a wide variety of genres to determine what helps you relax. If you have a portable

radio or an MP3 player, carry it with you to listen to music when you’re away from

home.

Listen to books on tape or compact discs. Many public libraries will let you borrow

books on tape. Take some out to see if it helps you relax. You don’t even have to pay

attention to the story line. Sometimes just listening to the sound of someone talking

can be very relaxing. Again, keep some of these recordings with you in your car or

loaded in your portable stereo.

Turn on the television and just listen. Find a show that’s boring or sedate, not some-

thing like Jerry Springer that’s just going to get you angry. Sit in a comfortable chair

or lie down, and then close your eyes and just listen. Make sure you turn the volume

down to a level that’s not too loud. Years ago there was a show on public television

featuring a painter named Bob Ross. His voice was so soothing and relaxing that

many people reported falling asleep while watching him. Find a show like this that

will help you relax.

Listen to a gentle talk show on the radio. Remember—a gentle talk show, not some-

thing that’s going to make you upset or angry. Stay away from political talk shows

26 The Dialectical Behavior Therapy Skills Workbook

and the news. Find something neutral in discussion, like Car Talk on National Public

Radio or a gardening show. Again, sometimes just listening to someone else talk can

be relaxing. Carry a portable radio with you to listen to when you’re feeling upset or

angry.

Open your window and listen to the peaceful sounds outside. Or, if you live in a

place without relaxing sounds outside, go visit a place with relaxing sounds, such as

a park.

Listen to a recording of nature sounds, such as birds and other wildlife. You can often

buy these in a music store and then take them with you to listen to on your portable

compact disc player, cassette player, or MP3 device.

Listen to a white-noise machine. White noise is a sound that blocks out other distract-

ing sounds. You can buy a machine that makes white noise with circulating air, or

you can turn on a fan to block out distracting sounds. Other white-noise machines

have recorded sounds on them, such as the sounds of birds, waterfalls, and rain forests.

Many people find these machines very relaxing.

Listen to the sound of a personal water fountain. These small electronic fountains can

be bought in most department stores, and many people find the sound of the trickling

water in their homes to be very soothing.

Listen to a recording of a relaxation exercise. Exercises such as these will help you

imagine yourself relaxing in many different ways. Other recorded exercises can even

teach you self-hypnosis techniques to help you relax. Recordings like these can be

bought at some bookstores and online at self-help publishers, such as New Harbinger

Publications. Go to www.newharbinger.com and look under “Audio Programs.” Then

you can take the programs with you to listen to when you’re feeling overwhelmed.

Listen to the sound of rushing or trickling water. Maybe your local park has a water-

fall, or the nearby mall has a fountain. Or maybe just sit in your bathroom with the

water running.

Other ideas:

Self-Soothing Using Your Sense of Taste

Taste is also a very powerful sense. Our tongue has distinct regions of taste buds on it to

differentiate flavors and tastes of food. These sensations can also trigger memories and feelings,

so again, it’s important that you find the tastes that are pleasing to you. However, if eating is a

Basic Distress Tolerance Skills 27

problem for you, such as eating too much, bingeing, purging, or restricting what you eat, talk to a

professional counselor about getting help for yourself. If the process of eating can make you upset

or nervous, use your other senses to calm yourself. But if food soothes you, use some of these sug-

gestions. Check () the ones you’re willing to do, and then add any activities you can think of:

Enjoy your favorite meal, whatever it is. Eat it slowly so you can enjoy the way it

tastes.

Carry lollipops, gum, or other candy with you to eat when you’re feeling upset.

Eat a soothing food, like ice cream, chocolate, pudding, or something else that makes

you feel good.

Drink something soothing, such as tea, coffee, or hot chocolate. Practice drinking it

slowly so you can enjoy the way it tastes.

Suck on an ice cube or an ice pop, especially if you’re feeling warm, and enjoy the

taste as it melts in your mouth.

Buy a piece of ripe and juicy fresh fruit and then eat it slowly.

Other ideas:

Self-Soothing Using Your Sense of Touch

We often forget about our sense of touch, and yet we’re always touching something, such

as the clothes we’re wearing or the chair we’re sitting in. Our skin is our largest organ, and it’s

completely covered with nerves that carry feelings to our brain. Certain tactile sensations can be

pleasing, like petting a soft dog, while other sensations are shocking or painful in order to com-

municate danger, like touching a hot stove. Again, each of us prefers different sensations. You have

to find the ones that are most pleasing for you. Here are some suggestions. Check () the ones

you’re willing to do, and then add any activities that you can think of:

Carry something soft or velvety in your pocket to touch when you need to, like a

piece of cloth.

Take a hot or cold shower and enjoy the feelings of the water falling on your skin.

Take a warm bubble bath or a bath with scented oils and enjoy the soothing sensations

on your skin.

28 The Dialectical Behavior Therapy Skills Workbook

Get a massage. Many people who have survived physical and sexual abuse do not

want to be touched by anyone. This is understandable. But not all types of massage

require you to take off your clothes. Some techniques, such as traditional Japanese

shiatsu massage, simply require you to wear loose-fitting clothes. A shoulder and neck

massage, received while seated in a massage chair, can also be done without removing

any clothes. If this is a concern for you, just ask the massage therapist what kind of

massage would be best to have while wearing your clothes.

Massage yourself. Sometimes just rubbing your own sore muscles is very pleasing.

Play with your pet. Owning a pet can have many health benefits. Pet owners often

have lower blood pressure, lower cholesterol levels, and reduced risk for heart disease

(Anderson, Reid, & Jennings, 1992), and they experience other general health improve-

ments (Serpell, 1991). In addition, playing with your pet and stroking the animal’s

fur or skin can provide you with a soothing tactile experience. If you don’t have a

pet, consider getting one. Or if you can’t afford one, visit a friend who has a pet or

volunteer at your local animal shelter where you can play with the rescued animals.

Wear your most comfortable clothes, like your favorite worn-in T-shirt, baggy sweat

suit, or old jeans.

Other ideas:

CREATE A RELAXATION PLAN

Now that you’ve read the suggestions to help you relax and soothe yourself using your five senses,

construct a list of techniques you’re willing to use. For ideas, review the activities that you checked.

Be specific about what you’re going to do. Make a list of ideas to try at home and a list of ideas

you can take with you when you’re away from home.

RELAXATION AND SOOTHING SKILLS TO USE AT HOME

Basic Distress Tolerance Skills 29

10.

Keep this list in a convenient place that’s easy to remember. You might even want to copy this

list and put it in places where you see it all the time, such as on your refrigerator, above your desk,

on the mirror in your bathroom, or next to your bed. This way you’ll remind yourself to relax and

soothe yourself as often as possible. It will also make it easier to soothe yourself when your painful

emotions overwhelm you and prevent you from thinking clearly.

Now create a similar list to use when you’re away from home. Again, review the soothing

skills you checked in the last few pages to give you ideas. But make sure that it’s possible to use

these skills when you’re away from home. For example, don’t list “take a hot bath” because, most

likely, there won’t be a hot bath available to you when you’re not at home.

RELAXATION AND SOOTHING SKILLS TO USE AWAY FROM HOME

10.

Now copy these last ten ideas on an index card to remind you what to do when you’re away

from home. Keep this list with you, in your car, in your wallet, or in your handbag. Then make

30 The Dialectical Behavior Therapy Skills Workbook

sure you have whatever’s needed with you, such as candy, a portable radio, pictures, and so forth.

This way you can practice relaxing when you’re not at home, especially when your painful emotions

overwhelm you and prevent you from thinking clearly.

CONCLUSION

You’ve now learned some basic distraction and relaxation skills. You should begin using these skills

immediately when you become overwhelmed with painful emotions. The next chapter will build

on these skills and teach you more advanced distraction and relaxation skills.

CHAPTER 2

Advanced Distress Tolerance Skills:

Improve the Moment

In the last chapter, you learned many important skills that you can use in a crisis. These skills

will distract you from painful situations and then help you soothe yourself and relax so that you

can deal with the situation in a more effective way. Remember, your plan for handling a crisis is

to distract, relax, and cope.

Now that you’ve been practicing the distress tolerance skills from the last chapter, you’ll be

ready for the advanced distress tolerance skills found in this chapter. These techniques will help

you feel more empowered when you encounter painful situations in the future, and they’ll help you

build a more relaxing and fulfilling life for yourself.

After trying each technique, mark the ones that are helpful so you can identify them later.

SAFE-PLACE VISUALIZATION

Safe-place visualization is a powerful stress-reduction technique. Using it, you can soothe yourself

by imagining a peaceful, safe place where you can relax. The truth is, your brain and body often

can’t tell the difference between what’s really happening to you and what you’re just imagining.

So if you can successfully create a peaceful, relaxing scene in your thoughts, your body will often

respond to those soothing ideas.

Make sure you conduct this exercise in a quiet room where you’ll be free from distractions.

Turn off your phone, television, and radio. Tell the people in your home, if there are any, that

you can’t be disturbed for the next twenty minutes. Allow yourself the time and the freedom

to relax. You deserve it. Read the following directions before you begin. If you feel comfortable

remembering them, close your eyes and begin the visualization exercise. Or, if you would prefer,

32 The Dialectical Behavior Therapy Skills Workbook

use an audio- recording device to record the directions for yourself. Read them aloud using a slow,

soothing voice. Then close your eyes and listen to the guided visualization you created.

Before you begin the exercise, think of a real or imaginary place that makes you feel safe

and relaxed. It can be a real place that you’ve visited in the past, such as the beach, a park, a

field, a church/temple, your room, and so on. Or it can be a place that you’ve completely made

up, such as a white cloud floating in the sky, a medieval castle, or the surface of the moon. It can

be anywhere. If you have trouble thinking of a place, think of a color that makes you feel relaxed,

such as pink or baby blue. Just do your best. In the exercise, you’ll be guided through exploring

this place in more detail. But before you begin, make sure you already have a place in mind, and

remember—thinking of it should make you feel safe and relaxed.

Complete the following sentences about your safe place before beginning the visualization:

 My safe place is

 My safe place makes me feel

Instructions

To begin, sit in a comfortable chair with your feet flat on the floor and your hands resting com-

fortably, either on the arms of the chair or in your lap. Close your eyes. Take a slow, long breath in

through your nose. Feel your belly expand like a balloon as you breathe in. Hold it for five seconds: 1,

2, 3, 4, 5. Then release it slowly through your mouth. Feel your belly collapse like a balloon losing its

air. Again, take a slow, long breath in through your nose and feel your stomach expand. Hold it for five

seconds: 1, 2, 3, 4, 5. Then exhale slowly through your mouth. One more time: take a slow, long breath

in through your nose and feel your stomach expand. Hold it for five seconds: 1, 2, 3, 4, 5. Then exhale

slowly through your mouth. Now begin to take slow, long breaths without holding them, and continue to

breathe smoothly for the rest of this exercise.

Now, with your eyes closed, imagine that you enter your safe place using all of your senses to ground

yourself in the scene.

First, look around using your imaginary sense of sight. What does this place look like? Is it daytime

or nighttime? Is it sunny or cloudy? Notice the details. Are you alone or are there other people or animals?

What are they doing? If you’re outside, look up and notice the sky. Look out at the horizon. If you’re

inside, notice what the walls and the furniture look like. Is the room light or dark? Choose something

soothing to look at. Then continue looking for a few seconds using your imaginary sense of sight.

Next, use your imaginary sense of hearing. What do you hear? Do you hear other people or animals?

Do you hear music? Do you hear the wind or the ocean? Choose something soothing to hear. Then listen

for a few seconds using your imaginary sense of hearing.

Then use your imaginary sense of smell. If you’re inside, what does it smell like? Does it smell fresh?

Do you have a fire burning that you can smell? Or, if you’re outside, can you smell the air, the grass,

the ocean, or the flowers? Choose to smell something soothing in your scene. Then take a few seconds to

use your imaginary sense of smell.

Advanced Distress Tolerance Skills: Improve the Moment 33

Next, notice if you can feel anything with your imaginary sense of touch. What are you sitting or

standing on in your scene? Can you feel the wind? Can you feel something you’re touching in the scene?

Choose to touch something soothing in your scene. Then take a few seconds to use your imaginary sense

of touch.

Last, use your imaginary sense of taste. Are you eating or drinking anything in this scene? Choose

something soothing to taste. Then take a few seconds to use your imaginary sense of taste.

Now take a few more seconds to explore your safe place using all of your imaginary senses. Recognize

how safe and relaxed you feel here. Remember that you can come back to this place in your imagination

whenever you need to feel safe and relaxed. You can also come back whenever you’re feeling sad, angry,

restless, or in pain. Look around one last time to remember what it looks like.

Now keep your eyes closed and return your focus to your breathing. Again, take some slow, long

breaths in through your nose and exhale through your mouth. Then, when you feel ready, open your eyes

and return your focus to the room.

CUE-CONTROLLED RELAXATION

Cue-controlled relaxation is a quick and easy technique that will help you reduce your stress level

and muscle tension. A cue is a trigger or command that helps you relax. In this case, your cue

will be a word, like “relax” or “peace.” The goal of this technique is to train your body to release

muscle tension when you think about your cue word. Initially, you’ll need the help of the guided

instructions to help you release muscle tension in different sections of your body. But after you’ve

been practicing this technique for a few weeks, you’ll be able to relax your whole body at one time

simply by taking a few slow breaths and thinking about your cue word. With practice, this can

become a very quick and easy technique to help you relax. Before you begin, choose a cue word

that will help you relax.

 My cue word is

To begin this exercise, you’ll need to find a comfortable chair to sit in. Later, after you’ve

practiced this exercise for a few weeks, you’ll be able to do it wherever you are, even if you’re stand-

ing. You’ll also be able to do it more quickly. But to begin, choose a comfortable place to sit in a

room where you won’t be disturbed. Make sure you’ll be free from distractions. Turn off your phone,

television, and radio. Tell the people in your home, if there are any, that you can’t be disturbed

for the next twenty minutes. Allow yourself the time and the freedom to relax. You deserve it.

Read the following directions before you begin. If you feel comfortable remembering them, close

your eyes and begin the relaxation exercise. Or, if you would prefer, use an audio-recording device

to record the directions for yourself. Then close your eyes and listen to the guided relaxation

technique that you created.

34 The Dialectical Behavior Therapy Skills Workbook