ERP Part 3: Distress Tolerance
Part 3: Distress Tolerance
*This is part 3 in my series on ERP. If you haven’t, I recommend you read the first and second posts before diving into this one.
Exposure and response prevention therapy helps us overcome OCD by giving us the opportunity to develop new skills and learn from new experiences. In this post, we’ll review one of the skills developed in ERP: Distress tolerance.
Before jumping into what distress tolerance is, let’s do a quick review of what occurs during ERP treatment. In ERP treatment, we complete exposures. An exposure is deliberately entering an experience that you believe will activate your intrusive thoughts and anxious feelings. When first starting exposures, we begin with exposure targets that are only mildly uncomfortable. As we get more practice, we gradually work our way up to more challenging situations. To help us determine what your exposure targets are, we create a graded hierarchy, which I discuss here.
The response prevention portion of an exposure includes entering into a scary situation while abstaining from completing the behaviors (physical or mental), during or after the exposure, that would make you feel safe (e.g., washing your hands, checking the front door, rearranging the object, neutralizing the taboo thought, etc).
This is a very basic description of what we do during an exposure. But how is it that exposures work to help us overcome our OCD and feel better? The answer: Multiple processes occur during exposures that help us overcome our OCD and feel better. One of those processes is learning new skills and we’re going to discuss one of those skills below: distress tolerance.
But before reviewing what distress tolerance is within an exposure, we’ve got to take one more quick detour by reviewing what a skill is.
A skill is a behavioral competency. A skill is a behavior you can effectively complete and there’d be a way of observing that you can effectively complete it.
For example, imagine you tell me that you’re skilled at riding a unicycle. What does this mean? Well, presumably, it means if I pull a unicycle out of my closet, you’ll be able to hop on and begin riding. The same idea applies to someone who is skilled at, for instance, speaking Spanish. If someone tells you they are fluent in Spanish, what they mean is that they are skilled at using the Spanish language and we could put them in a situation and observe them effectively communicating in Spanish. It’s the same for singing, juggling, and playing chess.
Practicing Distress Tolerance
Given the above, let’s notice two features of skills.
First, skills are developed by practice. What does it look like to practice a skill? Well, it can look a lot of different ways. But all of those ways are going to be related to the behavior itself. For instance, if I’m watching someone practice riding a unicycle, I’m going to see them, in one way or another, riding a unicycle. If I’m watching someone practice juggling, I’m going to see them, in one way or another, juggling. Maybe this means they’re practicing simply tossing one object over and over because this will help them when they transition from one object to three objects. Whatever the practicing looks like, it’s going to be related to participating in the behaviors involved in the executing the skill.
Second: Skills exist on a spectrum. What does this mean? Well, do you know how to ride a bike? If yes, you’ve got some level of skill riding a bike. But does this mean that you could compete in the Olympics in speed cycling or BMX freestyle? Similarly, when people find out I’ve played in chess tournaments, they often ask me, “Are you really good?” Well, on chess.com, the world's largest chess website, I’m ranked in the top 1% of players. So maybe that means I’m “really good”. But, then again, there are thousands of eight-year-olds who would easily beat me. So do I still count as really good? The key idea is that all skills are on a spectrum from zero competence (e.g., I can’t ride a bike at all; I don’t know how the chess pieces move) to extreme competence (e.g., I compete in BMX freestyle bike riding at the Olympics; I’m a chess grandmaster).
As I’m sure you already know, in general, the more we practice skills, the higher our level of competence with that skill.
Now that we’ve been specific about what a skill is, let’s look at one of the skills developed in ERP: distress tolerance.
Distress tolerance has two components: Emotional acceptance and emotional validation.
Emotional acceptance is deliberately welcoming painful emotions and feelings.
This does not mean that someone doing ERP likes or enjoys the painful emotions and feelings. Instead, ERP provides the opportunity for the OCD sufferer to practice experiencing and tolerating the painful emotions and feelings instead of immediately trying to make the feelings go away.
Emotional Acceptance
Practicing experiencing and tolerating emotions and feelings includes more precisely identifying where the individual experiences the emotions and feelings. For instance, if I’m completing an exposure with a client and the client reports to me that they’re experiencing anxiety that is at a five out of ten (more about what “five out of ten” means here), I’ll typically ask them “Can you help me understand where you’re feeling that five?” or “How do you know that you’re feeling a five?” My client’s responses vary. Sometimes, my clients will give me very specific answers, such as: “My head feels really hot; my heart is racing, I feel butterflies in my stomach.” Other times, my clients are only able to give more vague answers, such as: “I just feel stressed throughout my body; I feel really tense.” Oftentimes, we’re able to identify more precise feelings within these vague sensations. Sometimes not.
No matter how precise or vague the emotions and feelings, emotional acceptance is allowing those feelings to be there as long as they need to be, to take up as much space as they need to, and to be as mild or intense as they need.
Does this mean that the emotions and feelings feel good? No. Of course not. When we practice emotional acceptance, we’re practicing the skill of allowing uncomfortable or painful emotions and feelings to be there, even though we don’t like them.
It’s helpful to notice how emotional acceptance is a dramatically different way of responding to our emotions and feelings compared to what those of us with OCD typically do when we have an uncomfortable or painful feeling.
For almost all of us with OCD, before we begin treatment, when we have an uncomfortable or painful feeling, we try to get rid of the feeling as quickly as we can. For instance, imagine Courtney, who has harm-related OCD theme areas, in her kitchen chopping onions. All of a sudden, Courtney’s spouse comes in. Courtney has the thought “What if I lose control and stab my spouse?” Practically instantaneously, Courtney has very painful, anxious feelings in her body and she’s highly motivated to make those feelings go away as soon as possible. A typical way of making those feelings go away will be, for instance, for Courtney to put the knife down and immediately exit the room.
Although putting the knife down and exiting the room will probably eliminate or reduce Courtney’s intrusive thoughts and painful, anxious feelings momentarily, these behaviors will also fuel Courtney’s OCD, leaving her trapped in an endless cycle of intrusive thoughts, anxious feelings, and compulsive behaviors.
So, instead, imagine Courtney practicing her emotional acceptance skills in this situation. When Courtney’s spouse comes in, she has an intrusive thought and the related painful, anxious feelings. Instead of making those feelings go away (e.g., by putting the knife down and leaving the room), Courtney practices allowing the feelings to be there. Courtney says to herself, “I don’t like these painful, anxious feelings but these feelings can be here as long as they need to, taking up as much space as they need, and becoming as intense as they need.” And to really allow the feelings to be there means to stay in the room, still chopping onions, because putting the knife down or leaving the room would reduce or eliminate her painful, anxious feelings.
Of course, it could well be too overwhelming for Courtney to begin practicing emotional acceptance in this situation. That’s one of the reasons why we first practice exposures in session and use our graded hierarchy. Practicing exposures in session and using a graded hierarchy allows us to practice our skills in a way that’s uncomfortable and outside our comfort zone but not overwhelming.
Like all skills, the more we practice tolerating the painful emotions and feelings, the better we become. The better we become, the easier it is to handle the painful emotions and feelings, just like riding a bike or driving a car was hard at first and now almost effortless.
Emotional Validation
The second component of distress tolerance is emotional validation. Emotional validation is the process of telling ourselves, and our painful emotions and feelings, that the emotions and feelings are understandable.
Why do we say our anxious emotions and feelings are understandable? After all, we have OCD and one of the things we know is that we become very anxious in situations where other people don’t feel anxious at all. So, why would we say that our anxiety is understandable?
We say our anxious emotions and feelings are understandable for at least two reasons.
First, at a basic level, we say our anxious emotions and feelings are understandable because we have OCD and, as a result, we expect that we’ll have them. Imagine that you had surgery on your leg and, after surgery, your leg, and the area around your leg, is very painful. Do you like that it’s very painful? Not at all. But is it understandable that your leg and the area around your leg is painful? Of course. That’s what we expect it to feel like.
Likewise for OCD. Do you feel painful, anxious emotions and feelings when you have an intrusive thought? Almost certainly. Do you like the painful, anxious emotions and feelings? Not at all. But it’s entirely understandable that you’re having them because that’s what it is to have OCD.
The next reason our emotions and feelings are understandable is because OCD tells us scary stories.
To begin to see what I mean when I wrote that “OCD tells us scary stories”, I want you to imagine that you and I are standing outside a movie theater that is showing a scary film. After the film, we ask the exiting movie goers if they felt afraid during the film. Almost all of them tell us, “Yeah, that was a really scary movie.”
Imagine if we were to say to them, “Well, it doesn’t make any sense that you were afraid. Didn’t you remember, while you were watching the movie, that you were sitting in a movie theater and not in any danger?”
Each of these movie goers probably knew, in the back of their mind, that they were in a movie theater watching a scary movie and not in any realistic physical danger. But that knowledge doesn’t usually cancel out or override the scary feelings that occur when someone becomes engrossed in a scary film. That’s not how our bodies work. Our bodies respond to the sensory information being presented to us, including the images, sounds, etc. like it was real.
So, if our bodies can respond with fear to images and sounds within a scary movie as if it were real, imagine how our bodies can respond to the scary images and stories within our OCD theme areas, where it’s possible that those scary stories might come true.
Our OCD theme areas, whatever they happen to be, tell us very scary stories about events that actually could happen (even if they are tremendously unlikely). Because these events really would be scary if they happened, it’s entirely understandable that they activate anxiety when we are presented with thoughts or images about these events occurring.
For example, imagine Mindy whose primary intrusive thought was related to the possibility of her son dying if Mindy did not complete specific behaviors. Mindy reported to me that she had vivid images of the ways in which her son might die. It’s entirely understandable that Mindy would feel anxious when being presented with vivid images of her son’s death. Of course, that doesn’t mean that it’s likely that her son will die if Mindy doesn’t complete her compulsions. It simply means that the image of her son dying, regardless of the likelihood, understandably would activate some level of anxious feelings.
The phrase “some level of anxious feelings” is important because it is related to the difference between those of us with OCD and those without OCD.
Individuals without OCD probably wouldn’t enjoy having thoughts and images about, for instance, their child dying. The difference between those without OCD and those of us with OCD, is that those without OCD don’t become extremely anxious as a result of those thoughts and images (even if those without OCD don’t like or enjoy the thoughts and images).
So, the difference is not if the thoughts or images are pleasant but, instead, the intensity of the anxiety that becomes activated by the thoughts and images.
It’s worth noticing that those of us with OCD are in a similar boat to those without OCD regarding thoughts and images not within our OCD theme area.
For example, imagine being abducted by aliens (or imagine someone you care about being abducted by aliens). Imagine aliens doing absolutely terrible, tortuous things to you. Do these images activate any anxiety? If thoughts and images about aliens aren’t within your theme area, then you’re probably noticing only the smallest amount of anxiety, if any (even though the images aren’t pleasant).
Similarly, I once worked with a client who was afraid of being struck by a meteorite falling from the sky. This thought occurred frequently and caused significant anxiety (and related safety behaviors like staying in the basement). Have you considered that you might be struck by a meteorite? Do the thoughts or images of being struck by a meteorite activate your anxiety? Probably not. But if you really imagined being struck by a meteorite, and what the aftermath of being struck would be, imagining it probably doesn’t feel good.
Your emotional response to the thoughts and images of being struck by a meteorite are likely very similar to the emotional responses of someone without OCD experiencing thoughts and images of being struck by a meteorite. That is, both of you probably have very little anxiety even though it’s true that actually being struck by a meteorite is an unpleasant, scary idea.
The key idea is that those of us with OCD are extremely sensitive to the anxious emotions and feelings that occur within our theme area. This extreme sensitivity disregards the likelihood of the negative event occurring and, instead, focuses on how bad it would be if the event occurred.
To come full circle to emotional validation, it really is true that it would be bad if the scary story of our intrusive thoughts came true and, thus, it makes sense that we’d have some level of a painful emotional response when considering a bad event occurring. Our anxiety about our intrusive thoughts may be disproportional relative to the risk, but the anxiety isn’t crazy.
Just like practicing emotional acceptance, the more we practice emotional validation, the more skilled we become and the easier it gets. And, as a result, we develop a more understanding and compassionate approach to our anxious feelings.
You can learn more about the skill of psychological flexibility developed in ERP treatment for OCD by reading the next post in my ERP series, here.