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Helping Patients Confront Intense Feelings
“When I find myself getting anxious, I just go back to work. I feel like I know what I’m doing then and it soothes me.” This was said by a man who works many hours on a computer from a home office and whose family life was suffering from his nonparticipation. It was a real breakthrough for him because up until then, he seemed incapable of real introspection.
Perhaps it’s not often that we get such a direct glimpse into the dynamics of our patients. How often do we work with a person or couple and find that the dysfunctional pattern that brought them into therapy continues to be repeated, with each repetition signaling failure? They express distress at their own inability to change and that distress seems to be real, not feigned, covering an unwillingness to make changes for the sake of the relationship or their own happiness.
The first step in making any change is acknowledging the presence of something. In this case, it is some negative emotion, be it anger, loneliness, shame, or a feeling of emptiness. Often, when we have an uncomfortable feeling related to some “negative” emotion, our first reaction is to reject that feeling. We may tell ourselves the feeling is a “bad feeling” we do not want to have. And then, we may do something to try to get rid of the feeling, such as compulsive work as in this case or using drugs or alcohol to feel better.
MORE: Writing Our Lives as Fiction
Distress intolerance is a perceived inability to fully experience unpleasant, aversive, or uncomfortable emotions, and is accompanied by a desperate need to escape those emotions. Difficulty tolerating distress is often linked to a fear of experiencing negative emotion.
We know that people with borderline personality disorder (BPD), and other psychiatric disorders that involve intense emotional experiences, often have trouble accepting strong emotions and that is why dialectical behavior therapy involves skills training in mindfulness, emotional modulation, and distress tolerance. But often even those who do not meet the diagnostic criteria of BPD have developed a repertoire of avoidance behaviors that rejects strong or “negative” emotions; these avoidance behaviors, themselves, may actually make things worse for people and their relationships.
People raised in a shame-based family environment will adopt measures to avoid feeling like total failures. Shaming is very common, and is considered by many to be acceptable; it is not restricted to "abusive" families. Even in families that don’t shame, many children are not taught to “self-soothe” when feeling strong emotions; as adults, this distress intolerance can lead them to look for soothing from outside sources like food, drugs, or even compulsive work.
MORE: How to Work With the Story in Therapy
In a study in 2014, researchers asked participants to complete a questionnaire then sit quietly to take part in “thinking periods.” Some were told to think about whatever they wanted; others chose from several prompts, such as going out to eat or playing a sport, and planned out how they would think about it during the period. Afterward, participants reported they did not like the experience of sitting alone with their thoughts. Then the experiment took it a step further; participants were given the choice of sitting quietly with their thoughts or pushing a button to give themselves a mild shock to end the session. Sixty-seven percent of the men, and 25% of the women, chose to shock themselves rather than sitting quietly with their thoughts.
So, how to proceed in therapy with someone who has never learned to tolerate negative emotions or learned to self-soothe?
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Ask them to keep a record of how they handle strong emotional situations: Each time they are stressed, write down the source of the stress, what behaviors they engage in, and their consequences, good or bad.
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Teaching them to talk to themselves as they would talk to someone they care about—turn soothing into self-soothing.
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In a strong emotion situation, teach them to act in a new way. Don't just stop the self-sabotage behavior; replace it with something new and healthy—something that doesn't add more problems to an already difficult situation. For the man quoted at the beginning, that might mean activities that distract from thinking about his problems—getting physically active, developing a new hobby, engaging in conversation with others (about things other than personal problems).
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Learning mindfulness techniques as a way to “damp down” the newly felt emotions is crucial; otherwise, the person will feel they simply cannot “control” the emotions and are a failure. Teaching a positive skill gives the patient tools.
What measures have you found helpful with patients who have difficulty tolerating feelings?
References
Leslie Durr, PhD, RN, PMHCNS-BC is an advanced practice psychiatric-mental health nurse with a private psychotherapy practice in Charlottesville, Virginia.
The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of Psych Congress Network or other Psych Congress Network authors.
