Summary
Unlock the combined power of exposure therapy and distress tolerance skills from dialectical behavior therapy (DBT) to manage anxiety more effectively. This detailed guide explores how integrating DBT skills like Pros and Cons, Paired Muscle Relaxation, and Half-Smiling into your exposure therapy sessions can transform your treatment experience. Discover how these approaches help you face your fears gradually, reduce avoidance behaviors, and empower you to handle anxiety-inducing situations with confidence. Dive into the techniques that make anxiety management more bearable and effective, setting you on a path to recovery and resilience.
Why Exposures Matter in Anxiety and OCD Treatment
Exposure and response prevention (ERP) and other exposure-based therapies are among the most effective interventions for a wide variety of anxiety and related disorders. From social anxiety, performance anxieties, and specific phobias to generalized anxiety, and even obsessive-compulsive disorder and post traumatic stress disorder, exposures have been shown to offer meaningful symptom reduction and improvements in quality of life in a relatively brief amount of time. In short, no matter the type of anxiety, chances are your therapist will recommend incorporating some exposures into your treatment plan. And, that’s a good thing!
The Science Behind Exposures
Exposures provide a useful framework for approaching that which anxiety tells us to avoid. Why is this important? Avoidance might feel good in the short term, but it maintains anxiety in the long term by robbing your brain of potential corrective experiences. By avoiding opportunities to encounter what you fear, you never learn that you can tolerate more than your anxiety would have you believe you can and you’re not able to learn that many aspects of your fears may not be fully true. To put it simply, exposures work because they help promote new learning.
A Gradual Approach to Anxiety Treatment
Exposures tend to conjure up images of people encountering their worst fears right off the bat, but this isn’t quite how it works. TV shows and movies often paint exposures in a grim light.
The truth is, anxiety and OCD specialists tend to work with clients to pursue a gradated approach, sometimes called an exposure hierarchy, where clients tackle their fears over time. Traditionally, clients have tended to work their way up slowly to the stimulus that is most anxiety-provoking. This is done collaboratively, with your therapist assuming the role of a supportive coach. Additionally, many clients report feeling empowered and proud after completing exposures and they tend to emerge with a new perspective on their fears, themselves, and the world.
Even still, knowing how effective exposures are and how confident they’ll feel afterwards doesn’t take away the unsettling feeling that can often come with starting this type of therapy. After all, you may know that going to the dentist is good for you and will give you that sparkly clean feeling on your way out the door, but chances are you’re not all smiles in the waiting room. That’s a normal feeling! And there are skills and techniques that can help make exposure therapy more manageable.
Using DBT Skills to Enhance Exposure Therapy
Enter dialectical behavior therapy (DBT). A cousin of cognitive behavioral therapy (CBT), DBT is a type of treatment that emphasizes balancing acceptance with change to promote behaviors that are consistent with a client’s life goals.
To help shape clients away from engaging in behaviors that interfere with these life goals, DBT offers a set of distress tolerance skills that are designed to be used to get through a crisis without doing anything to make the situation worse. While exposures are certainly not crises, this group of distress tolerance skills can still offer a benefit for clients as they endure these anxiety-provoking situations.
Below you will find a few DBT skills that are good candidates to incorporate into exposures.
DBT Skill: Pros and Cons
How it’s used in DBT:
Clients write down the positive and negative consequences of acting on their impulse to engage in harmful behavior so they can reference this list during future crises.
How to use it with exposures:
Before working your way up to harder exposures, take time to record the pros and cons of engaging fully with exposures. Common advantages may include making progress with your anxiety or OCD, reclaiming aspects of your life or your ability to live the way you’d like to, or getting in touch with things you value. By giving yourself space to acknowledge the not-so-exciting parts of exposures (like, “This may be unpleasant”, or, “It would be much easier to keep avoiding”), it becomes easier to see that the pros far outweigh the cons.
DBT Skill: Paired Muscle Relaxation and Paced breathing
How it’s used in DBT:
Both of these skills are designed to bring the parasympathetic nervous system back online, which lowers heart rate, breathing rate, and generally counters the fight-or-flight physiology activated by the sympathetic nervous system. In paired muscle relaxation, clients intentionally tighten, hold, and release muscle groups, systematically working their way from their feet to their face. Paced breathing involves engaging in slow diaphragmatic breathing, ensuring that exhales are at least 2 seconds longer than inhales.
How to use it with exposures:
Exposures tend to be ineffective when clients are highly anxious. Neither of these states of arousal are conducive to facilitating new learning. To bring anxiety down from, say, an 11 out of 10 to a 7 out of 10, either of these skills may be useful to use at the start of an exposure.
DBT Skill: Half Smile and Willing Hands
How it’s used in DBT:
Clients adopt a serene facial expression and lift the corners of their mouth ever so slightly, in a barely perceptible smile, while placing their hands in their lap with palms facing up. This posture is a skill to help reduce feelings of willfulness, even when reality is unpleasant or unfair.
How to use it with exposures:
Half smiling and willing hands can be used during exposures to make it more manageable to sit with difficult thoughts and feelings that may come up during exposures. They can also help you to replace physical safety behaviors like gripping or clenching, as these behaviors send the message to your brain that you’re in danger. Small changes to your body language can have powerful effects on your state of mind.
DBT Skill: Self-Soothe
How it’s used in DBT:
Clients focus on increasing pleasant sensations through all five senses. Many clients opt to make a self-soothe kit they can turn to when the urge to engage in potentially harmful behaviors arises. These kits can include things like: A scented candle, your old Gritty plush doll, a favorite picture of your loved ones, or even a gift card to Philly Pretzel Factory that you always keep loaded with funds in case of emergencies.
How to use it with exposures:
Self-soothe is a great way to reward yourself after exposures. Create your own kit to use after sessions or homework practice to praise yourself for doing hard things!
These skills offer a more pleasant way of tackling exposures, while the integrity of the exposures remain intact. To borrow logic from Mary Poppins, the spoonful of sugar doesn’t change the strength of the medicine, it just helps the medicine go down easier.
A Word of Caution about Combining Skills with Exposures
Not all distress tolerance skills are created equally, and some do tend to make exposure interventions less effective. Several distress tolerance skills leverage the use of distraction, which may be highly effective for enduring a crisis situation, but are generally counterproductive for exposures. Distress tolerance skills that could fall into this category include many of the Wise Mind ACCEPTS skills (sometimes called the “Distract” skills) and IMPROVE skills, which include imagining pleasant imagery, taking a mini vacation, and repeating positive affirmations (e.g., “This won’t last forever”).
Why steer clear of these particular skills during exposures? The answer is simple, but not always easy to do: exposures are most effective when you are focused on the present moment. By encouraging your mind to wander away from focusing on the situation or stimulus at hand and instead to a pleasant scene in your imagination, your brain receives the opportunity to avoid the exposure. Even though you’re physically present, your attention is elsewhere. Your brain may learn that certain situations are tolerable only if distraction is possible. Distraction itself then becomes a safety behavior that maintains anxiety in the long run.
Conclusion: Using DBT Skills in Individualized Ways that Work for You
Ultimately, the goal of exposure therapy is not to produce anxiety for anxiety’s sake. Exposures are designed to help you learn about your fears and learn that you can tolerate that which your anxiety tells you to avoid. And, if distress tolerance skills can make exposures a little easier, great! As long as they aren’t colluding with your anxiety to engage in avoidance, distress tolerance skills are a great addition to treatment. Not all skills will work for all people in all situations, so it’s best to test out what works for you.
Engage with Us for Insight and Support
As you navigate your path to managing anxiety, remember that our resources extend far beyond this article. We warmly invite you to explore our comprehensive guides, detailed resources, and join our supportive community.
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- General methods: Learn about our structured and supportive techniques for overcoming OCD, anxiety disorders, and related challenges through our Treatment Approach page.
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This blog was brought to you by Kathryn Coniglio PhD.
