Hi Chris,

Welcome to the listserve and congrats on your first post. I look forward to more from you!

The idea of 'sitting inside the question' is something Kelly Wilson (one of the developers of ACT) talks about, or at least, that's where I know it from (it's origins may go back further than that). Essentially it means allowing yourself to be in the space of not knowing, not rushing to answer, but just staying with the question. Since being exposed to this idea at the ACT world con last year (or maybe the year before now), I've been working to do that more often. Asking a question and then purposefully pulling back from answering it straight away or from answering other people's straight away and I've found that in doing so, there really is the capacity for lots of other things to emerge. The thing is if you answer it straight away, then it's done and there's no more space for anything else. With 2 + 2, the answer's pretty obviously 4 (although as I write this I'm wondering if maybe there is any other possible answers.... anyway, to the best of my knowledge, the only answer is 4). But when it comes to the work that we do, the answer is never simply '4'. Oftentimes we try to make it that to make it easier for ourselves, but if we sit and not answer it, then we get to see the additional possibilities. I thought about this idea a lot when I was travelling in January with a non-psychologist friend through Central America. I kept saying "I wonder...." and then she'd answer with her opinion and I kept trying to explain to her that I just wanted to wonder, without having to have the wondering answered straight away. She thought it was very strange! Anyway, does that make the concept clearer?

Hmm, the acceptance vs DBT one's a biggie and there's a fair bit in the ACT archives where people have bounced this one back and forth (have a look at www.contextualpsychology.org). Strictly speaking, distraction is avoidance and to be black and white about it the idea in ACT is to reduce avoidance and move towards acceptance, however... sometimes avoidance is functional. Here's my understanding of the synthesis people have arrived around this and I'll talk about it in relation to BPD clients, cause that's where it's come up before - so, if you're completely overwhelmed and the option is to distract vs overdosing, then the choice more consistent with valued living is to distract. Distress tolerance strategies ala DBT are designed to be used in a crisis where you've got to find the way to bear the pain without making the situation any worse. So, how do we define a crisis? It's an interesting question in regards to eating. Is eating a crisis? Most of us would say no, it's refueling our bodies or perhaps indulging in something decadent. For someone with an Eating Disorder, is it a crisis? I don't know. Maybe. I'm recalling my client who said that she felt like she was on fire when she had an urge to binge and the only thing to do was to binge. Well, feeling like you're on fire could probably be defined as a crisis. The thing is that 'normal eating' (our dietitian will kill me for using that phrase) involves 3 meals and 3 snacks a day, so that's a lot of time to be in crisis. Who gets to decide if it's a crisis or not, us or the patients? In DBT, it's the patients, but then I'm thinking in the case of an Eating Disorder that if the patients tell us it's a crisis and we go 'oh okay, it's a crisis, let's use distress tolerance then', we miss out on the opportunity to really check out if it's a crisis, i.e., "I know if FEELS like one, but would it be okay for us just to have a look at it? You've feeling some really strong sensations in your body (check in with that) and your mind is having an awful lot to say about this (elicit) and what else (elicit). So, if it was possible to just let those feelings be there and let your mind say what it's got to say whilst we focus on what's important to you and do this for just one moment, would that be a crisis? And then if we could do the same thing in the next moment?"

Also the idea with distress tolerance is that you find a way to tolerate it UNTIL you can approach the problem. So, if the clients are always distracting at meal times, when do they learn to approach it? I really don't know the answers to these questions I would love others to weigh in around this, as I think the concept of acceptance vs DT strategies in an acute inpatient eating disorder setting is a really useful thing for us to think through...and sit inside the question of ;-).

In terms of your comment that it seems like a paradigm shift, I agree, I think it is. I think that's why whenever I teach ACT for the first time, people often look baffled and confused (of course it could be that I'm just a really bad teacher) but once they've had time to soak in and adjust to the paradigm shift, they can get what this is about. I also think it's generally the case that as clinicians we feel more comfortable with distress tolerance and distraction, it gives us something to do so we don't have to stay with our own anxiety in the face of the patient's intense anxiety. I feel safer and more comfortable when I'm talking to an intensely suicidal patient about going to hospital - I get to make my anxiety do down and on occasion it may be what's needed, but I think very often it's done in the service of bringing our anxiety down and not having to stay with the pain that the patient is in, when in fact us staying with our own anxiety whilst we stay present to their intense pain is likely just what is needed. So, yep, probably distress tolerance does feel safer for both patients and staff and yet....

Just to clarify, it's not that I'm anti- Distress Tolerance (even though it probably seems it). I do think it's got it's role, I just think our patients overuse it and at times we encourage that and I know I've played a role in our Borderline patients getting to the end of a year in DBT with some super dooper Distress Tolerance skills and some highly under-developed acceptance skills.

To cite you Chris, "all thoughts most welcome" ;-)

Carla.

>>> "chrisethornton" <ckthornton@...> 19-Feb-08 3:35 pm >>>

Hi Carla
Thanks for all your posts. I always learn alot from what you have to
offer. This is my first.

Could I get you to expand on the notion of "sitting inside the
question" a bit more.

I love where you wrote about being with the patient in intense
emotional distress and helping them be with the emotion. I was
wondering if you can say more about the balance between acceptance
strategies and DBT distress tolerance strategies. Working in an
inpatient unit there is such a focus on distress tolerance and
distraction at meal times which seems at odds with trying to help with
acceptance of the distress that will naturally come with doing
something so difficult. It seems like a paradigm shift for both
patients and staff - and both feel safer with distress tolerance and
distraction.

all thoughts most welcome

chris

--- In eatingconcernsandcontextualpsychology@yahoogroups.com, "Carla
Walton" <Carla.Walton@...> wrote:
>
> Hi Tyler,
>
> Thanks so much for expanding on your email and being as transparent
as possible. As you say, working in an outpatient setting is a whole
different ball game to working with clients in residential care with a
deadline hanging over your head. No wonder you want to switch to
distress tolerance strategies, so you can feel like you're giving them
something. I have always worked in outpatient settings and never in
inpatient settings and I take my hat off to you, because you see these
clients at their most severe and most distressed.
>
> One of the things that struck me about the residential setting is
the amazing opportunity to work with people in-vivo when they are
experiencing such intense emotions. I work in a DBT program and the
phone is our equivalent for people to call when they're in the crisis
situations to work with them at that moment. As therapists, it's so
much more challenging that when people come in all regulated and we
can just talk about what to do when the crap hits the fan, but also so
much more powerful.
>
> I'm very much a fan of Kelly's idea of 'sitting inside the question'
without the pull of the need to answer it.... and yet, I don't really
know how to do that on a listserve. If others also value the idea of
sitting inside the question to give space for something fresh to
emerge maybe we can work out how to do that together?
>
> My main suggestion would be to lean in when the emotions are intense
and notice with the patient. What is this thing that they believe is
impossible to have. Where do they notice the emotion, what does it
look like, if it had a colour, what colour would it be, or a shape,
can they just breathe into it and have a look at it and be curious
about it.... even whilst it's threatening to overwhelm them. At that
time the emotions seem like they could destroy them and I've been
playing around with your metaphor of the classroom being on fire in my
head. Maybe there's so much smoke that it seems like there must be a
fire and that everyone will die, but if they could stay and look at
the smoke and see through it, they could see that there's no fire
(kind of like the passengers on the bus claim that they could really
hurt you, and yet, experience shows that they never have). The smoke
makes it seem like there is a fire and they probably can't listen to
your words and what you're teaching because the smoke is demanding
their attention, so go to where they are and look at the smoke with
them and they will have an urge to run out of the room, but they've
done that before and being in that room is where they need to be for
life to be lived. Does this fit for you? I think your metaphor is a
really useful one and it'd be good to play around a bit with it. It
also reminded me of a client with Bulimia who talked about having
urges to binge that felt like she was on fire and the only way to put
the fire out was to binge. Not sure how that fits in here, but it was
so evocative for me and helped me to see how could she possibly feel
like not bingeing was an option when that actually meant feeling like
she was burning alive. i can't even remember how we addressed that in
therapy, but I do remember that over time she talked about the sense
of burning alive reducing.
>
> Also, I wonder if the more the emotional intensity the client
presents with, the more driven you feel to talk and help and coach
(that's what happens for me).
>
> Are you on the main listserve? Someone posted a question last week
about working with a young person with anorexia who is losing weight
fast and their were a couple of really lovely responses about the
therapist working on acceptance and being where the client is at.
>
> I also discussed this with some of my colleagues who had some
different ideas, so I will leave it to them to respond as I think
they'll do a better job of explaining what they mean than I will.
>
> I might leave it there for now. I had a few more half-baked thoughts
but I have a client downstairs waiting for me and if I wait to have
time to write a longer response it won't happen and I wanted to send
something off in response to your email.
>
> Thanks again for your honesty and willingness to be vulnerable and
to put your questions out there.
>
> Carla.
>
> >>> "jtbeach78" <jtbeach78@...> 06-Feb-08 2:30:30 pm >>>
> Hi Carla,
>
> Thanks for your response! I find myself using the very same
> strategies you describe. In my opinion, I think this works well in
> longer term psychotherapy situations when we can circle over and over
> until they're ready to approach.
>
> Where I'm having a hard time applying it is with my clients in
> residential care, where my they come in for 45-90 days. The situation
> is quite different in that all of a sudden these clients are faced
> with eating large food portions and tolerating changes to their BMI
> in very quick progression.
>
> In the interest of getting some focused feedback, I'm going to be as
> transparent as possible. The first few days are sort of a honeymoon
> where the food portions are typically small and patient anxiety,
> although still high, hasn't reached phobic intensity. At this stage,
> orienting someone to an ACT framework is relatively easy. In fact
> they really see how avoidance has caused so much trouble. Other
> treatments haven't been fully effective so maybe this is worth a try.
> But treatment changes quick from this point, and as we know many of
> these clients really have a hard time with change. Food portions and
> body changes start happening and emotional intensity and suffering
> spike to high levels. I try to prime my patients for this change as
> much as I can. When the petal hits the metal is when I feel the most
> unskilled at guiding my client. I validate, use metaphors, remind
> them of their values, remind them we've anticipated this reaction,
> etc. All of this helps some but in the middle of such intensity
> doesn't seem to sink in the same as it did before. Patients who were
> very eager several days before want to run for the hills. Sometimes
> my clients look at me like I'm crazy or they just repeat that they
> don't want to feel this way no matter what the cost. I validate their
> reactions and invite them to look at them. I talk about the nature
> of avoidance and how it can limit our ability to get free.
>
> I love the theory but many times with clients, this is the time that
> just feels weird to me. Sometimes I feel like I am trying to teach a
> class and requesting that my students please pay attention when the
> classroom is on fire! I start to worry and my brain starts producing
> worry thoughts:
>
> "Am I being presumptuous in thinking I can open them to this
> approach and then help them to see some benefit in a reasonable time
> period? Is there something else I could be providing them? Is this
> work appropriate for where they are? Am I reasonably confident they
> have the skills to tolerate this sort of intervention? Will they
> leave treatment with some concrete skills they can take with them in
> their continued recovery? Should I go back to my old DBT approach
> and validate the distressing nature of the current intensity,
> encourage distress tolerance (distraction) techniques, thought
> stopping and distortion challenges? Or should I focus exclusively on
> the validation strategy by empathizing as hard as I can, and put all
> of my focus on creating a corrective emotional experience?"
>
> So that is where I find myself sometimes. I sometimes get
> discouraged because I feel unskilled at assisting in reducing intense
> suffering in the moment without using distracting skills. Also, in
> spending more time coaching them towards their values, and analyzing
> language. I feel a bit pushy and invalidating of their current
> suffering. I remain patient and continue forward but its hard at
> times! Part of the journey for me seems to be able to integrate this
> in a way that allows me to tolerate my uncertainty.
>
> --Tyler
>
>
> --- In eatingconcernsandcontextualpsychology@yahoogroups.com, "Carla
> Walton" <Carla.Walton@> wrote:
> >
> > Hi Tyler,
> >
> > I'm not sure if I've got any big ideas for that issue, I'm really
> wanting to write back to support your wonderings and keep the
> conversation alive.
> >
> > WIth eating disorders, I find myself continually returning to
> Creative Hopelessness and particularly the idea of workability, i.e.,
> in your experience, has that worked and what's the cost been. I find
> with Eating Disorders more than any other client group I work with, I
> need to keep revisiting that, cause often just as soon as someone has
> opened up to other possibilities, the Eating Disorder comes in and
> takes over again. In fact, I guess I find with Eating Disorders, that
> I'm often circling back over lots of ACT aspects. My take on it is
> that when the lack of food intake affects people's cognitive
> abilities, it makes it harder to take stuff in and that the affect
> phobicness and fusion with thoughts is really strong with EDs.
> >
> > In the situation of ambivalence, I'd be likely to move into values,
> so that it makes it more meaningful. E.g., "would it be worth having
> (describe painful feeling) if it meant that (describe value)?"
> >
> > Not knowing each other in these situations, I always wonder when I
> write things whether these are the things people are doing anyway.
> >
> > Carla.
> >
> > Dr Carla Walton
> > Clinical Psychologist
> > Centre for Psychotherapy
> > James Fletcher Hospital
> > PO Box 833
> > Newcastle NSW 2300
> >
> > Ph: (02) 4924 6820
> > Fax: (02) 4924 6801
> > E-Mail: Carla.Walton@
> >
> > >>> "Tyler Beach" <jtbeach78@> 01/11/08 10:02 AM >>>
> > Hi group,
> >
> >
> >
> > I work as a psychotherapist at a residential eating disorders
> facility. I'm
> > new to ACT work. I'd done some reading on it and recently went to a
> > training offered by an ACT psychologist at Duke. I was originally
> trained
> > in DBT and mindfulness based psychotherapy, but after going to this
> recent
> > training, I realized I was doing a bit of ACT work (sans
> terminology or
> > framework) without even knowing it! For about a year I have been
> slowly
> > moving away from some of the distraction and blocking strategies
> taught by
> > DBT (which IMO certainly have their place for certain populations)
> and
> > leaned more heavily into the defusion strategies and mindfulness
> > experiencing skills. I find the work very rewarding and intense.
> It is
> > always an adventure during the intro stage, especially when I am
> engaging a
> > client in a conversation where I am actually asking them to stop
> fighting
> > their thoughts of being "fat" and corresponding feelings. My
> experience is
> > that most clients are quite intrigued and like the theory, but tend
> to
> > become more ambivalent in the presence of actual affect or intense
> thoughts.
> > I wonder if others are coming up against that and what strategies
> they use
> > to keep a client engaged in the approach vs. avoidance.
> >
> >
> >
> > --Tyler Beach, LCSW
> >
>
>
>
>
>
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