When ERP Feels Impossible: How DBT Can Help (with Rebecca DeLeon) | Ep. 498
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In this episode, I explore how adding DBT skills to ERP can help you tolerate overwhelming emotions, stay engaged in treatment, and move toward lasting OCD recovery with greater confidence and self-compassion.
In this episode, I discuss:
- Why struggling with ERP doesn’t mean you’ve failed treatment. It may simply mean you need additional distress tolerance skills.
- How DBT and ERP work together to help you face anxiety without relying on compulsions.
- Practical DBT tools, including mindfulness, TIPP skills, opposite action, and emotion regulation, that can make exposures feel more manageable.
- The important difference between using coping skills to support ERP and using them to avoid anxiety.
- How to respond to shame, self-criticism, and overwhelming emotions in a way that aligns with your values and supports recovery.
- Why willingness, not fearlessness, is one of the most powerful skills you can develop on your recovery journey.
When ERP Feels Too Hard: How DBT Skills Can Help You Stay on the Path to OCD Recovery
If you’ve spent any time learning about OCD treatment, you’ve probably heard that Exposure and Response Prevention (ERP) is the gold standard. And it’s true. ERP has helped countless people reclaim their lives from OCD.
But here’s something I don’t think gets talked about enough:
ERP is hard.
Maybe you’ve tried it before and felt completely overwhelmed. Maybe the anxiety felt unbearable. Maybe you shut down, avoided the exposure, or left treatment thinking, “Maybe ERP just isn’t for me.”
If that’s been your experience, I want to offer you another perspective.
What if you didn’t fail ERP?
What if you were simply missing a few important skills that could make ERP feel more manageable?
That’s exactly what I explored in this week’s podcast with Rebecca De Leon, a therapist on my team who specializes in both Exposure and Response Prevention (ERP) and Dialectical Behavior Therapy (DBT). Together, we talked about why these two treatments work so beautifully together and how learning a few additional coping skills can make all the difference for people who feel emotionally overwhelmed during ERP.
Content
ERP Is Still the Goal
Before we dive into DBT, I want to make one thing very clear:
ERP is still the gold standard treatment for OCD.
DBT isn’t designed to replace ERP.
Instead, think of DBT as giving you the emotional tools you need so you can successfully engage in ERP. It’s the support system that helps you tolerate the discomfort that naturally comes with facing your fears.
For many people, this combination is incredibly powerful because recovery doesn’t just require courage. It also requires emotional flexibility and distress tolerance.
Why ERP Can Feel So Overwhelming
One of the biggest misconceptions about ERP is that success depends on simply “being brave enough.”
That isn’t true.
During ERP, you’re intentionally facing situations that trigger anxiety without performing compulsions. Naturally, your brain sounds the alarm.
Most people experience significant anxiety during exposures. That’s expected.
But some people experience something even more intense.
Instead of feeling anxious, they may become emotionally flooded.
They might experience:
- Panic that feels impossible to tolerate
- Intense anger or rage
- Emotional shutdown
- Depression after exposures
- Self-harming urges
- Suicidal thoughts
- Feeling completely out of control
- A strong urge to escape the exposure immediately
When this happens, it doesn’t mean ERP isn’t working.
It often means your nervous system needs additional support before you can fully benefit from the exposure process.
The Missing Piece: Distress Tolerance
One of the biggest lessons Rebecca shared is that many people have never actually been taught how to tolerate emotional distress.
They’ve learned how to avoid it.
They’ve learned how to distract from it.
They’ve learned how to escape it.
But sitting with difficult emotions?
That’s an entirely different skill.
This is where DBT becomes incredibly valuable.
Distress tolerance skills aren’t about making anxiety disappear.
They’re about helping you stay present long enough to continue doing the work that leads to recovery.
That distinction is incredibly important.
What Is DBT?
DBT stands for Dialectical Behavior Therapy.
At its core, DBT combines two powerful ideas:
- Acceptance of where you are today.
- Commitment to meaningful change.
Instead of choosing one or the other, DBT teaches us that both can exist at the same time.
You can acknowledge that something feels incredibly difficult while also choosing to keep moving toward your values.
This balance makes DBT an excellent companion to ERP because ERP already asks us to practice willingness, uncertainty, and acceptance. DBT simply gives us additional tools for navigating the emotional intensity that comes with those experiences.
How Do You Know When You Need DBT Alongside ERP?
Everyone experiences discomfort during ERP.
But there are times when the emotional distress becomes so overwhelming that progress stalls.
Some signs that additional DBT skills might be helpful include:
- You avoid exposures because the emotions feel unbearable.
- You repeatedly quit ERP because it feels “too much.”
- You panic during exposures.
- You become emotionally dysregulated after exposures.
- You lash out at loved ones afterward.
- You rely heavily on compulsions just to make it through.
- You feel ashamed that you “can’t handle ERP.”
- Even low-level exposures feel impossible.
None of these experiences mean you’re failing.
They simply suggest that learning additional emotional regulation skills may help you move forward.
The Goal Isn’t Less Anxiety
This is one of the most important ideas from our conversation.
The purpose of DBT skills during ERP is not to eliminate anxiety.
The goal is to make the distress tolerable enough that you can continue practicing response prevention.
There’s a big difference.
If we use a skill to avoid anxiety, it can become another compulsion.
If we use a skill to calm our nervous system just enough to continue facing the fear, we’re supporting the recovery process.
Your intention matters.
Ask yourself:
“Am I doing this to escape anxiety?”
Or…
“Am I doing this so I can keep moving toward what matters?”
That distinction changes everything.
Mindfulness: Returning to the Present Moment
Mindfulness is one of the foundational DBT skills Rebecca uses with clients.
Many people with OCD spend enormous amounts of time:
- Replaying the past
- Predicting the future
- Trying to solve uncertainty
- Mentally reviewing situations
- Arguing with intrusive thoughts
Mindfulness gently redirects our attention back to what is happening right now.
Instead of trying to get rid of thoughts, mindfulness teaches us to notice them.
“I notice I’m having the thought that…”
That simple shift creates space.
And that space makes response prevention much easier.
Mindfulness doesn’t remove OCD.
It changes how we relate to it.
When Anxiety Reaches a 9 Out of 10
Sometimes anxiety becomes so intense that thinking clearly feels impossible.
In these moments, Rebecca often introduces one of DBT’s best-known distress tolerance strategies: TIPP skills.
TIPP stands for:
- Temperature (using cold water or an ice pack)
- Intense exercise
- Paced breathing
- Paired muscle relaxation
These skills work with your body’s physiology to help reduce overwhelming emotional arousal.
They’re not intended to erase anxiety.
They’re designed to help you regain enough emotional stability to continue your ERP work.
Think of them as resetting your nervous system, not escaping your fear.
One of My Favorite DBT Skills: Opposite Action
If you’ve listened to me for a while, you probably know how much I love values-based action.
That’s one reason I appreciate the DBT skill called Opposite Action.
Many emotions come with powerful urges.
Shame tells us to hide.
Fear tells us to avoid.
Guilt tells us to withdraw.
Opposite Action asks:
“What would I do if I weren’t following this emotion?”
Sometimes that’s simply showing up anyway.
Sometimes it’s speaking up when you want to stay quiet.
Sometimes it’s attending the gathering you want to cancel.
Sometimes it’s continuing the exposure even though every part of you wants to stop.
Rebecca also introduced the idea of Opposite Action All the Way.
Instead of making a tiny move toward courage, you lean fully into it.
That boldness can sometimes interrupt rumination and weaken OCD’s grip in surprising ways.
What About Shame?
One emotion that comes up repeatedly for people with OCD is shame.
I’ve met so many people who tell me:
“I should be able to handle this.”
“What’s wrong with me?”
“I feel like an adult trapped with a child’s emotions.”
Rebecca shared an approach I deeply appreciate.
Instead of immediately trying to argue with shame, she helps clients ask whether the emotion is justified.
Did you actually violate your values?
Or are you simply judging yourself for struggling?
If the shame isn’t based on your actions or your values, then the goal becomes responding differently rather than believing everything the emotion is telling you.
This helps people stop getting trapped in endless cycles of self-criticism and instead return to living according to what truly matters.
Willingness Changes Everything
One word kept coming up throughout our conversation:
Willingness.
Recovery isn’t about liking anxiety.
It’s not about pretending discomfort feels good.
It’s about becoming willing to experience temporary discomfort in service of a life that matters.
Sometimes willingness looks confident.
Other times it looks like saying,
“I really don’t want to do this… but I’m willing anyway.”
Both count.
Progress doesn’t require perfect confidence.
It requires willingness to take the next step.
Needing More Skills Doesn’t Mean You’re Failing
If there’s one message I hope you take away from this conversation, it’s this:
If ERP has felt too difficult, that does not mean you’re beyond help.
It doesn’t mean you’re “doing it wrong.”
It doesn’t mean you’re incapable of recovery.
It may simply mean your nervous system needs additional support.
Learning distress tolerance, mindfulness, emotion regulation, and willingness isn’t a detour from recovery.
For many people, it’s exactly what allows recovery to happen.
Final Thoughts
One of the things I love most about modern evidence-based therapy is that we don’t have to choose between approaches that work well together.
ERP remains the gold standard for treating OCD.
DBT gives many people the emotional skills they need to fully engage in ERP.
Together, they create a compassionate, practical path forward.
If you’ve ever felt like ERP was simply too overwhelming, I hope this conversation reminds you that there are additional tools available.
Sometimes the next step in recovery isn’t pushing harder.
Sometimes it’s learning how to support yourself while doing the hard work.
Recovery is absolutely possible, and you don’t have to do it by relying on willpower alone. With the right skills, support, and willingness, you can continue moving toward the life you want, one step at a time.
Transcription: When ERP Feels Impossible: How DBT Can Help (with Rebecca DeLeon)
Kimberley: ERP is the gold standard treatment for OCD. You probably already know that, and if you’re watching this or listening, there is a very good chance that you also know that ERP is not easy. Maybe you’re thinking, “I tried it, and I just could not do it.” Maybe the distress felt absolutely and completely unmanageable as you practiced ERP, and maybe you just completely shut down when you tried it.
Maybe you left feeling like you were too broken for the specific treatment that was supposed to help you. I want you to hear something before we go any further. You did not fail ERP. There was probably just a few skills that you are missing. Today, we have Rebecca De Leon. She is a DBT specialist and an ERP therapist who works in my private practice here in California in Los Angeles.
She is an incredible therapist, and she works every day with people who have been hit with exactly this concern when they’re practicing ERP. They feel like they just don’t have the skills, and their emotions are just too strong. Rebecca teaches us that ERP is still the destination, but we need something first.
We need skills to be able to tolerate the distress of ERP, and that is where DBT comes in. DBT is not here to replace ERP. It’s to use before ERP, alongside ERP, and as the thing that makes ERP manageable in those
Rebecca: moments when it feels like absolutely impossible.
Kimberley: Okay, Rebecca, I am so excited that you’re here-
mainly because this is a topic we talk about in supervision in our team all the time. Now, we know that ERP is the most evidence-based treatment, but you work a lot with our clients in teaching them what DBT is and how to use it. So before we get started, can you explain what is DBT?
Rebecca: Yes. Great. So DBT stands for dialectical behavior therapy, ’cause I know we don’t have a whole long time here.
In short, it’s the combination of cognitive behavioral therapy that really relies on change with the addition of acceptance- Mm … to meet the client where they’re at. So these two together were kind of created to make DBT what it is today, um, and allows the client to feel that acceptance while they’re moving through change.
Mm. And it comes with different modules that allow you to, you know, kind of have different benefits for whatever your needs are.
Kimberley: So how would you determine… So s- let’s say somebody is practicing ERP, they’ve got OCD or they’ve got an OCD-related condition. They’re trying to face their fears. They’re trying to reduce their compulsions.
How might they know that it’s time to also sort of bring in some DBT skills? Like, what would be some of the signs that they’re experiencing that might make them think, okay, or a clinician think, “Okay, it’s time to sort of add this additional modality to treatment”?
Rebecca: Sometimes the client doesn’t know, and when I’m talking with my clients and we’re trying to kind of gauge different exposures that they are doing or need to do, and when they let me know it’s just too tough or they let me know that they’re trying to just distract or, “No, I can’t sit with that discomfort,” I then will check in about, you know, “What do you know about distress tolerance skills, or what type of skills do you have to kind of tolerate, you know, the anxiety that you’re feeling?”
And sometimes they’re like, “None. Absolutely none,” and that’s when I can pull up my, or pull out my workbook and say, “Here’s what we’re gonna kind of get into today in this session,” and go over the main course of crisis survival skills- Yeah … in the distress tolerance module.
Kimberley: I love that you do this. Like, I’m just so grateful that you’re on our team and that you’re here today.
Me too. Yeah, it’s, it’s such a joy, truly. I’ve, I say to my staff all the time, I literally have the dream team. Like, it’s such an awesome team of human beings. I’m-
Rebecca: We agree that about you.
Kimberley: That so makes me so happy. Tell me, let’s, before we go into this, sort of the skills, like, what is the experience of someone…
What does, what does it look like for us as clinicians that might be signs that they need these skills? Like, we talked about it a little bit in the intro, but, like, what are some things they might be saying or feeling or, you know, what behaviors might they be showing that make us feel like, “Okay, this is something we need”?
Rebecca: Okay, so this is where I’m gonna struggle, Kimberly. I should have thought about, like, how do I actually… W- what am I noticing with my clients? And I don’t have anything off the top of my head, so I actually need to think about that. What are you thinking? ‘Cause maybe my brain’s just not getting there
Kimberley: Yeah, so let’s pause that.
Take that out, editors. I’ll start with a story, and we can riff. So let’s talk, Rebecca, about the client or the sufferer. What I have found is, you know, with normal ERP in the way that we practice it, we do a lot of psychoeducation about willingness to be uncomfortable, right? Willingness to be uncertain.
The goal of, like, face your fear, bring it on, right? Like, we’re doing all of this education at the beginning of treatment before ERP. And then what I find is that when they start to do ERP, it’s normal to feel distress. It’s normal to feel- Mm-hmm … like, “I don’t know if I can do this.” Maybe you’re at, like, an eight or a nine out of 10 with anxiety.
All of that is normal. But what I find is there are a set of clients who when they’re hitting those eights and nines, they’re not coping well. Mm-hmm. They’re either falling into a deep depression, or maybe they’re engaging in some sort of harmful behavior. Like, you know, they’re, they’re harming themselves, or they’re becoming so distressed that maybe they’re having suicidal ideation.
What are some other ways that a, a reason somebody might, you know, we might pull back on the ERP and discuss the idea of maybe bringing on some DBT?
Rebecca: Well, it’s interesting ’cause you said it right there in kind of like your first sentence. They’re unwilling, or they struggle with the willingness to feel that discomfort the way that is needed and necessary for ERP.
So there is a willingness in DBT where then I might break it down step by step when I see that, you know, if you’re struggling to be willing to feel the discomfort of ERP, it’s gonna be hard to kind of overcome this. So when they let me know, “I don’t know if I can do that,” or, “That’s too difficult,” or, “I’m not ready for that yet,” and it’s really hard for us to even start at lower level- Mm-hmm
distress- Yeah … you know, type exercises and exposures, then that’s when we kind of, like, run into that conversation of, “Well, let’s see what’s needed for you to be able to manage even low level, low sud, um- Yeah … exposures.” Yeah. So then it’s kind of when we start to, you know, use their hierarchy and see where can we start, and it just feels too overwhelming for them.
So we have that discussion about what are you willing to tolerate, and when it’s very minimal, then we start to see, like, maybe there’s nor- more skills needed here- Yeah … to get them going.
Kimberley: Yeah, yeah. And I found, too, that, you know, often a client… There’s been a couple places where I’ve even referred clients to you because as they’re doing the exposure, even they maybe they’re able to do the exposure, but then they feel very strong emotions like rage, or they- you know, lash out at family members or they’re, again, maybe they’re starting to inflict harm on themselves or, you know, you know, scratch themselves and so forth.
Mm-hmm. And, and I find that that has been another reason that people have benefited. So I think that what we’re really getting at here is it’s not your fault if you need- Mm-hmm … DBT, right? Like, I don’t want people… I hear it all the time, people feeling so ashamed that they’ve struggled with ERP and they haven’t been able to do it.
I really don’t want anyone to leave here feeling like there’s something wrong with them. Mm-hmm. I think what you’re really suggesting is there’s just these additional skills and experiments and practices we can use to sort of get the leg up on the work.
Rebecca: Yes. Very true. And I tell my clients, you know, most of my work before I came, you know, to work with you, Kimberly, was in residential, and I kind of let them know, here’s how I started using these- Mm
DBT skills with these clients that had self-harm or drug use, uh, and really needed to be able to tolerate emotion so that they didn’t kind of act out in ways that made things so much worse for them. And I, I let my clients know that it’s, it’s a great way to still use these skills even for the terms of what we’re using them for.
Yeah. That this is how I learned it and how I started it, but seeing, you know, such the, the vastness of how these skills can be applied for lots of different types of, you know, um, disorders and, and symptoms and needs.
Kimberley: Yeah. And to be honest, I went, took, took a DBT training earlier in my time of being a therapist, and these are really just skills for life.
It’s not-
Rebecca: They really are. They should be taught. They do… I have the DBT For In Schools book- Yeah … where they started it on the East Coast. It really should be taught to, you know, elementary school kids.
Kimberley: Yeah. Yeah, they’re just really good at handling very, very strong emotions.
Rebecca: Yes.
Kimberley: Okay. Yes. I’m- I love it. I love it.
So talk me through what you might do with a client when you’re… the primary goal is to get them to be able to face their fears or get back to their life and their functioning. What would it look like for you to start to practice this psycho-education, and what are some of the skills you might practice with them?
Rebecca: Uh, so recently I- I asked a client, like, “How do you feel kind of in your body when you’re having this anxiety and you’re having these obsessions and these thoughts? Like, how do you manage that feeling?” She’s just like, “I don’t.” I said, “Okay, I think we’re gonna pivot to me showing you some of these skills.”
So some of them already come into work with me, like I do meditation, I do body scans, and I can kind of gauge, you know, what’s working for you, how well does this work when you’re doing an exposure. But then when I wanna have a client where it’s like I- I don’t manage anything in my body, because I do a lot of virtual sessions, I will bring, you know, my DBT handouts on the screen and kind of say like, “Here’s where we’re gonna begin.”
‘Cause there’s no point to jump into these exposures if they’re not gonna be able to tolerate it and do the response prevention.
Kimberley: Yeah.
Rebecca: So I will just say like, “Hey, I wanna provide some of this, you know, background knowledge for you. Here’s what DBT is, and here’s the skills that I’m gonna introduce to you that can be of great benefit.”
You- And just kind of start that way.
Kimberley: Yeah, and you brought up such a beautiful point there, which is some people can do the exposure, but they can’t do the exposure without the response prevention. Rebecca, you just brought up such an important point, which is some people can do the exposure, but they can’t do it without doing a ton of compulsions.
Yeah. And that is such an important piece, right? Because exposures are successful when we can practice really good response prevention. And so I think that you’re really helping them to be able to practice that in the moment of w- tolerating the discomfort without just going back and white-knuckling it the whole way.
I think that’s so important.
Rebecca: Yes, and the white-knuckling is what I would share with my clients at times of you’re not winning the day if you white-knuckle the whole thing and then get to the end and kind of fall apart, so- Yeah … I’ll even do, you know, guided meditations with them in session if we’re doing exposures and need to reset, or they’re coming into session already kind of amped up.
Like, let’s do, you know, the distress tolerance and the mindfulness, really. I know I’m kind of jumping ahead, but they really kind of overlap each other- Yeah … um, in the DBT skills in a lot of ways.
Kimberley: Can you tell us about those two components?
Rebecca: The mindfulness and the distress tolerance?
Kimberley: Yeah.
Rebecca: So the distress tolerance are the specific skills that we use, and they’re broken down into, uh, two different sections.
The mindfulness I use as a way for a client to kind of come back to present, come back to center. I know that you talk a lot about OCD and ERP of like, we kind of just have to conquer what we’re dealing with today and right now and not what’s happened before or after. So the mindfulness really helps with the ERP work.
Um, another aspect of the mindfulness is when we talk about acknowledging a thought and letting it go, that’s mindfulness observed kind of at its core of I’m having the thought that-
Kimberley: Mm-hmm …
Rebecca: um, and then kind of like letting it be. So those two really work well in, in conjunction for the work that we do and the work that I do.
So there’s lots to it, so you let me know what you want to know about mindfulness and distress tolerance.
Kimberley: Let’s talk about how it differs from the more general work we do with ERP.
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Rebecca: remind you that recovery is possible. Please do not forget that. Now, big hugs, and let’s get back to the show
Kimberley: So in that moment, let’s talk about in the moment. So someone’s doing… Let’s talk about, we talk about this a lot with in supervision, like in the moment you’re doing an exposure with a client and they’re unable to tolerate that discomfort in that moment.
How might you walk them through these activities- Yeah … or are you even walking them through? Have you already discussed it with them, and are you asking them to prompt themselves? Like, how are you getting them into the exposure and through the exposure using DBT?
Rebecca: So like I said before, we’re trying to start with exposures that make sense for them.
So if we’ve, you know, gotten to one that’s like, you know, too intense or they’re just having an off day and I can see that they’re really struggling to kind of get through the exposure and those, you know, emotions are really kind of heightening, it might be like let’s just pause and take some deep breaths first.
Like, we don’t need to do anything further. Let’s just take a moment. A lot of things come back to breathing, and a lot of skills come back to breathing, so like let’s just take a moment and pause. And then like I said before, a really kind of helpful tool is let’s do a guided meditation together. Um, a lot of clients like to have something playing so they don’t have to just focus on the quiet of their breath.
Some do, but a lot of them like to have something playing, so I’ll do it with them. You put on something, you know, that’s comfortable for you, and I’ll sit here and do the breathing and the guided meditation with you. So we kind of just call it out in the moment and then ask them what they’re willing to do, and a lot of clients have heard about different types of breathing and different types of mindfulness, and so they might come in with their own skill.
But for ones that have no clue and have kind of never had to deal with this before or didn’t know how to, I, I usually will bring up let’s just work on focusing belly breathing and let’s do a meditation together and kind of reset.
Kimberley: Yeah. I know people who are listening who’ve listened to the podcast for years are probably questioning like that goes against what we’ve been taught, right?
Like Kimberly’s always saying, “Be willing to be uncomfortable and bring it on and don’t try and make it go down.” And so what is the nuance here? I mean, I’m, I’m guessing people are going to say, “But wait, isn’t that doing a compulsion?” Mm-hmm. And so I really want us to get really clear with people on that this is not done to undo the exposure and to do it as a compulsion.
It’s done so that- They can continue to practice engaging back in that exposure and, and sort of doing rep of facing discomfort. Would you agree with what I just said, or is there any specific little additional nuances you would add to sort of this question of like, isn’t that just a compulsion?
Rebecca: No, I agree with everything that you just said, and I make sure to tell my clients that it’s all about kind of intention.
Kimberley: Yeah.
Rebecca: And if it’s our intention to distract away and not feel something, that’s gonna be very different than I’m purposely moving toward soothing my body and soothing my mind so that I can continue my ERP work. And so that’s the difference, ’cause, you know, I’ve had those conversations where it’s, “But if I get up and I go do something else, how am I kind of sitting in my discomfort?”
It’s like, well, you sit for it until the anxiety lessens, and then you purposely choose a values-based behavior. So yes, that concept of what’s my intention and purpose with- Yeah … what I’m doing right now makes all the difference.
Kimberley: Right. What about really strong urges? So I’ve had clients where, you know, they’re doing an exposure, and as soon as they hit a certain SUDS level, right, like, um, let’s say it’s an eight or a nine out of 10, they kind of, like, flip their lid.
Like, they lose control of their body, right? You know, I’ve heard people say even as they’re panicking, like- I actually feel like I’m gonna punch somebody in the face- Mm … or I feel like I can’t control it and I have to, you know, engage in some kind of impulsive behavior, and that’s, you know, an extreme example, but it actually happens-
Rebecca: Mm-hmm
Kimberley: quite a lot for folks who are doing this work. What would you encourage those people, or how would we use DBT in those moments when, let’s say, oh, I can do the twos, threes, fours, fives, and six, but as soon as I hit eight, nine, and 10, then I kinda, like, lose my mind a little bit? W- is there a difference with that, or are you gonna s- use those same skills?
Rebecca: There are great skills called the TIPP skills, where you can use… It’s an acronym that stands for tipping the temperature for the T, intense exercise, paced breathing, or paired muscle relaxation. TIPP. So I think for someone in that moment who feels really, you know, kind of agitated and they, they need to get, you know, aggression out in some healthy way, the putting the face into ice-cold water to tip the temperature, that will elicit the dive response in the body that we have to kind of slow the heart rate down and conserve energy.
That one’s such a popular one. I don’t know how many of my more adult clients have used it, but in residential, it was big among the teens. That’s something I would recommend for someone to do, or ice packs if you’re like, “I can’t really stick my face in a, in a bowl of ice water right now.” You can do an intense exercise.
Again, the intention is if you feel like you wanna punch a wall, I don’t recommend punching a punching bag. Let’s get that energy out a different way. Run on a treadmill. Those are some really great skills that have been so helpful for people when it’s kinda going off the charts, and we have to kind of get that release out quickly.
Kimberley: Yeah. I remember many, many, many years ago, I was working with a client who had OCD and an eating disorder, and so there was obsessions and compulsions around food- from both her OCD and from the eating disorder. And so when she did eat certain foods or certain amounts of foods, which we needed to do, right?
We had to get the- Mm-hmm … food intake back up. It was just so intense. She was just like, “I feel like I’m… someone struck me with electricity. Like, I feel like I got hit by a lightning bolt.” Her whole body would go. And she actually said, we’re not here in California, when she went back home, her area where she lived where there was snow, she said literally, “One of the only things that did help me to know if I did hit that high level and I couldn’t,” is she would just literally open her back door and run and jump into the snow, right?
That cold ice- Yeah … sort of, I think, shocked her a little bit, and then was allowed her to be like brush herself off, brush the snow off- … and was like, “All right. Get back to your willingness. Get back to your mindfulness.” It’s, again, it was sort of like a, a pivot point to get her through that moment, and then by practicing and practicing, she was able to do it where she didn’t have to do that.
Rebecca: Yes, and I hope anybody listening sees that, yes, there is a great benefit to this. It’s not just some kind of silly little thing, but it actually does work.
Kimberley: Yeah. And I think what I would also say is this is not to make the pain worse. We’re really here to make the discomfort tolerable in this most compassionate, respectful, values-based way.
Talk to me about that. So you’re gonna give them these skills. Do they pick the skill they wanna use, or do you direct them to a skill that you think is beneficial?
Rebecca: I think, um, as I get to know my clients, I might pick something in the moment or suggest something that I think that they are going to like.
When I do teach and provide the psychoeducation on the DBT skills, I remind them that distress tolerance is about literally what it says, just tolerating the distress. It’s not gonna solve the problem. It doesn’t solve OCD. It doesn’t make the issue nonexistent anymore. It’s just helping us in that moment so that we can continue to problem solve, which in this case is continue the ERP.
So there are times where I think if they get to know the skills well enough, they can choose for themselves. Mm-hmm. But if we’re kind of heated in the moment, I’m gonna offer up something, and, and more often than not, they kind of go with my suggestion until they get much more familiar with the skills.
Kimberley: Yeah. And I think the truth is, from my experience, when we’re really, really emotionally dysregulated, we can’t even remember skills anyway. Like, they’re- Yeah … kind of out the window. So that is the- Yeah … benefit of having a DBT specialist who can sort of help- Or an even an ERP therapist who has these skills to sort of just help bring them back.
Because I get that. Mm-hmm. When you’re in panic, sometimes the skills do go out the window. I’ve had clients- Yeah … who are like, “Literally everything you’ve taught me, I cannot recall one of them right now.”
Rebecca: Yes, yes. And I do ask that clients maybe have, like, a little cheat sheet card of, like, try to have the skills somewhere with you.
Mm. Um, we used to make, like, little business cards and laminate them and hand them out, and it’s like, you know, I don’t see my clients in person for the most part, so I’ll, you know, encourage them to make something that is a helpful reminder, ’cause I let them know the skills are simple, ’cause they’re common sense.
They could be taught to children. They’re not always easy to use. Yeah. There’s a difference.
Kimberley: Yeah. Does DBT also work with shame, in your opinion? There’s so much of OCD and these strong emotions- Bring a sense of shame that something is wrong with us- Mm-hmm … that I should be able to handle. I can’t tell you how many full, highly functioning adults feel so much shame.
They’re like, “I should be able to handle my emotions. What’s wrong with me?” Mm-hmm. Like, feel like I’m a little kid trapped in a big person’s body because the emotions come out so strong. What DBT skills might you encourage them to practice if they have such shame for these big emotions? Mm-hmm.
Rebecca: This is when I’ll venture into the emotion regulation model, and I’ll show them kind of the different emotions that are slated in there.
And when we go to look at shame or guilt, just about maybe, like, their level of functioning or what they can’t do anymore or what’s not the same, I talk to them about that their feelings, no matter what, are always gonna be valid. No one gets to tell you if an emotion is right or wrong, good or bad. So we start with this feeling is valid.
It makes sense for what you’re dealing with. What I want them to understand is, is it justified or not? Does it make sense for your behavior? So when we talk about justified versus unjustified emotions, we have to know if it fits facts based on your own kind of moral code and values. So when someone says, “I feel guilty,” or, “I feel shame,” I lead them and direct them back to, “Did you do something outside of your value system?”
And they’ll be able to say, for the most part, “No, I just don’t like I feel this way,” or, “I feel bad at the way I’m functioning a- around my loved ones.” And I’ll say, “Well, you did not do anything outside your morals and values, which means this is unjustified, and here’s how we’re gonna treat it.” Mm. So again, it’s back to it’s okay to feel this way.
We’re gonna act opposite to kind of what your initial urge is, is to kind of pull away and, and dig into that guilt, and we’re gonna act opposite and kind of be loud and proud and continue to do what we need to do that does fit with our morals and values.
Kimberley: Yeah. I have to say, of the trainings that I have done in DBT, the opposite action-
is one of my favorites. And maybe you have some specific feelings about that skill, but in, particularly with OCD, I find that people have so many unjustified emotions, right? Mm-hmm. They feel guilty for things they didn’t do. They feel ashamed of thoughts that, we all have thoughts. They mean nothing about us.
So I love the idea of not getting… Like, again, a lot of talk therapists might spend a lot of time reassuring them that you didn’t do anything wrong, and you’re not a bad person. And- Mm … uh, and I love this idea of using opposite action to act the opposite of what your emotion is telling you to do. Mm-hmm.
Do you wanna share your opinion on that skill specifically?
Rebecca: Yeah, I mean, I think a lot of us have to use it in our day-to-day of, “I don’t wanna get up and out of bed. I don’t wanna go to work. I wanna go, like, you know, go to the beach. It’s summertime,” you know? And it’s kind of what is it that I need to be doing and is important to me to be doing and kind of, you know, dig in.
So for the purposes of these clients, if it’s, “I feel guilty,” or, “I feel sha-” shame, and so I kind of hide out, then it’s what can we do opposite to that that goes full force? And it’s I’m gonna go hang out with my friends. I’m gonna show up and do the best I can at work, and yeah, not really hide away with these obsessive and intrusive thoughts that they have, um, and the desire to act on certain compulsions.
So I do love the idea of opposite action. We even have opposite action all the way to really push yourself. I don’t think, you know, some of my clients quite need that, but that’s a great skill in general. Yeah. What do you
Kimberley: mean by all the way?
Rebecca: Well, I love this, uh, example that they have in the manual that I learned a long time ago, and it, it’ll be…
I kind of compare it to when I was going to grad school. It was I’m gonna sit in the back of the class because I don’t want the professor to call on me. I’m a little shy. So it’s opposite action all the way is not, okay, I’ll sit in the middle. Right. Opposite action all the way is I’m gonna sit in the front row.
They’re gonna see me. I’m gonna raise my hand. I’m, you know, I’m gonna get all into it. Yeah. So if necessary, I’ll encourage my clients to use it all the way, but let’s just start with some opposite action. Go against kind of that- Yeah … initial urge to kind of live in that guilt or shame. Let’s just kind of tweak it a little bit to start.
Kimberley: Yeah. It’s funny you mention that. I will never forget many years ago, I, I had a client who we talked about im- opposite action, and he had a ver- with social anxiety, had a very, very strong- Mm-hmm … shame response. So the minute he stepped out into public, the shame was, like, unbearable- Mm-hmm … in his words. And so it, we were trying to do these little, little exposures and- He was just spending the whole time, like, ruminating in his head about what he thought they were thinking.
And so we discussed this idea of, like, the sort of the, the big, bold opposite action for you saying it’s opposite- Yeah … action all the way. And he, like, wore two different colored shoes and rubbed- … like, pepper in his teeth, and had this big, like, Dr. Seuss hat on. And I, I didn’t ask him to do this. This was by his doing.
And he said he just tried it, and he said it- Mm … it w- actually allowed him to sort of… Basically, he said it, it was so big and bold and so opposite action- Mm-hmm … that it helped. He wasn’t able to s- to ruminate. He was too- … focused on the fact that he had done all these things. So I don’t know if that’s a good example, but- I think so
he said it was incredibly helpful, um, to again, reduce the mental compulsions that he was doing during those exposures.
Rebecca: Yeah, absolutely, ’cause he didn’t just go out in public and say, “I’m gonna go walk around.” He kind of really hammed it up with what his appearance looked like, so I would absolutely agree.
That is all the way.
Kimberley: I love it. Okay. So based on what we’ve talked about so far, is there one key or multiple key components of DBT we haven’t covered that you think that people need to understand to have a really sort of view of DBT and how we use it in addition to ERP?
Rebecca: Um, well, like I said, there’s different modules, and I think really utilizing the distress tolerance in the appropriate way to know that you’re not giving up or giving in, you’re learning to tolerate and really digging into that willingness to do more and more exposures and really kind of combat your, you know, your OCD.
I do also find that it’s helpful because I’m also working with clients that might have anxiety and panic attacks. OCD might not really be kind of, like, their major, you know, concern, but it’s, you know, how can I increase my willingness and radical acceptance? So there’s so many great components. And so sometimes I’ll just go through various parts of the modules in the manual with clients and kind of see what resonates for them.
But there’s so much good stuff and so many ways that certain modalities can complement another. So the way that DBT complements ERP is really wonderful. And so I just think, like, keeping in mind how the mindfulness plays in, how to learn how to kind of tolerate distress when I’m, you know, ruminating or practicing an exposure, and then using the little bit of emotion regulation of I really need to kind of get these emotions in check.
So I think just all those different things paired together. Anybody that’s never heard of DBT or doesn’t have a provider, you know, kind of assisting them with this, I, you know, would just suggest asking about it, looking into it. Um, it’s a great resource paired with ERP.
Kimberley: Yeah. I am so happy you’re here and we’re talking about this.
Me too. I feel like it’s such an important piece of the work because, I mean, I hear it all the time on social media, people saying, “ERP didn’t work for me,” or if, “It was too hard for me,” or, “I wasn’t in a place to be able to do it.” And I feel so sad- Mm-hmm … they feel that way because it could have been that they just needed those few additional skills and to slow it down- Yes
and, and get that additional help if that’s what they needed.
Rebecca: Yes, and it, it came so naturally. I think part of coming to work with you, it was like, oh, I have this behavioral background, so doing the ERP just felt really good and just noticing how I could combo them together, and it’s something that clients need to understand, that there are other support skills that can be in, done in conjunction with the ERP.
Yeah. And that they’re… yeah, they’re simple. It’s not a lot to try to, like, learn. It’s just, you know, you have to be willing to use the skills.
Kimberley: Yeah. I say it all the time, and I don’t usually talk about this on the podcast, but I have had lots of therapists who work for me, and I have such amazing team. When I bring on a new therapist who’s not been trained in OCD, if they have a DBT background, I have 100% success with them just getting it, like, right away.
It’s like the DBT work is perfectly the primer to going into ERP and practicing it. It is so good.
Rebecca: Yeah.
Kimberley: Yeah.
Rebecca: Agreed. Yeah. It d- they fit so well.
Kimberley: Yeah. Well, thank you so much for being here. I truly… again, I’m so grateful that you’re on our team and that you can sort of take the clients who feel like they need this additional component and that you bring it in with clients.
Is there anything that you wanna share before… that you think that listener may want to know? And if not, tell, uh, people where they can hear more about you.
Rebecca: One thing that kind of just popped up is that we talk to our clients so much about kind of willingness to tolerate, you know, the discomfort of their exposures, and so I think anybody that need to break that down step by step could really benefit from that part in distress tolerance.
‘Cause if we break down, we have to have the willingness, you know, to kind of move forward with the pain that we feel by doing these exposures. And so kind of just looking over those handouts, maybe doing some worksheets and seeing how they can break it down for it to feel more tolerable and manageable would be a great asset to them.
Kimberley: Yeah, for sure. The willingness is huge. Mm-hmm. I mean, I even remember it myself as I was doing some. Like, I felt like I just wanted to throw a huge tantrum. Mm-hmm. Like, I don’t wanna be willing. I’m sick of the will. I… you know? And it does take emotional regulation to handle the inner tantrum that- I wanted to throw, ’cause I knew I had to do the exposure- Yeah
but I wanted to throw a tantrum, and I had to use those distress tolerance skills to be able to do the exposure.
Rebecca: And that’s okay. That awareness to say, “I wanna throw a tantrum, and I’m willing to, like, you know, use a skill anyway and try to avoid the tantrum,” that awareness is great. We’ll take it.
Kimberley: Yeah, for sure.
Where can people hear more about you? And, you know, you work for me, but you also have your own practice.
Rebecca: Uh, I do see clients on Rula, and after working with you for about a year and a half, I did put on my Rula account that I can work with OCD, and, um, I just tried to bring some information over there to them.
But yes, I am on Rula. I do specialize, um, in OCD over there, um, borderline personality disorder, um, Asperger’s or autism spectrum, depression, anxiety, things like that.
Kimberley: Amazing. Yeah. You’re such a champion. I’m so grateful that you’re here.
Rebecca: I’m grateful, too, to be here. Oh. Thank you, Kimberly.
Kimberley: My pleasure. Thank you.
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