Dialectical Behavior Therapy teaches me that we all have four options when we are in distress. Four may sound like too few, but many times, we may think we only have ONE option when in distress - and that option may be ineffective, harmful, or destructive to self and relationships. Our thoughts or emotions may sometimes make it seem like we MUST do ONE SPECIFIC THING URGENTLY (drink, use another substance, impulsively shop, gamble, restrict food intake, binge, purge, etc.) in order to escape an undesirable emotional or psychological experience. So, really, four options is A LOT when you think or feel that you have only ONE.
The "four options when in distress" are not only informative but taken together, it is also a skill - the four options skill. When you are in distress, try going through these four options over and over and over again until your distress subsides to a tolerable level or completely!
1. Problem-Solve. This is for, you guessed it, problems that can be solved. For example, I feel anxious because I don’t know how to get to Palo Alto. I look up on Google Maps the directions, now I know, my anxiety goes away. Not all distress can be solved, however. An example would be grieving the loss of a loved one - there is not a “solution” to that problem. Additionally, it can be legitimately difficult to think when feeling very distressed, so sometimes we find that we cannot problem-solve when in heightened distress.
2. Change Your Interpretation. If you tried problem-solving and you are still in distress, try changing your interpretation. What this means is: be curious about alternative interpretations of your situation that you are currently finding distressing. Often, we become a bit (or more than a bit) myopic when in distress, seeing things “only one way” and we become convinced that this is the truth because that’s how it feels. However, if we can be curious about alternative interpretations of the situation, we may find that our distress lessens or dissipates. An example is: I see a parent not minding their children on a public bus and the children are being loud and running all over and being disruptive. My first thought is “What a bad parent! How annoying!” and I find myself getting agitated and internally angry. What if I thought to myself, “He could be having a really hard day and might be trying to hold it together right now while these kids are rambunctious” ? That would actually alter my original thought and the feeling that went with it - my agitation might subside, and I might feel compassion towards the man and his children. I don’t have data yet to support either of my thoughts - but being open to alternative interpretations of a situation (rather than going with my initial and distressing assumption) helps alleviate my distress, and that’s effective for me!
3. Radical Acceptance. So, say I tried changing my interpretation and I’m still in distress. Then it is time to try to radically accept my situation. What this means is: what do I need to radically accept that I cannot change in order to turn my attention to what I *CAN* change? Radical acceptance is NOT the same thing as condoning a situation. I can not LIKE a situation and even disagree with it while also Radically Accepting it. Radical Acceptance is about acknowledging that in this moment, there is something I cannot alter - and trying to alter it or wishing it were altered is making me more and more distressed or is causing more and more suffering. What is the thing I cannot in this moment alter? Ok - let’s accept that that’s just the way it is - I’ll set that thing aside for one moment. Then I’ll ask myself - what about this situation CAN I CHANGE? Once I shift my thinking and attention in this way - I’m now working at problem-solving! Radical acceptance can help me calm down emotionally just enough that I start to be able to think and then problem-solve. Note: sometimes the main thing I cannot change in the moment is my FEELING. My anger, anxiety, shame, sadness, etc. And trying to change THE FEELING is not working and may be making things worse. So if I can compassionately accept that I have this feeling and right now I cannot seem to CHANGE it - the question then becomes, how do I skillfully take care of myself as I have this feeling? And guess what? That’s bringing me into problem-solving!
4. Do Nothing Different and Stay Just as Miserable. Well, say I tried Radical Acceptance, and I’m still in distress, and now I’m just fed up with being in distress, and I still cannot think. There’s always this option, Option 4. This is here not because I am encouraging you to choose this Option (I'm not) but to let you know that you have a choice in how you react to your distress (a) and (b) no one can take this particular option away from you. Some people - myself included - can feel very threatened by the idea that we can *never* use an ineffective or maladaptive coping strategy ever again. I acknowledge that it is always your right to go with this option if you really want to. And, I am pointing out to you that it’s only one option among four, and you have a choice in which option you move forward with.
This option doesn’t mean DO NOTHING. It actually means: do what you always do (something ineffective) to deal with distress. Do nothing different. And (very important) stay just as miserable - that means, stay in that vicious cycle whereby you solve your distress with something maladaptive, which may actually result in more distress of some kind.
For example: say I am feeling really anxious because I got my credit card statement in the mail, and I am realizing I cannot afford to pay it off as I’d hoped I would. I am anxious and in distress about this, telling myself I am a failure and a terrible person and that everyone will think poorly of me, and I’m catastrophizing about my financial future. I feel ashamed, anxious, and guilty. My body feels jittery and on-edge, and I cannot sit still. Say I choose this Option (number 4) and choose to restrict my food intake for the rest of the day, because I know that will bring me quick temporary relief from my physical and emotional sensations and thoughts and will offer a sense of relief, an illusion of control and power, and a distracting place to put my attention. And say I do get some relief in that moment from those things. But then I feel a lot of shame for engaging in that behavior, particularly as I’m trying to learn new skills. And that shame becomes really consuming, and I feel sort of ill and trapped in my home and a different kind of jittery. I grab my keys and wallet and drive downtown to go window shopping and end up buying $500 worth of new clothes, which I put on my credit card, racking up more debt. See how this works? In this example, I’m using restricting to deal with anxiety that was in reaction to a credit card bill; I’m using compulsive shopping to deal with shame that was in reaction to restricting (creating more debt!). So. Then how would I feel after the temporary high of compulsive shopping? Probably guilty, ashamed, and anxious again. And how do I deal with that, when I'm not aware that I have other skills and options to use? Probably by using maladaptive behaviors again. Vicious. Cycle.
This is an example of doing nothing different and staying just as miserable. Even if I’m not yet in touch with the emotional, physical, and financial misery, I can look at this situation and think - yeah, this is creating a lot of suffering for myself. And I can ask myself - do I really want to keep doing that? NO. SO. If I’m using the 4 Options as a skill, I can get to this Option and think - ok, do I want to do nothing different and stay just as miserable? My hope is that the answer can be NO. If it is NO, then I go back to number 1 and try again. Can I problem-solve? Not yet? Can I change my interpretation? Still in distress? What do I need to radically accept? And so on.
Trying new behaviors when you are in distress is UNFAMILIAR. Even trying new OPTIONS when in distress is unfamiliar. That is not the same thing, though, as it being “hard.” Hard is actually a judgment word that often implies “impossible” or just impossible enough to not attempt. “That’s too hard” often means “Too hard to attempt.” When we think and talk in that way, we tend to be less likely to be willing to do the new “hard” thing! The language we use has a direct impact on our mental health and how we think! “Unfamiliar” reminds me that it’s new and not a habit yet - AND I can continue to practice to help it become more familiar, a habit. That is why it takes consistent practice to start thinking and behaving in new and different ways.
The Four Options help you start to engage in that practice - it is a practice and it takes PRACTICE. I practice DBT; I don't PERFECT DBT. If you notice you are starting on Option 4, be willing to shift into Option 1, then 2, then 3 and see what can happen. If you momentarily take Option 4 off the table and circle through Options 1, 2, and 3 for awhile, you may find that your distress goes down and allows you to take care of yourself in a new non-Option-4 way. It may be unfamiliar now; and, with consistent practice, it will become familiar and rewarding - and hopefully relieving!
*Adapted from Marsha Linehan's DBT Skills Training Handouts and Worksheets (2014) and supervision from Dr. Ellen Astrachan-Fletcher Years 2012-2015