The Coping Pantheon

The Coping Pantheon

A sequence we have seen repeatedly throughout these blogs is this: Awareness, Acceptance, Action. As we have already learned, awareness and acceptance alone can often transform our lives from unbearable to bearable, from unmanageable to manageable. Obviously, however, sometimes life requires additional action beyond awareness and acceptance. But here’s the good news: First, awareness and acceptance are already forms of action. Secondly, awareness and acceptance are precisely the foundation we need in order to respond to life with specific, concrete behaviors. Otherwise, we are just back to our old ineffective habits and impulsive reactions that only make matters worse.

Now that we have laid this foundation of awareness and acceptance, the rest of this blog series will focus on specific, concrete behaviors. In this blog, we will introduce some basic, short-term strategies we can use to cope in the moment and return to our Balanced Mind.

Remember all those ways our minds can get off balance? Sometimes our Thinking Minds are in over-drive, and we can’t stop worrying or obsessing. Sometimes our Thinking Minds aren’t working enough—and we make reactive or impulsive decisions. Sometimes our Feeling Minds are in over-drive, which makes us feel overwhelmed or out of control. And sometime our Feeling Minds aren’t working enough—which makes us feel numb, empty, or even dead.

People do many things when either their Thinking Minds or Feeling Minds are off balance. Some people use drugs. Some people rage. Some people engage in self-harm. Some people keep making the same mistakes over and over again. Perhaps you can relate to some of these patterns! But regardless, they all have the same outcome: Although many of these reactions may help you feel better in the moment—or at the very least provide some sort of temporary relief—they all make things even worse in the long haul. Just think about it: How could drugs, rage, self-harm, or knee-jerk reactions really help you turn your life around? You already know the answer to that!

Therefore, the entire purpose of all the coping skills in this chapter is to get you back into your Balanced Mind as efficiently and effectively as possible—without incurring further collateral damage. In other words, you will be learning alternate behaviors to replace the behaviors you would normally engage in.

As you learn each of these new coping skills, here are a few points to keep in mind: First, practice makes prepared—not perfect. The more you practice these skills, the more prepared you will feel to face your triggers. Don’t worry about perfection…save that for a different lifetime! Second, the time to practice these skills is when you are NOT in crisis. Please do not wait for a crisis situation to try out a new coping skill! Third, you need to integrate as many of these coping skills into your normal daily routine as possible. These coping skills will have both a preventative and rehabilitative effect. In other words, the more your coping skills become part of your normal lifestyle, the less you will feel triggered in the first place—and the better you will deal with those triggers when they do happen. Fourth, it is important to remember that all of these skills work for someone—but none of these skills work for everyone. The key is to figure out which of these coping skills will work for YOU!

So let’s get started already.

Pros & Cons

Pros and Cons is the first coping skill in this list, because this is the skill that helps us realize that we need to cope in the first place! This skill is especially useful when we would much rather do something impulsive (an action urge), as opposed to coping. It is well documented that previous trauma makes us more impulsive. In one study of 412 people with trauma histories, researchers identified the importance of replacing sensation-seeking tendencies, and especially when triggered by negative emotions, with more effective forms of coping (Contractor, Armour, Forbes, Elhai, 2016). So the next time you feel like doing something impulsive, it may be helpful to think through the pros and cons of engaging in your action urge (in other words, what you feel like doing in the moment), and then think through the pros and cons of instead choosing one of the coping strategies described in this book…and then think about which of the two options would be best for you in the long-term. It is especially helpful to ask yourself the following questions: Which option will help me get back into my Balanced Mind as soon as possible? Which options will help me best meet my long-term goals?

Half Smile

Research shows that changing our facial expressions can also change our mood (Linehan, 2015). This works for a variety of negative emotions, including anger, anxiety, and depression. One of the best ways to change your facial expressions (and therefore your mood as well) is simply to smile—even if you don’t feel like it. And if you can’t smile all the way, then don’t—just do a half smile! The goal here is to train your facial muscles to produce a more contented countenance. Research also shows that smiles are the facial expressions people can recognize from the farthest distance (Frank, 2016). In one study (Lynn, 2011), waiters increased their tips by 140 percent—just by smiling! Therefore, not only does smiling improve your own mood, but it is also a great way to contagiously get other people in a better mood as well…which in turn will make your day even better!  

Change the Temperature

Research shows that immersing your face in cold water has an immediate calming effect on the entire body (Neacsiu, Bohus, Linehan, 2015). Research also shows that feeling connected to someone and temperature are strongly linked (Vess, 2012). For example, you will feel more connected to someone if you are holding a hot cup of tea! In short, another way to influence your emotions is to shift your body temperature. So take a cold shower. Or take a hot shower. Or grab an ice cube. Or soak in some rays. Or drink a simmering hot beverage. Or drink an ice-cold beverage. You get the point!

Intense Exercise

Exercise releases natural chemicals in your brain which make you feel better. That’s why another way to quickly shift your mood is through rigorous physical activity. In one study of 81 people with PTSD, all 81 participants received comprehensive trauma treatment, including individual counseling, group counseling, and appropriate medications (Rosenbaum, Sherrington, and Tiedemann, 2015). However, only 39 subjects participated in an exercise program. By the end of the study, the exercise group had less PTSD, less depression…and less waist!

There are many ways to exercise. You don’t have to run marathons, become an Iron Man, get a gym membership, or buy lots of expensive equipment. It’s completely okay to just go for a walk or ride your bike. But if that’s too boring for you, here are some more options: Shoot some hoops. Lift some weights. Do some sit ups, push ups, or chin ups. Cut the grass. Cut the neighbor’s grass. Garden. Do a physical project around the house. There are many options for exercise—besides surfing the web or playing fantasy football!  

Controlled Breathing

Controlled breathing sends oxygen to your brain from your abdomen rather than through from chest. Breathing from your chest is one way to trigger or reinforce the fight, flight, freeze response we discussed earlier. However, breathing from your abdomen sends the signal to your brain that all is well, which in turn has a calming effect on your whole body. The good thing about breathing as a coping strategy is that it doesn’t take any extra time, since it’s something you have to do anyway!

In one study of veterans from Iraq / Afghanistan (Seppälä, Nitschke, Tudorascu, Hayes, Goldstein, Nguyen, Perlman, Davidson, 2014), breathing exercises significantly reduced both PTSD and anxiety symptoms....even one year after the study ended! There are many variations of controlled breathing. Here’s the basic pattern that most forms of controlled breathing follow:

  • Place one hand on your stomach.
  • Place the other hand on your chest.
  • Breathe in through your nose.
  • Breathe out through your mouth.
  • Exhale for twice as long as you inhale.
  • Make sure the hand on your chest remains still.
  • Observe the hand on your stomach rise and fall with your breathing cycle.

Muscle Relaxation

There are also many variations of muscle relaxation. However, all of the variations have one basic theme in common: learning to both tighten and relax your muscles. There are two reasons that such a simple exercise can be so helpful. First, it is helpful to simply become more aware of how our muscles feel when they are either tense or relaxed. Our bodies are constantly communicating to us, and often the body talks to us through our muscles. So when our muscles are tight, that usually means we are stressed about something. And secondly, learning to tighten and relax your muscles also teaches you that you have some control over how your muscles feel. For example, if you can deliberately tighten your muscles, that also means you can deliberately relax them—which then helps your entire system to relax. One study examined the effects of muscle relaxation on 80 women who had received hysterectomies. This study found that the 40 patients who practiced muscle relaxation following the operation had lower stress, anxiety, and depression than the 40 patients who only received the normal nursing care (Essa, Ismail, Hassan, 2017). Here are two of my favorite forms of muscle relaxation:

Method A:

  • Identify the major muscle groups in your body where you feel the most tension when stressed.
  • Tighten that muscle as hard as you can for 3 seconds; then release; then repeat the entire step.
  • Repeat Step 2 with the parallel muscle from the other side of your body (if applicable).
  • Repeat Steps 2 and 3 with all of the muscle groups identified in Step 1.

Method B:

1.    Tighten all of the major muscle groups in your entire body.

2.    Imagine that a gentle waterfall landing first on your head, and then slowly cascading through your entire body, all the way down to your toes.

3.    Starting with your head, relax each muscle group as the cascade passes through your body. 

Making Comparisons

Sometimes we feel like we are the only one with problems—or maybe not the only one, but our problems certainly seem much worse than everyone else’s! That’s when it is sometimes helpful to make some realistic comparisons to balance out our thinking. In one study of 70 people with spinal cord injuries, those who were able to compare themselves to others who were worse off had more constructive coping than those who did not make these comparisons (Buunk ,Zurriaga, & González, 2007). Here are some examples of comparisons that some people find helpful:

  • Think of someone who is worse off than you are.
  • Think of how your situation could hypothetically be worse than it is.
  • Think of a time in the past when things were even more difficult than they are now.
  • Think of all the progress you have made so far.

However, even though Making Comparisons can be very effective for some people, this technique does not work for everyone, for several reasons. For example, some people feel it is too negative to compare some else’s misery to your own. Other people feel this technique sends an invalidating message: “Don’t be such a wimp, when other people have it worse.” In addition, some people are so sensitive that just thinking about someone else’s suffering…makes their own suffering even worse! And still others feel that Making Comparisons can be used as a grounds for justification: “Well at least I wasn’t as drunk as she was!” If any of these scenarios apply to you, stayed tuned for the next coping skill…

Counting Blessings

For people that do not benefit from Making Comparisons, there is a great alternative called Counting Blessings. Instead of coping by reframing the negatives, Counting Blessings works by focusing on the positives: What is going well for me? What can I be thankful for? How have I been blessed? What gifts, strengths, and talents do I have? Who are my best friends and biggest supporters? One group of researchers studied the role of gratitude in 182 college girls with trauma histories. These researchers found that thankful college students had fewer PTSD symptoms, regardless of the severity of the trauma, extent of the previous trauma history, or the amount of time elapsed since the trauma occurred (Vernon, Jacqueline, Dillon, and Steiner, 2008). Another study involving 236 participants found that gratitude was associated with reduced self-blame, denial, and substance abuse…all of which get in the way of healing from trauma (Wood, Joseph, and Linley, 2007). 

Finding Humor

Humor is another great way to quickly shift your mood. Perhaps you have heard the adage that “laughter is the best medicine.” This is a very old concept, going all the way back to the ancient Hebrews. For example, the Hebrew Bible says: “A merry heart does good, like a medicine (Proverbs 17:22). Indeed, modern research supports this claim. For example, one study found that having a good sense of humor was linked to lower burn out and trauma symptoms in 179 firefighters (Sliter, Kale, Yuan, 2014). So it’s worth figuring out: What makes you laugh? What do you think is funny? Think of your favorite comedian. Think of a funny joke. Think of a really funny movie. Think of your funniest memory. Think of a friend that has a great sense of humor. Think of a YouTube video that makes you laugh, no matter how many times you see it. In short, create a “funny bank” that you can draw from, whenever you need to. In addition, try to find the humor in even the worst of situations. If you look hard enough, there’s almost always a funny side to life! 

Thought Stopping

Sometimes we have certain words, worries, images, or memories go through our minds, and we wish they wouldn’t. Sometimes the more we tell ourselves not to think about them, the more we think about them! Did you ever argue with someone about whether or not you were arguing? What happened when you tried to convince the other person that you weren’t arguing? You continued to argue, of course! It’s the same principle with your thoughts: Instead of trying to think about not thinking about something, sometimes you just need to find a way to stop thinking altogether. First example, one study found that thought stopping lessened feelings of anxiety and helplessness in children facing painful medical procedures (Ross, 2009). There are many ways of stopping your thoughts. Some people find a little pinch to be helpful (but please, no self harm!). Some people just shout “STOP!” in their minds. Some people find a private place and say “STOP!” out loud. And some people find the acronym “STOP!” to be helpful: “Stop, Take a step back, Observe your thought, and Proceed with a different thought.” (Adapted from Linehan, 2015). But how do you proceed with a different thought? That’s where the next skill comes in…

Memorization

Disrupting a recurring thought pattern by verbally or mentally telling your thoughts to “STOP!” (or with a little pinch) will at best accomplish that: Disrupt the thought. Now disrupting a disturbing or distressful thought is indeed a great start...but how do you replace that thought with a different one so that you don’t go back to the original one? That’s where memorization comes in handy. Once you have disrupted a problem thought, default to repeating something over and over again that you already know by memory. This could be a favorite song, poem, prayer, quote, expression, saying…or anything that can be turned into what I call a “mantra for the moment.”  

In one study of 182 women, the participants who regularly memorized the Koran demonstrated less anxiety / depression and better sleep / social function than those who did not (Kimiaee, Khademian, Farhadi, 2012).

Helping Others  

The original creators of the 12 Steps learned that helping others maintain sobriety was the best way for them to maintain their own sobriety—and that’s precisely why the twelfth step is all about helping others (Alcoholics Anonymous, 2002). There are many studies suggesting that helping others can be a great way of helping ourselves. In fact, one author reviewed almost 25,000 articles on volunteering. This researcher found that people who volunteer tend to have better mental health, physical health, life satisfaction, social interaction, coping, and even longevity. In one study researchers found that older adults who volunteered to provide support to other older adults seemed to benefit more from the volunteering than the people they helped! (Brown et al., 2003). More and more research shows that volunteering can especially help people heal from trauma symptoms. One study of 356 veterans returning from Iraq / Afghanistan found that participating in a national civic service significantly improved many aspects of physical health, mental health, and social health—including reduction in both depression and PTSD (Matthieu, Lawrence, Robertson-Blackmore, 2017). Think of ways that you could help someone else that would also provide you with a sense of purpose, fulfillment, satisfaction, or relief. This can be as simple as volunteering at a soup kitchen, babysitting someone’s children, or mowing the neighbor’s lawn.

Some people, however, are people pleasers in unhealthy ways, and they already focus too much on helping other people meet their needs—at the expense of their own. In fact, some people tend to help others as an escape from dealing with their own problems, or only feel like they have any worth when they are helping needy people. If you can relate to this description, then helping others may not be the best coping skill for you. But don’t worry—there are plenty of other options here to choose from!

Self-Care

Remember that DBT is all about balance? That’s why we need to balance helping others with taking care of ourselves. Both can be really effective ways of coping—but only with the proper balance! There are many ways of practicing self-care. Sometimes the first step in improving self-care is learning to practice basic habits of health and hygiene: eating well, sleeping enough, grooming ourselves, etc. The next step in self-care is learning to treat, pamper, and nurture ourselves—without feeling guilty! This will be different for everyone. For some people, this might be taking a nice long bubble bath. For others, it might be splurging on a well-deserved cup of gourmet coffee. Ironically, research shows that counselors are often not very good at practicing self-care themselves (Figley, 2002). (Note to self: Practice what you preach, Kirby!)

Looking Back

When we are in a funk, we tend to make things more permanent than they really are. We tend to think our problems were always this bad and will always be this bad. In other words, we take our current situation and project it both backwards and forwards in time. That’s why one way of coping in the present is to remember and reflect on positive memories from the past. Use this opportunity to remind yourself that things have not always been as bad as they seem right now. Recall good times from the past that can give you the strength, encouragement, and motivation to get through the present. In one study of 26 older adults with moderate to severe depression, reminiscing about positive events from the past significantly reduced their depression (Watt and Cappeliez, 2010). In fact, in one of the groups, 100% of the participants continued to demonstrate clinical improvement three months after the experiment ended!

Looking Forward

Life would be unbearable at times without hope. One way to cope in the present is to think ahead to when the current situation will be over or better. Make a list of your goals, plans, dreams, ambitions, and aspirations. Think about how what you are going through now is helping to prepare you for better things down the road. Look for the light at the end of the tunnel. Remind yourself: “This too shall pass!” There is a lot of research on the benefits of hope. In one study of 164 veterans with PTSD, higher levels of hope were associated with less depression and less trauma symptoms (Gilman,Schumm, Chard, 2012).

One Thing at a Time!   

Sometimes life becomes overwhelming because we start to think about all of our problems at once. That’s when it’s helpful to hit the pause button, take a step back, and chose just one thing to focus on. If necessary, make a list of everything you need to get done, rank these tasks in the order of importance—and then focus on one thing at a time.

There are decades of research indicating that learning to pay attention to just one thing at a time—in other words, mindfulness—helps improve just about every human symptom, whether physiological or psychological…including PTSD (e.g., Kearney, McDermott, Malte, Martinez, Simpson, 2011…among hundreds of examples).

Mini Vacation 

Something else we can do when everything starts to pile up is to simply take a temporary break from things—and then return when we are ready. There are many ways to take a “Mini Vacation.” Go for a walk. Take a bath. Go out to eat. Watch a movie. Go for a drive. Take a coffee break. Cook your favorite meal. The goal here is not to avoid your problems, but simply to take the time you need so that you can get back in the game as soon as you are ready. One study found that even people who have experienced major life-altering events (such as spinal cord injuries or chronic illness), improved their coping and made their immediate life circumstances more bearable by learning to take “mini vacations” (Hutchinson, Loy, Kleiber, Dattilo, 2010).

Cheerleading

In a previous chapter, we talked about judgments. As you recall, judgments come from the negative messages we hear from others. When other people say enough negative things to us over enough times, eventually we start to make those messages our own negative self-talk. Sometimes what we desperately need is for someone else to say something nice or positive to counteract those judgments running through our heads. And that’s great when that happens. But what do we do when there is no one around in the moment to be our cheerleader? That’s precisely when we need to be our own cheerleader! This skill is all about learning to provide ourselves with the positive self-talk that we need to compete with our negative self-talk. In this case, cheerleading does not mean putting on a small skirt and jumping up and down with pom-poms…but it does mean giving yourself a pep talk! How effective is cheerleading? Well, research suggests that positive self-talk will even improve your dart-throwing accuracy (Van Raalte, Brewer, Lewis, Linder, 1995). ’Nuff said…

Journaling

Another way of coping is through any sort of written expression—and it doesn’t even have to be words! Some of my clients love to write poetry (and I love to read their poems). And some of my clients love to draw (and I love to see their drawings). But regardless, finding creative ways to express your thoughts and feelings in written form can be very therapeutic. In one study of US veterans who had spent time in Afghanistan / Iraq, expressive writing resulted in less PTSD, anger, and physical complaints compared to veterans who did not write at all. In fact, veterans who wrote expressively even experienced better reintegration and social support than their peers (Sayer, Noorbaloochi, Frazie, Pennebaker, Orazem, Schnurr, Murdoch, Carlson, Gravely, Litz, 2015).

Enjoyable Activities 

What’s something you really enjoy doing that costs very little money—or no money at all? Sipping a cup of coffee? Watching the sunset? Walking your dog? Getting comfy with a good book? Taking a shower? If you want to cope well with life, you need to do at least one enjoyable activity per day! In one study, people who participated in more frequent enjoyable activities reported more positive emotions, life satisfaction, and social support as well as less depression, blood pressure, and stress hormones (Pressman, Matthews, Cohen, Martire, Scheier, Baum, Schulz, 2009). Life is simply too short of be a workaholic all the time. Take time to enjoy life! (Another note to self: Practice what you preach, Kirby!)

Soothing with the Senses

Research shows that mindfully engaging the five senses (sight, sound, smell, taste, touch) can lower symptoms of depression, anxiety, and PTSD. For example, one study found that systematic exposure to certain aromas decreased symptoms of both anxiety and depression (Lemon, 20014). Another study found that massage therapy significantly influenced brain chemistry. For example, massages decreased stress hormones (cortisol) while increasing neurotransmitters associated with positive emotions, such as dopamine and serotonin (Field, Hernandez-Reif, Diego, Schanberg, and Kuhn, 2005). Yet another study found that listening to music helped reduce anxiety in terminally ill patients—and even pain and fatigue (Horne-Thompson and Grocke, 2008). In fact, one study even found that music therapy could be more effective in treating depression than counseling (Castillo-Pérez, Gómez-Pérez, Velasco, Pérez-Campos, Mayoral, 2010)…but please do not tell your therapist that!

That’s why another way to cope in the moment is to mindfully engage at least one of your five senses—and use that sense to focus on something that has a calming effect on you. For example, mindfully gaze at something that is soothing to look at. Mindfully listen to something that calms you down. Mindfully absorb your favorite aroma or fragrance. Mindfully ingest your favorite flavor or ingredient. Mindfully relish a favorite tactile sensation (such as a comfy blanket or warm water streaming down your back). Some people even find it’s helpful to create a Five-Senses Pouch: Some way to have all five senses immediately accessible to you at all times (such as in your purse or pocket). For example, you might have perfume, candy, a small stress ball, and a favorite picture or song on your phone—all within reach.

Ride the Wave / Urge Surfing

This coping skill is all about visualizing your intense emotions as a wave, and then learning to interact with that emotional wave the same way you would deal with a real wave. If you are at the beach and a big wave is coming, you always have a couple of options. One option is to simply get out of the water, if you have enough time.

But if that is not possible, another option is to just ride the wave. Yes, it will feel uncomfortable. Yes, you will feel like you are losing control. But the only other option is to fight the wave, which will only make matters even worse. When people panic at the beach, their first instinct is to control the wave by kicking and thrashing. The only problem: You cannot control a wave, no matter how much you kick and thrash…but a wave can control you! In fact, the more you try to control a wave, the less control you actually have. And if a wave really controls you, you might even be completely knocked off balance…and then get caught in the undertow. Which, trust me, is a really scary experience. Since I grew up in Connecticut, which has awful beaches, I still have childhood memories of getting pulled under and dragged along the rocks and seaweed of the undertow!

All of these concepts apply to emotions. Sometimes if you notice an intense emotional wave coming, you can simply get out of the situation that is causing the wave. But if you cannot, then your next best option is to simply ride out the wave. Yes, you will feel uncomfortable. Yes, you will feel like you are losing some control. But just like a real wave, you cannot control emotions. And just like a real wave, the more you try to control emotions, the more emotions will control you. And just like people try to control a real wave by kicking and thrashing, people try to control their emotions through judgments. “I should not feel this way. This is stupid. I hate depression.” And if you judge your emotions too much, you just might end up in the emotional undertow, which will drag you through all kinds of emotional rocks and seaweed. Think about it: If you are angry, and you judge yourself for being angry, now you will be angry at the anger, which just made your anger problem even worse…not better! That’s why it’s always better to ride the wave than to fight the wave.

The same idea of learning to ride our emotional waves also applies to intense urges (such as craving a certain drug). That’s why this same basic skill is sometimes called “urge surfing.” Recent research suggests that “urge surfing” can be an effective way to overcome strong cravings for alcohol, nicotine, and other drugs (Bowen and Marlatt, 2009; Ostafin and Marlatt).

Imagery

It’s not always possible to cope by doing something specific. That’s when imagery comes in handy. Imagery is all about visualizing something instead of actually doing it. Visualizing is more accessible and more portable than some of these other coping skills, because you can do it anywhere / anytime. Think of some of the other coping skills we’ve been talking about, such as Self-Care, Enjoyable Activities, Mini Vacation, and Soothing with the Senses. In the event that you cannot actually implement these coping skills in the moment, would just visualizing them be helpful? If visualizing a coping skill is just as effective or almost as effective as actually doing it, then imagery is for you. In one study of 130 surgical patients, the participants who received guided imagery before, during, and following the operation experienced significantly less anxiety and pain…and required 50% less narcotic medications! (Tusek, Church, Fazio, 2006).

Finding Purpose

Some situations in life seem so painful that no amount of physical OR virtual coping will provide much relief. That’s when it is necessary to practice Extreme Acceptance. Something that can make Extreme Acceptance a little easier to implement is to think about how your current suffering can be redeemed for a greater purpose. Learn to ask and answer questions such as the following: What can I learn from this suffering that I could not have learned otherwise? How can this suffering prepare me for something that nothing else could have prepared me for? How can this suffering be used for good? If these sorts of deep philosophical questions are difficult for you, consult with a spiritual leader, such as a pastor, priest, or rabbi.  

Viktor Frankl was a Jewish psychiatrist who survived several different Nazi concertation camps during World II, including Auschwitz, where over one million people died from brutal treatment, including starvation. Frankl later wrote a book called Man’s Search for Meaning (1984), in which he described his experiences in the concentration camps. It is clear that Frankl inspired Marsha Linehan, the originator of DBT (2015). Throughout his book, Frankl especially describes the coping skills that both he and others used to survive their hellish experiences. In fact, almost every single paragraph in his book makes reference to skills described in this chapter (as well as other chapters). But as the title of his book implies, the most important coping skill Frankl references is finding meaning (or purpose) in suffering. Knowing that he was probably going to die anyway, Frankl decided against suicide and decided to use whatever time he had left in the camps to serve his fellow prisoners. According to Frankl, people who were able to find purpose in their suffering and maintain hope were much more likely to survive than those who did not.

Practice Makes Prepared

Perhaps two of the most researched coping strategies are controlled breathing and progressive muscle relaxation. There are lots of Internet resources which provide guided, step-by-step instructions on the many variations of these techniques. Once you learn how to do these skills, you need to incorporate them into your daily routine. You will need to figure out which routines work the best for you. One routine that is gaining some recent attention is to make controlled breathing and progressive muscle relaxation even more effective…by combining them! In order to combine these skills, you simply tense your muscles as you inhale, and relax your muscles as you exhale. For example, I love to combine controlled breathing and muscle relaxation when I go for bike rides. Every time I pedal, I both tighten and relax my muscles….while simultaneously inhaling and exhaling.

For practical exercises to learn more about specific coping skills, please refer to my new workbook: DBT Skills Workbook for PTSD: Practical Exercises for Overcoming Trauma and Post-Traumatic Stress Disorder…coming soon in 2019!