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Introduction

Clint is now in his third session and will be working on distress tolerance skills through the use of dialectical behavioral therapy (DBT). DBT is a cognitive behavioral treatment tool that combines individual psychotherapy with psychosocial skills training. DBT has been applied to treat mental health disorders and is known to target self-harming behaviors. DBT skills that are taught include mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance.

1. Mindfulness: quality of awareness that involves an individual to control their own mind instead of letting their mind control them.
2. Interpersonal effectiveness skills: focuses on effective ways of achieving social skills in interactions with other people.
3. Emotional modulation skills: include techniques for changing emotional states. Specific skills that are taught include identifying and labeling emotions and recognizing obstacles to change emotions.
4. Distress tolerance skills: ability to accept oneself and the current situation in a nonjudgmental manner. Distress tolerance is the ability to experience an emotional state without trying to alter one’s thoughts and actions. Distress tolerance techniques include distracting, self-soothing, enhancing the moment, and thinking of pros and cons.

(Brown, 2011)

Theory

Dialectical behavioral therapy (DBT) is based on cognitive behavioral techniques (CBT). CBT can be thought of as a combination of psychotherapy and behavioral therapy. The goal of CBT is to change the individual’s patterns of thinking or behaviors so that they can change the way they feel. This theory allows the client to address their emotions and learn to use strategies to aid in emotional regulation.

(Martin, 2016)

Evidence

A 2012 study done by Kraemer Luberto and McLeish* investigation sought to evaluate the moderating role of distress tolerance (DT) in the relation between the physical concerns (PC) dimension of anxiety sensitivity (AS PC) and panic and posttraumatic stress disorder (PTSD)-related re-experiencing symptoms in a nonclinical, undergraduate sample that was required to fill out both an Anxiety sensitivity index-3 (ASI-3) and Distress Tolerance Scale (DTS). Previous research efforts in this area have found that despite significant main effects for a number of forms of anxiety psychopathology, the only significant interactive effect between AS and DT was for hoarding symptoms. This study sought to clarify the nature of the AS DT interaction by increasing specificity and examining the interaction between DT and a specific AS subfactor (i.e., PC) and specific types of anxiety psychopathology (i.e., panic, PTSD). The authors found that Consistent with prediction, there was a significant interaction effect between AS PC and DT in regard to panic symptoms. This current study represents an important extension of previous work examining the interactive nature of DT and AS in relation to anxiety symptoms. These findings indicate that the AS PC DT interaction is specific to symptoms of panic as opposed to depression and anxiety more generally. Clinically, these findings suggest that individuals who are both high in AS PC and low in DT are an at-risk population for experiencing panic symptoms and possibly developing panic disorder and, thus, may benefit from targeted prevention and intervention efforts aimed at reducing AS and improving DT this coincides with the choice of using DBT to manage these specific anxiety issues that the client is facing.

http://eds.b.ebscohost.com.ezproxy.fiu.edu/ehost/pdfviewer/pdfviewer?vid=32&sid=33ba5f3a-c7ea-4fec-bac6-73bf74e57aba%40sessionmgr102

Case Study

Clint is a 25 year old male who goaltends for the Florida Panthers hockey team. About a month ago, his neck was slashed with another player’s skate during a game, almost killing him. Following this incident, he is plagued by PTSD, alcoholism, OCD, and has made a suicide attempt. Previously, playing hockey gave Clint a feeling of purpose; however, now the thought of the sport causes him to break out in a sweat and he is experiencing difficulty sleeping. This near death experience and his acquired anxiety disorder has kept him from returning back to work, and it is also affecting his roles at home as a father and a husband. Despite these feelings, Clint wants to return to work and provide for his family.Clint has already completed motivational interviewing as well as skills training for health management to improve his wellness. Currently he is seeing a psychotherapist. The psychotherapist is working alongside his occupational therapist to complete dialectical behavioral therapy specifically targeting distress tolerance in order to overcome his anxiety to get him closer to achieving his goal of returning to work and the sport he loves.

Intervention Plan

Problem statement

• Clint is unable to return to work due to poor emotional regulation skills secondary to anxiety.

2 long term goals

• Client will regulate distressing emotions 4/5 times using self-selected soothing techniques in preparation for returning to work in 4 weeks.
• Client will be able to watch video clips of hockey accidents without any symptoms of anxiety in 4 weeks.

3 short term goals

• Client will identify 3 self-soothing techniques for emotional regulation to be able to go back to work in 2 weeks.
• Client will improve the tolerance subscale score of the distress tolerance scale (DTS) from a mean score of 1 to a mean score of 3 in 2 weeks.
• Client will watch 4/5 video clips of hockey games without any signs of emotional distress in 2 weeks.

Intervention format

• Individual

Description of the setting

• Clint will meet with the occupational therapist individually at the outpatient health clinic at the Florida Panthers arena for 30 minutes twice a week for 1 month.

Supplies

• Paper
• Pen
• Hockey game video clips
• Television

Agenda

-Build rapport with Clint and ask how the client is feeling (2 min)

-Clint will complete the Distress Tolerance Scale (4 min)

-Educate Clint on distress tolerance and self soothing techniques (7 min)

-Watch a hockey game with client focusing on building distress tolerance (15 min)

-Summarize session with Clint (2 min)

Documentation

S: Client reports that he does not know how to calm himself in when trying to attend hockey practice. He states that although he wants to go back to work, dealing with his accident is too traumatizing

O: Client presented for a 30 min OT treatment session. At the beginning of the session, the client filled out the Distress Tolerance Scale (DTS). He scored a mean of 1 on the tolerance subscale of the DTS. Client was educated on distress tolerance skills and self-soothing techniques. He identified smelling essential oils, listening to Enya, and humming as 3 things that help him self-soothe in times of distress. Client watched three 5 minute intervals of a hockey game while documenting how he was feelings and the emotions it brought up. Client recorded feelings of anger, sadness, anxiety, and fear. During interval breaks client engaged in all 3 self-soothing techniques he previously identified.

A: Client’s heavy breathing, grimacing facial expressions and looking away from video indicated feelings of distress and anxiety. Client’s score on DTS indicated he had a very low distress tolerance. Client’s ability to engage in 3/3 self-soothing techniques indicates he is making progress in improving his distress tolerance.

P: Client will be seen for a 30 minutes OT session, twice a week, for one month to continue to work on improving his distress tolerance skills. He would benefit from a graded up experience from watching a clip of his accident.

References

Brown, C., Stoffel, V.C., & Munoz, J.P. (2011). Occupational therapy in mental health: A vision for participation. Philadelphia, PA: F. A. Davis Company. ISBN-10: 0-8036-1704-6

Kraemer, K. M., Luberto, C. M., & Mcleish, A. C. (2013). The moderating role of distress tolerance in the association between anxiety sensitivity physical concerns and panic and PTSD-related re-experiencing symptoms. Anxiety, Stress & Coping,26(3), 330-342. doi:10.1080/10615806.2012.693604

Martin, B. (2016). In-Depth: Cognitive Behavioral Therapy. Psych Central. Retrieved on

Febuary 2, 2018, from https://psychcentral.com/lib/in-depth-cognitive-behavioral-therapy/

Migliore, D. (2010). PREDICTORS OF BINGE EATING: PERFECTIONISM, DISTRESS TOLERANCE AND EATING SELF-EFFICACY. 1-94. Retrieved February 02, 2018.