Distraction – focusing on the ‘pleasant or present’
Distraction is a commonly used CBT therapeutic technique. It is based on the concept that we can only attend to one thing at a time, so it might as well be something pleasant or present. This displacement of negative thoughts, feelings and urges from centre stage provides respite from distress and also helps clients to start viewing negative cognitions as ‘just thoughts’ rather than factual truths.
However distraction is a double-edged sword because it can be interpreted as meaning:
1. ‘Moving away’ from negative cognitions and feelings
2. ‘Moving towards’ positive (or indeed neutral) cognitions and feelings
Another way of putting this is that distraction is either:
1. an avoidant behaviour or
2. an approach behaviour
Of course, one of the basic tenets of CBT is that avoidant behaviours generally give short-term relief but maintain long-term distress. This is because they can become safety-seeking behaviours, such that the client believes it’s the distraction that is allowing her to cope with her problems. Or because using distraction prevents the client from learning other skills that would build her confidence that she can actually take command of her problems.
A typical avoidant behaviour used by many when trying to self-distract, is thought suppression – pushing unwelcome thoughts away. The ‘don’t think about pink elephants for one minute’ exercise is an easy way to demonstrate in session the ineffectiveness of thought suppression/’moving away’/avoidant type of distraction.
Instead, the framing of distraction needs to be in the ‘moving towards’, approach mode. Having done the pink elephant exercise together with the client and debriefed what each of us observed about ourselves during it, I explain as follows:
‘As we’ve just seen, trying to suppress or ‘not think’ about something doesn’t work very well and in fact, makes us think about it even more. However we could try doing it differently, by moving our attention ‘towards’ something else. We can either imagine something really pleasant, like a favourite memory or a fantasy holiday. Or we can focus our attention on something in the present, in the here and now, like focusing on the sounds we can hear, or what we can see, touch or smell. Or we can become present by doing a mental exercise, such as counting backwards in 7s from 100 or reciting a poem. Which of these do you think might engage your attention most – then we can try it together now if you’d like? ’
We then do the selected activity as an exercise for two minutes. If I remember, I do ask the client to rate her anxiety/low mood/distress level out of 10 before the exercise and then again after it, to check the impact of the distraction.
If the client selects a pleasant image or memory to focus on, I encourage her to create a truly vivid image:
‘How does it smell and feel? What can you hear? And see? Really enjoy and savour this image slowly and in detail.’
I find that most patients can remember the ‘pleasant or present’ phrase easily and that it seems to encourage use of the technique. The concept of ‘pleasant’ also ties in nicely with the technique of scheduling pleasant (and rewarding) activities into the daily routine, in order to lift mood. I use activity scheduling as an early intervention in patients presenting with low mood whatever their underlying diagnosis may be. Tying in distraction as a form of providing an immediate small hit of pleasure, as well as respite from distress, seems to be a theoretically coherent and compassionate combination.
Some clients develop a matrix of distractions that work for them in different physical environments and for different levels of distress. e.g. imagining a favourite film scene while on the tube and mildly distressed but counting the number of people wearing glasses when highly distressed etc. Physical exercise is another useful distraction of course, but logistics often restricts its use to leisure hours and lunch-breaks.
Finally, it is important to review the client’s use of distraction in the next session, to see whether it is being deployed correctly or as avoidance or safety-seeking. I reviewed my very first client’s use of ‘putting the distressing thoughts into a balloon and letting it sail up into a very blue sky’, only to discover that she had been releasing balloons about 100 times per day in the intervening week… For this reason, I have largely shifted the content of the distraction exercises that I use away from ‘doing something’ with the negative thoughts themselves and towards doing ‘pleasant or present’ activities instead.
Summary points
The ‘don’t think of a pink elephant for one minute’ exercise is a quick way of demonstrating the difficulties with thought suppression in session
The phrase ‘pleasant or present’ is a helpful reminder for how to do distraction exercises
Check that the client does not use distraction as an avoidant or a safety seeking behaviour