This chapter analyzes the concept of distress and its application into climate matters. Distress emerges as a broad concept with many connotations. There are so many similarities between climate distress and climate anxiety as broad concepts that they may be used almost interchangeably, but when these phenomena are more carefully scrutinized, a wide vocabulary of various mental states and emotions is required. The history of the usage of climate distress is provided. The role of power dynamics in the usages is explored. Contextual factors are discussed, especially in relation to various cultures and languages. Related dynamics are explored via the example of discourses about climate distress in Finland and Sweden. It is argued that care is needed in analyzing the usage of concepts by various authors. The dual character of climate distress as both a potential mental health issue and fundamentally an adaptive reaction is highlighted.

Now we are really in a rhythm. The only thing that changes from now to the end of the treatment are the characters, related body sensations, and lessons about the body. The Zoomies and Shakies are the first session in which we really focus on emotional experience. If you think of an over-simplified classification system for emotions in terms of valence and arousal, then Session 4 focuses on high-arousal negative emotions (e.g., fear, anger). Betty the Butterfly, Tommy the Thunderbolt, and Julie Jitters are sample characters in this session. A sample investigation would be to try several activities and compare them to see which brings out the most butterflies. In this way, we directly alter the way that children are experiencing their emotions – rather than running or being afraid of them, they are actively seeking these emotional experiences in a playful context.

The Drowsies is our session about sleep. As a restful night of sleep is an important part of any pain management routine, we wanted to devote a session just to that. We explore that sensations that make it hard to get into bed (e.g., Stuck Stephanie – the feeling that you can’t stop doing something that you like doing (like playing video games) to do something you would rather not do (like get ready for bed). We remember some old friends that that may make it hard to fall asleep like Mind-Racing Mikella and Betty Butterfly and we investigate all the sensations that may contribute to a wonderful and cozy night of rest. Cozy Celeste, Sleepy Steven, Cool Cyrus, and Stretched-Out Comfy Cayla are some sensations we explore this session. Wait till you try out all of our different bedtime routines!

The Ouchies is our session about pain: emotional pain, poop pain, muscle pain, worry pain – among others. Investigations focus on the important messages of pain and explore what happens to certain pain sensations when you listen and respond to them. For example, what happens to emotional pain when you get a hug? Sample characters include Ella the Emotional Pain and Patricia the Poop Pain. Children challenge themselves to show how strong they are and how much they can do even when they feel a bit uncomfortable.

Pregnancy and the postnatal period can be a source of many worries – the health of you and the baby, safety, bonding, financial and partner stress are normal topics of worry. However, for some, the experience of worrying is time consuming, uncontrollable and jumps from topic to topic, causing stress and anxiety. Generalised anxiety (the experience of overwhelming worry) is one of the most common perinatal anxiety problems. This chapter will help you identify and recognise the processes involved in keeping worry going, such as getting drawn into ‘what if’ questions, thinking the worst and finding uncertainty difficult to cope with. Techniques are described to help you disengage from worry, deal with uncertainty, think through and challenge beliefs about worry and support yourself to gain control over your anxiety.

In this session, the patient is queried about issues of anger management, and is taught emotion regulation skills. This session presents the anger toolbox: a set of tools to use when angry.

The session introduces a Trauma-Recall Protocol, which consists of a set of “tools” (for example, emotion regulation techniques) to be used when unwanted trauma recall occurs, and that help the patient to tolerate exposure. During the teaching of the protocols, be sure that the patient does the stretching and other motions, and, if the patient does not, encourage the patient to do so. The therapist should maintain a playful demeanor. At times, to ensure that a sense of relaxation is being conveyed, the therapist should purposefully slow and deepen the voice. (This creates a sense of shift in the session.)

In this session, applied stretching is taught, and the patient is led once more through the whole body muscle relaxation (with contract-release and stretch-release relaxation) with visualization. As in almost all lessons, there is a section on mindfulness and stretching. As indicated in the last session, the therapist should be sure that the patient does the stretching and other motions, and, if the patient does not, the therapist should encourage the patient to do so, all the while with a playful mien, a playful demeanor. This models a positive way of interacting and it also creates new positive associations to the topics being discussed. At times, to promote relaxation, the therapist should purposefully slow and deepen the voice. This also creates a sense of shift in the session: a shift in voice and emotional register.

In this session, again somatic symptoms and associated trauma networks and catastrophic cognitions are explored and addressed (on our model of how somatic symptoms are generated, see the Multiplex Model of Trauma-Related Disorder). The session also reviews key information such as emotion protocols (e.g., anxiety and anger protocol) and the applied stretching protocol.

Applied muscle relaxation” is traditionally used to describe the relaxation of muscles by contracting a muscle, holding the contraction, and then releasing tension. This might also be called “contract-release muscle relaxation.” Another method of muscle relaxation, such as that used in yoga, involves stretching a muscle by forced elongation and then holding the forced elongation a certain time, then releasing it. This might also be called “elongation-release relaxation” or “stretch-release relaxation.” CA Multiplex CBT teaches both applied muscle relaxation (i.e., “contract-release” relaxation) and applied muscle stretching (i.e., “elongation-release” relaxation), but emphasizes elongation-release relaxation, that is, yoga-type stretching. Traumatized patients have multiple symptoms induced by muscle tension. Examples of sensations caused by muscle tension include joint soreness, muscle soreness, and headache. Additionally, as discussed in the Introduction, applied muscle stretching allows for the introduction of phrases and images that promote a positive self-image of flexibility and prime to being flexible. These are embodied metaphors.

In this session, diaphragmatic breathing is taught to illustrate that normal breathing relieves anxiety, and hyperventilation is used to show that abnormal breathing can induce symptoms but that those symptoms are not dangerous. The patient is educated about breathing and educated about trauma associations to and catastrophic cognitions about symptoms caused by hyperventilation and chest breathing, such as chest tightness, dizziness, and cold extremities. The patient is made to hyperventilate to educate about breathing-induced symptoms, to create positive reassociations to dizziness and other sensations, to address trauma associations to the symptoms, to reduce fear of the hyperventilation-induced symptoms, and to act as interoceptive exposure that creates new nonthreating associations to the symptoms.

In this session, the patient is queried about worry episodes and resulting distress. Among ethnic minority and refugee patients, worry is common, and often triggers somatic symptoms, for example, dizziness and headache; triggers psychological symptoms (e.g., poor attention and concentration); and triggers panic. We have found worry to be a key psychopathological process in many minority and refugee populations. This session addresses worry in many ways, such as eliciting causes, symptoms, catastrophic cognitions, and trauma associations. Many treatments are used, such as modifying catastrophic cognitions and teaching mindfulness, including introducing a new form of mindfulness (tea/coffee mindfulness exercise). As a form of switching attentional focus, to treat worry, we introduce two forms of behavioral activation: encouraging exercise (for example, wall push-ups), and prescribing pleasurable activities.

Interoceptive exposure is introduced, focusing on dizziness sensations that are induced by head rolling. We use head rolling to educate about dizziness, to modify catastrophic cognitions about dizziness, to create positive reassociations to dizziness, to address trauma associations to dizziness (and other induced symptoms), and to act as interoceptive exposure that creates new nonthreatening associations to dizziness (and other induced symptoms). Interoceptive exposure also acts as behavioral activation and as a way to create an attitude of playfulness, a sort of flexibility. In the session there is also further training in emotion regulation (emotion flexibility) by practicing certain emotions.