DBT Skills: Distress Tolerance

I’m in a DBT group right now. It’s comprised of four modules, and I just finished my second, which is distress tolerance. Of all the things I could possibly say about it, the most accurate would be that it’s a lot of work. Think of it this way: it’s a lot of practicing things that are aimed at reducing distress, regardless of what mood or state of mind one might be in. Thankfully my emotions are still pretty distressing on a regular basis, so I was able to more or less have something to compare the results to.

I suppose it might be helpful to first talk about what distress means. It can be one of any range of emotions, from sadness to anger, from guilt to anxiety, from jealousy to shame to panic to depression. There are many emotions that cause a person distress. These exercises are aimed to help a person alleviate distress, or perhaps avoid it altogether. They can (and should, for more effectiveness and to get a routine down) be practiced even when a person is not actually distressed.

There are a few basic ideas behind distress tolerance. One is to find ways in moments of upset to create feelings of safety and comfort by appealing to the senses. Another is to find ways to improve the moment by physically doing things. Listing pros and cons is another tool, as is practicing what is called radical acceptance.

Self soothing – appealing to the senses to calm and/or comfort – involves doing things that utilize the five basic senses. For instance, one might put on lotion that smells nice and leaves their skin feeling soft, or have a warm bath, or eat a bit of their favorite food (this one can be tricky to those with eating disorders, as I have discovered), or go to a place of beauty (nature, a hotel lobby, etc), or perhaps listen to calming music. My coach (a therapist assigned to me for the duration of the DBT group) has prescribed this as my homework for the week, even though I am no longer in this module, because self soothing is something I rarely think of doing. I put some satsuma lotion on my hands last night before bed and just breathed in the scent of it and it was interesting just how soothing such a simple act can actually be. Whether or not it works in a moment of distress remains to be seen, at least in this particular case. I know that for me, personally, listening to relaxing music works, as does, sometimes, listening to the loudest, angriest music I can get my hands on. Being in nature also helps. It’s like a reset for me: I breathe with the trees and allow them to transform me. It’s different for different people. Watching television is on the list as well, though the idea is not to tune out, but to do it mindfully. That can be said for all of these exercises; mindfulness is the key.

Improving the moment involves doing things to make a crappy moment better. It can be something like cheerleading for oneself, telling oneself things will get better. It can mean creating some sense of purpose for an event, through spirituality perhaps. What I mean by this is, sometimes people need a reason why bad things are happening to them. It doesn’t hurt to create that for oneself. This can be through prayer or meditation, the practice of a religion or reading books that are spiritually based. Improving the moment can also be things like calling a friend, volunteering, comparing the severity of personal experience to someone (or something) that is worse off (gaining perspective), or watching something that will cause an opposite emotion, like a funny movie.

Pros and cons is fairly straightforward. It’s meant to be a four-part list. For every harmful or destructive behavior one is wanting to engage in, the idea is to write out the pros and cons for the behavior, and the pros and cons against the behavior. For example, if I’m about to binge, I might write that the pros for the behavior are that it’s instant gratification, and gets me what I want, and helps me avoid whatever else I could be dealing with in the moment (usually feelings of some sort). The cons for the behavior are that I will feel bad about myself, spend money I don’t really have, feel bloated and most likely want to purge. Then I do the reverse: the pros and cons if I don’t act on the behavior. Each list can be as long or as short as I wish, though it probably helps to be as thorough as possible. This can help in cases where the situation is already elevated and the person wishes not to elevate it more.

Radical acceptance is the final part of distress tolerance, and perhaps the most difficult. It involves accepting what is happening just as it is, without trying to change it, and is geared more towards the things we either cannot change, or must endure for awhile. As the term implies, these things generally are not pleasant, and of course, just because we accept something doesn’t mean we have to like it (I get the two confused all the time). One way to practice radical acceptance is to offer up a half-smile in challenging situations. This does not mean to mock someone in a conflict, or to be insincere when the practitioner is in reality having a bad day. It is meant to offer a small measure of acceptance to a painful or uncomfortable situation, to say, Yes, I see you, and then greet the challenge like a friend, making room for it. Another way is through the breath. Much mindfulness practice is rooted in the breath, and radical acceptance is no different. If following the breath in and of itself is too difficult, one may use a rhythm, perhaps music, and follow the rhythm of the music with their breath. The breath is the one thing we all have that belongs to us, the one thing we can return to at any point in the day and clear our minds with. Some people find it useful to say mantras on the in- and out-breath. In one of our sessions we used ‘wise mind’ on the in-breath and ‘letting go’ on the out-breath. I personally found it an effective way to clear my mind and it was easier for me to come back to it when my mind wandered than when I was just focusing on the breath itself.

When practicing these exercises, it might be a good idea to record what works and what doesn’t. It might even be helpful to record what type of mood one is in during the exercise so that one may go back and remember, hey, this worked for me when I was in crisis, or, hey, I found this one difficult and might want to practice it some more. It might also help to either research the internet for resources or make lists of different types of exercises to try. One I found that is particularly relevant to what I am talking about:

http://www.dbtselfhelp.com/html/distress_tolerance.html