DBT 7: Distress Tolerance

Distress module provides important tools to help you to return to Wise Mind when your emotions become too powerful.  These are not permanent avoidance tactics. They are simple and important outs which will allow you a breather so that you can refocus, return to mindfulness and act effectively.  Important in this too are tools for self soothing and handling painful situations in non-judgmental ways.  They help you to accept reality even if you don’t approve of what’s going on. 

Distress Tolerance: Crisis Survival Strategies

DBT teaches us four sets of skills for tolerating (dealing with, getting through, accepting) the distressing events and activities in our lives. We can think of these as Crisis Survival Strategies. Some of them will fit and feel right, others won’t. Out of these skills, it is recommended to try them all and identify which especially work or apply to you. They are:

·         Distracting - Wise Mind ACCEPTS

·         Self-Soothing

·         Improving the Moment

·         Thinking of Pros and Cons

DBT emphasizes learning to handle difficult situations skillfully. The ability to tolerate and accept distress is an essential mental health goal for at least two reasons.

1.      Pain and distress are a part of life; they cannot be entirely avoided or removed. The inability to accept this immutable fact itself leads to increased pain and suffering.

2.      Distress tolerance, at least over the short run, is part and parcel of any attempt to change oneself; otherwise, impulsive actions will interfere with efforts to establish desired changes.

Although the stance advocated here is a nonjudgmental one, this should not be understood to mean that it is one of approval. It is especially important that this distinction be made clear to clients: Acceptance of reality is not equivalent to approval of reality.

Crisis Survival Strategies  The following are techniques to give you a break from dealing with negative emotions temporarily. They give you a break and allow you to transition from emotional mind to wise mind in order to effectively handle the situation.

DISTRACT (to reduce contact with emotional stimuli )
A useful way to remember these skills is the phrase Wise Mind ACCEPTS

Distract with Activities: Activity raises endorphin levels and gets you out of the crisis situation for a while. Do hobbies, watch a video, go for a walk, play a sport, cook, garden, go fishing, go shopping. 

·         What other activities can you think of that you can get involved in and distract yourself from your distress? Make a list of your activities and keep that handy so that you can relate to it when needed.

Distract with Contributing: Do volunteer work and contribute. Babysit so a friend can go out. Do something nice or surprisingly thoughtful for someone.

·         What have you done this week to contribute? What can you do next week to contribute? Plan something in advance. This takes you away from your pain and puts your attention on your concern for someone else.

Distract with Comparisons: Compare yourself to people coping the same as or less well than you. If you are doing better than you were a year or two ago, make that comparison. Watch disaster movies, watch soap operas, or a hospital waiting room. Some people find this helpful, others don't. Just do what works for you.

Distract with opposite Emotions.  Do something to evoke the opposite emotion to what you are feeling. If you are sad, watch a comedy or amusing anecdote. This helps to put you in a different place.

With Pushing Away  (use this skill last - as a tuning out): Push the situation away by leaving it for a while, leave the situation mentally or physically. Build an imaginary wall between yourself and the situation or push the situation away by blocking it out of your mind. Censor ruminating. Refuse to think about the painful aspects of the situation. Put the pain on a shelf. Box it up and put it away for a while.

Distract with other Thoughts  This is essentially a mini-meditation. Some examples are counting to 10 or counting the tiles in a floor or the panes in a window or the stars in the sky, anything to keep your focus on the counting.  This is a good one to use in a sudden emergency, when you need to pull something out of your bag of tricks really quickly. You may also try reading, watching TV or movies, doing crossword puzzles, writing poetry.

Distract with other Sensations. (other intense sensations): Hold ice in your hand, squeeze a rubber ball very hard, take a hot shower, listen to loud music, sex, snap a rubber band on your wrist, suck on a lemon. Any of these will help you to avert crisis.

Again, these are not permanent avoidance techniques. They are tools and avenues to take when your emotions are too hot to act effectively. They are good transitions back to wise mind and mentally give you a break from a difficult situation.

SELF SOOTHE  A way to remember these skills is to think of soothing each of your FIVE SENSES

With VISION:
Buy one beautiful flower, make one space in a room pretty, light a candle and watch the flame. Set a pretty place at the table, using your best things for a meal. Go to a museum with beautiful art. Go sit in the lobby of a beautiful old hotel. Look at nature around you. Go out in the middle of the night and watch the stars. Walk in a pretty part of the town. Fix your nails so they look pretty. Look at beautiful pictures in a book. Go to a ballet or other dance performance, or watch one on TV. Be mindful of each sight that passes in front of you, not lingering on any. Notice your appreciation.

With HEARING:
Listen to beautiful or soothing music, or to invigorating and exciting music. Pay attention to sounds of nature like waves, birds rainfall, rustling leaves. Sing your favorite songs, hum a soothing tune, learn to play an instrument. Call 800 or other information numbers to hear a human voice. Be mindful of any sounds that come your way, letting them go in one ear and out the other.

With SMELL:
Use your favorite perfume or lotions, or try them on in the store, spray fragrance in the air, light a scented candle. Put lemon oil on your furniture. Put potpourris in a bowl in your room. Boil cinnamon, bake cookies, cake or bread. Smell the roses. Walk in a wooded area and mindfully breathe in the fresh smells of nature.

With TASTE:
Have a good meal, have a favorite soothing drink, such as herbal tea or hot chocolate (but no alcohol). Treat yourself to a dessert. Put whipped cream on your coffee. Sample flavors at an ice cream store. Suck on a piece of peppermint candy. Chew your favorite gum. Get a little bit of special food you don't usually spend the money on, such as fresh squeezed orange juice or organic vegetables. Really taste the food you eat, eating one thing mindfully and focusing on its taste.

With TOUCH: Experience whatever you are touching, notice that the touch is soothing. Take a bubble bath, put clean sheets on the bed, pet your dog or cat, have a massage, soak your feet, put creamy lotion on your whole body. Put a cold compress on your forehead, sink into a really comfortable chair in a hotel lobby or in your home, put on a silky blouse, dress, or scarf. Try on fur-lined gloves. Brush your hair for a long time. Hug someone.

IMPROVE THE MOMENT: A way to remember these skills is in the word IMPROVE

With IMAGERY: Imagine very relaxing scenes or soldiers fighting and winning. Imagine a secret room within yourself, seeing how it is decorated. Go into the room whenever you feel threatened. Close the door on anything that can hurt you. Imagine everything going well. Imagine coping well. Imagine hurtful emotions draining out of you like water out of a pipe.

With MEANING: Find or create some purpose, meaning or value in physical or emotional pain. Remember, listen to, or read about spiritual values. Focus on whatever positive aspects of a painful situation you can find. Repeat them over and over in your mind. Make lemonade out of lemons. Endurance is the lesson.

With PRAYER: Open your heart to spirituality. It could be a God, nature or your own wise mind for instance.

With RELAXATION:  Try relaxing each large muscle group, starting with your hands and arms, going to the top of your head, and then working down. Listen to a relaxation tape, exercise hard, take a hot bath, or get a massage. Breathe deeply, half-smile, change your facial expression. Just the act of smiling will uplift you. Try a smile even when you are upset.

With ONE THING IN THE MOMENT:  Focus your entire attention on just what you are doing right now. Keep yourself in the very moment you are in. Focus your entire attention on physical sensations that accompany nonjudgmental tasks. (e.g. walking, washing, doing dishes, cleaning, fixing). Be aware of how your body moves during each task. Do awareness exercises.

With VACATION: Give yourself a brief vacation. For instance, from 2 p.m. to 4 p.m., get in bed and pull the covers over your head for 20 minutes. Rent a hotel room at the beach or in the woods for a day or two. Unplug your phone for a day, or let your answering machine screen your calls. Take a 1 hour breather from work that needs to be done. Look at a magazine, bundle up in a chair, eat slowly. Allow yourself to be a kid again - take a break from adulthood.

With ENCOURAGEMENT: Cheer lead yourself. Repeat over and over: “I can make it. This won't last forever. I will make it out of this. I'm doing the best I can. I can do it. There’s a lesson to learn here.”

Thinking of PROS and CONS 

·         Make a list of the pros and cons of tolerating the distress. Make another list of the pros and cons of not tolerating the distress - that is, of coping by hurting yourself, abusing alcohol, or drugs, or doing something else impulsive.     

·         Focus on long-term goals, the light at the end of the tunnel. Remember times when pain has ended. Think of the positive consequences of tolerating the distress.

·         Imagine in your mind how good you will feel if you achieve your goals, if you don't act impulsively.

·         Think of all of the negative consequences of not tolerating your current distress. Remember what has happened in the past when you have acted impulsively to escape the moment. Ask yourself, “Will this event that is distressing me going to matter in 5 years?”