Distress tolerance was the first DBT skills module I encountered (after mindfulness, of course.) I knew I needed help with distress tolerance, which is a set of crisis survival strategies, but my initial reaction to most of it was that it was bullshit, hokey, outdated, and wouldn’t work.
I was wrong.
Distress tolerance skills are about how to get through those tough moments that you can’t change, but simply have to find a way to accept and tolerate. Acceptance doesn’t signal agreement – accepting a crappy situation is not the same as approving of it, it’s just acknowledging that you don’t have control over it. For the purposes of DBT, “crisis” is anything emotionally upsetting – including spilling the milk – because distress is distress, regardless of scale, seriousness, or cause.
There are four main distress tolerance skill sets: self-soothing, distracting, improving the moment, and analyzing pros/cons. I really, really resisted for three reasons: I didn’t feel that I deserved to be less distressed; I was afraid that actively distracting myself from distress would cause even bigger problems due to ADD; and I didn’t really believe that anything I did would make distressing situations more tolerable. I also didn’t want to accept the distressing situations I found myself in, and that just made it worse.
What I found is that these techniques do work if you actually let them, but you have to experiment to find what works best for you. As expected, I do have to be careful with distracting, but I’ve learned that sometimes it’s exactly what I need to do (e.g., while waiting for Ativan to kick in when I’m in really bad shape). It also takes time and deliberate practice, but some of the skills are now automatic responses to distressing situations, which is how DBT is supposed to work.
Self-Soothing a Savage Beast
One of my first questions about self-soothing was how it differed from self-indulgence. I generally believed that being kind to myself was some kind of superfluous mollycoddling. It’s true that self-soothing is about making yourself feel better, but I didn’t feel I deserved or needed it. DBT held up a mirror that showed me I needed to practice self-compassion.
“Self-soothing with the five senses” is exactly what it sounds like. Using the lotion that smells so good and feels so nice that it makes you feel just a little less upset with the world. Flipping through a coffee-table book of visually-pleasing photos. Mindfully preparing a steaming mug of sipping chocolate (super-deluxe hot cocoa!) and then mindfully sipping it. Going outside somewhere that I can hear moving water – a creek, river, or lake. Baking cookies that make the whole house smell yummy. Hitting “play” on the playlist of songs that always make me feel good. These are little ways to make it easier to get through a bad moment.
All it really takes is realizing that I’m in distress, and asking if there is anything I can do to make the situation easier on myself (which requires some measure of mindfulness in the first place.) I mentally run through the five senses to check if any small, quick interventions will help me feel better right now.
Simple, really – but it took awhile to learn. Some of us forget to include “be nice to yourself” in our coping repertoires. I certainly needed the reminder.
I know I can distract myself from distress; I get distracted from just about everything. The trick is finding a non-destructive distraction when you’re in crisis (i.e., cutting not permitted), and for me, not losing too much time to it. I use distraction strategies sparingly because it’s hard for me to refocus afterward.
The acronym for DBT-approved distraction strategies is “Wise Mind Accepts” – accepting that we can’t change the situation, but can change our reaction to it. These are mostly “right now” strategies for immediate distractions. There are lots of options for ACCEPTS strategies, but here are a few that are effective for me:
- Activities – I take a walk, do some knitting, or write blog posts. Sometimes I go birding, which is especially effective because it demands more mindfulness and focus than many other activities.
- Contributing – I do Postcrossing and send cards and surprises to friends to do something nice for others, which shifts my thinking to an outward focus.
- Comparison – I compare the current situation to other similar (or worse) situations I’ve survived, and remind myself that I’ll be OK.
- Emotion opposites – who doesn’t watch comedies when they feel blue? I also have a “Dr. Feelgood” playlist for when I’m down, a “soothe” playlist for when I’m anxious, and a “zen” playlist for when I need to chill out already.
- Pushing away – I don’t do this much – I’m more likely to use the Imagery strategy (below) to mentally leave a situation.
- Thoughts – I calculate powers of two in my head. I know, that’s weird. Alternately, I’ll take a walk and count my steps in Russian, French, or Spanish. Sometimes I count or calculate the number of floor or ceiling tiles in a room. These are reliable strategies when I need a distraction right now, like when I’ve got the uncontrollable crying going on and I’m at work or when my heart rate is slowly rising with anxiety in a doctor’s office.
- Sensations – I turn up my car stereo really loud and sing along at the top of my lungs to a playlist of singable favorites – for me, this is good at dispelling
road rageanger and fear. Sometimes I’ll take a hot bath with herbal bath salts that I mix up myself – also a self-soothing tactic.
Improving the Moment (or At Least How I Feel About It)
Improving the moment is basically about acceptance and doing what we can to buffer ourselves against emotional distress. To me, these are techniques help in ongoing bad times, as opposed to in-the-moment interventions.
- Imagery – I take myself on a mental hike in the Adirondacks. Specifically, on the Dog Pond Loop section of the Cranberry Lake 50. It’s a warm midsummer day, around 10 AM, with dappled sunshine on the leaves of the trees, which are forming a green arch above us. Watching where I put my feet, seeing my husband moving ahead of me on the trail in the periphery of my vision, stepping over rocks and through mud and picking my way through creeks, feeling the humid but cooling breeze off the lake, hearing the buzzing of dragonflies and cicadas, just moving down the warm green path with the irregular rhythm of hiking. After my mental hike, I feel more centered and calm, so I can handle emotional problems more rationally.
- Meaning – this is essentially about finding silver linings to make meaning of my suffering. I’m able to do this more often since I started keeping a gratitude journal, because that mentality is just easier to access with practice.
Prayer– not part of my repertoire, thanks.
- Relaxation – a cup of herbal tea, deep breathing, yogic breathing, a massage from my sweetheart, sometimes even a short nap…
- One thing at a time – mindfulness and meditation: by staying in the present, I can avoid the additional suffering of worrying about the past or future. This really, really helps and I use it a lot.
- Vacation – Just get out of the situation entirely for awhile – quite possibly my favorite strategy, until I have to go back to reality land. A walk in the woods is a good mini-vacation, even if it’s in a city park; better yet is a day trip to a new birding hotspot. Adding a day or two of vacation to business trips gives me literal vacation that helps reduce anxiety about/from the intense social interactions of the business part of the trip.
- Encouragement – I kind of hate “cheerleading” statements, but I’ve found one that I’m OK with: I’m doing the best I can under the circumstances. That leads me to think critically about the circumstances and admit that it’s (usually) not a personal failing but a difficult situation, and I really am doing the best that I can.
Analyzing Pros & Cons
I wrote about the process of analyzing pros and cons in some detail when I went through it the first time. While I don’t use it all that often, I still keep a filled-in pros/cons 2×2 table in my top desk drawer for “avoidance.” It’s easy for me to remind myself why I need to resist avoidant behavior, and I think of it in moments when I realize I’m avoiding something that I probably should be facing. I found this strategy particularly useful because of its analytic approach, which is compatible with how I like to think about problems.
Next topic: Interpersonal Effectiveness