What Are DBT’s Distress Tolerance Skills?

What Is Distress Tolerance?

Distress tolerance is the ability to navigate highly stressful and frustrating circumstances in life. It is a part of the human condition to experience low frustration tolerance occasionally. The key is adaptability in the face of distress. Persons with low distress tolerance often self-sabotage their circumstances further. In contrast, a person with high distress tolerance can tap into their resources accordingly.

Examples of Low Distress Tolerance

Low or poor distress tolerance is when a person responds impulsively and/or destructively to life’s troubles and/or pressures.² Low distress tolerance skills often occur due to a person having attachment trauma in early life, adverse childhood experiences (ACES), genetic and/or temperamental predispositions.

For example, ACES are linked to poor attachment in early life. Our earliest attachment style contributes to our ability to relate to others later in life.³ Therefore a person with anxious attachment, avoidant attachment, or disorganized attachment will likely struggle with adaptation, especially in relationships.⁴

Examples of low distress tolerance include:

• Binge eating
• Substance misuse
• Self-harm
• Self-sabotaging behaviors
• Impulsivity
• Instability in relationships
• Extreme anger and/or outbursts of rage
• Paranoia
• Dissociation

Examples of Healthy Distress Tolerance

Healthy Distress Tolerance can be defined as an ability to adapt well to adverse circumstances. Often, a person develops healthy distress tolerance skills through secure attachment in childhood and/or a more fluid temperament, likely based on genetics. While these positive pre-dispositions are ideal, a person’s resources and resiliency play a role as well. Therefore, healthy distress tolerance can be developed later on in life with enough insight and care.

Examples of healthy distress tolerance include:

• Reality testing
• Well-regulated emotions
• Cultivate healthy relationships
• Critical thinking
• Problem solving
• Assertive communication

What Is Dialectical Behavior Therapy?

Dialectical behavior therapy (DBT) is a type of cognitive therapy that brings together the regulation of emotions and behaviors, coupled with mindful practice and interpersonal skill building. DBT works in a multifaceted therapeutic form with individual therapy, group skills training, and coaching with a therapist in times of crisis.

The goals of DBT are to improve a person’s self-awareness and ability to move through adversity effectively. DBT’s approach to distress tolerance is part skill building and part coaching, in that specific skills are taught to foster self-awareness and coaching in order for persons to develop insight into when and how to use these skills in everyday life.

What Are DBT’s Distress Tolerance Skills?

DBT’s distress tolerance skills are tools that one can use in moments of extreme stress that help to soften the intensity of emotional distress. Stress and frustrations will cause imbalance for anyone; however, DBT’s distress tolerance skills can enable a person to meet the challenges in their life with more ease rather than discomfort.

DBT Crisis Skills

Crisis skills in DBT are skills to get you through the moment of crisis without circumstances becoming worse. These skills are used in situations such as urges to self-harm, thoughts of suicide, panic, dissociation, and impulsivity, to name a few. The hope is to encourage a self-regulated response rather than an overreaction.

1. The STOP Skill

The STOP Skill is an acronym for the following steps: Stop, Take a step back, Observe, Proceed Mindfully. Mindfulness is at the heart of DBT’s practices and teachings. The STOP Skill seeks to support the idea of mindfulness by limiting reactions and encouraging responses. This skill is best practiced in the midst of extreme anger, frustration, and impulsivity, amongst other strong emotions.

The STOP skill stands for:

• Stop: Literally stop whatever it is you are in the midst of doing.
• Take a step back: Once you have stopped, take a step back from your emotions. Widen your perspective to include the whole picture, not just your emotions at the moment.
• Observe: Take a moment to notice your body. Observe your feet planted on the floor.
• Proceed mindfully: Once you have done the latter, take a breath and proceed with the situation at hand in the capacity for which you need to or must.

2. Pros & Cons

The second DBT skill is pros and cons. This skill differs from what you may think of when hearing “pros and cons”. These pros and cons are specific to one’s reaction to distress in the moment. It asks what is the pro of tolerating distress adaptively versus the con of giving into low distress tolerance. This skill is helpful when initially met with adversity as it can guide decisions on the next steps and responsiveness thereafter.

3. TIPP Your Body Chemistry

DBT TIPP skills are distress tolerance skills that intend to change your body’s central nervous system response. Our central nervous system is broken into the sympathetic, or fight-flight-freeze-fawn system and our parasympathetic, “cool” or homeostatic system. The parasympathetic is where our body is functioning most adaptively.⁸ TIPP skills hope to bring us back to parasympathetic homeostasis and bring our distress level down significantly.

The TIPP skills are:

• Temperature: When mammals dive into a body of water, it brings the body back to a state of calm. In practicing this technique, a person tips their head into a bowl of water to mimic this experience. However, this skill is not always feasible in all areas of life. The good news is any “cooling” method is helpful in taking us out of the sympathetic state distress puts us in. A few techniques to try are: running one’s hands under cold water, standing in front of a fan or AC, patting cool water on your face or neck or rubbing ice cubes on your face and neck, and holding them in your hands.
• Intense exercise: Engage in an exercise that matches your distress level at the moment. This could be dancing, running in place, fast walking, sprinting down the hallway, doing jumping jacks, or calisthenics, such as push-ups or sit-ups. This hopes to release any “pent-up energy” you are holding.
• Paced breathing: Paced breathing is intentionally pacing your breath, which calms the sympathetic nervous system down and allows us to begin thinking in a calmer and more logical manner. A few breathing techniques to try are: boxed breathing, diaphragmatic breathing and coherent breathing.
• Paired muscle relaxation: You can practice paired muscle relaxation (PMR) in a few different ways. If you are in a private enough place, you can scan your whole body and tense each muscle group at a time. Breathing in and tensing for five seconds, then releasing. After scanning your whole body, you can tense all muscle groups together while breathing in, from your face to your toes, for five seconds, and release. If you are in a more public setting, you tense your toes, pelvic area, or hands while breathing in for five seconds and then releasing.

4. Distract With ACCEPTS

ACCEPTS Skills are methods of distracting from triggering stimuli. The acronym stands for Activities, Contributions, Comparisons, Emotions, Pushing Away, Thoughts, and Sensations. When pros and cons or problem-solving feel difficult or overwhelming, allow yourself time to distract and consider the following:

• Activities: Similarly to the vacation skills in IMPROVE. Focus on a task you need to get done. Play a word puzzle. Go for a run. Spend time with your pet. Go for a walk. Any fruitful activity for your soul.
• Contributions: Volunteer at a local soup kitchen. Help a friend. Read to children at the local library. Any gesture of contribution can leave one feeling more at ease.
• Comparisons: This is not to compare in an unhealthy manner. Suffering is suffering, and you should not feel guilty for your experience(s). This is to replay a time in your mind when you felt differently. Look at the “older you” and the “newer you”, what do you notice? What are you proud of? What would you like to see yourself do more of or less of? Again, this comes from a non-judgmental stance.
• Emotions: Watch, read, or listen to something that brings up emotions of happiness and joy and even makes you laugh.
• Pushing Away: Imagine putting the difficult situation on a shelf and leaving it there for a while. You can even put a literal box or jar on a shelf in your home/office and write the situation on a piece of paper and then put it in the box/jar to stay for a period of time.
• Thoughts: Harness your thinking to more neutral activity. Counting by 3’s or 7’s. Naming all the words you can that start with the letter “A’. Memorize a favorite song or poem.
• Sensations: Engage in a sensation that offers soothing, similar to self-soothing with 5 senses just a little more active. Hold an ice cube in your hand. Rub a feather or soft item across your arms. Any safe and helpful activity to bring your sensations into the moment.

5. Self-Soothing With the 5 Senses

Self-soothing using the 54321 method supports bringing you back to what is really in front of you. This skill is best practiced when feeling overwhelmed to the point of dissociation and/or having racing thoughts.

Self-soothing using the five senses entails:

• Step 1: Take a step back and look around you

• Step 2: Identify 5 things you can see. Name them and then turn your attention to one thing in particular. What colors can you see? What shape is it? What is supporting it? What else do you notice?
• Step 3: Identify 4 things you can touch. Pick one to turn your attention to. What does it feel like? Is it cold to touch or at room temperature? Is it soft or textured in any way?
• Step 4: Identify 3 things you can hear. Focus on one of them. What does this sound remind you of? Is it soothing? If not, accept it as it is, without judgment.
• Step 5: Identify 2 things you can smell. What do the smells bring up for you? Focus on the smell most enjoyable. Is there a memory you can connect to it? If not, allow yourself to enjoy the moment of noticing it.
• Step 6: Lastly, identify 1 thing you can taste. If you have water, a stick of gum, or if you can imagine your favorite meal, drink, or snack. How does it taste? What flavors, if any, do you notice?

6. IMPROVE the Moment

IMPROVE the moment is a set of skills that involves challenging one’s negative beliefs and emotional response through body-focused relaxation and affirmation. If a person intends to improve themselves and their circumstances, then they can put this skill into practice. It is best practiced when low distress tolerance signs are occurring, such as self-harming urges.

The IMPROVE skills stand for:⁶

• Imagery: Close your eyes and imagine yourself in a relaxing place, free from worries. What do you see? What are you doing? What do you feel? What do you smell? Allow yourself to sit with this image for a moment. Then, transition yourself to imagining the currently distressing situation going well. What do you notice?
• Meaning: Meaning-making is not a linear concept. With the not-so-good, there is also good. List the ways that you can grow from your current distress.
• Prayer: This does not have to be a prayer to a higher power. It can be a prayer to ourselves, to a loved one we have lost, or to the universe. Send a prayer acknowledging what you cannot control and seek guidance around that for which you are currently struggling.
• Relaxation: Engage in any relaxing skill you would like. Stretch, do yoga, or try diaphragmatic breathing.
• One thing in the moment: Immerse yourself in any distracting activity for the moment that you can truly focus on. Complete a word puzzle, do a chore around the house, or color.
• Vacation: Take a break from the distressing circumstances and do something you enjoy. Read a book. Write a poem. Watch your favorite TV show.
• Encouragement: Select an affirmation to tell yourself when feeling overwhelmed. Ensure it is words of encouragement for which you believe. Sentiments such as: “I have survived before and will again”. “I’ve felt this before, and it has passed”.

DBT Reality Acceptance Skills

A key tenet of DBT is the ability to accept the world and people around us for what and who they are. These skills do not mean for us to be “okay” or to “condone” others’ poor choices and the many wrongs within the world, such as hunger. It simply encourages us to acknowledge that we are responsible first and foremost for ourselves.

1. Radical Acceptance

Marsha Linehan, who developed DBT, discussed radical acceptance as the ability to accept what is without judgment.⁵ This is a means of responding to the unpredictability of life through a lens of understanding that we can only control what is actually within our control, which is ourselves. Otherwise, we work to accept that other people and circumstances are largely out of our control.

2. Turning the Mind

Turning the mind is a skill best used in conjunction with radical acceptance. It can be hard to radically accept situations and circumstances at times. Turning the mind seeks to offer you support in the moments where you are struggling to radically accept and get your back on track. For example, imagine you took a wrong turn and are ten more minutes behind on your arrival. It may be hard not to berate yourself at the moment. However, your hands are the ones guiding the steering wheel and getting you back on track. Turn your mind to what is in your control rather than the mistake.

3. Willingness

Willingness is understanding that we are all a part of something bigger than ourselves. Marsha Linehan described this best in an analogy of batting cages. The balls are recurrently coming at you. You can either refuse and perhaps even throw a tantrum, complaining about how unfair it is. Or you can hit the balls you can hit and let the rest go.⁸

4. Half-smiling & Willing Hands

Half-smiling and willing hands are an intricate part of the practice of willingness. A half-smile is a practice to utilize throughout your day and in moments of distress. Half-smiling is simply and slightly upturning your lips. This is a serene and neutral expression. For example, practice a half-smile as soon as you wake up in the morning. When you start to notice your body’s reaction to the distress, close your eyes, relax your jaw, and engage in a half-smile before anything else.

Additionally, willing hands are an open posture. Simply take your hands and face your palms to the ceiling. Being open is the keyword here. The more we open up our posture, the more relaxed we are. When we constrict, we build tension. Allow your hands to fall into this open posture to prompt the relaxation of muscles when needed.

5. Allowing the Mind: Mindfulness of Current Thoughts

Mindfulness of current thoughts is another mechanism of radical acceptance. We are not our thoughts. This is a key principle to consider when practicing mindfulness of current thoughts. Start by noticing the thought similarly to the ebb and flow of ocean waves. Become curious about these thoughts and wonder where they came from. Let the thought be as it is, without judgment or any effort to suppress it. Much like the waves, our thoughts simply come and go.

How to Practice Distress Tolerance Skills

Distress tolerance skills are applicable to everyday life. The biggest piece is being able to remember to do them when you need to. Part of this is setting an intention around your practice of these skills. For example, setting reminders in your phone of a few different skills you can utilize throughout the day. Not all situations and scenarios can afford us the time and space to practice skills as readily. Therefore, it is important to find practical means in our day-to-day life.

Practical ways to practice distress tolerance skills include:

• Take a mindful moment: Build in a moment of self-soothing each day. Engage in grounding with your five senses, or allow a moment to tap into your sensations.
• Engage in physical activity: Exercising for mental health can help with helpful distress tolerance. As discussed, physical activity helps to release pent-up tension in our bodies.
• Help others: Doing for others is rejuvenating for our spirit and soul. No act of support and kindness to another is too small.
• Daily Affirmations: Tell yourself the thing you most need to hear each day. Ensure it is something you can believe. For example, “I am braver than I believe”, and “I can do hard things”.
• Radically accept to start your day: Reminder yourself each morning what is and what is not within your control. This gentle reminder can carry you into the day with a more grounded sense.
• An act of self-care: Do one act each day that gives back to you. From a stretch to watching your favorite TV show or listening to your favorite podcast.
• Breathe it out: Take one minute a day to connect with your breath, especially if you experience stress.

When to Seek Professional Help

We all experience distress. There are times when distress and our emotions can get the better of us. If you find yourself easily overwhelmed, overreacting, feeling guilty thereafter, or engaging in impulsive behaviors, it may benefit you to seek support. Feelings of guilt and shame, low self-esteem, difficulties identifying who you are, persistent difficulties with persons in your life, and behaviors that are not aligned with who you believe yourself to be are all experiences where therapy can make a difference.

Furthermore, there are many different online therapy options to find a DBT practitioner.  You can check out an online therapy directory to find care in your local area.

In My Experience

In my experience, distress tolerance skills and DBT skill building can benefit all persons. It is a part of the human condition to protect ourselves. Society and our modern day have made things more complicated. I have found these carry a significant impact on already difficult circumstances in our lives. That being said, distress tolerance can build up our resiliency against many aspects of which we are not in control.

Lastly, as a trauma-informed practitioner, I find these skills to be particularly helpful when managing trauma-related symptoms. I want to enforce that trauma responses are natural responses to an unnatural and horrifying experience. Exhibiting difficulties with distress tolerance following trauma is understandable and should not be viewed from a place of deficit. Distress tolerance skills offer a means to more comfortably wade through the difficult waters of life.