How to Use Distress Tolerance Skills

How many times have you found yourself so upset that you have no idea what to do to help calm down your brain and body? For some, this happens every day, while for others, it may be once a week/month/year etc. While the frequency may change from person to person, the fact is everyone at some point in time faces crises like this. DBT (dialectical behavioral therapy) has identified several skills to help people to cope with these crises. These skills are known as Distress Tolerance Skills.

Almost anyone can benefit from learning Distress Tolerance Skills. These skills were originally developed to help people with Borderline Personality Disorder (BPD) and they have been proven to be effective for people with many other presentations. Those with diagnoses of depression, anxiety, bipolar disorders, eating disorders, behavioral difficulties, and self-harm have all benefited from learning these skills. Children, teens, and adults of all ages have developed and utilized these skills to help them live their lives within their values.

There are 3 goals to distress tolerance: survive crisis situations without making them worse, accept reality for what it is and find ways to move forward, and become free of having to satisfy the demands of your own intense emotions. The first step to meeting these goals is to identify when you are in a crisis. Crisis situations are highly stressful, short-term, and there is intense pressure to find a resolution. A crisis situation could include finding out a loved one is sick, breaking up with your partner, getting a bad grade, or even missing your flight home for the holidays. They also occur when you want to act on your emotions but know it will make things worse, you are overwhelmed and have demands to meet, or emotions are taking over and you desire to remain skillful.

Once you have identified the crisis situation, the STOP Skill can be used to help determine what to do next. The key to this skill is to help you to pause and think before making an impulsive decision that may cause further distress.

S- Stop! Freeze! Pause your mind and body so that you can stay in control of your emotions

T- Take a step back! Take a break, a deep breath and slow down your emotions.

O- Observe! Look around and notice what is going on around you and within you. What are you thinking? What are you feeling? Who else is around you?

P- Proceed mindfully! Take in your thoughts, feelings, and surroundings. Think about your goals and make a decision that helps you reach your goals.

Now you might be thinking this sounds great, but what happens if I get so distressed I cannot pause my mind and body or slow down my emotions or even remember what my goals are. In moments of crisis, it can be difficult to access these skills in your mind. In this case, the TIPP skills can be used. The purpose of these skills is to change your body chemistry in order to reduce extreme emotion FAST! The key to using TIPP skills successfully is to practice, practice, practice! The more you try out these skills, even when you are not in crisis, the more they will become like second nature and will come to mind quickly for you to use.

1. Temperature: Grab an ice pack, bowl of cold water, bag of frozen peas or whatever you can find in your freezer and put it on your face for 30 seconds. You can even try the back of your neck where your vagus nerve is to really shock your system. By exposing our face to something cold, we cause our mental focus to shift from what is distressing us to focusing on the sensations happening to our body. This shock to the system can provide a way to ground yourself back to reality quickly. Once you are “back to reality” you will be more likely to be able to access other skills to help you cope with whatever situation you are facing.
2. Intense Exercise: When we are at our highest level of distress, it may feel like we have a lot of pent up energy in our bodies that needs to be let out. So go for a quick run, do jumping jacks, ride your bike, or whatever you are able to do to get that extra energy out of your body. Physical exercise gives us the opportunity to calm our physical body down when emotional energy has taken over.
3. Paced Breathing: Who hasn’t been told to take a deep breath when they are feeling overwhelmed, anxious, upset, etc? Focusing on our breaths helps us to slow down our breathing and feel more in control of our emotions. The goal with paced breathing is to breathe in deep into your belly and then slowly breath out (ex. Breathe in for 5 seconds, breathe out for 5 seconds) at a rate of 5-6 breaths per minute. By being more in control of your breathing you will be able to better access the other skills you have learned to help problem solve your current situation.
4. Progressive Muscle Relaxation: Have you ever noticed that the more distressed you are, the more you tense up your muscles? As you pace your breathing, practice relaxing your muscles by saying in your mind “relax”. Start to focus on feeling the tension leave your body. If you’re having trouble relaxing certain muscles, you can intentionally tense up a muscle group and then slowly release the tension you created. A quick way to try this is to make a super tight fist and then as slow a possible release your fist. You should be able to physically feel that tension leave your body and feel your mind calm down with it.

Both STOP and TIPP skills are used to address the first goal of distress tolerance, to survive crises. The second goal, to accept reality for what it is, is achieved through practicing Radical Acceptance. We all know and understand that we will face painful and troubling events and emotions in life. We practice radical acceptance when we realize that we cannot stop these painful events or emotions from coming our way. There are 3 parts to Radical Acceptance:

1. 100% complete and total acceptance
2. Acceptance in your mind, heart, and body
3. Fully stopping fighting reality and letting go of bitterness

Why should we practice radical acceptance? The truth of it is, denying reality does not make it go away or make us feel any differently. By not accepting reality for what it is, you are then actively choosing to sit in pain and suffering and are unable to make any meaningful changes. By accepting reality as it is, you can then begin to make the changes needed to grow from the pain. It is important to note that radical acceptance is not: approval, compassion, love, passivity, or against change. It is an active choice to accept what has/is happening and to then move forward. Here are a few steps you can follow to begin practicing radical acceptance.

1. Remind yourself that the unpleasant reality is just one event that you cannot go back and change. Reframe reality in the form of “this is what happened” with no emotions attached.
2. Remind yourself that there are causes for the current reality. Observe and consider what factors may have led to the current reality. Consider how these factors and the history of the others involved contributed to the situation.
3. Allow disappointment, sadness, and grief to come.
4. Acknowledge that life can still be worth living even when there is pain.

The final goal of DBT Distress Tolerance skills is to become free of having to satisfy the demands of your own intense emotions. One of the ways to achieve this goal is to replace willfulness with willingness. What is willfulness? Willfulness is refusing to tolerate the moment, giving in, refusing to make changes, trying to fix every situation, insisting on being in control, and attachment to yourself and what you want right now. Willfulness gives into the demands of emotions, without considering what would be in your best interest or the best interest of others.

Willingness is the opposite of willfulness. It is readiness to enter and participate fully in life and living. Willingness is doing what it is needed in each situation wholeheartedly and without dragging your feet. By practicing willingness you listen carefully to your wise mind and act with awareness. Willingness is not just a mental state but also a physical state. We can practice willingness by “half-smiling” and having willing hands.

Half-smiling involves relaxing your face from the top of your head down to your jaw. Then allow both corners of your lips to go up slightly, just enough that you feel it but others do not have to see it. By having a calm face and half smile, you are communicating to your brain that you are open and willing to accept reality.

Having willing hands looks like relaxing your arms from your shoulders down to your fingers. Then place your hands on your lap or thighs unclenched, turned outward, and palms up. This can be done sitting or laying down. Willing hands connect your mind to your body and communicate openness with reality.

Practicing willingness can be difficult at times. Here are 5 ways in which you can practice willingness:

1. Observe the willfulness. Label it. Experience it.
2. Radically accept that you are feeling willful.
3. Turn your mind toward acceptance and willingness.
4. Try “half-smiling” and a “willing posture”
5. When the willfulness is immovable, ask yourself “What is the threat?”

Utilizing DBT Distress Tolerance skills can help one create a calm within the storm they are facing. These skills help you to calm down quickly in times of crises, accept reality as it is, and not allow emotions to dictate your behavior. Distress tolerance skills can be used anytime and anywhere when you find yourself facing a crisis.