In my final article on the modules of DBT, I will cover a topic we discussed earlier…distress tolerance. Distress tolerance is a measure of the degree to which an individual evaluates the experience of negative emotions as unbearable and is also defined by some as the ability to persist in goal-directed behaviour when distressed. In other words, if I have low distress tolerance, it will take less stress for me to reach a point at which I am overwhelmed by what I am feeling. Individuals with borderline personality disorder (BPD), the disorder for which DBT was originally designed, are characterized by low levels of distress tolerance, which is believed to contribute to maladaptive behavioural outcomes such as non-suicidal self-injury, substance use and binge eating and purging. Because of its potentially vital role in facilitating many of the problematic outcomes in BPD, distress tolerance is the focus of a substantial amount of attention in DBT skills training.
Presented as the final module, distress tolerance training is often met with a certain degree of reservation by clients, as it is the least validating of all the skill sets. The distress tolerance module, at its core, tells clients that there are times when they simply will not be able to stop feeling bad and that they are going to have to learn to weather the storm. This is a frustrating idea for anyone, but that is especially true for individuals who experience chronically shifting, powerful emotions and who struggle to regulate those feelings without resorting to problematic behaviours. Nonetheless, the overall message of the distress tolerance module is a positive one: this too shall pass. Underlying this message is a simple fact, that emotions are temporary experiences powerless to actually cause us real harm, no matter how powerful they seem.
Distress tolerance skills are thus centred on methods for individuals to manage difficult emotional states without using dangerous behaviours. There are four general categories of distress tolerance skills: distraction, self-soothing, improving the moment, and focusing on the pros and cons. The first several of these categories are addressed through an acronym, ACCEPTS:
- Distract with simple, healthy, pleasurable activities like taking a walk, watching a movie, gardening, or playing a sport
- Help others when feeling distressed
- Compare your situation to that of those less fortunate and attempt to feel thankful not to be worse off
- Compare yourself to how you were doing prior to treatment and focus on progress
- Dangerous when overwhelmed by negative emotions, as cognitive distortions (e.g., dichotomous thinking, discounting positives) may skew perceptions of progress
- Engage in activities that are opposite to current negative emotion (e.g., listening to happy music when sad)
- Take a “planned vacation” by focusing your mind on something pleasant that is unrelated to the current distressing situation
- This is different than problematic dissociation. In this instance, the individual is exerting control over his thoughts as he disengages from the immediate environment and focusing only on positive imagery and memories
- Distract with neutral thoughts like counting the number of tiles in the room, reading the titles of all the books on your bookshelf, etc…
- Distract with physical sensations
- Some individuals hold ice cubes or take warm showers and focus on the resulting physical sensations
The ACCEPTS skills, thus, help clients to focus their attention away from aversive thoughts and feelings and to engage in either pleasurable or neutral activities until their emotional state returns to a calmer, baseline level. Some of the skills are more proactive than others and different clients will respond differently to different skills, so practising between sessions and experimenting with different methods for implementing the skills is pivotal.
Additional skills for improving the moment are provided after the co-leaders discuss the ACCEPTS skills and the group members spend time practising them between sessions. These additional skills include using positive mental imagery (e.g., imagine your favourite place and focus your energy on observing and describing every detail you can as precisely as possible), creating meaning (e.g., “make lemonade out of lemons”), praying, relaxing (e.g., progressive muscle relaxation), and doing one thing in the moment (e.g., mindfully engage in one distracting activity, allowing all other thoughts and sensations to pass through your mind as though they are on a conveyor belt). Some of these skills overlap with other distress tolerance skills, but providing multiple angles for explaining similar concepts can increase the likelihood that all group members find a way to relate to the topic.
StormFocusing on the pros and cons of a situation, another general category of distress tolerance skills, is also fairly straightforward, although it asks clients to go a step further than standard pro/con lists. If an individual is considering self-injury, for instance, she would be asked to make a list of the pros and cons of engaging in this behaviour, as well as the pros and cons of not engaging in the behaviour. Four columns are created, and the client is encouraged to be thorough and fair in all four columns. There will obviously be overlap between several of the columns, but the point of the exercise is simply to slow down the behavioural response of the client and encourage her to consider all the possible repercussions of her decisions. I have found that clients readily engage in this activity and find it incredibly helpful. Remember, while some individuals naturally engage in this type of thoughtful analysis before making decisions, for others, a lifetime of impulsive, emotionally driven responses has made such approaches seem foreign and difficult.
The final distress tolerance skill is the one that I believe may be the most important of all: radical acceptance (see Radical Acceptance: Embracing Your Life With the Heart of a Buddha for a more thorough description). Radical acceptance asks individuals to accept what they cannot change and let go of fighting what is true. At first, clients often think this means lowering their standards, endorsing things against their beliefs, or declaring a bad outcome a good one. This could not be further from the truth, however. Radical acceptance simply states that screaming about your current situation is more likely to exhaust you than it is to effect the desired change. Rather than engaging in fruitless exercises likely to only increase and prolong negative moods, acknowledge that what is happening is, in fact, happening, and begin to consider the best possible outcome given your current set of circumstances. For instance, if a client in an inpatient ward fixates on how badly he does not want to be there, how miserable his situation is, and how nothing is the way it should be, he will likely increase his depressive symptoms while doing little to change his unfortunate set of circumstances. If, however, he accepts that he is there and will be for the foreseeable future and looks to find ways to make that situation livable as he works toward changing it, his experience is likely to improve. He’ll still be in a place he does not want to be, but he’ll be more likely to enjoy what positives are there and to find a workable solution to his problem than he would be if he simply focused on his negative emotions and his desire to be elsewhere. In this scenario, the client does not lie to himself or candy-coat what is an objectively aversive experience but rather acknowledges his reality and works within the confines of that situation to find the best possible outcome.
Distress tolerance skills are imperative, not only for individuals with mental illnesses addressed by DBT (i.e., BPD, bulimia, binge eating disorder), but for anyone. Individuals with these particular disorders simply tend to need more training in these skills. By teaching individuals how to keep their balance amidst emotions and situations they are powerless to change at that moment, DBT skills trainers can reduce the sense of panic and helplessness that such individuals have grown accustomed to feeling when upset and replace it with an understanding that even the most powerful storm passes and, though it may leave damage in its wake, there is utility in avoiding strategies that would only make it worse.
This post is by Mike Anestis who is a doctoral candidate in the clinical psychology department at Florida State University