Distress Tolerance, Part 1:
All right- we've overviewed Mindfulness, Interpersonal Effectiveness, and Emotion Regulation. We're going to finish up by discussing Distress Tolerance and exploring some links where you can get more information. This article will be divided into two parts because Distress Tolerance is that important, and because there are a lot of skills and techniques to overview.
So, what do you do when it feels like you're coming apart at the seams, and that it will never end? The first thing is, take care of yourself. When emotions get overwhelming or when you can't "make things better right away" (quoting from Linehan's DBT manual), then there are some skills you can use to help yourself get through it, or "ride the wave." These are, in a phrase, crisis survival skills.
When I teach distress tolerance, I like to use an analogy. Imagine you are standing on a beautiful, warm, sandy beach. The weather starts getting nasty, and you find out that there is a tsunami coming at you. You can't run away, because it's coming too fast. You have a spoon, and you think you have to fight the tidal wave with the spoon. How likely is it that you'll survive the tidal wave by trying to hold it back with the spoon? Probably not very good, right? So here's the thing - intense emotions and emotional situations are like the tidal waves, and the spoon is like the coping tools we use. What we try to do a lot of the time is fight against the emotions - we try to "spoon out" our way through it. And...it doesn't work too well. So, what do we do? Well, the challenge is to NOT fight the tidal wave - to try to ride it out instead and use the spoon to paddle. In other words, don't fight the emotion, accept it (even if you don't like it) and let it flow through you; while you are doing that, use your tools (skills) to help you get through. The emotion won't kill you - promise. It might feel like it will, but at it's core it's simply an emotion. That's it.
The goal here is simple: Get through the situation/emotion and come out without having made things worse. The skills you'll use are TIP (Temperature, Intense exercise,Paced breathing, and Paired breathing and muscle relaxation), STOP, DISTRACT (sound familiar?) with "wise mind ACCEPTS," SELF-SOOTHE using your five senses, "IMPROVE THE MOMENT," and use PROS AND CONS. We'll also talk later about accepting reality - a topic which sounds easy but can be very difficult. One thing a lot of people have difficulty with in regard to the distress tolerance skills is that they are not designed to make things better. That's a hard pill to swallow. They are designed to help you survive a situation - a crisis - without doing something that will make the situation worse for you. Ideally, they will help you feel better, but really, that's not what their purpose is. These skills are to help you first, survive a crisis and second, accept the reality that is, not the reality you want it to be.
So what are these skills? They are divided into two sections: Crisis survival skills and acceptance skills. This article will address the crisis survival skills.
TIP and STOP are new to the 2nd edition materials. TIP stands for "Temperature, Intense exercise, Paced breathing, and Paired muscle relaxation." The idea here is to use your body's physical responses to intense stimulation (temperature and intense exercise) or deliberate calming strategies (the breathing and muscle relaxation) to help cope with the overwhelming stress or crisis. These skills, when used mindfully, can be incredible effective and calming.
Distraction is pretty simple - you try to take your mind off whatever it is that's bothering you. I know - way easier said than done! The ACCEPTS piece gives you some ideas on how to do that. As with the other modules, the mindfulness piece comes in with using your "wise mind. So, lets start with these. First, you can distract with Activites - do something. Contributing (like volunteering or doing something nice for someone) can also help. Comparisons (being gentle on yourself, remind yourself of some situations where you haven't coped as well and can see improvement or where your situation might be better than others), or using Opposite Emotions (see the Emotion Regulation article for more on this skill). You can also distract with Pushing Away (mentally "setting down" the situation for a while. It will probably be there when you come back), with other Thoughts (like counting to 10, concentrating on the musical variations in the soundtrack to a TV program, etc), or with intense other Sensations (like holding an ice cube on your wrist until you can barely stand it, getting a really hot shower, snapping a rubber band on your wrist, chewing on a hot pepper - anything that physically gives you another intense sensation to concentrate on that is NOT harmful).
While you distract yourself, you can also soothe yourself. You can also soothe separately from distraction. Using SELF-SOOTHE will help you relax your body along with your mind. Use your five senses: you can look at something beautiful, or go sit in a museum and look at the exhibits or other people, you can listen to music, or sing a song, maybe practice an instrument. Listening to some guided imagery or meditation tapes is another option. You can use taste and smell: go to a bakery and breathe in the scent of the freshly baked pastries or muffins - maybe taste something succulent like a blueberry muffin or sweet like some hot cocoa. Suck on a piece of peppermint candy, go to a store and sniff perfumes or candles (compare and imagine which one you'd like best, or conduct a "survey" and try to figure out what elements were used in each one). You can also use touch - take a bubble bath, or hot shower, rub in lotion (combine scent here and use something that smells really good), wrap yourself up in your favorite blanket, quilt or afghan, or put a cold/hot compress on your forehead or another achy area of your body.
The key here is that you really want to be mindful of the sense you're using. REALLY see, hear, smell, taste or feel whatever it is that you're doing. One thing that I've found to be helpful is to make up a self-soothing basket, box or bucket BEFORE you're triggered. I don't know about you, but when I feel triggered, I have a hard time thinking straight and the last thing I want to do is try to think of how to calm down. If the basket is made up ahead of time, you won't have to think about it when you need it. Fill your basket with things that help you feel good, pampered, and/or soothed. If you have perishables in your basket, go ahead and enjoy them when you're not triggered - just replace them so that there is something there when you need it.
Another thing you can try is to "IMPROVE THE MOMENT." What this means is that you can do some things to help you remain mindful and in "wise mind." Linehan uses the "IMPROVE" acronym to help you remember the skills used here. You can improve the moment with Imagery - imagine soothing scenes or situations, or imagine yourself coming through the crisis with everything working out. Imagine hurtful comments or emotions simply washing away in a stream going out toward the ocean, or that the wave of emotion is washing over you and you're coming out whole on the other side. You can improve with Meaning - find some value or growth in the experience, or work on your spirituality and find your place in the universe, or with Prayer. I know the idea of prayer may feel threatening, phony, or "smarmy" to some people, and I'm not talking about any one faith tradition here. BUT, opening your heart and soul to something bigger than yourself, seeing yourself as having a place within it, and asking for strength to get through the crisis is something that may help. You can also try Relaxation using progressive muscle relaxation or by exercising hard and then purposely relaxing with a bath, hot tub sit, or cold water. You can also simply get comfortable and breathe - don't underestimate the power of simply breathing and focusing on your breath. Finally, you can use "One Thing in the Moment." With this skill, you focus your entire attention on exactly what you are doing at this particular moment in time. Focus on the physical sensations of the task, and keep yourself firmly in the present moment. Here's an example: If you are doing dishes, feel the temperature of the water, the slipperiness of the dishsoap, the smoothness of the place or the roughness of pottery. Breathe in the scent of the soap, and slowly pay attention to each movement your hands and arms make - what movements go into washing each dish? How different is the wash water from the rinse water? How do the dishes look when they're in the rack drying? (You get the picture!)
Another technique in the IMPROVE sequence is to take a brief Vacation. Here, you want to "get away from the world" in a very minor way - the key words here are brief and minor. Do something like get some "light reading", some chocolate ice cream and spend the morning in bed. Or, take a blanket and pillow to the park and watch the clouds - remember the game we played as kids where we would guess what the clouds looked like? This is time to revisit that. Watch cartoons for half a day or get in bed and pull the covers over your head for a morning - this is a brief escape. The last thing in this skill set is Encourage yourself. When you think, "I can't stand this anymore," contradict yourself with , "I can stand this. I'm doing it now, even if it's second by second. I'm doing it." Or try, "I'll really get through this. I'll come out ok." "I'm doing the best I can, and I'm really trying hard." Encourage yourself!
You can also weigh PROS AND CONS. What you want to do here is list the pro's and con's of tolerating the distress. Then, you make a list of the pro's and con's of not tolerating the distress. Here, you want to focus on your long-term goals, and what you'll get out making it through the crisis. Focus on the pro's of tolerating the distress and the con's of not tolerating it. What are the really bad consequences of not tolerating it? What will you get out tolerating it? Think about what has happened in your past when you haven't tolerated distress - what were the results? What happened with you did tolerate distress? Were there positive outcomes? The point here is that you want to see that 1) you have options, 2) there are some real benefits to gutting through the crisis, and 3) there is a light at the end of the tunnel - you CAN make it through this.
Next up: More Distress Tolerance. If you have any comments or questions, please feel free to contact me: thepowerofeachother@outlook.com
Please Note: The content in these articles is intended for informational purposes only. This is not therapy, and if you wish to work in therapy, please contact your local mental health agency or your physician for a referral.
If you are in crisis or danger, please call 911 for immediate help. Please, again, realize that seeking out help really IS a sign of strength and not a sign of weakness. You don’t have to be alone in facing these things – there are people who care and who will help.
So, what do you do when it feels like you're coming apart at the seams, and that it will never end? The first thing is, take care of yourself. When emotions get overwhelming or when you can't "make things better right away" (quoting from Linehan's DBT manual), then there are some skills you can use to help yourself get through it, or "ride the wave." These are, in a phrase, crisis survival skills.
When I teach distress tolerance, I like to use an analogy. Imagine you are standing on a beautiful, warm, sandy beach. The weather starts getting nasty, and you find out that there is a tsunami coming at you. You can't run away, because it's coming too fast. You have a spoon, and you think you have to fight the tidal wave with the spoon. How likely is it that you'll survive the tidal wave by trying to hold it back with the spoon? Probably not very good, right? So here's the thing - intense emotions and emotional situations are like the tidal waves, and the spoon is like the coping tools we use. What we try to do a lot of the time is fight against the emotions - we try to "spoon out" our way through it. And...it doesn't work too well. So, what do we do? Well, the challenge is to NOT fight the tidal wave - to try to ride it out instead and use the spoon to paddle. In other words, don't fight the emotion, accept it (even if you don't like it) and let it flow through you; while you are doing that, use your tools (skills) to help you get through. The emotion won't kill you - promise. It might feel like it will, but at it's core it's simply an emotion. That's it.
The goal here is simple: Get through the situation/emotion and come out without having made things worse. The skills you'll use are TIP (Temperature, Intense exercise,Paced breathing, and Paired breathing and muscle relaxation), STOP, DISTRACT (sound familiar?) with "wise mind ACCEPTS," SELF-SOOTHE using your five senses, "IMPROVE THE MOMENT," and use PROS AND CONS. We'll also talk later about accepting reality - a topic which sounds easy but can be very difficult. One thing a lot of people have difficulty with in regard to the distress tolerance skills is that they are not designed to make things better. That's a hard pill to swallow. They are designed to help you survive a situation - a crisis - without doing something that will make the situation worse for you. Ideally, they will help you feel better, but really, that's not what their purpose is. These skills are to help you first, survive a crisis and second, accept the reality that is, not the reality you want it to be.
So what are these skills? They are divided into two sections: Crisis survival skills and acceptance skills. This article will address the crisis survival skills.
TIP and STOP are new to the 2nd edition materials. TIP stands for "Temperature, Intense exercise, Paced breathing, and Paired muscle relaxation." The idea here is to use your body's physical responses to intense stimulation (temperature and intense exercise) or deliberate calming strategies (the breathing and muscle relaxation) to help cope with the overwhelming stress or crisis. These skills, when used mindfully, can be incredible effective and calming.
Distraction is pretty simple - you try to take your mind off whatever it is that's bothering you. I know - way easier said than done! The ACCEPTS piece gives you some ideas on how to do that. As with the other modules, the mindfulness piece comes in with using your "wise mind. So, lets start with these. First, you can distract with Activites - do something. Contributing (like volunteering or doing something nice for someone) can also help. Comparisons (being gentle on yourself, remind yourself of some situations where you haven't coped as well and can see improvement or where your situation might be better than others), or using Opposite Emotions (see the Emotion Regulation article for more on this skill). You can also distract with Pushing Away (mentally "setting down" the situation for a while. It will probably be there when you come back), with other Thoughts (like counting to 10, concentrating on the musical variations in the soundtrack to a TV program, etc), or with intense other Sensations (like holding an ice cube on your wrist until you can barely stand it, getting a really hot shower, snapping a rubber band on your wrist, chewing on a hot pepper - anything that physically gives you another intense sensation to concentrate on that is NOT harmful).
While you distract yourself, you can also soothe yourself. You can also soothe separately from distraction. Using SELF-SOOTHE will help you relax your body along with your mind. Use your five senses: you can look at something beautiful, or go sit in a museum and look at the exhibits or other people, you can listen to music, or sing a song, maybe practice an instrument. Listening to some guided imagery or meditation tapes is another option. You can use taste and smell: go to a bakery and breathe in the scent of the freshly baked pastries or muffins - maybe taste something succulent like a blueberry muffin or sweet like some hot cocoa. Suck on a piece of peppermint candy, go to a store and sniff perfumes or candles (compare and imagine which one you'd like best, or conduct a "survey" and try to figure out what elements were used in each one). You can also use touch - take a bubble bath, or hot shower, rub in lotion (combine scent here and use something that smells really good), wrap yourself up in your favorite blanket, quilt or afghan, or put a cold/hot compress on your forehead or another achy area of your body.
The key here is that you really want to be mindful of the sense you're using. REALLY see, hear, smell, taste or feel whatever it is that you're doing. One thing that I've found to be helpful is to make up a self-soothing basket, box or bucket BEFORE you're triggered. I don't know about you, but when I feel triggered, I have a hard time thinking straight and the last thing I want to do is try to think of how to calm down. If the basket is made up ahead of time, you won't have to think about it when you need it. Fill your basket with things that help you feel good, pampered, and/or soothed. If you have perishables in your basket, go ahead and enjoy them when you're not triggered - just replace them so that there is something there when you need it.
Another thing you can try is to "IMPROVE THE MOMENT." What this means is that you can do some things to help you remain mindful and in "wise mind." Linehan uses the "IMPROVE" acronym to help you remember the skills used here. You can improve the moment with Imagery - imagine soothing scenes or situations, or imagine yourself coming through the crisis with everything working out. Imagine hurtful comments or emotions simply washing away in a stream going out toward the ocean, or that the wave of emotion is washing over you and you're coming out whole on the other side. You can improve with Meaning - find some value or growth in the experience, or work on your spirituality and find your place in the universe, or with Prayer. I know the idea of prayer may feel threatening, phony, or "smarmy" to some people, and I'm not talking about any one faith tradition here. BUT, opening your heart and soul to something bigger than yourself, seeing yourself as having a place within it, and asking for strength to get through the crisis is something that may help. You can also try Relaxation using progressive muscle relaxation or by exercising hard and then purposely relaxing with a bath, hot tub sit, or cold water. You can also simply get comfortable and breathe - don't underestimate the power of simply breathing and focusing on your breath. Finally, you can use "One Thing in the Moment." With this skill, you focus your entire attention on exactly what you are doing at this particular moment in time. Focus on the physical sensations of the task, and keep yourself firmly in the present moment. Here's an example: If you are doing dishes, feel the temperature of the water, the slipperiness of the dishsoap, the smoothness of the place or the roughness of pottery. Breathe in the scent of the soap, and slowly pay attention to each movement your hands and arms make - what movements go into washing each dish? How different is the wash water from the rinse water? How do the dishes look when they're in the rack drying? (You get the picture!)
Another technique in the IMPROVE sequence is to take a brief Vacation. Here, you want to "get away from the world" in a very minor way - the key words here are brief and minor. Do something like get some "light reading", some chocolate ice cream and spend the morning in bed. Or, take a blanket and pillow to the park and watch the clouds - remember the game we played as kids where we would guess what the clouds looked like? This is time to revisit that. Watch cartoons for half a day or get in bed and pull the covers over your head for a morning - this is a brief escape. The last thing in this skill set is Encourage yourself. When you think, "I can't stand this anymore," contradict yourself with , "I can stand this. I'm doing it now, even if it's second by second. I'm doing it." Or try, "I'll really get through this. I'll come out ok." "I'm doing the best I can, and I'm really trying hard." Encourage yourself!
You can also weigh PROS AND CONS. What you want to do here is list the pro's and con's of tolerating the distress. Then, you make a list of the pro's and con's of not tolerating the distress. Here, you want to focus on your long-term goals, and what you'll get out making it through the crisis. Focus on the pro's of tolerating the distress and the con's of not tolerating it. What are the really bad consequences of not tolerating it? What will you get out tolerating it? Think about what has happened in your past when you haven't tolerated distress - what were the results? What happened with you did tolerate distress? Were there positive outcomes? The point here is that you want to see that 1) you have options, 2) there are some real benefits to gutting through the crisis, and 3) there is a light at the end of the tunnel - you CAN make it through this.
Next up: More Distress Tolerance. If you have any comments or questions, please feel free to contact me: thepowerofeachother@outlook.com
Please Note: The content in these articles is intended for informational purposes only. This is not therapy, and if you wish to work in therapy, please contact your local mental health agency or your physician for a referral.
If you are in crisis or danger, please call 911 for immediate help. Please, again, realize that seeking out help really IS a sign of strength and not a sign of weakness. You don’t have to be alone in facing these things – there are people who care and who will help.