At some point in their lives, everyone experiences extreme emotional states and variances. For some people, the presence of overwhelming or uncontrollable feelings in response to stress occurs regularly.
What is Distress Tolerance and What are Distress Tolerance Skills?
Experts define distress tolerance as an individual’s ability to manage their internal emotional state in response to stress-inducing factors. If someone has a low distress tolerance, they will likely become overwhelmed by mildly stressful situations that cause emotional stress, potentially responding in negative mental and behavioral ways including:
- impulsive behavior
- unhealthy behaviors
- self harm
Fortunately, for individuals who struggle with an inappropriate stress response, several therapeutic strategies may prove helpful them build positive stress tolerance skills when faced with emotional crises. Traditionally, treatment often focused on stressful situational avoidance, but newer practices and therapies have emerged which individuals can both pursue on their own or with the aid of a care professional. These newer treatment modalities involve embracing the stressful situation(s) and learning to engage with them appropriately.
One popular new treatment is called dialectical behavior therapy (DBT). It involves a combination of psychologists and psychotherapy (talk therapy), to help patients build adequate distress tolerance skills for optimal living. Under a therapist’s guidance, patients can practice distress tolerance skills and learn how to persevere through a stressful situation. Dialectical behavior therapy DBT includes a distress tolerance module.
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Significance for Patients
Frequent periods of severe emotional distress can be crippling on many different levels. Frequent or uncontrollable stress can have significant effects on the body, on the mood, and on the mind. This includes symptoms like:
- muscle tension
- sleep problems
- over or undereating
- angry outbursts
- feelings of overwhelm
- social withdrawal
- change in sex drive
These symptoms have the potential to:
- damage social or marital relationships
- decrease work performance
- wreak havoc on the physical body
- lower overall quality of life
Distress tolerance is a priority in situations where an individual’s stress factor can’t be practically avoided, or the individual has no realistic means of escaping their negative feelings. DBT distress tolerance skills for anxiety and depression (which globally affect over 500 million people) have also proven extremely important in the current healthcare landscape. Building right stress handling skills is also particularly important for patients who suffer from any kind of mental illness, as they can be lifesaving for those at risk of self-harm.
Common Practices and Strategies
One of the modules within Dialectical Behavior Therapy is Distress Tolerance. There are several “crisis survival skills” taught in this module. We discuss some of the most frequently used (and most effective).
The fundamentals of distress tolerance skills revolve around an individual becoming more aware of their internal emotional state and its effect on their current thought patterns or actions. Essentially, a patient needs to learn the practice of self-soothing, or the ability to both calm the body and maintain self-awareness. Common practices for self-soothing that patients can employ at home and/or on their own include:
- controlled breathing
- progressive muscle relaxation
According to the National Alliance on Mental Illness, distress tolerance skill work must include an individual’s development of a positive identity and the ability to healthily manage inwardly directed negative emotions. Many people choose to incorporate tangible objects, rewards, or physical actions into their routines of self-soothing and positive identity work. This may include indulging in a small snack, exercising, or listening to a favorite song in response to intense negative emotion. Care must be taken with these practices, as they are appropriate behavioral responses only when they are utilized in healthy ways.
Embracing Radical Acceptance
Many care providers claim that the concept of radical acceptance is a key ingredient in the development of distress tolerance, and they actively encourage their patients to fully embrace the idea. Radical acceptance applies to situations in which the source of the painful or crippling emotions can’t be avoided, so a person must instead learn to accept them. Because a patient cannot avoid the source(s) of their pain, they need to learn how to confront it and (hopefully) slowly change the way they feel about it over time.
This process cannot and does not happen overnight. Radical acceptance typically takes place in several stages. Four common skills that are taught in these stages are:
- Distraction: The ability to shift negative thought to a more enjoyable place; neutrality
- Self-soothing: The ability to “nurture self;” often through engagement of the five senses
- Improving the moment: The ability to use positive mental imagery to improve a stressful situation
- Focus on pros and cons: The ability to list the pros and cons of tolerating or not tolerating the stressful situation well; past consequences for past poor responses may be brought up as cons
Practicing radical acceptance skills in response to stressful situations should ease patients towards a state where they can both accept their reality and control their reactions to that reality.
TIPP Skills are easy distress tolerance skills that we can implement independently. The acronym TIPP stands for:
- Intense Exercise
- Paced Breathing
- Paired Muscle Relaxation
TIPP skills are easy to implement during times of crisis or overwhelming emotions. They are effective skills to use when we need to calm down or gain control of our emotions.
A change in temperature can decrease the intensity of an emotion. Even something as simple as splashing cold water on your face can make an improvement in our mood. Dipping your face in a sink full of cold water and holding your breath can also be helpful.
Engaging in intense cardio allows us to engage our body to deescalate emotions. Twenty minutes of intense exercise is ideal. Healthy adults should try and reach a heart rate that is 70% of its capacity.
Paced Breathing in a controlled method can also help calm nerves. Slowing your breathing to allow each inbreath and outbreath to last 10 to 12 seconds is sufficient. There are cell phone apps
Paired muscle relaxation is another great way to reduce stress. Tensing and relaxing your muscles can help you differentiate the feelings of tension and relaxation. Tighten a specific muscle group for a few seconds and then relax them. Go through each muscle group of the body, paying attention to how the relaxing phase feels.
Pros and cons
It’s important to stop and think about the choices we are faced with. When we make quick decisions without thinking through the ramifications, it can lead to negative consequences. Writing down a list of pros and cons can help you see your choices in a logical manner. Writing them down and thinking about them can help remove the emotional aspect of decision-making. Weighing the pros and cons can help reduce emotional stress and maintain some control during an emotional crisis.
The STOP Skill
The STOP Skill is a distress tolerance skill that can help you ride out a crisis and work through intense emotions. The STOP acronym stands for:
- Take a step back
- Observe what’s going on both inside and around you
- Proceed mindfully
We’ll work through a stressful situation using STOP skills.
You’ve had a fight with a close friend and are worried they will never want to see you again. You are upset and emotional and aren’t sure what to do.
- Stop- Don’t say or do anything
- Take a step back- put down your cell phone or step away from your computer so you aren’t tempted to contact the friend.
- Observe- think about your thoughts and feelings. Observe your surroundings to stay grounded. Are you afraid to lose your friend? What would losing your friend mean to you?
- Proceed mindfully- think rationally and ask yourself what your wise mind wants you to do. Should you beg for forgiveness? Have a conversation?
Distraction can help with distress intolerance by purposefully doing something else other than what your emotions are telling you to do. There are several positive ways to distract including:
- Doing an activity that you enjoy like playing a video game or going out for a latte at your favorite coffee shop
- Doing something nice for someone else like volunteering or helping a friend
- Doing something that elicits the opposite emotion as you’re feeling like watching a comedy if you are angry or listening to dance music if you are sad.
- Changing your thinking. This one is good if you can’t remove yourself from a stressful situation. You could try counting or think about your favorite song lyrics.
- Engaging your senses. Take a hot shower, drink something very cold, suck on a sour candy or a lemon
While distraction is one of the most powerful distress tolerance techniques, it is only a temporary way to help cope with a stressful situation.
IMPROVE the Moment
Sometimes self-soothing distress tolerance skills don’t work as well as we had hoped they would. Fortunately, there’s a set of skills that can be utilized when that happens. IMPROVE can help get thru those situations where other skills haven’t been effective. IMPROVE consists of:
- Imagery- Imagine a safe place where the stressful situation is absent. It can be a real place, or something completely made up. Imagery can also be used to imagine a feeling like sadness pouring out or anger being lifted.
- Meaning- Look for things that have an important meaning or value to you. Somethings our circumstances aren’t our fault, and our values can help guide us. Focus on those values and let them be your guide.
- Prayer- Prayer can be used in a variety of ways. Some people will pray to a higher power and ask for strength. Some people use prayer to acknowledge that the situation is bigger than what they can handle alone.
- Relaxing Actions- There are plenty of relaxing actions that can help deescalate an emotional situation. Sometimes a warm bath or a hot shower can do the trick. Other times a long walk or time spent in nature doing yoga are helpful. Do whatever will help you relax and take a step back from participating in emotionally driven behaviors.
- One Thing in the Moment- Sometimes our emotions and feelings get charged thinking about the future or the past. Focusing on the moment can help bring things into perspective and not get caught up in those feelings.
- Vacation- Sometimes all we need is a break. The vacation skill involves recognizing when you just need to take a break from the situation and return to it later when you have a clear head. It can involve going to take a nap, turning off your phone, or watching tv or a movie.
- Encouragement- Think positive, encouraging thoughts to help get thru a crisis or tough situation. Telling yourself you are doing your best or you’ll get thru it can help you stay positive and provide the self-love you need.
Distress Tolerance Skill Building Plays an Important Role in the Treatment of Mental Health Disorders
It’s no surprise that the distress tolerance module of DBT can help with the symptoms of Post Traumatic Stress Disorder. DBT distress tolerance skills can help ease emotional pain and avoid behavior that can make symptoms worse. Self-soothing and other easy-to-use strategies use the body’s own chemistry to reduce anxiety and return the mind to a calmer state.
Distress tolerance techniques are also used in therapy for borderline personality disorder. Therapists recommend using the following distress tolerance skills to help individuals with BPD:
- Improving the moment
- Pros and cons
What is Distress Tolerance in DBT?
Many clinical psychologists help patients learn how to tolerate sources of distress through a dialectical behavioral therapy DBT program. DBT is a cognitive-behavioral therapy that is talk-based. There are three many components to DBT. It is:
- cognitive based
Patients of DBT usually have individual psychotherapy sessions and group sessions. The individual sessions are meant to assist the patient in learning and/or improving basic social skills, while the group therapy sessions should help teach interpersonal communications, reality acceptance skills, emotional regulation, and mindfulness.
Like many other psychological practices, programs are patient-oriented and are developed around the specific needs of each individual. In general, therapy is designed to help the patient:
- regulate their emotions
- worry less
- tolerate ongoing sources of stress
Therapy also helps patients build social skills (especially through group therapy) to help them create more positive relationships and situations for themselves in the future.
Many different tips, tactics, and therapies can provide relief from frequent periods of extreme emotional distress. Some can be achieved at home and on one’s own, while other individuals are going to need assistance from a care provider. Because every case is defined by different circumstances and different biological makeups, personalized solutions are fundamental to long-term successful improvement. Though it may take time, money, and vulnerability to build adequate distress tolerance skills, accomplishment can lead to tangible and lasting improvement in multiple areas across one’s life and lead to emotional tolerance.
ABA Programs Guide Staff
Updated July 2022
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