Dialectical behavior therapy (DBT) distress tolerance skills address the tendency of some individuals to experience negative emotions as overwhelming and unbearable [1]. People with a low tolerance for distress can become overwhelmed at relatively mild levels of stress [2], and may react with negative behaviors. Many traditional treatment approaches focus on avoiding painful situations, but in the distress tolerance module of DBT, clients learn that there will be times when pain is unavoidable and the best course is to learn to accept and tolerate distress.
A key ingredient of distress tolerance is the concept of radical acceptance. This refers to experiencing the situation and accepting the reality of it when it is something the person cannot change. By practicing radical acceptance without being judgmental or trying to fight reality, the client will be less vulnerable to intense and prolonged negative feelings. Within the distress tolerance module, there are four skill categories:
- Distracting
- Self-soothing
- Improving the moment
- Focusing on pros and cons
These skills are aimed at helping individuals cope with crisis and experience distress without avoiding it or making it worse.
Skill No. 1: Distracting
The first skill, distracting, helps clients change their focus from upsetting thoughts and emotions to more enjoyable or neutral activities. This skill is taught with the acronym ACCEPTS:
A – is for activities and distracting oneself with healthy, enjoyable pursuits such as hobbies, exercise, and visiting with friends.
C – is for contributing and doing things to help others, through volunteering or just a thoughtful gesture.
C – is for comparing oneself to those less fortunate, finding reasons to be grateful.
E – is for emotion; identifying the current negative emotion and acting in an opposite manner, such as dancing or singing when one is feeling sad.
P – is for pushing away, by mentally leaving the current situation and focusing on something pleasant and unconnected to the present circumstances.
T – is for thoughts; diverting one’s attention from the negative feelings with unrelated and neural thoughts, such as counting items or doing a puzzle.
S – is for sensations, and distracting oneself with physical sensations using multiple senses, like holding an ice cube, drinking a hot beverage, or enjoying a warm foot soak.
Skill No. 2: Self-Soothing
The second skill in distress tolerance is self-soothing [5]; clients can use the five senses to nurture themselves in a variety of ways:
- Vision: Look at beautiful things such as flowers, art, a landscape, or an artistic performance.
- Hearing: Listen to music, lively or soft, or enjoy the sounds of nature such as birds chirping and waves crashing. Savor the voice of a relative or friend.
- Smell: Use a favorite lotion or perfume, light a scented candle, notice the scents of nature, or bake an aromatic recipe.
- Taste: Enjoy a hearty meal or indulge in decadent dessert. Experiment with a new flavor or texture, and focus on the food’s flavors.
- Touch: Pet an animal or give someone a hug. Have a massage, rub on lotion, or snuggle up in a soft blanket.
Skill No. 3: Improving the Moment
In the third distress tolerance skill, the goal is to use positive mental imagery to improve one’s current situation. The acronym for this skill is IMPROVE:
I – is for imagery, such as visualizing a relaxing scene or a successful interaction. Imagine negative feelings melting away.
M – is for creating meaning or purpose from a difficult situation or from pain, i.e., finding the silver lining.
P – is for prayer—to God or a higher power—for strength and to be open in the moment.
R – is for relaxation, by breathing deeply and progressively relaxing the large muscle groups. Listen to music, watch a funny television show, drink warm milk, or enjoy a neck or foot massage.
O – is for one thing in the moment, meaning the individual strives to remain mindful and focus on a neutral activity in the present moment.
V – is for vacation, as in taking a mental break from a challenging situation by imagining or doing something pleasant. This could also be taking a day trip, or ignoring calls and emails for a few hours.
E – is for encouragement, by talking to oneself in a positive and supportive manner to help cope with a stressful situation.
Skill No. 4: Focusing on Pros and Cons
In focusing on pros and cons, the individual is asked to list the pros and cons of tolerating the distress and of not tolerating the stress (i.e., coping through self-destructive behaviors). It can be helpful to remember the past consequences of not tolerating distress, and to imagine how it will feel to successfully tolerate the current distress and avoid negative behaviors. Through evaluating the short-term and long-term pros and cons, clients can understand the benefits of tolerating pain and distress, and thereby reduce impulsive reactions.
The distress tolerance skills are valuable tools in helping individuals maintain balance in the face of crises, teaching them to accept the distress and cope with it in healthier ways. By practicing the skills of distracting, self-soothing, improving the moment, and focusing on pros and cons, clients can weather stressful circumstances and decrease painful feelings and destructive impulses.