Distress Tolerance in Dialectical Behavior Therapy

GoodTherapy | Distress Tolerance in Dialectical Behavior TherapyDialectical behavior therapy (DBT) distress tolerance skills address the tendency of some individuals to experience negative emotions as overwhelming and unbearable. People with a low tolerance for distress can become overwhelmed at relatively mild levels of stress, 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:

  1. Distracting
  2. Self-soothing
  3. Improving the moment
  4. 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; clients can use the five senses to nurture themselves in a variety of ways:

  1. Vision: Look at beautiful things such as flowers, art, a landscape, or an artistic performance.
  2. 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.
  3. Smell: Use a favorite lotion or perfume, light a scented candle, notice the scents of nature, or bake an aromatic recipe.
  4. Taste: Enjoy a hearty meal or indulge in decadent dessert. Experiment with a new flavor or texture, and focus on the food’s flavors.
  5. 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.

© Copyright 2013 GoodTherapy.org. All rights reserved. Permission to publish granted by Suzette Bray, MFT, Dialectical Behavior Therapy Topic Expert Contributor

The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the preceding article can be directed to the author or posted as a comment below.

  • Leave a Comment
  • Debbie Corso

    January 17th, 2013 at 10:39 PM

    This is a great summary of the DBT Distress Tolerance skills.

  • Jayme g

    January 18th, 2013 at 3:58 AM

    I wonder why it is that some are able to tolerate huge amounts of stress and actually thrive from it. . . while there are others that any little bit of upset sends them into a tailspin?

    I know people on both ends of the spectrum, and I tend to be a little more like those who don’t handle stress very well at all. I can’t say that it was how my parents behaved or raised me, it’s just this has always been kind of who I am. I am not affected by it to the extreme like I am sure others are and have never even had to seek help for it, but it is something that I try to stay mindful of and try to keep under control so I don’t feel like I am going to lose it if there is a stressful even in my life.

    For me I think it has always been more about that loss of complete control that does not feel good to me.

  • Karenn B

    December 18th, 2019 at 10:49 AM

    Wow, I loved this presentation. Very helpful!

    Jayme, I think you kind of answer your own question, and should look deeper into how to build resilience. The people in my life, as examples for dealing didn’t handle stress super-well, either; and I also have some of the same ‘sensitive’ wiring and DNE as my living social examples.

    I know whatever I do to get in a good zone helps me immensely: -> goto happy or fun activities, yoga, meditating, the right music for the moment, or singing or playing music; nature, walking, writing poetry to express mindfulness about a thing or place [or, moving slowly FOR mindfulness awareness; reading for my own interests, or a momentary fantastical or humorous imagery. Even a scent, a color, the sunshine, enough light in gloomy weather, or dim and cool, or hot/ warm/ cool water can change my mental scenery. You can make a space especially for chilling out, or use your imagination ANY time.

    There are SO many unique ways to do all these things, and in their time/ place.

    Another way is to find something about the situation I am actually thankful about. It can be hard, but, realizing this is a momentary challenge which will provide me with insight (e.g about anxiety) helps me realize I’m not the only one, and that I’ll understand better when someone else goes thru it, not just nod and think about something I know better. I am always learning SOMEthing. I have become aware of and thankful supportive friends, who kind of come out of the woodwork at rough times, and imagine their kind actions supporting me. You can imagine the presence of anyone in this life or spiritual who you know has your back, being right with you, as you deal.

    We can stop and think about better ways of framing our responses – this helps put us back in a constructive place, and revives our intelligence and wiring for being prepared instead of reactive.

    Being gentle and giving credit to where we are with our abilities moment to moment is important, and removes the struggle to demonstrate ‘being better’ than this, so we can FEEL better about this.

    Building and growing ourselves is done on positivity and on fun, believe it or not! So, as quickly as we can move to a ‘better place,’ the more resilient we can become.

    With warmest regards ~ K

  • Robinm

    January 18th, 2013 at 9:18 AM

    I think a simplified verson of this therepy intorduced to the public workforce as simple stress reducers could help so many. It is only natural for those who feel out of control to suffer fear and transfer it to anger when there is no coping skills. I would hope proactive human recource directors could recognize these skills and apply them to all types of workforce.

  • brandi

    January 18th, 2013 at 9:43 PM

    I do not remember when it started or what triggered it but since the past few years even small amounts of stress can send me running for cover.I will readily back off from a situation if there is even some amount of stress involved in it.I am ashamed of myself for having done so for this long but I just cannot control it.

    I though distracting myself would be a good idea.It does work to a certain extent but does not provide me with a lot of benefits.That is the only thing from the given list that I have tried.I shall now try to do the others.But I really could do with a little assistance in the same.Who could help me?Would a friend be a good idea?

  • Dena Michnowich, LMSW

    January 24th, 2013 at 10:35 AM

    Marsha Linehan is the creator of the DBT module. You can google her to find her website…she sells CDs which teach you more about how to use mindfulness to help with distress tolerance, etc.

  • Ruth R

    December 7th, 2013 at 6:10 PM

    I would like to learn more skills of torence of stressful situations

  • Karen G

    March 25th, 2014 at 5:56 AM

    My daughter had a panic attack last night. I think this would help, any other readings I should look up

  • Karenn B

    December 18th, 2019 at 11:03 AM

    A mentor [family member or friend who you think would have an affinity to this content], someone who also is trying to tease out coping factors is a good buddy to pair with, supportive counselor, or almost any therapist could help you think of ways to use the skills offered here. Consider using APPs for DBT, and for various kinds of self-support. Scouring the web for various ideas expressed on self care, calming, coping, relaxing music…. TEDx, YouTube, brilliantmindfulness.com the supply is endless!! and fun to try out!!

  • Sharon

    September 18th, 2020 at 6:02 AM

    My stress is out of control. I seem to have no power over it. I am to upset to sit besides trying to relax my muscles. I pace and pace until my legs give out. Would like your newsletter. This is the first thing that has made sense to me.

  • LaurenGT

    September 18th, 2020 at 8:10 AM

    I’m so glad this post helped! I’ll make sure you get added to our public newsletter. :)

  • Katharine

    July 9th, 2023 at 8:56 PM

    For this one: “P – is for prayer—to God or a higher power—for strength and to be open in the moment.”
    I wonder if there’s a non-prayer alternative? Otherwise it’s leaving out a fair proportion of the population.

Leave a Comment

By commenting you acknowledge acceptance of GoodTherapy.org's Terms and Conditions of Use.


* Indicates required field.

GoodTherapy uses cookies to personalize content and ads to provide better services for our users and to analyze our traffic. By continuing to use this site you consent to our cookies.