What is "Distress Tolerance" in Dialectical Behaviour Therapy (DBT)?
Distress Tolerance is one of the modules in Dialectical Behaviour Therapy which teaches the necessary skills to get through a crisis without making things worse.
The module happens early in the course of therapy — alongside Core Mindfulness, it's the first skill taught.
Of course, it's perfectly natural when experiencing painful emotions, for our immediate impluse to be to try to avoid them. And this strategy may be helpful at times. A pilot, for example, will try to find a pocket of calm air when flying into a storm in order to avoid it altogether, and reduce any discomfort.
But imagine if, like your emotions, the storm were all around you and there was no way but through it. To people who are emotionally sensitive, this is, quite literally, a terrifyingly real scenario.
A pilot can rely on his training, experience and expertise. But for people suffering with Borderline Personality Disorder (BPD) skills in weathering an emotional storm are limited.
The fact is, not only do they have a lack of skill, they experience emotions so intensely they would do anything, rather than feel them. It's very hard to teach someone who is desperate not to feel pain that it is more effective to go through the storm rather than to try to circumvent it, even if past experience has shown them that their normal way of dealing with crises leads to more heartache and problems in the long run.
A that's where a Dialectical Behaviour (DBT) therapist can be of value. Just as with a co-pilot, it's possible to guide and assist the person in how to be more skillful at getting through a crisis without causing more harm or damage to themselves or their relationships.
What does Distress Tolerance teach us?
As human beings, we have an amazing ability to use our imagination, which sets us apart from animals. In both humans and animals, we have a fear alert system, that switches on when danger approaches, and off when it passes. Humans' fear systems have an added feature, a 'What-if?' mode. And, as Mark Williams has suggested, we often enable a“Why me? Why now?” add-on.
The simple act of asking this question keeps our fear system switched to the on position and we become afraid of being afraid. We have to be able to switch off our fear system when there is no evidential danger.
Distraction is the skill to help this happen. The person learns that it is possible to distract from their pain by filling their short-term memory with thoughts and sensations, other than the hard to shift fear or pain thoughts, images and memories that are overwhelming them in that moment.
To understand this, just think about what a mother might do to distract her little boy from the 'tunnel vision' that happens when his fear system switches on. She may say “Oh look there's Josh over there, do you want to go over and talk to him”? Or “Oh look at the pretty balloons” or “Guess what we are having for tea tonight, its your favourite thing ever!”
If she catches her young child's attention for long enough she knows, she can cajole him along until the crisis has passed.
Distress Tolerance Distraction works on the same principle.
The point is to be creative and 'wrong foot' your brain into letting go – even for a few seconds – of its tunnel vision to give you a chance to get more space between an urge to act in a harmful way and the act itself.
Putting more space between an urge and a harmful behaviour means you get the one thing you need – more CONTROL.
2. Self soothing
One of the features of being under extreme distress is a problem called Dissociating. A defence mechanism to help a person tolerate extreme distress, anyone experiencing these symptoms knows how distressing it can be.
The feeling of being detached from your body, floaty, hazy, zoning out and at an extreme, losing time, is a worrying experience for the person who usually does not link it to their anxiety or distress but often misinterprets it as another sign that there is something fundamentally wrong with them. The remedy for this is often found in 'grounding' strategies.
Self soothing is a skill used to keep the person grounded and soothed in the moment using their five senses: sight, sound, taste, touch and smell. Often shifting from one to the other, many of my patients tell me that this is the skill they like the best and one of the first they find really makes a difference quickly.
A short term strategy, self soothing is something that should last minutes rather than hours and again gives the person time to get their balance in order to move to other DBT skills.
3. Improve the moment
Encouraging the person to see every moment mindfully means that they can ask themselves the question “What is more effective in this moment, and in this moment, and now in this moment”?
After many weeks of using skills to good effect, one of my clients suddenly hit another crisis. He emailed me to say it felt like falling down “the same old well again and hitting the bottom in a sepectacular way!”
I said to him “Wow, yes we know that old well intimately right? If I remember rightly, though, it's a pretty long way from where you were, somewhere near the top to the very bottom of that well. Can you tell me what you were doing as you were falling?”
The point of course is that free-falling is neither skilful nor effective. Sometimes it's unavoidable as a crisis can sneak up on the most skillful of people. However, after effectively working on a behavioural chain analysis, solutions need to be found for the person to try to pull the DBT 'parachute cord' as soon as they can. Improve the Moment skills acts like that parachute, a toolkit of skills to help break your fall by asking “what can I do to make my landing a little softer”.
4. PROs and CONs
Being taught skills is one thing. Getting motivation to use them is quite another. Discussions about 'effectiveness' and 'building a life worth living' dont even begin to register with some impulsive people.
I used to wonder why would someone would want to jump out of the window when they can use the stairs? For those of us who dont live with intense emotional experiences on an hourly basis, we can use this logic, and it makes perfect sense.
However, my BPD patients would argue the opposite. “Why on earth should I use the stairs when I can jump out of the window, its much faster and, OK, even if I dont like some of the consequences, it works” (my arguments about a broken leg or fractured skull fall on deaf ears as they either choose to ignore the logic in a rather wilful way or just dont believe that the stairs will get them to the same place as jumping would.)
Well-used strategies such as alcohol, self harm, suicide attempts, sleeping around give immediate and short-term relief, they can also become quite addictive behaviours. Working on PROs and CONs gives a 360º look at the problem behaviour and helps to generate a more balanced view and to help get the person unstuck from their rigid viewpoint.