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Understanding Distress Tolerance in Dialectical Behavior Therapy (DBT)

Dr. Melanie du Preez

1. Introduction to Distress Tolerance

DBT therapists, recognising that not all people with BPD are the same, strive to understand an individual's unique modes of dysregulation. This understanding forms the basis for tailoring the treatment modalities to fit the targeted individual. DBT is not a one-size-fits-all approach but an individual treatment focusing on specific needs. Distress Tolerance, a skill that should be personally tailored, is a key component of this approach. So, let's embark on a journey towards perfecting a tolerable distress level that is unique to each individual.

Distress Tolerance skills are not just about preventing impulsive and self-destructive reactions due to the intensity of an emotional reaction. They offer a sense of hope and the ability to disengage from situations and circumstances that are harmful to us. Distress Tolerance empowers us to tolerate pain in difficult situations, not because we have no other choice, but because we recognize that our ability to 'tolerate' the distress gives us the time needed to think and adjust course, thereby preventing the situation from worsening.

Distress Tolerance skills are often seen as skills that balance out the overwhelming feelings inherent in the rest of the DBT skills (which focus more on reducing negative emotions).

Distress Tolerance is a critical concept in Dialectical Behavior Therapy (DBT). It is taught in two stages where the client learns to accept the current situation, while at the same time remembering the skills they have been taught. This tension between 'acceptance' and 'change' is central to the whole of DBT. In it, we focus on often paradoxical, seemingly opposing phenomena. We ask clients to accept who they are while they move towards change. Skills used to move towards acceptance and move towards change are often at odds with one another. Yet, this is DBT - learning to live with the paradoxes life presents 'skillfully.'

1.1. What is Distress Tolerance?

Distress tolerance is believed to influence whether someone adopts an adaptive coping response. Distress tolerance and patient premature termination of treatment have a particularly salient role in dialectical behavior therapy (DBT), a treatment designed for BPD. DBT carefully addresses these issues, teaching patients to tolerate and, rather than escape, distress, focusing on lowering distress in the long term, and teaching adaptive coping skills. The teaching skills of distress tolerance are targeted to help the patient accept and cope with negative thoughts, feelings, and physiological sensations. This increases the range of triggering events the patient sees as 'high risk' and lowers distress in the future. DBT assumes that if patients learn to cope with the distress associated with their psychiatric diagnosis effectively, maladaptive behavior will be significantly reduced.

Borderline personality disorder (BPD) is a disorder characterised by dysregulation in several domains, including emotion and impulsive control. Studies have demonstrated that people with BPD beliefs are less willing to tolerate and ineffective at tolerating distress and negative emotions. These people use maladaptive coping strategies to escape distress (e.g., being destructive towards themselves). Extreme levels of distress contribute to using completely maladaptive ways to cope with their suffering to the extent that these coping methods make their distress worse (e.g., feeling worse after binge eating or feeling even more isolated after a suicide attempt).

1.2. Importance of Distress Tolerance in DBT

Patients who are in severe psychological distress are generally not capable of using interpersonal skills or of learning behavioral skills with their therapist. When patients are experiencing severely distressing or painful emotions, it may appear to them that suicidal, self-destructive, or substance-abusing behaviors are the only way to escape their feelings. To prevent these behaviors, specialised skills are needed to manage high levels of distress. Distress tolerance skills build on core mindfulness skills. The current emphasis in DBT on distress tolerance was mainly in response to problems in its adaptation for substance-abusing patients. DBT includes the elements of distress tolerance, such as willingness, and merges them with the DBT characteristic of self-soothing and non-judgmental. The goal is to help the patient increase the capacity to (a) accept reality and (b) tolerate both physical and emotional distress by teaching skills parallel to those taught to patients with Post-Traumatic Stress Disorder (PTSD). Radical acceptance of life problems that cannot be changed is also essential to the DBT style. Although distress tolerance lies within the therapy domain of emotional regulation, it may not occur until many other skills have been trained, such as interpersonal skills building or distress tolerance. Indeed, many more sessions are devoted to distress tolerance skills than any other DBT module.

2. Differentiating Between Normal Distress and Crisis

The original skills training model in DBT distinguishes between emotional reactions regarding distress and crisis. Distress tolerance (DT) skills are the most helpful skills during a crisis. Century-mobile individuals in society rarely, if ever, develop these skills until behaving in a self-destructive way has been developed. In DBT, a crisis, or crisis dysregulation, is defined as when a person cannot cope and begins to act impulsively or non-adaptively. Paradoxically, these coping deficiencies reveal themselves during stress. By helping clients to accept an emotion, to ride it, not to react impulsively or destructively, and to see portions of the original distress that initially triggered the impulsive behavior, a client’s confidence in their ability to tolerate a distress rise. Helping the client to recognise that the distress will gradually subside on its own is a crucial goal for the counselling experience. Distress tolerance skills are the primary skill set used before, during, and after the decision to tolerate an impulse until it is helpful. The client must recognise that some crises will happen, learn from them when they occur, develop a coping style that does not interfere with basic DBT skills when a crisis does occur and plan for these emotional attacks.

2.1. Signs of Normal Distress

At this point, it is essential to convey that exhibiting low levels of distress tolerance is normal. Temporary reductions in distress tolerance may occur during times of illness, times of exhaustion, times of exposure to extreme circumstances, times of required suppression of emotion, or times of engaging in therapeutic work. Individuals are also more likely to face increased difficulty with high emotional states in times of rapid mood changes, increases in stress, heightened vulnerability, financial insecurity, significant life and environmental stressors, exposure to repeated emotional distress, or events that act as reminders of past traumatic experiences.

To clarify the difficulties faced by individuals with low levels of distress tolerance, it is helpful to delineate the characteristics of distress tolerance in individuals who can tolerate discomfort effectively. It is beneficial to explore the signs of normal distress here. When faced with expected and usual levels of distress, individuals attend to emotions, facial expressions, thoughts, and physical sensations. Affect labelling and problem-solving can occur, and the person is usually willing to remain in distressing emotional states. During expected and expected levels of discomfort, individuals can engage in ordinary daily activities and responsibilities alongside their emotional experience. Finally, when the stressful situation subsides, the individual participates in activities promoting emotional soothing and self-care.

2.2. Identifying a Crisis

Pyszczynski and Greenberg present eight different categories of events that serve as prompts or warnings about possible crises. Among these factors, the two most critical components are client assessments of the intensity of the potential crisis and the fairness of the response from the environment. While it is important to note that not all emotional extremes or lethality of action should meet a client's criteria for a legitimate coping emergency, helping clients to objectively assess factors that indicate whether a potential crisis related to intense distress or inappropriate behavior that is occurring, as well as gauging the emotional intensity of the behaviors that are observed, are essential tasks for DBT therapists.

Once it can be determined that dyscontrolled events (such as self-harm, urges toward suicide or other self-destructive behaviors, or adverse public displays) are crisis events, it is essential to determine whether the client is likely to be either damaging themselves (e.g., they are so anxious and agitated that they are likely to self-harm) or behaving in such a problematic fashion that it is requisite that DBT skills coaching strategies are quickly applied. Guidelines for identifying a crisis include client reports of suicidality or percentage likelihood or intensity, the sensation of out-of-control emotions (perhaps related to the environment), and drastic changes in baseline behaviour that require immediate attention and skill-building guidance. Gratz and Gunderson, Miller et al., and Neacsiu et al. further detailed these areas.

3. Crisis Management Skills in DBT

A significant skill set is needed to manage crises effectively. These distress tolerance skills help clients to process a crisis, limit the likelihood of engaging in self-destructive behavior, and to prepare themselves to participate in effective problem-solving. Over time, the client will learn that they have the psychological tools to work through complex problems and that crisis is actually transformative in building their resilience.

The client's responsibility is to utilise distress tolerance and other skills to deal effectively with stressors, and the therapist's job is to ensure that the client has the support and the knowledge to use the skills before a crisis develops. If a crisis does develop, the client has the "Cardinal Skill of Willingness", which enhances the likelihood of using the therapeutic relationship to solve rather than act out the crisis.

In DBT, it is assumed that most crisis management is actually "crisis prevention". That is, clients engage in behaviors that result in their experiencing a crisis when they have not used their other skills to manage stressors effectively. Individuals often have fragile coping skills, and thus, the odds of developing a major psychiatric disorder are then enhanced.

Crisis management skills in DBT. The concept of "psychological survival skill" is fundamental to DBT. Specific skills are taught to reduce the likelihood of engaging in suicidal behaviors, self-harming, treatment-interfering behaviors, and the suffering of the therapist or significant others. DBT therapists take the fact that they are seriously helping clients learn the skills necessary for survival.

3.1. Accepting Reality

Acceptance of the Golden Gate to change is challenging for many people to endure. Acceptance and Change are opposing goals in life. We are asked to accept and appreciate ourselves first to prepare to make changes for the better. Opposites are essential to understand each other. No one can be completely passive and still influence others and the environment. No choices are accepted if there is no alternative. Active and Passive behaviours are essentially each other, and alternate roles are taken to fulfil the entire task of survival. This acceptance of powerlessness can be challenging and is examined in Step 1 of A.A., where people admit powerlessness over alcohol. A Buddhist state of acceptance is conveyed through the Four Noble Truths and Eightfold Path. The principle of acceptance is a significant contemplative practice in Buddhism. Peacefulness comes with the realisation that you can survive if everything you were attached to didn't. Acceptance means being willing and pacified to have things move through you, to contain all, and to let go spontaneously and uncontrollably. As Tao advises, accept yourself, and the most excellent acceptance of all is the acceptance of not accepting everything.

Dealing with life without distress is a lesser-known and appreciated goal of DBT, but the skill set and philosophy are a cornerstone of our work with every client. They are a foundation because discomfort is a central notion to our understanding of BPD and behavioral disorders in general. As Marsha Linehan so eloquently described her research on BPD clients, "These data indicated that BPD clients... experienced life as unacceptable and aversive rather than finding some enduring and rewarding purpose for living. Their reported lives were not of ease and comfort but of fear, emotional pain, apprehension, and dread." And in a line that every DBT therapist will ask to be repeated: "To simply ask [these clients] to accept reality would be asking them to settle for an unacceptable environment." However, DBT also teaches us what to do with the suffering we cannot accept or change. After obtaining awareness and being present by identifying where we are at any moment, the next step, one that is a distinctive responsibility function of the mammalian brain, is to accept the current moment.

3.2. Distraction Techniques

Physical activities (walking, shooting baskets) or soothing (taking a warm bath, petting the dog). It is essential to use different skills for different levels of arousal. For example, if you are mildly disturbed, relaxation techniques are helpful. Activities that are more absorbing and require greater concentration (like solving math problems, reading an intricate book, or throwing yourself into a chosen project) are more helpful if you are at high risk for urges to self-destruct. Some patients enjoy watching a long series of short, funny video clips available on YouTube. The patient and therapist can brainstorm other distraction techniques individualised to the patient's specific likes and interests.

Regular use of distracting activities can act as a protective factor against stress and upset. It can be a very effective tool in preventing or stopping non-suicidal self-injury or other dangerous behavior. Identifying helpful activities that can be done easily and quickly may help develop a personalised action plan. Engaging in distraction reduces the current emotional level and makes you feel better for a short time. Activities that can be done quickly and are highly involved are beneficial, such as distress tolerance skills. Some patients keep a list of activities that work for them on their cell phones, along with emergency phone numbers for friends, clinicians or national distress hotlines.

3.3. Self-Soothing Strategies

While teaching clients this skill is essential, prospective facilitators of this activity must also initially ensure they understand how to calm patients to determine what will be effective at helping them. There is an unending list of different strategies if the facilitator understands that the goal is to provide a pleasant quick change. The individual must practice these skills when not experiencing distress to prepare better to engage these skills when triggered. Using these skills long before becoming upset is essential to learning appropriate behaviour, and engagement in coping skills is a functional and automatic action.

Self-soothing strategies are designed to help clients relax during times of distress. People may be more likely to engage in self-destructive behaviors if they do not have practical self-soothing skills or access to comforting activities. Behaviors must be identified and practised in less stressful times and done routinely to prepare for discomfort. Standard media that may be found when facilitating clients in learning self-soothing techniques may include using the five senses to divert the individual from their anxieties or discomfort quickly. Behaviours such as stretching, deep breathing, using music, watching a favourite movie, using essential oils, taking a warm bath, using scented candles, or engaging in calming activities can also be beneficial.

4. Practical Tips for Building Distress Tolerance

Letting clients destroy themselves because they do not have the skills to manage their emotional distress and vital ancillary issues of healing a life worth living have not been addressed through many non-behaviour therapy activities. These are the touchstones on which we ensure that therapy works for distressed clients. We too often discover through clinical experience that some clients are not faring well in therapy. Providing an optimal treatment environment and offering the best in many non-specific factors does not always work. When clients are experiencing intense and pervasive emotional suffering, their ineffectiveness can contribute to their failure and ultimate demise. With this in mind, we have developed the protocols within dialectical behavior therapy to be used with life-threatening clients who require a specific program.

We find several components of DBT that are critical when clients have a low tolerance for emotional distress. They include the following: clients must be taught to change complicated emotional regulation strategies, including self-mutilation and suicide, as reactions; clients are unaware, unskilled, or in emotionally vulnerable situations in the skills they have learned but do not use or do not want to use them; clients improve their emotional regulation strategies and better manage emotional dysregulation through skill utilisation and increase life-threatening problems by applying skilful means.

DBT provides several skills for managing distress but does not work well for everyone. A skill is not a skill if a person knows how to use it but cannot or chooses not to use it. This paradox is the basis of the DBT assumption that clients with GD have a low tolerance for emotional distress. It is also one of the primary reasons that DBT was developed.

4.1. Mindfulness Practices

Though believing in personal choices and working towards a positive idea of religion can be crucial, the opinion and beneficial experiential aspects of connecting and relieving guidelines certify a business' ability to acknowledge mindfulness to go better regularly. We try to teach to develop individuals since they come to mind everyday relations and outlet venues along with individual and professional practice and accomplish their responsibilities within their department and subsequently as individuals as they have recognised dialectically to developing our clients' mindfulness.

Mindfulness practice is the foundation of distress tolerance in DBT services. Although Dr Linehan has mentioned several times that the contemplative practices in DBT programs, especially the sequence of mindfulness meditations taught in the standard dialectical behaviour therapy, draw from the Zen Buddhist tradition, the complete sequences of mindfulness meditation described in her texts do not match those usually taught in these customs. The individual function of her job development and coaching positions them in the Western Buddhist custom or a Western fixture of those strategies. The other pertinent factor when educating the necessity of a single mixing association trained in DBT programs is to spotlight the individual gain in consistently preparing purification for the customer, agency, and professional.

4.2. Grounding Exercises

Recent research has found that grounding is a helpful method for reducing distress. People can benefit from grounding techniques if they are willing to commit to the exercise and if loved ones join them while doing it, which helps support them through distressing moments. Other exercises could include physically touching objects around you or using a smartphone to take photos of various things in the room. Grounding can also be helpful outdoors, with minimal distractions, and someone can observe and fully tune into their five senses. Animal videos or music with lyrics will help distract from distressing thoughts.

Grounding exercises help someone regain connection to the present moment and the physical reality around them. This can be especially useful for those who tend to dissociate from their feelings or experience depersonalisation, where they feel detached from their body or who they are. Some exercises include noticing objects, shapes, colours, or details in the room to help return awareness of the current surroundings.

5. Conclusion

Distress tolerance (like mindfulness) unites the central tenets of DBT on a behavioural level. DBT conceptualises clients as doing the best they can with the skills they have while building a life worth living. DBT emotionally and behaviorally aligns clients with long-term benefits as they acquire the internal balance and external coping skills that permit effective decision-making, self-management, and the deliberate pursuit of proactive, prosocial goals. Understandable motivational and self-regulatory deficits result in the frequent lack of the will and the skill to live more mindfully.

Competent distress tolerance increases the likelihood that clients will skillfully choose and use effective coping strategies, instinctively refrain from burnout and despair about onerous tasks, gain a sense of mastery by enduring painful emotions, and share gratifying experiences with others. Difficulty in the use of these skilful behaviors probably accounts for much of the morbidity of patients with disordered emotion regulation: attempts at suicide, non-suicidal self-injury, oppositional maladaptive coping strategies, substance misuse, strained relationships, shame, lack of persistence, inadequate distress tolerance, occupational dysfunction, and failure to get along with others. Helping clients withstand the discomfort associated with new, more effective problem-solving strategies and adaptive coping skills probably accounts for much of the efficacy of dialectical behavior therapy.

5.1. Summary of Key Points

5) It is recommended that clinicians refer to DBT as involving both skills to reduce negative affect and abilities to increase positive experiences, a clarification that may help to disambiguate the distress reduction goal of many other treatment modalities.

4) Findings from a bootstrapped mediation model suggest that enhanced emotional regulation skills may account for improved client psychological symptoms.

3) Research is needed to validate processes of change particular to DBT and assess whether the distress-focused (specific) components of the DBT model are necessary.

2) A primary change mechanism in DBT is improved distress tolerance, and there is evidence that exposure to distress and using DBT skills are part of this change process.

1) Dialectical behavior therapy treats a range of disorders, including those with impulsive behaviors, and is efficacious for women with these problems.

This post is for informational purposes only. It should not be considered therapy. This blog is only for informational and educational purposes and should not be considered therapy or any form of treatment. We are not able to respond to specific questions or comments about personal situations, appropriate diagnosis or treatment, or otherwise provide any clinical opinions. If you think you need immediate assistance, call your local doctor/psychologist or psychiatrist or the SADAG Mental Health Line on 011 234 4837. If necessary, please phone the Suicide Crisis Line on 0800 567 567 or sms 31393. 

This blog is only for informational and educational purposes and should not be considered therapy or any form of treatment. We are not able to respond to specific questions or comments about personal situations, appropriate diagnosis or treatment, or otherwise provide any clinical opinions. If you think you need immediate assistance, call your local doctor/psychologist or psychiatrist or the SADAG Mental health Line on 011 234 4837. If necessary, please phone the Suicide Crisis Line on 0800 567 567 or sms 31393.