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What are DBT Distress Tolerance Skills?

Dr. Marsha Linehan, the clinical psychologist who developed Dialectical Behaviour Therapy, or DBT for short, describes the term Distress Tolerance as meaning the “ability to bear pain skillfully”. She comments that although many other therapies focus on changing unwanted or upsetting events and circumstances, pain and distress are in fact unavoidable elements of life that cannot be totally avoided or eliminated. Thus, the ability to tolerate and accept distress is essential for mental health.

 

Problems in emotion regulation lead to problems in distress tolerance

 

DBT was developed to address disorders of emotion regulation (Please see articles “What is Borderline Personality Disorder?” and “What is Dialectical Behavior Therapy?” for more detail). Emotion dysregulation involves very high negative emotionality as the norm, high sensitivity to emotional events, intense and often sudden emotional responses to things (so-called “quick-to-light”), and slow return to emotional baseline again (so-called “slow-to-burn-out”). Thus people with poorly functioning emotion regulation systems experience high intensity emotions much of the time, and as a result often feel overwhelmed by the emotional experience and struggle to tolerate it. 

A person who struggles with emotion dysregulation in this way has often developed coping strategies to help manage or problem-solve episodes of intense emotion. When his or her  threshold for tolerance is reached, the priority becomes almost entirely focused on immediately reducing that distress, and if the person has reason to believe that certain behaviours will reduce distress (usually because it has on previous occasions), then she or he is likely to engage in those behaviours even if they are highly maladaptive in the long term, potentially creating a host of other psychological and social problems. These behaviours can include abusing alcohol or other drugs, self-injurious or suicidal behavior, binge eating, and other problematic impulsive behaviors.

 

The DBT Distress Tolerance module is designed to provide an alternative to these maladaptive problem-solving and distress tolerance behaviours, that is, teach effective and sustainable distress tolerance skills. The DBT Distress Tolerance module has two sets of skills, Crisis Survival Skills and Reality Acceptance Skills.

 

DBT Distress Tolerance - Crisis Survival skills

The “Crisis Survival Skills” target the ability to tolerate acute painful events and situations, and thus get through the painful situation without resorting to impulsive behaviors that make it all worse. The skill set includes skills to interfere with an impulsive behaviour pattern, reduce arousal in the nervous system, distract, soothe and relax. The DBT Distress Tolerance module emphasizes that not all life is a crisis, and ultimately we need to use the second set of skills, reality acceptance, as well as problem solving, to create a life worth living.

DBT Distress Tolerance - Reality Acceptance skills 

The second set of skills in the DBT Distress Tolerance module is called “Reality Acceptance Skills”. The reality acceptance skills flow from Marsha’s inclusion in DBT of ideas perhaps more often considered by religious and spiritual leaders. These skills teach the ability to accept without judgement or evaluation the reality of one’s self and current situation. The notion here is that the opposite of acceptance, which is of course fighting reality, turns the already present pain into additional suffering. Therefore acceptance is key to distress tolerance. Importantly acceptance does not imply approval or liking. DBT Reality Acceptance skills include the Radical Acceptance skill, which involves a complete and total acceptance of the facts of reality, and skills for turning towards acceptance, developing willingness, accepting reality with the body, and observing thoughts.

The Crisis Survival Skills and the Reality Acceptance Skills help us survive immediate crises without making the situation worse, and accept reality even when it is not the reality we wanted, and together provide increased ability to tolerate the inevitable distresses of life.