Surviving a Crisis: Dialectical Behavior Therapy (DBT) Distress Tolerance Skills
I take my 3 year old to gymnastics once a week and while she is in class I sit in the waiting area with the other parents. One of the mom's is a talker and her conversation is invariably the same: her brain tumor, the surgery, the medications, the pain and being unable to have more children. Listening to her, it is clear that she is in the midst of a life crisis. Luckily her prognosis looks good, but she is young and is still struggling with the sudden and unexpected changes brought on by this health scare.
In an unpredictable world where we don't have complete control over our environment, our health or the people around us, we are all sure to experience times of crisis. It can come in many forms and can be both big and small. Crisis can be those moments when we're faced with mortality, financial disaster, the loss of a job, failure to achieve or meet our own or others expectations, accidents, being a victim of abuse or a crime and moments of embarrassment, to name a few. Whatever form it takes, crisis is unexpected and accompanied by overwhelming emotion.
Some people seem to survive a crisis and, having survived, emerge even stronger. Others are overpowered by emotion, debilitated by circumstances and find themselves escaping into negative and destructive behaviors, like addiction or self harm. Distress tolerance skills in Dialectical Behavior Therapy are designed as short term strategies for surviving the upheaval caused by crisis. They are essential life skills that help us get through those moments that we're not sure we'll survive otherwise.
What are Distress Tolerance Skills?
Distress Tolerance skills are separated into two different types of strategies: strategies to accept life in the moment and strategies to tolerate and survive the crisis. The "acceptance" strategies have to do with the ability to accept non-judgmentally yourself and the current situation. The assumption behind these skills is that pain and distress are a part of life and that avoiding and denying this fact leads to increased pain and suffering. The "crisis survival" strategies focus on finding ways to survive and tolerate the moment without engaging in problem behaviors.
It is a not true that if we simply refuse to accept and tolerate a situation it will magically change. We resist accepting situations because it means accepting that we have not gotten what we want, that things have not turned out the way we want and that we are faced with a situation that is painful and scary. However, acknowledging, enduring and accepting painful situations decreases, rather than increases the pain we suffer.
DBT acceptance skills include specific activities for becoming more accepting, as well as principles for understanding and accepting reality. The activities include breathing exercises, half-smiling exercises and awareness exercises. Each of these exercises is intended to help you accept and tolerate yourself, the world and reality. The basic acceptance principles include radical acceptance, turning the mind and willingness. These principles are designed to help you let go of fighting reality and to choose to accept and respond to the situation as it is, not as you want it to be.
Crisis Survival Skills
Crisis survival skills are about doing what works to get through the moment of crisis. They are concrete skills designed to help you get through a situation without making it worse. The four sets of crisis survival skills include distracting, self-soothing, improving the moment, and thinking of pros and cons. These skills are designed to reduce contact with things that upset you, help you comfort and nurture yourself, improve how you are thinking about the crisis and help you stay motivated to get through the crisis.
Research on avoidance indicates fear and avoidance of trigger cues are common in Post Traumatic Stress Disorder (PTSD) and other anxiety disorders. Suppressing and avoiding all contact with and cues of pain ensure that the pain will continue. However, there are also times when it is healthy to distract yourself from pain. Crisis situations and the pain they cause cannot always be immediately processed. Some situations call for us to be able to function, despite the crisis that we are currently experiencing. It is at these times that crisis survival skills are essential. In the short term, they are effective in getting through those difficult moments. They can help us return to work and school and survive day to day life, despite emotional pain.
Etkin, A. & Wager, T. D., (2007). Functional Neuroimaging of Anxiety: A Meta-Analysis of Emotional Processing in PTSD, Social Anxiety Disorder, and Specific Phobia. American Journal of Psychiatry, 164, 1476-1488.
Linehann M. M. (1993). Skills Training Manual for Treating Borderline Personality Disorder. New York: The Guilford Press.