Distress Tolerance

Imagine this scenario. You wake up feeling very well rested, enjoy the most delicious breakfast you’ve had, and find the train ride to work a breeze. But when you arrive at work, you are called by your manager and are informed that you are being laid off.

Even if you are in full control of yourself, there are things that are beyond your control. These painful events, which will be called “crises'' in this article, are a normal part of life. Everyone will experience extreme emotional distress like depression, anger, or fear.

This is where distress tolerance skills come into play.

Distress tolerance is your ability to manage actual or perceived emotional distress. Whether the crisis is big or small, your tolerance determines how you decide to manage the situation. Distress tolerance skills help you build those tolerance muscles so you are more well-equipped whenever these crises come.

Distress Tolerance as a DBT Module

One of the modules of Dialectical Behavior Therapy (DBT) focuses on developing distress tolerance skills. This is crucial because emotional crises can continue to occur even while you actively work on other aspects of your psyche.

With the skills listed in this module, you can learn how to cope with these crises and accept them without making them worse.

This page currently lists 13 skills to master in DBT Distress Tolerance.

The Distress Tolerance skills are divided into three sub-skills: “Crisis Survival Strategies”, 
“Reality Acceptance Skills”, and “Tolerance Building”.

1. 1

   Crisis survival strategies: These skills are intended to help you get through immediate and intense emotional pain without making the situation worse. Note that these are not designed to solve the crisis, but to survive it.
   

   • exercise T1: Cost Benefit Analysis Helps you assess what problematic behaviors are costing you and whether it is worth making a change.
   • exercise T3: Distracting Activities Create a list of distracting activities to use when you start to approach an emotional crisis.
   • exercise T4: RESISTT Technique Techniques to help you deal with unhealthy urges during emotional crises.
   • exercise T5: Grounding Reconnect with the present moment when thoughts about the past or future are becoming unproductive.
   • exercise T8: Grounding Use your five senses to help reduce out-of-control emotions.
   • exercise T10: TIPP Calm emotions with Temperature, Intense exercise, Paced breathing, and Progressive muscle relaxation.

1. 2

   Reality Acceptance skills: These skills focus on accepting reality as it is, not as you want it to be, which is crucial in reducing the suffering caused by non-acceptance.
   

   • exercise T6: Willingness vs. Willfulness See how to approach situations flexibly to become more effective.
   • exercise T7: Radical Acceptance Learn how to become accepting of realities without unproductive emotions.
   • exercise T9: Actions Based on Values Aligning your actions with values helps you deal with difficult situations.

2. 3

   Tolerance Building: This involves developing your tolerance for distress.
   

   • exercise T2: Recognizing Emotional Crisis Learn to detect when an emotional crisis is starting.

In practicing the distress tolerance skills found on this page, you gain tools to calm yourself in challenging situations, reducing the likelihood of impulsive actions driven by intense feelings.

These skill building exercises include practicing techniques like distraction (focusing your mind on something other than the distress), self-soothing (engaging in activities that are comforting), and radical acceptance (accepting the reality).

By mastering these skills, you're better equipped to handle moments of extreme anxiety, fear, anger, frustration, and discomfort! This leads you to a more balanced emotional state and improved overall mental health.

How Does Printable Distress Tolerance Worksheets Work With Therapy?

Printable distress tolerance worksheets are valuable tools in therapy. Here's how they contribute to the therapeutic process:

• Structured Learning and Practice. These worksheets provide a structured way for clients to learn and practice distress tolerance skills. The exercises, prompts and guides help you understand how to apply the techniques. They can be used during therapy sessions or practiced on your own at home.
• Enhancing Self-awareness. As you work through the worksheets, you become more aware of your emotional triggers and responses. The worksheets may ask you to reflect on past experiences of distress, identify your usual reactions, and consider more effective coping strategies.
• Reinforcing Skills Learned in Therapy. Worksheets are an extension of the skills you have learned so far, like mindfulness, by allowing you to apply what you have learned so far.
• Personalized Approach: Therapists can select or customize worksheets that best fit your specific needs and challenges to make the process more personalized and effective.

DBT emphasizes a variety of practical and effective strategies for diverting your attention away from intense emotions, such as:

• Engaging in regular physical activity helps you apply the skills found in Distracting Activities and TIPP. You do not have to enroll in a gym – walking or running daily around the neighborhood or just doing some jumping jacks at home will do.
• Volunteering at a shelter or participating in a drive is a beneficial way to engage in Distracting Activities, a key concept in managing intense emotions. By focusing your efforts on helping others, you shift your attention away from distressing thoughts and feelings.
• Implementing self-soothing techniques that you have learned is a vital step in calming yourself during times of stress or emotional upheaval. These techniques, including deep breathing, mindfulness meditation, or engaging in a comforting activity, are designed to reduce anxiety and promote relaxation.
• Make it a point to affirm what you most need to hear each day. Choose affirmations that resonate with you and feel authentic. Examples include, “I possess more bravery than I realize” and “I am capable of tackling difficult challenges.”

How Do You Build Distress Tolerance?

Apart from engaging with the exercises, watching the videos, and completing the worksheets provided in our DBT skills section, there are several other strategies that you can use to build your distress tolerance:

• Practice Mindfulness. Remember the first module? Regular application of the mindfulness techniques keeps you in the present moment, priming yourself for managing distress emotions, thoughts, and feelings.
• Develop Healthy Coping Mechanisms. The easiest is to engage with activities like joining a club, or gym or taking up home hobbies. Having a trusted friend or getting a therapist you can talk to is also a great option!
• Learn and Apply Acceptance Skills. Sometimes, accepting things as they are, rather than fighting them, is crucial. Techniques like radical acceptance can be powerful in helping you manage distress.
• Set Realistic Goals. Set small goals to start your journey, then gradually build up as you become confident with your newfound skills. For example, you can practice mindful breathing for five minutes but gradually increase it to ten when you are comfortable.
• Celebrate Small Wins. When you reach a goal or a first, remember to celebrate! This will motivate you to continue and focus on meeting more wins.

Distress tolerance and emotion regulation are both modules of DBT, but they serve distinct functions.

Distress tolerance is all about helping you withstand negative emotions or stressful situations without becoming overwhelmed. It focuses on equipping you with tools to endure emotional pain in situations when a solution isn't possible.

Emotion regulation, on the other hand,  involves helping you understand, accept, and effectively manage emotions. It's about experiencing emotions appropriately and expressing them in a healthy way.

The DBT Distress Tolerance skills and exercises found on this site are also suitable for teenagers. We suggest you give them a try!

Numerous indicators can suggest that you have low frustration tolerance. Here are a list of questions that can help you determine whether you have a low distress tolerance:

• Do you find yourself avoiding challenging emotions, people, or situations?
• Do you tend to react excessively or inappropriately in certain situations?
• Do you notice a lack of interest or curiosity in things around you?
• Do you overlook or disregard the emotions of others?
• Do you often become angry quickly?
• Are you prone to showing irritability or moodiness?
• Do you seek immediate satisfaction and show impatience for the results?
• Do you adopt a pessimistic outlook or frequently exaggerate negative aspects?
• Are you often impatient with people and circumstances?
• Do you hold beliefs that are not supported by scientific or logical reasoning?

If you find yourself answering “yes” to most of these, you probably have low distress tolerance.

If you answered “no” to these, you have a high distress tolerance.

It is very worthwhile to teach children distress tolerance. Kids who can handle emotional distress well can easily control their emotions and connect well with other people. Here are some ideas to engage kids in when moments of emotional crises occur:

• Square Breathing: Coach the kid to breathe in, hold, breathe out, hold, each lasting about four seconds. For smaller children, it could be effective to help them imagine they are blowing a bubble.
• Playing, Running, and Jumping: Running, jumping, and playtime can keep the children off the emotional crisis (intense exercise part of TIPPS). Playing along could also help younger children.
• Dancing: Time to play that fun nursery rhyme! Dancing can also be a great way to teach children distress tolerance. Movement is a part of self-soothing activities.
• Read or Make up Stories: This is another distracting activity. Joining them in engaging a story also helps a lot!
• Drawing or Coloring:  Art can be a great way for kids to express their emotions and calm their minds.

• NIH National Library of Medicine. "Distress Tolerance and Psychopathological Symptoms and Disorders: A Review of Empirical Literature among Adults"
• NIH National Library of Medicine. "Mindfulness as taught in Dialectical Behaviour Therapy:
  A scoping review"
• Linehan, Marsha. "Why Distress Tolerance Skills Are Necessary"
• Idaho Youth Ranch. "5 DBT Skills to Help Your Kids Manage Stress"