wise mind accepts

Work hard. Play hard. But you know what else? Laugh hard. Love harder.
—  Nicole Addison @thepowerwithin
Distress Tolerance: Distract with Wise Mind ACCEPTS

This is a skills of Distraction.  It might not solve the problem, but it will help you get through the painful experience and get in a better emotional state to solve the problem.  

ACCEPTS:

A: Activities - do something else, something you enjoy.  It can be anything from listening to music, coloring, walking, watching TV, or cleaning.

C: Contributing - take your mind off of yourself by volunteering, making something for someone else

C: Comparison - this is best described as ‘counting your blessings’.  Make a gratitude list.

E: Emotions - try to replace the negative emotion with a more positive emotion.

P: Pushing Away - physically leave the situation if you can, if it’s an emotion, push the emotion away by focusing on other things

T: Thoughts - think of something else, think of positive things

S: Sensations - focus on an extreme sensation instead of an extreme emotion; for example, put your face in a bowl of ice water, hold ice, take a cold shower.

Short Description of DBT Skills

This is just a short directory to explain, in one sentence or two, what these concepts mean, and what the use of each skill is by defining it.  Come to this page if you can’t remember what IMPROVE or DEAR MAN stands for, but don’t want to have to read the long post that introduced those skills on SBD.

See the DBT Skills Masterpost for posts that go into each of these skills or sets of skills in depth.

Mindfulness Skills:

  • Wise Mind: The Wise Mind is the balance between Emotion Mind and Logic/Reasonable Mind
  • Observe: Notice without getting caught in the experience.  Experience without reacting to the experience.
  • Describe: When a feeling or thought arises, or you act, acknowledge it with a description of the thought or action or sensation, etc.  Describe to yourself what is happening and label your feelings.
  • Participate: Enter into your experiences, act intuitively, be completely immersed in the experience, in the present.
  • Non-Judgmental: See, but don’t evaluate.  Focus on the “what” happened, not on what “should” or “should not” have happened.
  • One-Mindful: Focus on the moment–do one thing at a time and completely focus on what you are doing or whom you are with.  Let go of distractions.
  • Effective:  Do just what is necessary in a situation to achieve your goals.  Focus on what works, and direct your efforts there.  Act skillfully, because the more you practice acting skillfully, the more Effective you will become at attaining your goals.

Distress Tolerance Skills:

  • STOP:  Stop, Take a step back, Observe, Proceed Mindfully
  • TIP: Temperature, Intense Exercise, Paced Breathing/Paired Muscle Relaxation/Progressive Muscle Relaxation (used to change your level of distress quickly)
  • Distract using Wise Mind ACCEPTS: Distract yourself with Activities, Contributing, Comparisons, Emotions, Pushing away, Thoughts, Sensations
  • Self-Soothe: Use the senses (vision, hearing, taste, smell, touch) to soothe your physical self in order to make your emotions less painful.
  • IMPROVE the Moment: Improve the moment with Imagery, Meaning, Prayer, Relaxation, One thing in the moment, Vacations, Encouragement
  • Pros and Cons: Examine the short term and long term pros and cons of acting and not acting on your urges/impulses using a chart.
  • Radical Acceptance/Reality Acknowledgement: Acknowledge what is, let go of fighting or denying reality.  Use TURNING THE MIND to commit to acknowledgement over and over again.

Interpersonal Effectiveness Skills:

  • Clarified Priorities: What is most important to you in this interpersonal interaction 1) Obtaining your objective, 2) Maintaining the relationship, or 3) Maintaining your self-esteem/sense of self-worth
  • DEAR MAN: Describe, Express, Assert, Reinforce, stay Mindful, Appear confident, Negotiate (used for saying “no” or asking for something; obtaining your objective)
  • GIVE: Be Gentle, act/be Interested, Validate, use an Easy manner (used for maintaining a relationship)
  • FAST: Be Fair, no Apologies, Stick to values, be Truthful (used to maintain your self-esteem/sense of self-worth)

Emotion Regulation Skills:

  • PLEASE: For reducing vulnerability, treat PhysicaL illness, balance Eating, avoid mood-Alerting drugs (as in street drugs or non-prescription drugs), balance Sleep, get Exercise
  • ABC: Accumulate Positive Emotions/Experiences: For reducing vulnerabilities in the Short Term: Do pleasant things that are possible now.  For reducing vulnerabilities in the Long Term: Make changes in your life so that positive events will occur more often.  This helps “build a life worth living for you.”
  • ABC: Build Mastery: Engage in activities that make you feel competent and in control.
  • ABC: Cope Ahead: Cope ahead of time with emotional situations.  Rehearse a plan ahead of time so that you are prepared to cope skillfully with emotional situations.
  • Opposite Action: Change emotions by acting opposite to current emotions/urges. Used for when emotions don’t fit the facts of a situation.
  • Check the Facts: Check out whether your reactions (emotional or behavioural) fit the facts of the situation.  Changing beliefs and assumptions to fit the facts can help you change your emotional reactions to situations.
  • Problem Solve: When the facts themselves are the problem, solving emotional problems consistently and effectively will reduce the frequency of negative emotions and increase your sense of competency in regards to dealing with these emotions/urges.

-Pandora

DBT Skills To Use For Better Body Image

Raise your hand if you have struggled or are struggling with body image.  OK, good, so lots of people.  The majority of people are going to struggle with body image at some point in their lives, whether it’s feeling like they are not good enough based upon media representations, dealing with a disability or disfigurement, or struggling with body dysmorphia and/or an eating disorder.

There are some DBT skills that can be really helpful when dealing with crappy body image.  The ones I have found most helpful are Wise Mind, Radical Acceptance, and Opposite Action.  

In regards to wise mind, it’s important to recognize when you are in an emotional state of mind regarding body image.  If you are upset about your body, you are in an emotional state of mind, and therefore may not make the best decisions in regards to having a healthy body.  This could range from restricting your food intake, to self-injury, to overeating.  So, it’s important to recognize when you are emotional and to try to not make decisions until you have rationalized the emotions and are in wise mind, the synthesis of recognizing and accepting your emotions and being reasonable about them.

Radical acceptance is probably one of the best skills to use when you are having trouble with body image.  Basically, it is saying that you need to accept your current situation/body for what it is in the present time.  Accepting it non-judgmentally and with an open mind.  Radical acceptance also deals with accepting that everything has a cause.  Your body may look a certain way or you may perceive your body a certain way for a specific reason.  It’s important to recognize the cause buy not dwell on it.  The final steps of radical acceptance focus on recognizing that no matter how your body looks in the present moment, you still have a life worth living.  You will not be worth more if your body were different.  Turn the mind towards acceptance and be willing (instead of willful) to try to radically accept your body.

Opposite action is a final skill that is helpful when dealing with negative body image.  It deals with acting opposite to the negative emotions you are feeling towards your body.  This can be anything from wearing clothes you might not be comfortable in for an exposure, eating that meal you don’t think you need, doing something nice for your body (like a warm bath or favorite scented lotion).  Acting opposite to the emotions that make us want to harm our bodies more.

Self-acceptance is nothing more than a shift in consciousness. It requires only a change of mind. If you hair is falling out, then you have the choice to mask it, worry about it or accept it. Acceptance means that you really have to do nothing. You honor your body and the divine intelligence that is at work. When someone else implies that you have a problem because your hair is falling out, you don’t know even know how to relate to their observation. Acceptance removes the label of “problem.
—  Wayne W. Dyer
As you work towards self improvement, be sure to do it with positive intention. Don’t change yourself as a form of punishment, but solely to become a stronger, kinder, and wiser person as a whole.
—  Nicole Addison @thepowerwithin
There is some truth to DBT.

Lately I’ve been on the fence about all the DBT skills and stuff. I mean I’ve known it all since 12th grade, I have two binders filled with skills handouts from the two rounds of DBT group that I went through, and yet here I am still feeling stuck. So I was just all, “DBT skills don’t work, this is dumb, why try if nothing helps?” That kind of emotion-mind thinking.

But then after the experience I just had (refer to previous post, it doesn’t sound like a big deal but it was for me), I googled “Wise Mind ACCEPTS”, which is the DBT skill for distracting. It’s an acronym for activities, contributing, comparing, opposite emotions, pushing away, distract with other thoughts, and sensations.

I was reading about this on some DBT self-help page and something that was written there really hit me: “All of these are strategies help us to get though difficult feelings and situations, to tolerate (deal with, get through, sit with, accept) the things that we can’t immediately change.” 

I used to be so against distractions. Like hey, after I do the distraction I’m right back where I started, so what’s the point? But this statement from the website really resonated with me and made me realize: these distractions are not supposed to make all the bad stuff go away. They are just meant to get us through the moment. To sit with the emotions. To “ride the wave”, as every therapist likes to say. No, the emotions and feelings will not disappear. But these are crisis survival skills. 

Metaphor time (cuz I’m a nut who loves metaphors): let’s say that a boat you are on is sinking. You are stuck in the freezing cold ocean and you can easily drown. Suddenly you see something to float on (Think Titanic, although that’s depressing. Oops.) so you grab it and climb on. 

Is the boat still sinking? Yes. Are you still in the water? Yes. But you are floating. You are getting through it. You are surviving.

I think that is the most important part to these skills. Don’t go into it thinking that everything will change in that moment and you’ll be fine. Because then you’re just setting yourself up for disappointment. Recognize that the situation sucks but you are doing whatever you can to tolerate it – to not be broken down.

To stay above the water.

DBT Skills and Related Information Masterpost 2.0

All the content in this post uses the Skills Training Manual (Second Edition) by Marsha Linehan as the basis of every post on skills and concepts.  Rather than just copying out what is written in the Manual, I’ve elaborated on these skills, concepts, and their components using what has been taught to me in my DBT group sessions as well as my own personal understanding of the skills.  Nevertheless, the Manual is the basis and starting point of all the posts here except for the “Other Information” section.  Everything that is covered in the Manual’s Skills component will eventually be covered in posts contained in this masterpost.

General DBT Information:

Mindfulness:

Distress Tolerance and Radical Acceptance:

Interpersonal Effectiveness:

Emotion Regulation:

Other Information:

NOTE: This post will be updated on a semi-regular basis as we add more DBT posts to the blog. If you’re seeing a reblogged version of this, be sure to check the original post to see if it has been updated.  This is a Work In Progress and will be updated regularly as I write more posts.   Each time I write a post, it will get immediately added to the list.  

Also additional posts may be added that are not already included on this list.  Now that the inbox has been re-opened, feel free to request one of the topics on this list that you would like me to prioritize.  I’m currently in the process of learning the Emotion Regulation unit, so those posts are likely a couple weeks away at least and I won’t be able to get to them if they’re requested until I’ve learned about them in my DBT group.

This post will be reblogged every time four or five new DBT posts have been added to it, so that you can have an up-to-date record.

-Pandora

Life experience is different for each person you comes across. It is through these events in our lives that we learn how to handle certain things. We develop our values and beliefs. We grow, and ultimately gain a deeper sense of appreciation for life itself. Each of us develops these aspects at a different pace, and thus we must be patient with one another as we follow our own journey through this wonderful thing called life.
—  Nicole Addison @thepowerwithin
When life gives you a hundred reasons to cry, show life that you have a thousand reasons to smile.
—  Unknown Author
Distress Tolerance Skills: the TIP skill

The second Distress Tolerance Skill I’m going to cover is called TIP.  TIP is an incredibly useful skill for changing your emotional state very quickly.  It’s one of my favourite skills because of how effective it is for the job it’s intended to do.

When you’re in a crisis or an extremely emotionally distressing situation, people who have BPD end up entering a state of mind called “Emotion Mind”. Emotion Mind is a mental state where you are controlled by your emotions and your decision-making is dependent on your emotions and your need to satisfy you urges. Sometimes in extreme cases, the level of emotional distress you experience can cause you ability to use skills to break down.  Since TIP is so easy, it can be used to help you recover your ability to use other skills and tolerate distress that would otherwise be intolerable. 

TIP is a skill that can calm you down quickly enough that you can then pair this skill with another Distress Tolerance Skill to be able to exit the state of Emotion Mind and enter the state of Wise Mind instead.  It’s an incredibly useful skill all on its own, and when paired with other skills it becomes even better.

TIP means:

  • T stands for Tip your body temperature:  The goal here is to use cold temperatures to flip your “dive reflex” or “dive response” which will slow your heart-rate down and generally make you feel “zen.”  This effectively lowers the intensity of high-energy emotions like anger and rage and fear.  The core of the skill is cooling your face, primarily your temples, for 30 seconds while holding your breath.  There are 3 main ways to do this:
  1. Fill up a basin with cold water, hold your breath, and then dunk your face in the cold water for 30 seconds. It’s important that your temples are submerged.  The water can be just regular cold tap water, and shouldn’t be any colder than 10 degrees Celsius (but seriously who is going to stick a thermometer into their water to check how cold it is when they’re in a serious amount of distress? No one)
  2. Cover your forehead and temples with an ice-pack, though you might not be able to endure 30 seconds of something that cold.  Be careful not to give yourself a brain freeze! Again, make sure you hold your breath while you do this.
  3. Rub an ice cube on your face, going under your eyes, over your temple, across your forehead, down your other temple, and under your other eye, and then follow the same path in reverse.  Again, do this for 30 seconds while holding your breath.  Holding your breath while doing this is very important or it won’t work properly.
  • I stands for Intense Exercise: this is good for both high-energy emotions like anger and fear, but also for low-energy emotions like sadness.  When you’re feeling a high-energy emotion, doing intense exercise raises your heart-rate but quickly tires you out so that you don’t have the energy to feel so intensely mad or scared.  Conversely, if you were experiencing a low-energy emotion and then used Intense Exercise to change your emotional state, your increased heart-rate will cause you to feel invigorated and momentarily snap out of the depressed feeling that results from intense sadness or lethargy.
  • P stands for three things Paced Breathing, Paired Muscle Relaxation, and Progressive Muscle Relaxation.  
  1. Paced Breathing: What you do is you place a hand on your belly and inhale so that your belly fills up like a balloon (diaphragm breathing).  You breathe in to a count of four (doesn’t have to be four seconds, it can be longer depending on the rhythm at which you breathe), you hold your breath at the very top of your inhale for a couple seconds, and then you exhale for as long as you can (more than 4 counts).  This will regulate your breathing and calm you down.  Even though this works rather quickly, don’t get to focused on wanting it to work fast because you might end up speeding up the rhythm of your breath, which would render the skill ineffective.  Paced Breathing works so well because when you’re focusing on your breathing, you’re not focusing on the problem.  It’s also very discreet.
  2. Paired Muscle Relaxation: Paired Muscle Relaxation is doing Paced Breathing while doing elements of Progressive Muscle Relaxation.  You do the breathing regulation of Paced Breathing while clenching all your muscles on the inhale as tightly as you can, and then during the pause at the top say “Relax” and then, on the exhale, release all your tensed muscles.   This is really relaxing if you do it right, because again, when you’re focusing on your breathing, you’re not focusing on the problem.
  3. Progressive Muscle Relaxation: Progressive Muscle Relaxation means tensing your muscles in groups, starting from your feet and working your way up your body to your head and your face.  For each group of muscles, you tense them as tightly as you can, and then you release them.  Then you move on to the next set of muscles and do the process again.  You continue doing this all the way up your body. Then at the end, I like to finish it off by tensing my whole body very tightly, say “Relax” in my mind or out loud, and then release the tension.  This really helps on emotions like anger or anxiety which cause tenseness naturally.

It’s important to note that TIP is not a set of steps (i.e. you don’t do the T and then the I and then the P).  You choose one of these options as the method you’re going to use to calm yourself down. If that method doesn’t work, you can try another option from the list, but be careful not to do some of them too close together (particularly if one of the one’s you’ve tried is the I)–basically you want to be safe when you’re doing this, you don’t want to elevate or lower your heart-rate to a dangerous level.

If you want to calm down as fast as possible, the T or the P would be the most effective, with the T being the fastest to work.  The T is my go-to skill when I have a crisis at home, or if I’m in an environment where I have the access to ice or the ability to fill a sink. The I is good for getting a little more distance from a crisis situation, though it can be hard to find an opportunity to use it when you’re in a crisis.  For example, there have been times where I’ve been having an argument with my parents, I’ve told them that I need a break, and then I put on my gear and go for a run.  But when I have a breakdown when I’m out of the house and don’t have the ability to start exercising intensely, using the I is not an option but using one of the P’s would be. Both of the P’s are really good if you need to calm down quickly but discreetly.

TIP is a good skill to use after you’ve had to use STOP because TIP doesn’t require you to do much thinking, so if you’re skills have reached the point where they’re breaking down because of the amount of stress you’re under and how upset you are as a result and therefore no longer have the capacity to do anything complicated or complex, TIP is still something that is usually going to be within your capacity to do, precisely because the T and the P especially are simple processes that don’t require you to do much thinking or processing.  The I can also be easy to do when your skills are breaking down (like my example of going for a run), but if your skills are breaking down that badly, the I may not be a safe thing to do.  It’ll be hard to use your good judgement (which comes from your Wise Mind) when you’re in a skills breakdown scenario, so my general rule is to not use the I if my ability to process information is severely compromised during a skills breakdown.

TIP enables you to become calm enough that sometimes you can leave your Emotion Mind and can then access your Wise Mind, which is a state of mind where both emotions/values and reason/logic have equal importance. (Sometimes you can’t leave Emotion Mind and enter Wise Mind until you’ve used additional skills.) From there, you can use other Distress Tolerance Skills (like Distract using Wise Mind ACCEPTS, Self-Soothe, and IMPROVE the Moment) to regain your ability to tolerate distress and lower your vulnerability to distress, which will then give you the capacity to use problem solving skills (including Emotion Regulation Skills and Interpersonal Effectiveness Skills) to address and resolve the crisis, or you can use Radical Acceptance to accept a crisis that you do not have the power to change.

As my DBT Group leader calls it, TIP is the “big red hammer” of Distress Tolerance Skills because it so effectively and quickly breaks down the distress that we feel during a crisis.  Of course, you can also use TIP when you’re not in a “crisis” but are still experiencing extreme emotional distress.  I would suggest practicing the T when you’re not in crisis mode so that you become familiar with what engaging your “dive reflex” feels like.  It’s an odd sensation and I don’t want you to be alarmed by it if you’ve never experienced it before.

Further Reading: Intro to Distress Tolerance (What is a Crisis, When to Use Distress Tolerance Skills, and the Goals of Distress Tolerance), The STOP Skill, What Is Radical Acceptance, How to Practice Radical Acceptance, Emotion Mind and Wise Mind

TL;DR: TIP is a very useful Distress Tolerance Skill for calming yourself down very quickly, and often discreetly.  TIP stands for: 1) Tip your body Temperature, 2) Intense Exercise, and 3) Paced Breathing, Paired Muscle Relaxation, or Progressive Muscle Relaxation. 

TIP is a skill that is easy to use even when you are in a state of extreme distress and you’re experiencing a cognitive and skills breakdown, because TIP doesn’t require much thinking.  It can be paired with a number of other Distress Tolerance Skills to make it more effective and help you to leave Emotion Mind and enter your Wise Mind so that you can resolve the problem that caused you the distress that you needed to use TIP to cope with.

-Pandora

Distress Tolerance Skills: the STOP skill

The very first skill covered in the Distress Tolerance unit of DBT is called the STOP skill.  It’s an acronym, like many of the skills in DBT and in the Distress Tolerance unit in particular.  It is a very simple skill, and when it’s first introduced, some people (myself included) feel like it’s a little condescending because it’s so simple, but actually, it’s a really helpful skill for people with BPD to learn because our brains are particularly bad at doing this on their own.  While people that don’t have BPD are often able to use this skill naturally when they’re experiencing an emotionally intense and distressing moment, our brains just… don’t.

What happens to people who have BPD is that during moments where we experience extreme emotional intensity, we enter a state of mind that DBT calls “Emotion Mind.”  It is a state of mind where our emotions are totally in control of us and we disregard reason, logic, and facts.  All that matters when we’re in Emotion Mind is how we feel in the moment.  Emotion Mind also makes us very vulnerable to our urges and to acting impulsively in order to satisfy our immediate desires right now, even if those desires and urges are harmful to us or will have negative consequences.  So, when we’re in a crisis and get stuck in this mental state where we are particularly vulnerable to acting impulsively, we often can’t “stop” ourselves from doing things that we later regret. This is why we have to train our brains to “stop” because Emotion Mind won’t “stop” on its own.

STOP stands for the following:

  • Stop: Literally stop.  Freeze.  Pause.  Breathe.  Your emotions will try to make you act or continue to act without thinking, so do not react while you’re using the STOP skill.  Sometimes it helps to visualize a big red stop sign, something that will make you pause.
  • Take A Step Back: Take a mental step back from the situation.  Sometimes it helps to take a literal step back, because physical cues can inform emotional cues.   Take a break from the situation for a moment.  Pause your feelings for this moment.  Basically you don’t want to find yourself acting impulsively while you try to use this skill, so detaching yourself from the situation momentarily can give you perspective, or just breathing room.
  • Observe: Essentially you want to look at the situation as if you’ve pressed the “pause” button.  Notice what is happening, within you and outside of you.  Notice your needs in this situation, notice your urges. Pausing the situation, including the emotions you feel and the urges they can be causing, often helps deescalate the intensity of your emotions.  Basically with this step you’re giving yourself some more mental breathing room.  The Mindfulness Skill of Observe is helpful in this situation, though it’s more general than the Observe that is part of STOP.
  • Proceed Mindfully:  This also means proceed effectively. Proceeding effectively means doing what the situation requires to achieve your goals, both short term and long term goals. Act with awareness.  In deciding what to do, consider your thoughts and feelings, the situation, and other peoples’ thoughts and feelings. Ask yourself which actions will make things better or worse? Consider the consequences.

The STOP skill could mean a brief mental pause, or it could mean walking out of the room for a few minutes, or it could mean stopping the situation entirely, depending on what you think would be the healthiest thing to do, and depending on your level of control over a situation (sometimes walking out is just not an option, for example).  Also, you can “STOP” even if the other people in the crisis situation are not “stopping.”  It’s hard, but possible.

“Proceeding Mindfully” usually means figuring out a brief plan of action so that you remain mindful of your goals rather than get caught up in needing to satisfy your urges.  This can be particularly hard because sometimes we might not even be aware of what our goals are during a crisis because we’re too overwhelmed with urges.  But ultimately the biggest goal in the face of a crisis is to survive the crisis without making it worse.

So, “Proceeding Mindfully” essentially means figuring out a simple plan for how you can get through this intense moment without making it worse.  Usually this means getting yourself into a position where you’re able to use other Distress Tolerance Skills to further deescalate the situation and prevent you from engaging in impulsive behaviour that will result in negative consequences for you or other people.  The STOP skill is essentially a bridge to get you from Emotion Mind to a place where you can use other skills to eventually get you to Wise Mind. 

STOP is the skill we use when our capacity to use other skills has broken down severely due to our emotions. Basically it’s the only skillful thing we’re capable of doing. That’s why STOP is so simple.  Therefore, you want to use STOP in order to respond to the crisis rather than react to the crisis, because using a skill means you have an end goal in mind.  If you can use STOP to deescalate a situation or even better, get yourself away from a situation, your end goal for using STOP should be getting you to a place where you have recovered enough of your ability to use skills to use another (or multiple) Distress Tolerance Skill, and these include TIP, Pros and Cons, Distract using Wise Mind ACCEPTS, Self-Soothe, and IMPROVE the Moment

A particularly good skill to use after STOP is TIP, to calm yourself quickly. I personally like to use TIP and then follow it up with either Distract using Wise Mind ACCEPTS or Self-Soothe, or both!  This gets me out of Emotion Mind and into Wise Mind quite well when paired with Mindfulness Skills.  (All these skills will be covered here on SBD in the coming weeks.)

And then, eventually once you use Distress Tolerance Skills to calm yourself down and tolerate the distress until it reaches a manageable level, you can then use problem solving skills to respond to the crisis or, if you can’t change the situation, use Radical Acceptance/Reality Acknowledgement skills to accept what happened that you can’t change.

You can practice “STOPing” during less intense moments, even just during moments in your daily life, so you get used to responding this way.  That way, when you need to use STOP in a crisis, you’ll have had practice with it and the skill will come more easily to you when otherwise it might be extremely difficult to remember.

Further Reading: Intro to Distress Tolerance, What Is Radical Acceptance / Reality Acknowledgement, How do you Practice Radical Acceptance / Reality Acknowledgement, The TIP Skill, Intro to Mindfulness, Emotion Mind and Wise Mind, Mindfulness “What” Skills, Mindfulness “How” Skills    

TL;DR: In this post we covered STOP, the most basic and entry-level Distress Tolerance Skill.  It’s to be used when our ability to use all other skills has broken down and this is our only way left to be skillful.  STOP stands for: 1) Stop, 2) Take a Step Back, 3) Observe, and 4) Proceed Mindfully

When you Proceed Mindfully you want to create a brief plan that has your goals in mind (chiefly, to not make the crisis worse). STOP is then used as a bridge to get you from a distressing, crisis situation to a place where you can use other skills to calm yourself and solve the problem or Radically Accept the problem.

-Pandora

Intro to Distress Tolerance: What Is A Crisis, When To Use Crisis Survival Skills / Distress Tolerance Skills, and the Goals of Distress Tolerance

As you all are likely very aware, when you have BPD you experience a lot of highly distressing moments that can be characterized as a “crisis.”  It’s in these moments that we need to use Crisis Survival Skills, also known as Distress Tolerance Skills, to, unsurprisingly, survive the crisis and tolerate the distress we feel.  Distress Tolerance is one of the four main modules of DBT, and the skills taught in this module are your first line of defense against painful and intense emotions and the urges that might accompany them.

In order to know when to use these skills, you first have to determine whether you’re in a crisis. Crises warrant the use of distress tolerance skills, which include a variety of techniques such as self-soothing, distraction, or pushing yourself away (but not continuously “running away”) from the crisis.  You are in a crisis when the situation is:

  1. Highly stressful
  2. Short-term (as in, it won’t last a long time)
  3. Creates intense pressure to resolve the crisis immediately (which can mean making the stress stop as well as meaning solving the problem)

So, to use an example I’ve used before, a conflict between yourself and a coworker at work could be a crisis, but feeling stressed about having to go to work in general would not be a crisis.  

When you’re in a crisis, this stressful and often painful situation causes intense emotional arousal, and the intensity of your emotions or your distress essentially causes your other skills (like Mindfulness Skills, Interpersonal Effectiveness Skills, and problem solving skills) to break down in this moment, which is where the Distress Tolerance Skills come into play.  This set of skills is meant to be used in highly stressful, short-term situations–by definition, a crisis–so you can get yourself back to a place where you can function and resolve the situation.

The main goal of using Distress Tolerance Skills is to, obviously, tolerate distress.  That means bringing down the intensity of your distress to a level where you can actually address the problem or accept the situation and move on from it (this usually means using Radical Acceptance / Reality Acknowledgement, which is a Distress Tolerance Skill).  It doesn’t mean avoiding addressing or accepting the situation, but it does mean that you can distract yourself from the intensity of your distress so that you can ultimately use other skills (like Emotion Regulation Skills or problem solving skills) to help yourself get out of/resolve a stressful situation–in this case, the crisis you’re experiencing.

According to the DBT Skills Training Manual, you can decide to use crisis survival skills/Distress Tolerance Skills when:

  1. You have intense pain that cannot be helped quickly
  2. You want to act on your emotions, but it will only make things worse
  3. “Emotion mind” threatens to overwhelm you and you need to stay skillful
  4. You are overwhelmed, yet demands must be met
  5. Arousal is extreme, but problems can’t be solved immediately

Often we use a scale called Subjective Units of Distress to measure the level of distress on a scale from 0 to 100 at the beginning of the crisis (where you distress is likely very high) and then measure the level of distress after you’ve used Distress Tolerance Skills (where the goal is to lower your distress on the scale).  Where you begin on this scale can help you determine which Distress Tolerance Skill to use.

We can’t use crisis survival skills/distress tolerance skills to avoid everyday problems because avoidance doesn’t help us lead a functional life.  Avoidance means not trying to problem-solve and just indefinitely putting off addressing the situation in a meaningful way.  You also can’t use Distress Tolerance Skills to change your life in a meaningful way, which means these skills can’t be used to help you build a life that you feel is worth living.  They can improve your quality of life, yes, but only momentarily, not long-term.

It’s possible to end up using Distress Tolerance Skills too much and using them in situations where you don’t actually need them.  This is unhealthy and doesn’t move your life forward or get your any further in your recovery (if recovery is something you’re working towards).  It can be easy to fall into a pattern of using these skills as a crutch that you fall back on when confronted with even the slightest challenge, which not only keeps you stuck in a constant loop of distraction and self-soothing, but it also reduces the effectiveness of these skills when a true crisis arises and you really need these skills.   Here is a post I wrote that gives some guidelines for how to tell whether you’re using Distress Tolerance Skills in an unhealthy or ineffective way.

DBT is all about walking the middle path and finding balance.  This means using your Wise Mind.  There are four modules to DBT Skills, and those are Mindfulness, Distress Tolerance, Emotion Regulation, and Interpersonal Effectiveness.  If you imagine a teeter-totter or a beam balanced on a fulcrum in the middle, Distress Tolerance and Mindfulness would be on one side, representing skills for staying in the moment, and Emotion Regulation and Interpersonal Effectiveness would be on the other side, representing skills for changing things in your life in a positive way.  All four modules are meant to be used together, so that the teeter-totter, or the beam, stays in balance, rather than tipping to one side or the other. 

The middle path of DBT means validating what you feel in the moment, but also learning how to change things in your life to improve these moments in order to live a happier and more stable life.

Therefore, each module has a different set of goals for what they aim to achieve in your life.

The goals of Distress Tolerance as a skill set is to help you do the following three things:

  1. Survive crisis situations without making them worse
  2. Accept reality, where you replace suffering with simply “Ordinary Pain” and the possibility of moving forward
  3. Become free of having to satisfy the demands of your own desires, urges, and intense emotions

Distress Tolerance Skills don’t help you heal from a painful situation/crisis, but some of them can be the very beginning of the healing process. These skills are also meant to give you the breathing room you need in order to use actual problem solving skills to either fix the situation, or accept the situation and move on from it.  

One of the not explicitly stated but equally important goal of using Distress Tolerance skills is that they give you the breathing room required to be able to access your Wise Mind so that you can make sound, non-impulsive decisions that are not determined by your urges.

I would also like to point out that, while not addressed in DBT, you can also use Distress Tolerance Skills on low-spoon days to help replenish your emotional reserves so that you have the spoons to do other things in your life.  Particularly useful Distress Tolerance Skills for this would be Distract using Wise Mind ACCEPTS, Self-Soothe, and IMPROVE the Moment.  So there are other times besides when you’re in a crisis when it’s appropriate to use Distress Tolerance Skills. 

Further Reading: How Do I Know When to Use Distress Tolerance Skills vs When I’m Using Them in an Unhealthy Way?, Distress Tolerance: The STOP Skill, Distress Tolerance: The TIP Skill, What Is Radical Acceptance / Reality Acknowledgement, Willingness, Half-Smiling and Willing Hands, Spoons Theory 

TL;DR: A crisis is a highly stressful short-term situation that you want to resolve or end immediately.  Distress Tolerance Skills are used to manage intense emotions and urges during a crisis, and can also be used to replenish your spoons on low-spoon days.  Distress Tolerance Skills don’t actually fix the problem or resolve the crisis, but they give you the breathing room you need to lower the intensity of your distress so that you can use other skills to get you out of the crisis.  The main goal of Distress Tolerance is to survive the crisis.

-Pandora