5 DBT Distress Tolerance Skills For Depression, Anxiety & PTSD

5 DBT Distress Tolerance Skills For Depression, Anxiety & PTSD 5 DBT Distress Tolerance Skills For Depression, Anxiety & PTSD

If you have depression, anxiety, PTSD and/or another mental health illness or issue, then there will almost certainly be times when you find yourself experiencing distress. For example:

  • When your depression is so strong that you can’t envision there ever being better days ahead;
  • When your anxiety is so intense that you can no longer function;
  • When you’re so overwhelmed and stressed out that you’re bawling your eyes out;
  • When you’re re-living traumatic memories or having a flashback to a traumatic experience;
  • When you’re consumed with rage.

And, during moments of intense distress such as these, as you may be able to relate to, it’s common for people to try to cope in unhealthy ways – such as by, for example:

  • Numbing yourself with alcohol and/or drugs;
  • Binge eating or starving yourself;
  • Overspending on “retail therapy”;
  • Avoidance (for example, by suppressing your thoughts or avoiding any situation that scares you);
  • Taking your overwhelming emotions (for example anger, frustration, etcetera) out on one or more people who don’t deserve it;
  • Self-harm;
  • Resigning yourself to a joyless life that consists of nothing but suffering.

However, while unhealthy coping methods such as these may give you some temporary relief from distress in the short-term, they ultimately end up causing you even more pain and suffering in the long-term. Consequently, it’s extremely helpful to know some distress tolerance skills1 – which, as you may already know, are one of the four core skill components of dialectical behaviour therapy (which is a specialised form of cognitive behavioural therapy, and one that’s been shown to be highly effective at treating depression, anxiety, PTSD, borderline personality disorder, substance abuse and various other mental health issues1).

In particular, distress tolerance skills can help you to cope with distress in a healthy way that not only gives you short-term relief, but that also doesn’t compound your distress in the long-term.

And, with this objective in mind, in this blog post, we're going to share with you 5 DBT distress tolerance skills!

Are you ready?

DBT Distress Tolerance Skill #1: The S.T.O.P. Skill

The first distress tolerance strategy we’d like to share with you is “S.T.O.P.” – which is an acronym that stands for “Stop”, “Take a step back”, “Observe”, and “Proceed mindfully”. This is a simple, straightforward strategy that, the next time you find yourself feeling distressed, can be implemented as follows:

DBT S.T.O.P. Skill Part 1: STOP

Like we just said, the “S” in “S.T.O.P.” stands for “stop”, which can be extremely worthwhile when you’re feeling distressed as it can prevent you from acting in an impulsive, unhealthy way that you’ll later regret. In the heat of the moment, it can take the form of, for example, literally saying the word “stop”, taking a few deep breaths to centre yourself, or freezing on the spot.

DBT S.T.O.P. Skill Part 2: TAKE A STEP BACK

This is about giving yourself a break from the distressing situation you’re in. In practice, it may take the form of, for example:

  • Leaving the room if you’re in a heated argument;
  • Moving from the kitchen to another room if you were about to binge eat;
  • Turning off your phone if you were considering engaging in “retail therapy”;
  • Reminding yourself that you do not want to engage in the same unhealthy habits that you’ve previously resorted to engaging in, and that this time, you want to do something different (even though you may not be sure what that “something different” is yet).

DBT S.T.O.P. Skill Part 3: OBSERVE

This involves trying to gain clarity on the situation you’re in. For example, by considering questions such as:

  • What is happening here?
  • What am I thinking and feeling?
  • What are the facts of the situation I’m in?
  • Does this situation warrant getting this distressed about? Or, am I getting distressed about something relatively trivial that if I didn’t have depression / anxiety / PTSD / another mental health issue and therefore wasn’t already dealing with so much, would probably not bother me at all?
  • What options are available to me right now? What are the pros and cons of engaging in each?
  • Which of the options available to me would end up making everything worse in the end (even if they would make me feel temporarily better right now)?
  • Which of the options available to me would help me deal with the distress I’m feeling in a way that I won’t later regret, and that aligns with the person who I want to be?

DBT S.T.O.P. Skill Part 4: PROCEED MINDFULLY

This involves adopting your chosen course of action in a mindful way.

A FAQ About The DBT S.T.O.P. Skill: "Won't this be hard to implement in the heat of the moment?"

Right now, it may seem hard to envision yourself implementing this strategy in a distressing situation – because, for example:

  • It may seem like too much to do in the heat of the moment when you’re overwhelmed with distress;
  • Similarly, you may think that, when you’re overwhelmed with distress, you won’t be able to remember to implement this strategy.

However:

  • While this strategy may feel like too much to do in the heat of the moment right now, the more you practice it, the easier and easier you will find it, and in time, it can become second nature to you.
  • Additionally, to help you remember to use the S.T.O.P. strategy in a distressing situation, try to do something to remind yourself of it in some way. For example, if you’re prone to binge eating when you feel distressed, you could write S.T.O.P. on a post-it note and stick it to your fridge. Alternatively, if you’re prone to using your phone to engage in overspending on “retail therapy”, you could have S.T.O.P. written on your background / screensaver.

Lastly, please keep in mind that you may need to use S.T.O.P. more than once in any given situation in order for it to work as well as it can1. This is because the course of action you initially choose may not achieve its desired result. If this happens, then repeat the S.T.O.P. process again – this time choosing a new way to mindfully proceed. There is no limit to how many times you can use this strategy in a given situation, so we encourage you to continue doing so until the situation has either been resolved, or until you can effectively extract yourself from it1.

DBT Distress Tolerance Skill #2: Radical Acceptance

Radical acceptance involves accepting that a difficult, painful, challenging situation unfortunately is what it is, and, rather than, for example, continuously wishing that it wasn’t so, wishing that you were someone else who doesn’t have this problem, and/or telling yourself how bad your life is and how everyone else’s life is so much better, instead trying your best to focus your attention on how you can healthily deal with the situation, and move forwards as effectively as possible2.

Why is this worth doing?

Because, when you’re going through a difficult, challenging, painful experience, as natural, understandable and human as it can be to wish that things were different, to wish that you were someone else who doesn’t have these problems, and/or to keep on telling yourself how bad your life is and how everyone else’s life is so much better, doing so won’t actually fix or improve the situation you’re in. On the contrary, all it’s likely to do is add to your suffering, and divert your attention away from fixing- or making the best of the circumstances you’re faced with.

Consequently, practicing radical acceptance is a more fruitful alternative. Not only can doing so help you to avoid a lot of this “additional suffering”, but by keeping you focused on how you can healthily deal with the situation you’re in as effectively as possible, it also gives you the best possible chance for a brighter future.

Now, with all of that being said, to see how radical acceptance can work in practice, let’s have a look at a few different examples from our CBT-based journal "Everybody's Life Is Not Better Than Yours" - which we wrote to help people cope with the common negative thought "everybody's life is so much better than mine".

Everybody's Life Is Not Better Than Yours

Free excerpt

DBT Radical Acceptance Skill Example #1: Being Ripped Off

Imagine that for the last six months, you’ve been saving up to go on your dream vacation. However, one morning you wake up, check your bank balance, and then realise that $500 is missing from your account. As it turns out, you’ve been the victim of a debit card scam. You spend all day on the phone to the bank, but in the end, there’s nothing they can do. Your $500 is gone, and there’s unfortunately no chance of you ever getting it back.

Now, if this happened, you may feel a range of emotions, such as, for example:

  • Anger, rage and fury – at the scammer for stealing your hard-earned money, and perhaps at the bank for not being able to help you get your money back.
  • Frustration – at wasting your entire day on the phone to the bank (particularly when, as it turned out, they weren’t even able to fix the problem and return your money to you).
  • Sadness and misery – because you were supposed to go on your holiday in two months’ time, but without that $500, you won’t be able to afford it.
  • Additionally, you may also experience negative thoughts like “I’m so unlucky in life … everyone else’s is so much better than mine”.

However, moving forwards, you have a choice:

  1. You could spend the next two months until your planned holiday date filled with anger at the scammer, continuously dwelling on how unfair the situation is, wishing you were someone else who hadn’t been ripped off and who was able to go on their dream vacation, and telling yourself again and again how unlucky you are in life and how much better everyone else’s life is than yours.
  2. Alternatively, you could say to yourself: “OK, what happened to me is really upsetting, wrong, and not something that I deserved at all. However, there is absolutely nothing I can do about it, and all feeling angry, wishing I was someone else, and/or telling myself how unlucky I am and how everyone else’s life is so much better than mine is going to do is make me even more miserable than I already am, and plunge me into another depressive episode. So instead, I’m going to accept what happened, do my best not to obsess and dwell over it, and focus all of my energy on trying to move forwards and deal with this setback as best as I can.”

Now, in this example, the first option will almost certainly compound your suffering – and, because there’s little-to-no thought being given to how to move forwards as effectively as possible and make the best of the situation you’re in, you’re much less likely to overcome the setback you’ve experienced (i.e. it’s likely that you’ll miss out on your holiday, which will of course compound your suffering even more). On the other hand, however, the second option – i.e. practicing radical acceptance – will limit your suffering, and because all of your energy is being focused on trying to move forwards and deal with the situation you’re in as effectively as possible, you’re also much more likely to make the best of it (which, for example, may involve taking on some extra shifts at work to make $400 and then borrowing $100 from a friend – so that you can still end up going on your dream vacation).

DBT Radical Acceptance Skill Example #2: Losing Your Job

In this example, imagine that you’ve recently lost your job – while meanwhile, your sister’s business is thriving, your best friend has gotten a promotion, and all your other friends are employed. In this case, the emotions you may feel include:

  • Disappointment and shame – as a result of losing your job;
  • Worry and fear – about how long it will take you to find a new job, and about what the financial implications of being unemployed may be;
  • Envy and jealousy – of your sister’s and your best friend’s success, and because all your other friends are employed when you aren’t.

Furthermore, in a situation such as this, you may feel extremely prone to ruminating on thoughts such as: “I wish I had a successful business like my sister”; “I wish I’d gotten a promotion like my best friend”; “I wish I was employed like all of my friends are”; “my life is such a mess right now”; and/or “everybody else’s life is so much better than mine”. However, as natural as this can be, continuously wishing that your circumstances were different, continuously wishing you were someone else who doesn’t have the problems you have, and continuously telling yourself how bad your life is and how everybody else’s life is so much better will – once again – only serve to make you feel even worse. Consequently, you’re once again much better off doing your very best to practice radical acceptance, and focus all of your attention on trying to healthily deal with the situation you’re in as effectively as possible. In practice, this may take the form of, for example:

  • Updating your resume;
  • Searching for new jobs and immediately applying to every single one that’s relevant to you;
  • Applying for unemployment benefits;
  • Assessing your finances and putting together a budget to minimise how much you eat into your savings while you’re looking for work;
  • Making the most of the increased free time you likely now have, and doing things that you’d previously been too busy working to do – such as, for example, fixing that broken draw in the kitchen, reading the book about cognitive behavioural therapy you’d bought the previous month to help with your depression, planting a new collection of flowers and plants in your garden, and/or spending some more time with your loved ones.

DBT Radical Acceptance Skill Example #3: Being Diagnosed With An Illness

In this example, let’s say that you’ve been diagnosed with an illness that isn’t terminal, but will at times result in you experiencing moderate levels of pain and discomfort, will lead to you feeling tired more easily than you otherwise would, and will make it harder for you to do the hobbies that you’ve customarily enjoyed. Now, while being diagnosed with such an illness will likely be very upsetting for you, the degree to which you suffer as a result of it will be influenced by how you handle this diagnosis. In particular:

  1. You could spend endless hours wishing that you’d never been diagnosed with this illness, dwelling on how much harder your life now is as a result of it, telling yourself how unfair it is that you’re the one who got sick when most of your friends live more unhealthily than you do, and telling yourself how bad your life is and how all your friends’ lives are so much better.
  2. Or, you could practice radical acceptance, by telling yourself: “No matter how much I wish I didn’t have this illness, I do, and no amount of wishing it wasn’t so or negatively comparing my life to my friends’ lives is going to change my reality. In fact, living with this illness is going to be challenging enough, so the last thing I want to do is to compound this challenge by engaging in unhelpful self-talk and negative comparisons with others. Instead, I’m much better off firstly, accepting that I am where I am; secondly, focusing my energy on coping with this illness as best as I can – so that I can minimise the impact it has on my life; and thirdly, cultivating the best life possible for myself in spite of this illness – such as by developing new hobbies and finding new interests that are more suitable to my health than my previous ones are.”

Yet again, as you can hopefully see, practicing radical acceptance in this situation will limit your suffering as opposed to compound it, and can help to quieten negative thoughts like “my life is so bad” and “all my friends’ lives are so much better that mine”. And, by focusing on how to move forwards as effectively as possible and make the best of the situation you’re in, you’re much more likely to do just that.

End of free excerpt

What The DBT Radical Acceptance Skill Is Not

Radical acceptance can be a difficult concept to grasp, and for this reason, it’s common for there to be misconceptions surrounding it. Consequently, it’s important to note in particular that:

  • Radical acceptance does not mean being helpless and doing nothing to change a difficult, painful, challenging situation2. Quite the opposite, actually – such as in our first example, where radical acceptance actually paved the way to making the best of the situation, and finding alternative ways of regaining the stolen $500 so that you could still go on your dream vacation. In fact, as this example shows, you can’t actually change something that you don’t accept2, and once you do accept reality as being what it is, you empower yourself to be able to make the best of the situation you’re in moving forwards.
  • Radical acceptance does not mean that you approve of bad behaviour2. After all, in our first example once again, there was no approval given to being robbed – and nor should there have been. Remember, radical acceptance involves accepting that what has happened has happened, and focusing your energy on healthily dealing with the situation and moving forwards as effectively as possible. And, it is indeed possible to do this without approving of bad behaviour that was directed towards you.
  • Radical acceptance does not involve denying or neglecting all of the emotions that arise due to a difficult, painful, challenging experience – such as anger, misery, worry, fear, and each of the other emotions we mentioned in the above examples. Again, practicing radical acceptance just involves accepting that a difficult, painful, challenging situation is what it is, and trying your best to focus your attention on healthily dealing with it and moving forwards as effectively as possible. And, in the course of doing so, you can and almost certainly will feel all of the emotions that that difficult, painful, challenging situation gives rise to.

Tips For Practicing This DBT Radical Acceptance Skill

Because it can amount to a new way of thinking, practicing radical acceptance can be challenging at first. However, the following tips can help you to gradually get used to it.

  1. Firstly, when you’re just starting out with it, you may find it extremely difficult to practice radical acceptance when it comes to particularly challenging situations (such as losing your job like in our second example or being diagnosed with a life-altering illness like in our third example). Consequently, when you’re just starting out, it can help to begin practicing radical acceptance in relatively minor situations3 – such as, for example, when you come home to realise that the bread you just bought at the supermarket was stale, when you get a flat tire on the way to work, or when you find yourself stuck in traffic. Then, once you get more and more used to practicing radical acceptance, you can “build up”, so to speak, to more difficult, painful, challenging situations.
  2. Secondly, when you’re first starting to practice radical acceptance, you may find it helpful at times to repeat a supportive affirmation to yourself1. For example: “I choose to focus on what I can control moving forwards, not on what’s already happened in the past"; “I choose not to dwell on painful thoughts and emotions which will hurt me not serve me"; or “there’s no useful purpose getting distressed about something that I can’t change.”

DBT Distress Tolerance Skill #3: Distraction Skills

In many cases, distraction can be a useful method of tolerating distress4 - such as by, for example:

  • Watching your favourite television show;
  • Listening to music;
  • Playing with a pet;
  • Doing a jigsaw puzzle;
  • Reading a book;
  • Drawing.

In saying this, however, it's important to note that:

  • When you’re using distraction as a distress tolerance strategy, it’s important that you do so mindfully3 - i.e. where you are solely focused on the distraction activity that you have chosen. After all, if you’re still focusing on your distress while you’re engaging in your distraction activity of choice – such as if you were continuing to brood on your anger while going for a run, for example – then it’s not actually distracting you from your distress.
  • Additionally, please be careful not to overuse distraction as a strategy. After all, while it can be effective in helping you tolerate distress in the short-term, it is not a long-term solution to problems, and in this way, it runs the risk of being overused in situations where it would be much more helpful to problem solve that situation or to reframe your perception of it4.

DBT Distress Tolerance Skill #4: Engaging With A Cold Sensation (AKA "Cold Water Skills")

Yet another effective distress tolerance strategy can be to engage with a cold sensation – for example, by:

  • Dunking your face in icy-cold water;
  • Having a cold shower;
  • Placing an ice pack between your shoulder blades or on your forehead;
  • Holding an ice cube;
  • Wrapping your hands around an icy-cold drink.

Strategies such as these can be very effective at helping you manage distress, because they can turn on your nervous system’s relaxation response and slow your heart rate5. Furthermore, a physiological distress tolerance strategy such as this one can at times be preferable to some of the previous strategies that we’ve looked at – since it doesn’t require any form of thinking or analysis.

In saying that, though, depending on how you choose to implement this technique, it may be sensible to consult with a medical professional (particularly if you’re pregnant or dealing with a health issue, for example).

DBT Distress Tolerance Skill #5: Progressive Muscle Relaxation

Yet another physiological distress tolerance strategy, progressive muscle relaxation is a stress-relieving technique that involves tensing and relaxing individual muscle groups. In addition to helping you feel more relaxed and better able to tolerate distress1, progressive muscle relaxation also has physical health benefits6, and has proven effective at relieving symptoms of anxiety7 and depression8, as well as improving quality of sleep9. Moreover, when The Depression Project asked it’s 1,000,000+ person Facebook community to share how they dealt with anxiety and distress, practicing progressive muscle relaxation was a common response.

Now, in order to practice progressive muscle relaxation, please try the following exercise:

  1. Make sure you’re sitting or lying down in a comfortable place where you will not be disturbed.
  2. Then, begin by taking several slow, deep breaths, before bringing your attention to your forehead. Tighten the muscles in your forehead for a count of 15, and then release this tension over 30 seconds. Tune in to how different your muscles feel when you tense them compared to when they’re relaxed
  3. Next, move on to your jaw. Tense your jaw muscles and grit your teeth gently. Hold this for 15 seconds, then relax for a count of 30, or until your jaw muscles are fully relaxed.
  4. The next muscle group to focus on is your shoulders and neck. Tense your shoulders, bringing them up as close to your ears as possible. Again, hold this for 15 seconds, before releasing the tension as you count to 30, and feel how the tension seeps out of your body.
  5. Now, focus on your hands and arms. Ball your hands into fists and bring them into your chest, holding this tension for 15 seconds. Pay attention to the relaxing sensation when you release the pressure over a 30 second period.
  6. Focus on your buttocks, repeating the 15-second tension and 30-second relaxation sequence before moving on to your legs, and then finally, to your feet.

As you progress through this exercise, keep your breathing slow. At its conclusion, before you open your eyes and carry on with your day, notice the feeling of relaxation throughout your body. If you’re like many people, then you will indeed find yourself feeling calmer and less distressed.

If you're fighting depression, anxiety, PTSD and/or another mental health issue, then we really hope you find practicing these 5 DBT distress tolerance skills helpful!

All our love,

The Depression Project Team.

References

McKay, M., Wood, J. C., & Brantley, J. (2019). The Dialectical Behavior Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance. New Harbinger Publications.

Linehan, M. M. (2014). DBT Skills Training Manual. The Guilford Press.

Pederson, L. & Pederson, C. (2019). The Expanded Dialectical Behavior Therapy Skills Training Manual, 2nd Edition: DBT for Self-Help and Individual & Group Treatment Settings. PESI Publishing.

Astrachan-Fletcher, E., & Maslar, M. (2009). The Dialectical Behavior Therapy Skills Workbook for Bulimia: Using DBT to Break the Cycle and Regain Control of Your Life. New Harbinger Publications.

Kinoshita, T., Nagata, S., Baba, R., Kohmoto, T., & Iwagaki, S. (2006). Cold-Water Face Immersion Per Se Elicits Cardiac Parasympathetic Activity. Circulation Journal, 70(6), 773-776.

Mateu, M., Alda, O., Inda, M. D., Margarit, C., Ajo, R., Morales, D., Van-Der Hofstadt, C. J., & Peiró, A. M. (2018). Randomized, Controlled, Crossover Study of Self-administered Jacobson Relaxation in Chronic, Nonspecific, Low-back Pain. Alternative Therapies In Health And Medicine, 24(6), 22–30.

Manzoni, G. M., Pagnini, F., Castelnuovo, G., & Molinari, E. (2008). Relaxation Training For Anxiety: A Ten-Years Systematic Review With Meta-Analysis. BMC Psychiatry, 8(1).

Merakou, K., Tsoukas, K., Stavrinos, G., Amanaki, E., Daleziou, A., Kourmousi, N., Stamatelopoulou, G., Spourdalaki, E., & Barbouni, A. (2019). The Effect of Progressive Muscle Relaxation on Emotional Competence: Depression–Anxiety–Stress, Sense of Coherence, Health-Related Quality of Life, and Well-Being of Unemployed People in Greece: An Intervention Study. EXPLORE, 15(1), 38–46.

Harorani, M., Davodabady, F., Masmouei, B., & Barati, N. (2020). The Effect Of Progressive Muscle Relaxation On Anxiety And Sleep Quality In Burn Patients: A Randomized Clinical Trial. Burns, 46(5), 1107–1113.

P.S. If you'd like to learn more about how to tolerate distress, then we encourage you to take our Distress Tolerance Bootcamp, in which:

  • You’ll learn 18 DBT strategies that can help you tolerate distress in a wide variety of situations;
  • Then, after sharing all of these healthy strategies with you, we’ll help you to develop your own personalised distress tolerance plan – for you to implement moving forwards any time you feel distressed.
The DBT Distress Tolerance Bootcamp

Access to this Bootcamp and lots of others are included as part of our Depression Bootcamps Membership Platform - which you can learn more about by clicking the button below.