Everyone experiences uncomfortable situations – sitting in a traffic jam, realizing you’re out of coffee as you go to make your morning joe, or having low phone battery without access to a charger. At times in our lives, we suffer through more serious distress and pain, like the end of a relationship, the death of a loved one, or losing a job. Some individuals, especially people with borderline personality disorder – or BPD – feel the pain and discomfort of these situations more keenly than others. In fact, they may feel an overwhelming sense of pain that seems to come from inside, that may not seem to be related to anything happening around them.
If individuals with BPD haven’t learned to use healthy coping skills to tolerate the distress they feel, they may resort to unhealthy behaviors like self-harm, substance use, or other impulsive behaviors that may seem like an immediate “fix”, but in the long-term these behaviors can make the pain worse.
Dialectical behavior therapy – or DBT – is a form of therapy created specifically for individuals with borderline personality disorder. DBT is taught in four modules, including distress tolerance. Through DBT, highly sensitive people learn distress tolerance skills that allow them to navigate uncomfortable or painful situations and manage urges to engage in harmful behaviors. DBT creator Marsha Linehan, divides distress tolerance skills into three categories:
- crisis survival techniques
- sensory body awareness
- reality acceptance
The intensively trained DBT treatment team at Skyland Trail helps clients in our DBT residential treatment program learn and practice these skills as they work toward ending the painful cycle of feeling stuck and out of control. In this blog post, we’ll explore crisis survival skills.
When to Use Crisis Survival Distress Tolerance Skills
Crisis survival skills should be utilized when:
- Someone is experiencing intense pain (physical and emotional) that won’t go away soon.
- An individual wants to act based on emotions that will only make things more difficult.
- A situation is overwhelming, yet there are demands that must be met.
- An individual is extremely stimulated or motivated to resolve an issue that can’t be settled immediately.
Conversely, it’s important to not use the following crisis survival skills for everyday problems or to solve all of the issues that may occur throughout one’s life. Crisis survival skills should be reserved for managing a crisis situation only. If someone wants to change a situation or an emotion, then a different set of DBT skills called emotional regulation skills should be used.
The STOP Skill
The STOP Skill is a great tool to use first in a crisis situation.
S – Stop! Don’t react to whatever stimuli you may be facing. Stay in control of both your emotions and your physical body. Remain still.
T – Take a step back! Remove yourself from the situation. Take a quick break or a deep breath. Don’t act impulsively based on your feelings.
O – Observe! Take a moment to notice your surroundings and environment—both inside and out. How do you feel? What are others doing or saying?
P – Proceed mindfully! Think about your goals in the situation and act with total awareness. What can you do to make the situation better, and what kind of action will make the situation worse?
Pros and Cons
Make a list of the pros and cons of acting on your urges. Examples of acting on your urges might be engaging in dangerous, addictive, or harmful behaviors as well giving in, giving up, or simply avoiding what needs to be done. Make a separate list of pros and cons for what could happen if you resisted those urges.
Carry your list with you and review it often. When a crisis situation or urge for impulsive action arises, reference your list. Consider what has happened in the past when you acted on crisis urges. Use your pros and cons list to help you choose a different course of action this time.
Distracting with Wise Mind ACCEPTS
Sometimes, a great way to see yourself through a crisis situation is to distract yourself from the problem in the short-term. This allows us to step away momentarily and come back refreshed to whatever challenge or crisis we’re facing. It’s important to remember though that there’s a big difference between simply distracting yourself over a short period of time as opposed to consistently avoiding an issue over a longer period of time, which could make things worse.
There are various distracting techniques we can utilize. One way to remember them is the acronym ACCEPTS.
- A – Activities: Watch an episode of your favorite Netflix show, go for a walk or exercise, play video games, clean up a room or area in your home, hang out with a friend or your family, read a book, or complete a puzzle.
- C – Contributing: Sign up to do some volunteer work. Help a buddy or family member with a project. Donate items you no longer need, or simply do something nice for someone else such as providing words of encouragement or giving someone a hug.
- C – Comparisons: Think about how you feel now as compared to a different time. Remember how fortunate you may be, and think of the different people in the world who may be dealing with your same issue.
- E – Emotions: Read an emotional book. Watch an emotional movie. Listen to a powerful song or album. It can be all types of emotions. Watch a scary movie or a comedy or listen to relaxing music.
- P – Pushing away: Whatever the situation is, simply push it to the side for a while. Deny the problem for a moment. Block out painful thoughts or images from your mind and refuse to think about it.
- T – Thoughts: Count something, whether it’s to 10 or the number of flowers in a pot. Repeat words of your favorite song in your head or watch or read something thought-provoking.
- S – Sensations: Squeeze that stress ball. Take a hot or cold shower. Or crank up some loud music.
Self-Soothing with your Five Senses
By focusing on your five senses, you’re shifting the focus of your mind from the stressful situation to something entirely different. This short break helps you reconnect with your entire self and the world around you in a moment of crisis.
- Vision: Stimulate your eyes with something. You can go people-watching or window-shopping. You can build a fire or light a candle and get lost in the flame. You can go to a park and enjoy the visuals of nature. Watch the sunset or sunrise, or check out some art.
- Hearing: Go outside and listen to the leaves in the wind, water flowing through a stream or the honks and beeps of city traffic. Take note of the hums of an air conditioning unit or pick up your favorite instrument for a quick jam session.
- Smell: Burn some incense or a scented candle. Open a window. Take a bath with your favorite soaps or splash on your favorite perfume or cologne.
- Taste: Eat your favorite food or make a soothing cup of tea. Chew a piece of gum or pop that butterscotch candy in your mouth. Whatever you choose, focus on really tasting the food one item at a time.
- Touch: Pet your dog or cat. Sink into a comfy chair. Take a warm bath, or curl up in your favorite blanket. Remember to notice the soothing feeling of whatever it is you’re touching.
Improve the Moment
Another excellent DBT distress tolerance skill that helps with confronting crisis is IMPROVE.
- I – Imagery: Use your imagination to create a relaxing setting or decorate an imaginary room with secure doors and windows to where nothing can hurt you. Make up a calming fantasy world or relive a happy memory moment by moment.
- M – Meaning: Search for the purpose in a painful moment. Focus and repeat the positive aspects in your mind.
- P – Prayer: Open your heart to a supreme being, God, or your own Wise Mind. Ask for strength and put your faith in God or another higher being.
- R – Relaxing actions: Relax in a hot tub. Do some yoga or stretch. Breathe deeply. Relax the muscles in your face.
- O – One thing in the moment: Keep yourself in the moment by focusing all of your attention on what you’re doing.
- V – Vacation: Give yourself a short vacation. Jump in bed and pull the covers over your head. Head to the beach, the woods, the lake, or the river for a day. Turn off your phone, or just sit in a park for a whole afternoon.
- E – Self-encouragement and rethinking: Be your best cheerleader. Say or think of phrases like, “You got this,” “I will be OK,” or “You’re the man!”
The TIPP Skill is unique because it’s physiological. By changing your body chemistry, you’re able to change your thoughts. This is one of the best skills for reducing extreme emotion very quickly.
- T – Tip the Temperature: Put your face in a bowl of ice water or hold a zip-lock bag of ice to your face, eyes, cheeks and temples.
- I – Intense Exercise: Use all of that stored up physical energy that your emotions are creating and channel it into something like running, lifting weights, or playing a physically demanding sport. Work up a good sweat.
- P – Paced Breathing: Slow your breathing down. Take big deep breathes in through your nose and exhale for even longer periods through your mouth. Focus. Try breathing in for five seconds and then breathe out for 7 seconds. Repeat for as long as you feel necessary.
- P – Paired Muscle Relaxation: While breathing in, tense the muscles in your body. Take note of how that tension feels. When you breathe out, let go of that tension and notice the change in your body. Try it just using the muscles in your legs or your arms then move onto other muscle groups.
Another great physiological trick to use when you’re in a crisis is cold water. Hold your face under cold water for 15 to 30 seconds. This triggers a response by your brain that is referred to as the “dive response.” Essentially, your brain literally thinks you’re diving underwater. To compensate and protect your body, your brain slows down your heart rate. Blood flow to your extremities is slowed and blood is redirected to vital areas of your heart and brain. This can be a very effective skill to use when you’re experiencing extreme or very strong emotions or urges to engage in particularly dangerous or harmful behavior. Find a safe, quiet place to try it for yourself.
At Skyland Trail, we use dialectical behavior therapy to help individuals regulate their emotions and responses to stimuli. DBT is one of the most researched treatments for borderline personality disorder and is significantly effective in reducing harmful thinking, behaviors, and impulsivity. Clients admitting to our residential psychiatric treatment programs aren’t given a one-size-fits all treatment plan. Our integrated treatment teams utilize a combination of individual and group psychotherapy, expressive therapies, pastoral counseling, and physical activity to help clients find recovery from mental illness and get back to a life worth living.
These DBT Distress Tolerance skills can be found in DBT Skills Training Handouts and Worksheets, Second Edition, by Marsha Linehan.