Dialectical Behavior Therapy : Distress Tolerance Overview  



By Tara Arnold, Ph.D., LCSW

Dialectical behavior therapy or DBT is an offspring of cognitive behavior therapy that incorporates Eastern meditative practices.  The dialectic comes from the synthesis of opposites, particularly acceptance and change that is a tenet core of the DBT philosophy.  We accept ourselves as good enough, and we recognize the need for all of us change and grow.  These two concepts could seem contradictory, but through the persuasive dialogue, or dialectic, we can understand the seemingly opposing truths side by side. 

DBT is taught as a series of skills in four modules: mindfulness, interpersonal effectiveness, emotional regulation, and distress tolerance.  We are going to explore distress tolerance in the current article.  In most approaches to treatment, we are taught to avoid painful situations, so in distress tolerance, there is a premise that we must be in stressful situations at times thus we must learn to experience the pain.  We need to learn to accept, tolerate, and find meaning for distress.  In addition, simply learning to change creates distress, so we have to learn distress tolerance in order to change without sabotaging the change when we get uncomfortable. 

The skills in distress tolerance are learning to tolerate and survive crises and accepting life in the moment without making it worse.  Distress tolerance emphasizes the point that at times, when we try to avoid pain, it can make certain situations worse (Deepak Choprah states that holding on to past pleasure is addiction, holding on to past pain is anxiety).  Some people try to prove how bad a situation is making it worse.

There are four methods of crisis survival distracting, self-soothing, improving the moment, and focusing on pros and cons.  Each of these methods helps us to cope with intense painful emotions and difficult situations.  The first of these methods is Distracting with ACCEPTS.  Distracting is important because it helps reduce exposure to painful stimuli.  A- is for activities- distracting by doing other tasks to keep your focus elsewhere.  C- is for contributing or doing things for others.  By contributing, we often have positive experience or make more meaning out of life, thus making our life seem more worthwhile.  C- is for comparisons to those less fortunate producing often a sense of gratitude.  E- is for emotions and is taught by identifying the current emotion and trying to do things to produce an opposite emotion.  P- is for pushing away through leaving the situation or blocking the events in your mind (this can feel similar to dissociating or depersonalizing, and it should only be used in emergencies, and thus not overused).  T- is using thoughts to distract by filling our short- term memory with other thoughts to interfere with the presence of negative thoughts.  Last, S- is for sensations because using multiple senses can decrease the intensity of the other senses (like holding an ice cube to distract and decrease painful emotions). 

The second method of distress tolerance is Self-soothing using the five senses.  Self-soothing is similar to being kind, gentle, and nuturing to oneself.  We use each of our senses to engage a comforting response.  Using vision to self soothe would be finding beautiful things to look at- art, nature, flowers, etc.  Hearing would be listening to sounds we enjoy like running water, waves at the beach, or our favorite music.  To use our sense of smell for self- soothing, we could burn candles, bake bread, go into the forest to be exposed to our favorite smells.  For utilizing our taste senses, we could have mints, candy, or eat your favorite meal.  Last, for touch we can self- soothe by petting animals, rubbing lotion on our body, or cuddling with a blanket on the couch. Self -soothing is a wonderful way to nurture yourself and help to create resilience from intense emotions.  Some people resist self- soothing out of guilt or feelings they do not deserve to pamper themselves, so it is important to detract from these rationalizations and emphasize skill development.

The third distress tolerance skill is improving the moment using the acronym IMPROVE.  I- is for imagery which is used to distract, soothe, bolster confidence and courage and make future rewards seem more tangible.  With imagery you shift from the current situation.  M- is for making meaning out of difficult situations in order to accept the situation more readily.  P- is for prayer.  We pray to be fully open in the moment (not praying to take away the suffering or ask why).  R- is for relaxing. By de-stressing the body we can often experience less pain.  O- is for One thing in the moment, which is a mindfulness skill used to help focus on one thing in the moment in a crisis so we do not get overwhelmed and feel worse.  (this can be similar to AA’s idea of one minute at a time, one day at a time, etc).  V- is for vacation from adulthood.  It is to be used  when it will not make our situation worse.  You can take a mental break from a stressful situation and play online, think of a positive event, etc.  E- is for encouragement by talking to yourself gently and positively to help get through the situation. 

The final distress tolerance skill is pros and cons.  Pros and cons is a valuable skill in evaluating the decision of tolerating the distress (not making the situation worse) or not tolerating distress (i.e. suicide, self harm, using).  This helps people evaluate the long term benefit of learning to tolerate pain.  It is important to look at short- term and long- term pros and cons to each decision.

Overall, distress tolerance skills help build a repertoire of methods to use on a regular basis to enhance our ability to cope with life’s challenges.  The more often we use these skills, we refine them for our own personal use, and they become more and more effective.  Confident in our ability to cope can actually decrease our emotional intensity and build mastery and self esteem.  By practicing these skills, we create a life worth living that is increasingly pleasurable and manageable. 

If you have questions about DBT or want to inquire about groups or consultation, please call Dr Tara Arnold at 404-964-6629.  


Linehan, M.  (1993).  Skills Training Manual for Treating Borderline Personality Disorder.  Guilford:  New York.

- By Tara Arnold, Ph.D., LCSW


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