DBT Distress Tolerance Skills

Anna Hink, MSW, LICSWClinician Trainer

UW AIMS Center

Learning Objectives

After this training, participants should be ableto:

• Determine when to use DBT’s DistressTolerance skills with your patients

• List the Distress Tolerance skills

• Integrate the use of Distress Tolerance skillsinto your practice

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Case Example: DS

54 y/o Hispanic woman, lives withhusband, some college

Key Complaints“There’s nothing I can do when I’m

in pain; I’m arguing with myhusband all the time; I’m worried

about cancer returning”

OUD. Stopped opioids x1 week.Longstanding anxiety & depressive

symptoms:Baseline PHQ 9 = 10 (mild)

Baseline GAD 7 = 15 (moderate)

Buprenorphine Naloxone 24 8mgqd

Venlafaxine XR 275mg qd

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What Is A Crisis?

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A serious problem thatcan’t be solved right now

Crisis

There is pressure to solvethe problem, and it isdifficult to stop trying

Emotions are high, so theproblem is distressingHigh emotions generally

make things worse

It’s short termIf it is happening all the time,it is not a crisis. It is your life!

Can You Solve The Crisis?

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If Yes…

If No(or not right

now)…

• STOP trying to solve it• Trying to solve the unsolvable can make it

worse or send emotions through the roof• Focus on Distress Tolerance skills

• Stick with it• Don’t take your eye off the ball• Do what it takes!

DT skills aredesigned just foran unsolved crisis

Who Are Distress Tolerance Skills For?

• Pain flares• Frustrations with medical care• Intense emotions• Family conflicts• Housing issues• Money issues• Drugs and alcohol• Dangerous neighborhoods• Long waits for social services

• Large caseloads• Difficult and sick patients• Hearing many traumatic stories• Inability to help their patients• Lack of time or resources to helptheir patients

• Frustrating interactions withsocial services

• Unhelpful rules or regulations• Paperwork

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Patientsface many stressors

Cliniciansface many stressors

Purpose of Distress Tolerance Skills

• Help you survive the crisis by not making thesituation worse

• Not intended to make you feel better (thoughsometimes you might)

• If skills prevent the crisis from getting worse,but you do not feel better don’t stop!– An escalated crisis may make you feel worse

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Ways toWorsena Crisis

Yelling atsomeone

Using drugs oralcohol

“Retailtherapy” withmoney you

can’t afford tospend

Eating toomuch or too

little

Complaining somuch folks

don’t want totalk to you

Giving up onlife

Benefits of Distress Tolerance Skills

• Learn to survive acrisis withoutmaking it worse

• Become moreconfident andcapable ofnavigating futurecrises

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DBT Distress Tolerance: The 4 Steps

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Step 1:BehavioralAssessment

Step 2:Make the Pitch

Step 3:Choose

Strategy &DetermineHomework

Step 4:Follow up,Evaluate andProblem Solve

Step 1: Behavioral AssessmentAsk Three Questions:1. What triggers the distress?– Be behavioral (i.e., talking with a family member,thinking a thought)

2.How did the patient respond to distress?– Be behavioral (i.e., yelled/started a fight, stayed inbed all day)

– Listen for helpful and destructive behaviors3.How did their response make things worse?– From the patient’s perspective (not yours as theprovider)!

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Step 1: Behavioral AssessmentRevisiting Case Example DS1. Triggers

Intense back pain flares for hoursTends to overdo things when feeling better

2. ResponseBedboundDoes not eat or hydrate

3. What Made it Worse“I feel so guilty after I yell at my husband. He’sjust trying to help”

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isolates selfyells at husband

DBT DT: The 4 Steps

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Step 1:BehavioralAssessment

Step 2:Make the Pitch

Step 3:Choose

Strategy &DetermineHomework

Step 4:Follow up,Evaluate andProblem Solve

Step 2: Make the Pitch• Explain the concept of distress tolerance– “These are skills to help you with (1. triggers).You’ve told me you tend to (2. response).”

• Explain the goal of distress tolerance skills– “The goal is to not make things worse. This isvery different than ‘feeling better.’”

– “DT skills help you bring down your emotions soyou think more clearly.”

– “You’ve told me things are worse when you (3.what made it worse).”

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Step 2: Make the PitchRevisiting Case Example DS

“These are skills to help you with the intense painflares you experience. You’ve told me you tend to needto stay in bed for many hours, not eat or drink water,isolate yourself from your family, and yell at yourhusband.

The goal is to not make things worse. This is verydifferent than ‘feeling better.’ DT skills help you bringdown your emotions so you think more clearly. You’vetold me things are worse when you yell at yourhusband.”

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DBT DT: The 4 Steps

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Step 1:BehavioralAssessment

Step 2:Make the Pitch

Step 3:Choose

Strategy &DetermineHomework

Step 4:Follow up,Evaluate andProblem Solve

Step 3: Choosing Strategies

Distress Tolerance skills• Distract

• Self Soothe

• IMPROVE the Moment

How to choose a strategy• Patient preference

• What has worked in the past?

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Distract

• Distraction isdeliberatelyturning yourattention awayfrom the crisis– Remember: WiseMind ACCEPTS

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Activities

Contributing

Comparisons

Opposite Emotions

Pushing Away

ThoughtsSensations

Self Soothing

• How would you comfort a loved one goingthrough a crisis?– Do the same for yourself!

• Don’t make a situation harder by being moreuncomfortable than required– For instance, don’t wear tight shoes to thedentist

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Self Soothe With Five Senses

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Vision Decorate your space, go somewhere inspiringDecorate your space, go somewhere inspiring

Sound Music, soothing voices, nature soundsMusic, soothing voices, nature sounds

Self Soothe With Five Senses (cont’d)

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Smell Cooking, lavender, the beachCooking, lavender, the beach

Touch Comfortable clothes, pet animal, foot massageComfortable clothes, pet animal, foot massage

Taste Favorite food, hard candy/mint, good cup of coffeeFavorite food, hard candy/mint, good cup of coffee

Checkpoint

Think of a time when you experienced a crisisat work:• What distress tolerance strategies have youused?

• What was the impact of using the skill?

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IMPROVE the Moment

• Strategies foraccepting painand reducingsuffering

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Imagery

Meaning

Prayer

Relaxation

One thing in the moment

Vacation

Encouragement

Checkpoint

• What additional skill(s) would you like to try?

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Step 3: Choosing StrategiesRevisiting Case Example DS

• Distraction: watchmovies, listen to music

• Self soothe: sit in acomfortable chair

• IMPROVE the moment:mini break fromhousehold chores,spending quality timewith husband,relaxation, deepbreathing

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Isolates self

Bedbound

Yells at husband

Does not eat

Does not drink

Make a Specific Plan• When planning, consider:

– Date or days of the week– Time of day– For how long?– With whom?– What is Plan B?

• Ask patient:– How likely are you to do this?– What will you do if you don’t feel like doing it?

• The more detailed the plan, the more likely it willbe followed

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DBT DT: The 4 Steps

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Step 1:BehavioralAssessment

Step 2:Make the Pitch

Step 3:Choose

Strategy &DetermineHomework

Step 4:Follow up,Evaluate andProblem Solve

Step 4: Follow up, Evaluate, AndProblem Solve• ALWAYS ask about homework at follow up• Expect patients might not do the homework–What barriers stopped them from doing so?

• Do not judge

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Step 4: Follow up, Evaluate the Outcomeand Problem Solve Barriers (cont’d)

• If they don’ttry DistressTolerance,ask thesethreequestions:

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Do they have buy in to thetreatment?

Did they simply forget?

Did they do the plan, but itdidn’t meet goal?

Strategies For Ambivalence: Pros &Cons

Pros ConsMaking it worse by:• _______________

• •

Tolerating distress by:• ________________

• •

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Revisiting DS Case Example: IntensePain Flare

Pros ConsMaking it worse by:• Staying in bed and

isolating

• won’t have to bearound others andtry to control temper

• not being there forhusband

• not getting support fromothers

• life “on hold”

Tolerating distress by:• Distracting with

activities, self soothing,or choosing toIMPROVE the moment

• emotion may go inthe background

• quality time w/husband

• life continues

• may get more frustratedon top of hurting

• temper may still be anissue

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Tips For Distress Tolerance Skills

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Tip 1: Match Skill To Level Of Distress

• Make sure the DT skill chosen is appropriate for theintensity of the distress– If you have the urge to die, ironing is probably not goingto help!

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Tip 2: Match Skill To Situation

• Distracting with Sensations doesn’t last long– If crisis continues, pair with Activities orContributing

• Distracting with Thoughts lasts for minutes tomaybe an hour– Good for the bus, traffic, staff meetings, or theline at the DMV

• Take a “vacation” for as long as time allows

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Tip 3: Be Wary of Overusing DT Skills• This can make things worse

– Soothing by taste is not a good choice if you eatcompulsively or are gaining weight

– Taking too many vacations = neglecting tasks– Distracting with TV or novels can take over your life

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Tip 4: Don’t Distract When You Can’tAvoid The Situation

• Distraction can seem like the only way to copewhen you can’t solve the problem

• Sometimes you need to stay with the crisis– e.g., staying in class, at your worksite, or with yourchildren or clients

• Remember to Self Soothe and IMPROVE theMoment as much as Distract in these situations

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DBT DT Educational Resources

• Marsha Linehan’s Skills Training Manual forTreating Borderline Personality Disorderhttps://www.guilford.com/books/DBT SkillsTraining Manual/MarshaLinehan/9781462516995/reviews

• Many online resources and handouts bysearching for “DBT distress tolerance”

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Acknowledgments• Kate Comtois, PhD; CHAMMP University of Washington

• Stacy Shaw Welch, PhD; Evidenced Based Treatment Centersof Seattle

• University of Washington AIMS Center

• Mental Health Integration Program

• Community Health Plan of Washington

• Public Health – Seattle & King County

• Washington State Department of Labor & Industries

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