The first module proper I will be talking about is distress tolerance. Distress tolerance is not intended to solve problems. It’s not even intended to make you feel better about problems. Sometimes, you are in a situation, it sucks, and you can’t do anything about it; there’s nothing for it but to endure until the situation resolves on its own. However, because the universe hates us and wants us to be unhappy, you usually have a whole bunch of exciting ways to make the situation worse. So that’s what distress tolerance is about. Hold on, stay alive, don’t give yourself 100 problems when you started out with 99.
This post is about crisis survival; the next post will be about radical acceptance, and the post after that about compulsive behavior.
Crisis survival techniques are for crises. If a problem happens to you every day, it is what is technically referred to as a ‘routine life problem’, and you need a different technique to deal with it– namely, the technique of “figuring out why you are having a crisis every day and how you can stop because that sounds extremely tiring”.
A crisis is a situation that you cannot solve– either because you literally can’t do anything about it (you sent a love letter to someone you’ve had a silent crush on for three years and you’re waiting for them to reply), you don’t know how (you have a flat tire), or you are so fucking emotional you can’t fix it (you would be able to do your homework, except you’re too busy crying about what a terrible person you are). A situation may be a crisis if you are fantasizing about how to escape it– quitting your job, joining the French Foreign Legion, just starting to walk and never stopping. A situation is also a crisis if you are having intense, self-destructive urges. Common self-destructive urges include self-injury, suicidal ideation, excessive use of drugs or alcohol, binging, starving yourself, just not studying for your test and seeing what happens, and deliberately exposing yourself to triggers so that you have flashbacks/a panic attack/a breakdown/whatever. (Of course, these aren’t self-destructive for everyone. Know yourself.)
I am going to be listing off a bunch of crisis survival skills. No one uses every crisis survival skill. The important thing is to get five or six skills you can rely on that you can keep in your back pocket and pull out when you need them. If something doesn’t work for you, great! Try something else.
Also, DBT is a big fan of acronyms. This is not my fault.
STOP is what you do the second you notice you are in a crisis. The first step is, conveniently, stop. Don’t do anything. Take a break. You will have impulses to do stupid shit. Remember that you can always do the stupid shit; it is not like you can’t binge-eat or attempt suicide or yell at your partner or whatever it is you want to do later. The next step is to take a step back. Separate yourself from your emotions. Take a deep breath. Try using one of the IMPROVE skills discussed later. The third step is to observe. How do you feel? What sensations are in your body? What emotions are you experiencing? Who’s in the room with you? What’s the situation? What are you feeling impulses to do? The fourth step is to proceed mindfully. Think about the situation and your goals. What’s likely to make you feel better? What’s likely to make you feel worse?
The second skill is one everybody probably knows: pros and cons. It’s pretty simple: write down every option you have, then list the good things that will happen if you do it and the bad things. If you only have two options (for instance, “kill myself” and “don’t kill myself”), this can feel pretty redundant, but a lot of the time framing it both ways helps you think of pros and cons you otherwise wouldn’t. If you want to get really fancy, you can list long-term and short-term pros and cons.
TIPP skills are for lowering arousal. It turns out that there’s a feedback loop between your emotions and the way your body feels. There’s a famous experiment where they had men walk over a rickety bridge and a relatively safe bridge, then gave them the phone number of the attractive female experimenter; the men who walked over a rickety bridge were more likely to call her to ask for a date. That’s because their bodies were like “hey, my heart is racing, I’m breathing really fast, why is this happening? Oh! It must be because she is really hot!” You might have experienced a similar thing if you’re a very anxious person: you start worrying about something actually worrisome (maybe you got a scary email) and next thing you know you’re worrying about nuclear war, and wild animal suffering, and whether your girlfriend really loves you, and whether your cat has kidney disease. And this is also why stimulants make you anxious.
Fortunately, bodies are really stupid, so if you lower your arousal, then your body will be like “okay! Nothing wrong here!” even if you’re still in a stressful situation.
Three of the TIPP skills are pretty obvious. The first is temperature: splash cold water on your face or put an ice cube on your forehead. You feel colder, your heart rate lowers, you calm down. The second is paced breathing: breathe slowly in and out. It often helps to count: for instance, breathe in on a count of four, hold for a count of four, then breathe out on a count of four. The third is paired muscle relaxation. Again, pretty simple. Breathe in and tense your muscles; breathe out and relax them. It can help to go by muscle group: for instance, start with your arms, then your shoulders, the top half of your face, the bottom half of your face, your neck, your chest, your stomach, and finally your legs.
The second skill, intense exercise, is weird. Doesn’t exercise raise your heart rate? Yep! But the thing is that a lot of times when you’re aroused you’re jittery, you have a lot of excess energy. So if you go do the seven minute workout, then you’re working off all that excess energy, and even though your heart is racing, you might feel better.
Distract is a fun skill! The acronym for distract is ACCEPTS, which are all the different things you can distract with. If you plan on using distract skills, it’s important to come up with specific plan for how to distract.
The first thing you can distract with is activities. This is basically anything you want to do– you can read a book, clean your room, watch TV, play cards, talk to a friend, do sudoku. But dthe key is that is has to be absorbing enough that you’re not thinking about your crisis. If you’re half watching TV and half ruminating about how everyone hates you, it’s not helping. If you talk to your friend, talk about fandom or politics or so-and-so’s new girlfriend; don’t talk about your problems.
Next, contributions. I know we’re all effective altruists here and we love to bash ineffective altruism. However, when you’re using contributions, it is not time to optimize for doing good in the world. It is time to optimize for warmfuzzies. Talk to someone about their problems; surprise someone with a card or a hug; ask someone if there’s anything you can do to help them. Or, yes, write a check to GiveWell.
The next one is comparisons. This is a very high-variance skill. The idea is to compare your life to other people’s or to your life in the past and notice all of the good things you have. For some people, this makes them feel gratitude and relief. For other people, this makes them feel really sad because other people are hurting, or guilty because they can’t stop it. If you are in the latter group, don’t do this one.
Emotions. The idea with this skill is to do something with a different emotion from the one you’re currently feeling. A lot of times, when people are sad, we listen to fucking Joy Division. And then we feel worse! No one feels better after they listen to Joy Division! Not even the lead singer of Joy Division felt better after listening to Joy Division! When you’re sad, you really ought to listen to Tom Lehrer instead. A lot of times people think this has to be a happy emotion, but it doesn’t have to be. I like listening to angry country music about people’s cheating boyfriends. You might like watching a horror movie. The important thing is that it’s different from the emotion you’re currently going through.
Pushing away. This is my personal favorite! When you push away, you tell yourself very firmly that you are not thinking about this problem right now. If you are a visualization kind of person, it can help to imagine putting the problem in a box and putting it on a very high shelf. When I catch myself thinking about my problem, I say to myself very sharply, as if to a dog, “No!” This is a very easy skill to overuse: at some point you’ll have to stop watching TV or listening to Tom Lehrer or writing a check to GiveWell, but there’s no one making you take that imaginary box off the shelf. If you find yourself regularly putting your problem in a box in your mental closet, it is time to take the box down and see what’s in it and what you can do about it. And you should never use this skill when you actually can do something about the problem.
Thoughts. Count to ten. Double numbers in your head. Recite poetry. Sing songs inside your head. Count all the colors you can see. Try to find something in the room whose name begins with every letter of the alphabet. Repeat a mantra to yourself. This is a good one to use when you need to be still: for instance, when someone is yelling at you, or when you’re an agoraphobic person who has to be outside without their comfort objects.
Sensations. This is good if you’re in physical or mental pain, or you’re in a state of overwhelm. What you’re looking for here is intense sensations. Listen to very loud music. Take a cold shower. Squeeze a rubber ball very hard. Jack off or have sex. My therapists didn’t mention this because they are very anti-self-harm, but if you can self-harm responsibly it is a very good example of sensations. (Of course, if for you self-injury is a compulsive or self-destructive behavior, that would be a very bad thing to do and you should try taking a cold shower instead.)
Self-soothing is the art of creating physical sensations that make you feel warm and happy inside. The problem I had with self-soothing for the longest time is that I was like “okay, I looked at a flower, just like the list suggested, and I still feel terrible!” That is the exactly wrong way to do it. You are supposed to do something that makes you feel safe and comfortable, not something that makes the creators of Alternatives To Self-Harm lists safe and comfortable. It is totally okay to self-soothe through listening to angry metal music or looking at porn or whatever, if that’s what works for you.
One way to remember self-soothing is to think about your senses; you can self-soothe using any sense. The DBT book mentions vision, hearing, taste, smell, and touch, but of course those aren’t the only senses. It is totally possible to self-soothe through your proprioceptive sense.
IMPROVE the moment
IMPROVE skills are very similar to the distract skills. My therapist informs me that the distract skills are supposed to be doing something other than the distressing thing, while IMPROVE skills are supposed to be for when you have no choice but to deal with the distressing thing. However, in that case, “thoughts” clearly belongs on the IMPROVE skills list, and “vacations” clearly belongs on the distract skills list. I think Marsha Linehan was just trying to come up with clever acronyms.
Imagery. Basically, there are two things you can do with imagery. If you’re a more visual person, you can imagine that you’re in some sort of peaceful and relaxing environment, or that you’re going into a safe place inside of yourself. If you’re a more verbal person like me, you can tell yourself a story. For some reason, the stories that work for me are usually post-apocalyptic stories. I get a lot of mileage out of pretending that when I’m on my bicycle I’m actually running from zombies.
Meaning. Essentially, “meaning” is finding some sort of purpose in the pain. You might reframe it as an opportunity for personal growth: for instance, it can let you develop your compassion for other people who’ve had to go through the same thing, or give you an opportunity to show off your virtue. Or you might remind yourself about how what you’re going through is important for your greater goals– while it might be distressing to have to send that email, it will help you keep your job, which means you can donate money, which will help you gather utils for the util god.
Prayer. No doubt going to be unpopular among my mostly-atheist readerbase, but this is a strategy that works really well for some people (including me– acts of contrition ward away self-hate). An important caveat: you can feel free to go “God, this really sucks and I don’t like it and I wish it weren’t this way”, or to pray for strength, or to turn over the situation to God. You cannot go “God, please make the distressing thing go away!” That is not radically accepting and (as will be discussed in a later blog post) radical acceptance is one of the key skills for distress tolerance. Conveniently, this also limits your prayers to things that you can actually get through prayer.
Relaxation. Basically, relaxation is just doing something that relaxes you. You can stim, or stretch, or give yourself a scalp massage, or make yourself a cup of tea. The most famous relaxation strategy, of course, is to take a deep breath.
One thing in the moment. One thing in the moment is throwing yourself completely into whatever is currently happening. Focus on what’s going on right now. Notice the sensations in your body, the small sounds you can hear, the details of what you’re looking at, the way it feels to move, your emotions, your thoughts. Don’t time-travel! Do not think about what happened in the past; don’t think about what’s going to happen in the future. Concentrate just on what is going on right now in this moment.
Vacations. Give yourself a brief vacation. For instance, you can put yourself in bed and pull the covers over your head, or set a timer for twenty minutes in which you don’t have to worry about work at all. There are two important caveats to make about vacations. First, you should not take a vacation that hurts you. If you are stressed out because you have three papers and a test in the next twenty-four hours and you haven’t started any of them, now is not the time for using vacations. Second, you shouldn’t take long vacations– a few hours is fine, but if they’re getting to be longer than a day, you are avoiding your problems and probably going to make the situation worse when you get around to dealing with them.
Encouragement. This is positive self-talk. When people think “positive self-talk”, a lot of times they think about those sort of hokey affirmations: “I am strong. I am happy. I am beautiful. I have all the love I need. I am a success. I am kind.” The problem with this sort of affirmation is that a lot of times you know you’re an asshole, a failure, lonely as hell, and completely fucking miserable, and attempting to believe that you are a kind, successful, beloved, happy person just highlights your current state. So you want your self-talk to be true. You can tell yourself about the positive traits you have, or you can try “I’m doing the best I can”, or “I can stand this.” I get a lot of mileage out of “I’m not as bad as I could be!” It can often help to remind yourself that this thing will be over soon, that nothing lasts forever, and this too shall pass. Another important rule is that you must say it to yourself firmly, as if you actually mean it. It can help to pretend you’re being talked to by someone else.
A lot of these strategies are, well, kind of obvious. I think a lot of therapy veterans have had the experience of telling a therapist about their problems and then the therapist says “I’m going to tell you about something new, it’s called breathing.” But just because we know about the strategies doesn’t mean we have access to them when we’re in a crisis. It can help to put up a list somewhere you can see it, or tell a friend that next time you are in crisis they should remind you about using the coping strategies you planned to use.
A lot of coping strategies manage to combine more than one of these skills. For instance, one of my go-tos is listening to loud angry country music. That’s using at least three skills– distracting through activities (listening to music), distracting through emotions (anger is different from self-hatred), and self-soothing through the sense of hearing. If you can come up with a strategy that does that, it’s great! Attack the problem from multiple angles.
Roughly speaking, people have two kinds of crisis skill problems: they do it too much, or they do it not enough. (Some ambitious people manage to have both problems.) If you don’t do it enough, you might feel like you don’t deserve it, or like wanting to take care of yourself when you’re in crisis is wrong; you also might not know what works for you. In that case, you should practice using these skills when you aren’t in distress. It is much easier to deal with your feelings of guilt when you don’t also have to deal with whatever bad shit is going on with your life. And through carefully observing what soothes you or absorbs you, you can come up with a crisis strategy that works for you. Many people don’t have access to these skills while they’re in crisis: if that’s you, you should put extra effort into coming up with a specific crisis plan (not just “distract with activities” but “first, turn on Carrie Underwood’s Two Black Cadillacs”). It may help to create a self-care box of things that soothe or help you.
If you use your crisis skills too much, you’re using them on things that aren’t crises, or instead of dealing with your problems, or in ways that actually make the situations worse (for instance, by distracting instead of doing your homework). Fortunately, most of the rest of DBT is for you. When you’re in distress, you should instead practice radical acceptance, which I’ll talk about in the next post in this series.
If you are an ambitious person who has both problems, you use crisis survival skills on minor problems or problems you can fix, and then when an actual crisis comes along you can’t use them. Fixing that problem is very much Hard Mode: you’re going to have to deal with your feelings of guilt and shame about self-care while you’re in crisis, and you’re going to have to discern whether something is an actual crisis or you not wanting to deal with your problems. However, with a lot of work, you can get yourself in a healthier way of relating to crises.