Crisis Survival Skills from DBT Distress Tolerance


We all go through unenjoyable experiences, which can be unpleasant all the way up to a full-blown crisis.  At the mild end of this spectrum, it could be the cat seriously stunk up the litter box, you forgot to put out the garbage before the collection time, or someone left just a quarter-cup of milk left in the carton – you know, enough for them to lazily put it back in the refrigerator, but not enough for you to do anything with it. These are all a series of annoyances but generally they are not enough to disrupt our entire day.

There are also those times in our lives when we will experience far more severe circumstances, such as the death of someone we cared about, the end of a relationship, or financial hardships. Sometimes these events can be compounded, too, further adding to the burden. For instance, perhaps you were the caregiver to the person who died. During the caregiving journey, your romantic partner became fed up with your anxiety about the person’s illness and oncoming death, and so they broke up with you. That exacerbated your stress further, and you found yourself recklessly spending to cope with all the stressors. But then you fell behind on paying your credit cards, utilities, and other bills. As a result, you feel as if you are drowning from all the pressures.
However, some people, such as those with borderline personality disorder (BPD) feel the distress of these situations more intensely than others. Furthermore, their psychological pain can be seemingly out of nowhere, as if driven only by internal factors – it can be difficult for them to identify the source or reason of the pain, and only know that it hurts.

It is important to learn effective, healthy, long-term skills to properly cope with intense psychological pain, thereby surviving crises. For those with BPD or other disorders where emotional pain can be especially sharp, if they have not learned the right coping skills to tolerate these issues and the emotions, they may end up coping through dangerous or impulsive means for an immediate “fix” to the situation (i.e.., self-harm, substance abuse, promiscuous sex, overspending, etc.). These behaviors may feel helpful in the moment because they take the edge off, but in the long term they are only making things harder for the individual.

And why is this pain more intolerable? Consider the following. Dr. Marsha Linehan, Ph.D., ABPP, who developed a renowned therapy for BPD called dialectical behavior therapy (DBT), said, “people with borderline personality disorder (and those like them) are people with third-degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement.”


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Dialectical Behavior Therapy (DBT)

Through DBT, people who experience severe emotional turmoil can learn distress tolerance skills that will let them endure painful situations and cope with the urges to surrender to harmful behaviors. Dr. Linehan splits distress tolerance skills into three groups: crisis survival techniques, sensory body awareness, and reality acceptance. Please note as this article is meant to be a simple introduction to DBT, the skills listed below all pertain to crisis survival skills; it is not meant to be an exhaustive, final list of all the distress tolerance skills!

Distress Tolerance

DBT is a subform of cognitive behavior therapy (CBT). Originally, it was designed for people with BPD and/or suicidal ideation – essentially, the people in the greatest emotional turmoil. Over time, research found that DBT can be effective in the treatment of other mental health diagnoses, too, such as depressive disorders, anxiety disorders, and post-traumatic stress disorder. Some of the skills are useful regardless of if a person has a mental illness or not, and simply need a better way to cope with a situation.

DBT is especially beneficial for people with a highly sensitive temperament.

DBT is taught in four modules: mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness. This article will only focus on distress tolerance as the writer plans to cover the other modules in future articles.

The Goals of Distress Tolerance

According to Dr. Linehan, the point of the distress tolerance skills is the following:

  • Survive crises without making them worse through behaviors.
  • Accept reality as it is. Replace suffering and feeling “stuck” with manageable, normal pain and the belief of moving forward from the crisis.
  • Become liberated of having to “give in” to intense emotions, desires, and urges.

The When/Why/How to Use Distress Tolerance Skills for Crisis Survival

The crisis survival skills are considered skills of last resort. They should not be executed for coping with minor frustrations, or changing a situation or emotion, as those issues are better for the emotional regulation skills. Rather, the crisis survival skills should be employed for the following cases – anytime there is an actual or perceived crisis:

  • An individual is going through severe emotional or physical pain that will not be relieved soon (i.e., diagnosed with a serious, chronic medical issue).
  • Someone wants to behave on an emotion or urge that will only make the outcome worse (i.e., drinking to “drown out” a problem).
  • A situation is exhausting and overwhelming, but there are needs that must be addressed (i.e.., someone may feel depressed about a heated argument with their romantic partner, but they still need to care for their baby).
  • Someone desires to “fix” an issue that cannot be resolved right away.

Below are three of the distress tolerance skills for crisis survival.

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Final Points…
The skills listed above are not the typical “psychology 101 self-help” skills, but rather are ones that are meant to be utilized only after being fully understood to thus prevent misuse that could end up making the situation backfire. Without context and more background, it can be difficult to know when, why, and how to properly use the skills. This writer emphasizes the importance of working with a DBT-informed therapist for DBT skills. Contact Suffolk Family Therapy today if you are interested in such help!

– Valerie Smith, LMSW, CFTG