Distress tolerance is one of those rare psychological terms whose meaning is clear. It means the ability to experience negative stress without being overwhelmed by painful feelings. It is a skill that you can learn and improve upon, just as you might work on improving your tennis or bridge game. It is not an inborn characteristic like blue eyes that you either have or don’t have.
Distress tolerance is a key skill taught in dialectical behavior therapy to handle situations that are impossible or very difficult to change, such as divorce, job loss, or health problems. Distress tolerance is an acquired resilience that helps you regulate the anxiety you feel in such challenging life experiences (Linehan, 1993).
In this chapter you will learn five ways to improve your distress tolerance skills: mindfulness, relaxation, self-soothing, positive distraction, and coping thoughts. These are all techniques that will help you reduce anxiety in stressful situations that you can’t or shouldn’t avoid.
There is one time when you should not use the distress tolerance techniques you learn in this chapter: when you are doing the exposure exercises you learned in the earlier chapters of the book. Since research has shown that exposure exercises work best and fastest when you fully experience the target emotion of anxiety, using distress tolerance techniques at the same time will just make exposure take longer.
Mindfulness is a centuries-old practice that originated in Eastern religions. In Western psychology, mindfulness has become an important part of emotional awareness in all three of the universal treatments for emotional disorders: dialectical behavior therapy, cognitive behavioral therapy, and acceptance and commitment therapy.
There are three aspects of mindfulness: awareness, acceptance, and present-focus. First, you experience the world around you with all your senses while at the same time being aware of your internal sensations. Second, you observe without judgment, without being for or against what you perceive. Third, you confine your perceptions to the present moment, letting go of all thoughts of the past or future.
Mindfulness helps reduce anxiety by shifting your attention away from ruminating on the past or dreading the future. It also allows you to see that your anxiety is only a part of the present moment, and that anxious thoughts and feelings are transitory—arising, peaking, and declining over time.
Five Senses
This is a simple exercise you can do in two or three minutes, almost any time. Just pay attention to what each of your senses is telling you, taking the five senses in turn:
Distracting or judgmental thoughts will pop up: This is silly, or There’s that stupid dog barking again. When that happens, let the thought go and return to cataloging your sensations. You’ll be surprised how calming and centering this exercise can be.
Mindful Breathing
Breathing meditations have been used for thousands of years in many cultures. When you pay attention to your breathing, you automatically take attention away from your anxious thoughts. Mindful breathing has three components: attending to your breath, labeling each breath, and letting go of distracting thoughts.
Mindful breathing works best if you do it two or three times daily. Start with two-minute sessions. After a few days, increase to three minutes for a few more days, then go to four or five minutes.
Mindfulness of Emotions
Once you have experienced mindful breathing for a while, you can go on to mindfulness of emotions, a systematic way of observing the natural ebb and flow of painful feelings without being swept away by them. This technique is particularly helpful when you are starting to feel anxious about something, especially if you are tempted to avoid the feeling. Trying to avoid anxiety makes it stronger and more enduring. Practicing mindfulness of anxiety makes it weaker and briefer.
The secret to this skill is to allow the feelings of fear and nervousness to exist. Don’t try to block or stifle them. Every emotion is like a wave in that it starts small, grows to a crest, and then declines. If you observe this happening, without amplifying the feeling, analyzing it, or judging yourself, then you will get a clear picture of the temporary nature of emotions.
Watching your emotions like this allows you to see them for what they are: feelings that come and go while you continue to live in the full context of your existence. It’s like feelings are weather and you are the sky. Weather constantly changes, but the sky remains the sky. Sometimes the weather can get very violent and scary, but it never destroys the sky. The sky persists no matter how dark the clouds, and eventually the sun always comes out again.
Carol, a bookkeeper for a casino in Nevada, was terrified of being assaulted when she had to drive downtown or to the store after dark. When she had to drive after dark, she used mindfulness to calm herself before starting the car. When she parked at the store or on a downtown street, she would take a minute to watch her emotions and sense impressions before getting out of the car. While she was shopping or dining, she would label her intrusive fearful thoughts: planning … worrying … living in the future.
Many different cultures and traditions use attention to your breathing as a way to relax.
When you’re feeling anxious, your body tenses and your breathing becomes faster and more shallow. By consciously slowing your breathing and drawing air deep into your lungs with your diaphragm, you send your body a strong message that everything is okay and it can relax. Your diaphragm is the wide, strong sheet of muscle at the bottom of your rib cage. It moves down and out to fully inflate your lungs and moves up to push air out of your lungs. The instructions for diaphragmatic breathing are simple.
Practicing diaphragmatic breathing two or three times a day will go a long way toward increasing your distress tolerance.
When you have become familiar with the relaxing feeling of your mindfulness or breathing exercises, you can use cue-controlled relaxation to very quickly lower your feelings of tension or anxiety. To prepare, choose a “cue word” that you will use to remind yourself of what relaxation feels like. It can be calm … relax … easy or any other word that appeals to you.
Close your eyes for a moment and scan your body for tension. Notice wherever your muscles are holding tension. Then say your cue word to yourself and let your whole body relax.
Denny’s cue word was serenity. He pictured the word carved in flowing script on a hardwood log, deep in the forest. When he was feeling nervous about entering a meeting at work or making a confrontational phone call, he would close his eyes, take a deep diaphragmatic breath, and say “serenity” to himself, imagining that he was seeing the word carved into the log, surrounded by the peaceful woods. It helped a great deal to remind him of his relaxation skills and allowed him to let go of tension quickly.
Any activity, experience, or pastime that you enjoy or that relaxes you can qualify as self-soothing. It can be listening to music, playing an instrument, reading, taking a walk, knitting, painting a picture, or some other kind of craft or hobby. (Dangerous or destructive habits such as drinking, taking drugs, or driving recklessly are not appropriate.) Self-soothing is one of the key distress tolerance skills taught in dialectical behavior therapy (Linehan, 1993).
Take the time to soothe yourself by feeding your five senses. Watch a sunset; listen to a song; taste and smell good food; wear soft, comfortable clothes.
Since sight is perhaps your most important connection with the outside world, what you look at can have profound effects on tension and relaxation. Look over this list of pleasures involving sight, check off those you want to try, and add any other items you can think of:
Go to a favorite spot and just look at water or mountains or art in a gallery.
Carry a favorite photo in your wallet or purse that you can pull out and look at whenever you want.
Put up pictures on your walls at home and at work.
Get picture books from the library of whatever you like to look at.
Make a drawing or a collage of images that please you.
Other:
Other:
Other:
What you hear has a huge effect on how you feel. Have you ever watched a movie with the sound muted? It’s amazing how much the emotional impact of a scene is created by the music and other sounds. Taking the time to add pleasant sounds to your environment can lower your stress level in a big way. Try some of these suggestions, or add favorites of your own:
Listen to an audiobook. Most libraries have a selection. You don’t even have to follow the storyline closely. Just hearing a human voice in the background can be soothing.
Listen to the kind of music you like best. Pop, classical, jazz, new age, world—it doesn’t matter as long as you enjoy it.
Use the TV or a fan as white noise to relax you. Turn the sound down low so that it is like a babbling brook, a soothing background mumble.
Or actually listen to a white noise recording or machine. This can mask other distracting or annoying sounds such as traffic or noisy neighbors.
Get a fountain that you like the sound of.
Open the window so you can hear the birdsong and wind and other natural sounds. Or if your window doesn’t offer that option, get a recording of nature sounds that you like.
Other:
Other:
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You have to eat and drink every day, so why not make meals and snacks an opportunity for self-soothing? On the other hand, if you are overweight because you already do a lot of self-soothing with food and drink, perhaps you should concentrate on your other senses. If eating is not a problem for you, try some of these ideas and add some of your own:
Enjoy your favorite foods, savoring every bite and really getting into the taste, texture, temperature, and so on.
Carry a favorite food with you to snack on later in the day.
Eat a juicy piece of fruit, enjoying the cool sweetness.
Drink your favorite beverage, such as coffee or tea. Have it in a special cup or glass and really pay attention to all the sensations of thirst and satisfaction. Don’t have anything else with it and don’t do anything else while you’re drinking.
Have a special treat, like ice cream or candy, once in a while.
Other:
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Humans are instinctively drawn to pleasing smells. The sense of smell plays a big role in memory, in appetite, and in sexual attraction. Don’t overlook your sense of smell when searching for ways to soothe yourself. You can try these ideas or come up with additional smells you like:
Wear perfume or cologne that pleases you.
Burn incense or scented candles.
Drop by the bakery, florist, or restaurant whose smell you love.
Bake cookies or a cake and enjoy the smell that fills your home.
Put some fresh flowers on your desk or dining table.
Other:
Other:
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Your skin is the largest organ in your body, rich in sensitive nerve endings and a powerful source of pleasure. From this list select some ways to pamper your sense of touch and add other ideas of your own:
Stretch to loosen your muscles and ease aches and pains. You can do real yoga or runner’s stretches, or just experiment with your own moves.
Wear your most comfortable clothes—the worn jeans or soft sweatshirt that just feels good.
Take a hot bath or cool shower and enjoy the sensations of water on your skin.
Carry some worry beads or a small polished stone with you in your purse or pocket, to touch when you feel tense.
Have a massage, or just massage your own muscles.
Pet your cat or dog. Research shows that contact with animals is very soothing.
Other:
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Jeanie used self-soothing to counteract her tendency to ruminate about her failed marriage and poor relationship with her ex-husband. She brightened up her studio apartment with colorful prints and some throw pillows in vivid colors and soft fabrics she loved. She hooked up her laptop to her receiver so she could put her favorite music on “shuffle” and have it playing in the background while she fixed dinner or did the laundry or dishes. She swapped her old, scentless shampoo and body wash for products whose smell she liked, and sometimes she burned sandalwood incense. She set up a weekly date with a friend to treat themselves to manicures, movies, or hot fudge sundaes.
To keep chronic anxiety going you need to pay regular attention to your worries. Distraction reduces anxiety by turning your attention elsewhere, away from your fears. We call this “positive distraction” to distinguish it from the kind of knee-jerk, desperate, negative, momentary distraction that serves as a safety behavior. Positive distraction involves planning ahead to engage over time with other people in meaningful activities, or to occupy your mind with pleasurable games or productive thoughts such as planning exciting home improvements or a vacation.
Volunteer. Serve at the soup kitchen. Visit shut-ins. Stuff envelopes for your favorite nonprofit. Collect unwanted items for the community rummage sale. By doing something positive for other people, you will distract yourself from the negative things in your own life.
You don’t have to get involved in an organized charity to pay attention to other people. Call up a family member or friend who needs help and offer your assistance. Help your grandma organize her photos. Help Uncle Bill clean out the garage. Babysit while your friend goes to the doctor. Or just have lunch with friends and listen to their problems instead of dwelling on your own.
In fact, you don’t even have to know the other people you are using for distraction. Go people-watching at the park or mall. Plant yourself in the middle of a lunch counter and let your awareness of others expand. Eavesdrop on their conversations. Observe how they sit, stand, and walk. Keep a tally of bright or dull colors, kinds of shoes, or hairstyles. If you catch yourself worrying about your own usual problems, refocus on what other people are doing.
You can use photos of other people to distract yourself when you are alone. Carry pictures of people you love or admire. Take them out and look at them for a ready source of distraction.
What other ways can you think of to distract yourself by observing others?
Tasks and chores can take your mind off your worries. If you’re like most people, there are plenty of things in your life that you have been meaning to do, but you never seem to get around to them. Take a moment right now to update your “To Do” list. The next time you find yourself consumed by anxiety, do something on the list as a distraction from worry. Here are some typical items to get you started, and room to add your own tasks:
Reorganize your filing system, address book, desktop, etc.
Cook a real dinner for yourself or friends.
Get a haircut or your nails done.
Pay your bills.
Wash the dishes.
Make a phone call you’ve been putting off.
Write down a plan to get a better job.
Fill a box with stuff you don’t want and drop it off at the thrift store.
Flatten all the cardboard boxes in the recycling.
Rearrange the furniture.
Really clean up one room.
Weed a flower bed or mow the lawn.
Cut your toenails.
Polish shoes or jewelry.
Straighten out a messy drawer or cupboard.
Other:
Other:
Other:
It’s hard to stop thinking about your worries because the deliberate attempt to suppress a thought often makes that thought more likely to occur. This mental quirk was studied in the 1980s by social psychologist Daniel Wegner, who called it the “ironic mental process” (1987). Over a hundred years earlier, Russian novelist Fyodor Dostoevsky put it this way: “Try to pose for yourself this task: not to think of a polar bear, and you will see that the cursed thing will come to mind every minute” (1863). To this day people refer to ironic mental processes as the “white bear problem.”
You can escape the white bear problem by consciously choosing to think about other, more interesting things. Here is a list of alternative trains of thought onto which you might jump to avoid the white bear:
Recall happier times. Dwell on your experiences in the past that were fun, exciting, or gratifying. What happened when? Who was there? How did events unfold? Go into great detail with all the sense impressions of sights, sounds, smells, and so on.
Indulge in sexual fantasies you enjoy. What would you like to do? Who would you like to do it with? Think of as many details as you can.
Become the hero of your own story. Reimagine a past experience and edit the scene so that you are the center of the action, the one who pulls off amazing feats, wins the game, saves the day.
Imagine that someone you greatly respect is praising you. Listen as this person tells you how smart, important, accomplished, attractive, or special you are.
Enjoy a fantasy in which a dream comes true: how you would spend six million dollars, what it would be like to win a gold medal at the Olympics, what you would say when you received the Nobel Peace Prize.
If you have a favorite saying, quotation, or prayer, write it out carefully on a small card and carry it with you. When you need to distract yourself from other thoughts, pull out the card and read the inspiring words.
Other:
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Sandy took her mind off her health and financial troubles by staying busy. She volunteered at the public library, shelving books and pricing paperbacks for the annual book sale. Each week on Sunday morning she cleaned out one drawer or cabinet in her house, sorting things into “keep here,” “move there,” “throw out,” or “donate.” When thoughts about her dwindling savings or possible future surgery intruded, she reminded herself to take it “one day at a time,” a meaningful saying that she had written on an index card and kept in her purse.
Tolerating distress is largely a mental ability. In this section you will improve your mental distress tolerance by exploring the probabilities that the events you dread might come to pass, and by preparing mental coping statements to use when you do have to get through distressing situations.
If you live in fear of having a panic attack, this is the section for you. It counteracts the two processes that can lead to panic: overestimation and catastrophizing. Overestimation is the tendency to overestimate the odds of bad things happening. For example, the chance of the average driver having an auto accident in any 24-hour period is 0.0015 percent, or about one in ten thousand; however, a panicky person drives as if it were a 60 percent possibility.
Catastrophizing is the tendency to predict that when a bad thing does happen it will be a total catastrophe. So a panicky driver will assume that if an accident happens then everyone will die, even though only 1 percent of traffic accidents involve a fatality.
The way to fight panic is to explore your overestimation and catastrophizing and revise your thinking about probabilities. To do that, use the following Probability Worksheet. (A downloadable version of the worksheet is available at http://www.newharbinger.com/34749.) Here are instructions:
| Event | Automaticthoughts | Probability 0–100% | Anxiety 0–100% | Evidence pro and con | Coping alternatives | Probability 0–100% | Anxiety 0–100% |
|---|---|---|---|---|---|---|---|
How did you do? Hopefully the process of weighing the evidence and your coping alternatives accomplished two goals: helping you estimate risk more accurately and increasing your confidence in your ability to cope.
Here is how Juan filled out his Probability Worksheet to process his fears about his daughter’s safety:
| Event | Automaticthoughts | Probability 0–100% | Anxiety 0–100% | Evidence pro and con | Coping alternatives | Probability 0–100% | Anxiety 0–100% |
|---|---|---|---|---|---|---|---|
|
My daughter Angela will get mugged and raped |
She’s so vulnerable, it’s bound to happen |
90% |
95% |
Pro: it happened to her mother, this is a dangerous neighborhood. Con: she’s careful, doesn’t walk alone at night, we have Neighborhood Watch now. |
Her mother survived it, there is less stigma and more counseling these days, she has loving parents. |
35% |
45% |
To prepare for the events you dread, prepare cognitive coping statements ahead of time. These are short mental affirmations that perform many important functions in regulating anxiety. They remind you that you have coping alternatives, that there is no need to panic, and that you can relax away any stress you feel. Your coping statements should say that catastrophic fear is not valid and provide a realistic estimate of the worst that could happen. Finally, these statements can help you lower unreasonably high expectations and focus on meeting the challenges of difficult situations. Here are some examples of good cognitive coping statements:
Now try composing some cognitive coping statement for yourself:
In this chapter you have learned five different ways to build up your tolerance for anxiety, starting with mindfulness and relaxation exercises to aid you in feeling calmer when you need to. The suggestions for self-soothing and distraction can help in forming positive new habits and making lifestyle changes that will make anxiety a smaller and less constricting part of your daily life. Finally, your increased skill in formulating coping thoughts will get you through unavoidable stressful situations with less anxiety.
Please keep in mind that the distress tolerance techniques in this chapter should not be used while you are doing the exposure exercises in the earlier chapters. In exposure treatment, the goal is to actually experience the full range of emotions. Practicing distress tolerance at the same time will make exposure less effective.