Distress is a fact of life. It’s a wide range of triggers: it’s not always our turn, or we have bad luck, or we make a bad decision and have to suffer the consequences or we experience oppression and injustice and so on. How upsetting these different degrees of distress are depends not only on the magnitude of the event, it depends on us—the same event may be annoying to one person and catastrophic to another. Most of us have different ways of dealing with different levels of distress. People who are more emotionally vulnerable don’t differentiate as well, and actually experience any amount as intolerable.
How DBT teaches distress tolerance
This might be the most misunderstood skill set in evidence-based practice. Radical acceptance was initially a very challenging idea: that one must complete accept reality as it is without being driven to change it in order to move forward. This doesn’t mean that we can’t make changes or that we shouldn’t try, but that to do so we first must accept things as they are.
If this sounds familiar that may be because mindfulness has become a lot more popular in psychotherapy since the original DBT text was written. In fact, mindfulness has become the basis of more than one evidence-based therapy. But not all advances in evidence-based practice made understanding DBT helpful. In fact, a better understanding of anxiety is the source of objections to the other set of DBT distress tolerance skills.
Getting through the crisis
Crisis response coping is crucial for individuals with poor emotion regulation. When people are flooded with emotions or dissociate too easily, it is crucial to have skills to become grounded. Only once someone is back in the window of tolerance (which is explained here), can they begin to use more complex skills.
Crisis response skills mostly involve stepping away mentally or physically from the problem to regulate by relaxing, distraction, grounding, refocusing, connecting, etc. But we know from anxiety treatment that these coping skills used on a regular basis make anxiety worse: the more we avoid the thing that makes us anxious, the more anxious we get about confronting the thing that makes us anxious, and the more affirmation we get that avoiding the thing that makes us anxious is a good decision.
So what’s up with the contradiction? Linehan is very clear: crisis strategies don’t teach emotion regulation in the long run and clients and therapists must ensure that they aren’t overused and instead are used only to prepare the client for the mindfulness and dialectical-behavior strategies that bring about long lasting change. But clients with the emotional dysregulation of complex trauma and borderline personality disorder need a bridge to get through the crisis moment before they can use skills that require abstract reasoning and action planning so these skills are crucial to recovery.