Taking the Edge Off- Distress Tolerance Skills
When I was in graduate school to become a therapist, the first year was rooted in the classroom. We sat together online and in lecture halls. We learned the theories and participated in humiliating role plays where we would undoubtedly adopt insufferable personalities to shake things up for our peers. We wrote the papers, spoke about the reading, and developed our first draft of who we would be as counselors.We were absorbing a lot of information but we were all squirming in our seats to get to the action! We wanted to sit with real clients, we wanted to get started with the work we all desperately wanted to do. In all of our eagerness, we each landed in our respective internships and it came time to do the damn thing. Unsurprisingly, transitioning from practicing with our gracious classmates to real people who needed support was quite the adjustment and wake-up call.
Sitting with clients as their actual therapist for the first time was a kaleidoscope of colorful feelings. Exciting and terrifying. An honor and a huge responsibility. I felt like everything I had learned in school was barely enough foundation to stand on. I was clinging to a life raft in the open ocean. I recognized that I would need to adopt some new skills and techniques quickly, both to fulfill my duty to these people I promised to care for and to calm myself, struggling and gasping for breath in the waves. I wanted tangible, reliable and teachable skills to give to my clients as I figured it all out with them. It was during this season that I began my on again off again love affair with Distress Tolerance skills.
As a baby therapist, you must complete an internship with an organization in the community. A nine-month long internship, with a caseload of diverse clients each with unique identities and presenting concerns, this was exciting and overwhelming. Talk about an identity crisis, one day I am a girl, the next day I am a girl responsible for providing ethical and informed healthcare to vulnerable people. Don’t worry, the weight of it all eased immensely through time. But during this chapter, it was heavy. The thing that held me up was an incredibly supportive internship site, a skilled and seasoned supervisor and mostly my wise and beloved peers. I forgave them for the role-plays.
My first supervisor was a badass. She was incredibly skilled, composed, and specialized in high risk populations. High-risk populations are folks with pathology that require more intensive intervention. High-risk populations usually are referred to clinicians who practice Dialectical Behavioral Therapy or DBT for short. Dialectical Behavioral Therapy is a modality of therapy developed by Marsha Linehan originally to address highly-suicidal patients. DBT has become the gold standard for treating many personality disorders and severe pathology. Generalized greatly, DBT places an emphasis on the combination of acceptance and distress tolerance skills. Accept the things we cannot change and cope with the discomfort along the way. A simple but incredibly nuanced equation. My supervisor worked from a DBT lens and in rearing me as a therapist, instilled many of the tenets of DBT in my practice.
Distress Tolerance skills are basically exactly what they sound like. They are skills we use to tolerate distress and take the edge off our intense and big feelings. To this day, I use distress tolerance skills as a foundation for my clients and in my own life. Distress tolerance skills do not solve our problems nor do they prevent them from returning. However, they do arm us with something to do when a big emotion strikes. I see distress tolerance skills as our place to turn when our feelings become overwhelming and we must react to lessen the impact. Distress tolerance skills are often used in the case of panic or unmanaged anger. Dialectical Behavioral Therapy outlines many different distress tolerance skills, they are all useful and impactful. In my practice, I tend to gravitate towards a certain set of skills branded by the acronym, TIPP.
TIPP is a set of different physiological skills that help calm our nervous system by interacting with our bodies chemistry. TIPP skills are suggested to be the best skills to use when you need to alter your emotion quickly or your emotion feels out of control. The way I explain these mighty skills to clients is that they are a fail safe way to take the edge off. They might bring your emotion from a 7 in intensity to a 5 where you feel more equipped to manage and process it. In this blog, we will be covering the first of four skills included in this helpful acronym, the temperature skill.
By changing our bodies temperature, we are able to decrease the intensity of an emotion. The temperature skill is a simple and effective way to regulate when we are having an overwhelming feeling. To execute this skill, you must choose a cold medium. Whether that’s an ice-pack, a bag of frozen fruit, or a ziploc filled with ice, any chilly object that is somewhat malleable will work. With your frozen something in hand, you will pull in a big inhale and hold your breath as you would if you were about to dive into cold water. With breath held, press the ice-pack to your forehead, temples, and eyes. Hold for as long as you can hold your breath. When you need to breathe, pull the ice pack away from your face and breathe. Repeat this process until you feel your emotion lessen.
Now,the visual might be silly but the impact is meaningful in changing the course of your big emotion. When you expose your body to cold temperatures, it triggers something called the mammalian dive reflex. This is the same response that happens when we are submerged in cold water. In this state, our heart rate slows and our parasympathetic nervous system switches on. Meaning, this skill can literally move you from fight or flight to rest and digest. The best part, you literally cannot mess it up, your body does it all for you.
The temperature skill is just the tip of the iceberg when it comes to distress tolerance skills. If this works well for you, you might consider exploring the rest of the acronym. What I love about distress tolerance skills is that they often empower clients with tools to combat intense emotions. Much like the temperature skill, there are skills for intense emotions that just work because they relate to your body's chemistry. They are reliable, simple to implement and often make lasting change in a client's confidence to care for their emotions.
When I was finding my footing those first nine months of my career, I held tightly to distress tolerance skills. I knew that educating clients and sending them with an actual skill in hand leaving session was a way I could undoubtedly show up as I figured it all out. You don’t need to be a DBT therapist to see the value in the tool kit it lends. What began as a way to feel useful in the therapy room, has become a pillar of my therapeutic approach. Pairing tangible evidence-based tools with all the depth of psychoanalytic therapy allows us to explore the root and treat the symptom all at the same time.
This week, I challenge you to think about distress tolerance skills you may already have in your toolkit. I’ve found that there are rituals and practices I participate in that inherently help calm me down. Drinking a cold glass of water, petting my cat or reading my book all feel grounding and regulating. I encourage you to reflect on the things in your life that may serve already as a skill when tolerating discomfort. We can always add new tools to our tool box but often they never work as well as the ones that are inherently natural to us. Lean on your existing skills and stay open-minded to adding new strategies to your arsenal. Wherever you tread this week, remember you are the exact person to soothe and comfort any big feeling that comes your way, you’re the hero of this story.
