Distress Tolerance

A wonderful young woman we have been seeing for a few months asked for some recommendations for skills to help her deal with her experience of moments of overwhelming negative emotions that often seem to come out of nowhere.

This post is a relatively quickly pulled together document derived from Marsha Linehan’s Dialectical Behavior Therapy.

Think of it as a “draft” – something we hope to modify and revise.

If you find it helpful please buy the excellent book  from Harbinger Press: “Dialectical Therapy Skills Workbook” by Matthew McKay , Jeffrey C. Wood , and Jeffrey Brantley.

All of the central ideas come from the work of Dr. Marsha Linehan of the University of Washington. Her development of Dialectical Behavioral Therapy (DBT) transformed the approach to people with dysregulated emotion.

The key concept we will be talking about is something called emotion regulation: developing the ability to influence which emotions you have, when you have them and how you experience and express them. To do that, of course, you need to understand them. You need to be able to identify your emotions. Often just identifying what they are can help you develop the ability to regulate them. It can be very difficult to influence your feelings when you don’t understand where they come from or why they’re there or even how to describe them.

Of course one of the best ways of changing your emotions is by preventing the development of painful emotions or feelings and you can do this by changing your environment and your relationships. This section won’t be talking about those ideas of prevention but they are often very important.

Radical acceptance

In addition to some specific skills, dealing with challenging and turbulent emotions starts with a different attitude toward life. Often when we’re in pain our first impulse is to try to eliminate the experience and perhaps look for a cause in the outside world.

The trouble with this approach is that an angry response to an unpleasant feeling can make the pain worse. And anger also makes it harder to see the true nature of the emotion and of the thoughts that go with that emotion. Anger or upset feelings help to prepare us for a fight, but for many situations that cause emotional pain, there really is no one to fight. This creates two problems: anger makes it harder to see the real situation since it tends to reduce problems to a choice of “fight or flight,” and if there is no one to fight we can often turn upset or angry feelings against herself which certainly doesn’t help to deal with overwhelming emotions but rather adds “fuel to the fire.”

Radical acceptance involves acknowledging the reality of the current situation with its upsetting emotions, without judging the events or criticizing yourself. The idea is to focus your attention on the nature of the situation. Trying to fight reality or telling yourself that something “shouldn’t” be the way it is will only lead to more suffering. Radical acceptance means looking at things as they are, looking at your emotional responses to them and acknowledging them.

To put it another way, emotions themselves are neither good nor bad. Trying to assess feelings as good or bad is generally not helpful. As we talked about, a better approach is to focus on describing them and understanding them.

And just as rejecting emotions is not helpful, so too suppressing emotions tends to be a temporary solution that makes problems worse in the long run.

So the goal of emotion regulation is to reduce emotional suffering not to get rid of painful emotions.

Here are some examples of statements that you could tell yourself that reflect this stance of radical acceptance:

  • this is the way things have to be
  • everything in the past has led to this place
  • I can’t change what has already happened
  • there’s no point in trying to wrestle with the past
  • the only thing I can change is what I do in the present not what led me to this place
  • wisdom is in seeing the possibilities for change in the present

Since this is a new way of thinking about problems it is best to begin with the situations that are not too overwhelming. Start with smaller events or moments of emotional upset. Write down any of the statements that you think fit with how you think about things and add to that list one or two ideas of your own that deal with the concept of acceptance and acknowledgment of things as they are, and carry that list around with you. You can put it on an index card or something else that is easy to carry with you and pull it out when you’re dealing with or facing an upsetting situation. Actually read the list and try to “tell yourself” how better to respond to the situation.

Crisis survival skills

When emotion gets too overwhelming it can interfere so much with thinking and decision-making that it becomes impossible to practice any of the skills we’ll talk about in the next sections.

The first skill then is making sure that the crisis doesn’t lead to some irremediable or impulsive action.

We begin with the STOP skill.

  • Stop – notice that this is a crisis situation.
  • Take a step back – begin to recognize that a crisis is always short-term. The sense of urgency to do something right now is a distortion.
  • Observe – notice in as clear and detailed a fashion as possible what the thoughts are, the emotions, and the physical sensations in your body. Describing them will help to give you a sense of perspective.
  • Proceed mindfully – which could also be said to represent cautious and self-aware action. Recognize that you are more likely to get into trouble in a crisis from what you do than from what you don’t do.

The TIPP skill can be used to change your body chemistry quickly and to damp down the fight or flight response.

  • Temperature – use something to cool your face down, a bowl filled with cold water, an ice pack …, all of these stimuli will reduce the “heat” of the moment quite literally.
  • Intense exercise – physical activity that challenges yourself is almost always followed by a relaxation response afterwards.
  • Paced breathing – slowing down the exhalation phase of your breathing and using some self-monitoring process such as a clock or an audio track to help you do that. There is a video that has an example of this kind of breath retraining or paced breathing on YouTube.
  • Paired muscle relaxation – this practice involves using and then relaxing muscles and is also known as progressive muscle relaxation.


Distraction skills can temporarily stop you from thinking about your pain and give you time to come up with an appropriate coping response. They help you to let go of the pain by thinking about something else and buy you some time. However it don’t mistake distraction and avoidance. When you avoided distressing situation you choose not to deal with it but when you distract yourself it is so that you can find a time in the future to deal with a situation that’s more appropriate.

Distract yourself with powerful sensations or actions

One approach to distraction involves doing something that will catch your attention and draw you away from the circular processes of emotional upset. Because it can be difficult to go from emotional upset to calm (which might seem to be a better option) distraction may involve breaking circular chain of anger and upset and self-recrimination by refocusing on some other less negatively charged action or sensory experience.

Here are some ideas for distraction.

  • If you’re someone who will do things that are harmful to yourself in situations of overwhelming emotion, try holding an ice cube in one hand and squeezing it. The numbing sensation from the ice can be a distraction from emotional pain and won’t hurt you.
  • Dig your fingernails into your arm without breaking this again.
  • Snap a rubber band on your wrist.
  • Throw foam balls, rolled up socks or pillows against the wall as hard as you can.
  • Find a punching bag.
  • Scream as loud as you can into a pillow or scream someplace where you won’t upset other people.
  • Sometimes people will do other things instead of becoming tearful because they’re afraid that once they start crying the tears won’t stop, but this never happens, in fact crying can make you feel better because of the hormones that are released when we cry.
  • Other non-hurtful distractions that you can come up with.

Again, it is helpful to write down one or two ideas for distraction activities and carry the list with you. When you find yourself in a situation of emotional upset or pain choose to do one of those distraction activities without questioning it. Just to see if it helps get you out of a stock or trapped place.

Distract yourself with pleasurable activities

Distraction doesn’t have to be about doing things that are painful. Sometimes you can choose to do something pleasurable and healthy when you feel upset.

This is a shortened version of the Big List of Pleasurable Activities from the Dialectical Behavior Skills Workbook (as you go through the list check the ones you’re willing to do and add any other ideas that come up)

  • talk to a friend on the telephone
  • go out and visit a friend
  • text message someone
  • exercise
  • stretch your muscles
  • go for a long walk or run in a park or someplace else that’s peaceful and beautiful
  • do something exciting like surfing, rock-climbing or kayaking
  • go play something that you can do on your own like basketball, bowling, miniature golf, etc.
  • get a massage
  • get out of your house even if it’s just to sit outside
  • go for a drive or take public transportation someplace new
  • take a nap
  • eat dark chocolate
  • cook your favorite dish or meal
  • go out for something to eat
  • go outside and play with a pet
  • go outside and watch the birds or other animals
  • find something funny to do – like watching a funny movie or reading the comics
  • listen to the radio or music that you enjoy
  • go to the movie theater and watch a movie that you would never choose to see on your own
  • visit your favorite websites (try Calm.com)
  • get a haircut or manicure
  • go to a library or bookstore
  • visit the museum or art gallery
  • go to the mall or some other place where you can watch people
  • sing some favorite songs
  • turn on loud music and dance
  • take photographs
  • do some gardening
  • take a bubble bath or shower
  • work on your car, truck, motorcycle or bicycle
  • put on an exercise video
  • write a letter to somebody who’s done something good for you

Distract yourself by paying attention to someone else

Sometimes it can be helpful to focus on another person as a way of distracting oneself from negative thoughts about oneself.

Here are some ideas, but for this approach it may be especially helpful for you to think of specific examples that are relevant to your relationships:

  • do something for someone else – call a friend and ask if you can help doing something like a chore, grocery shopping or housecleaning; ask your parents, grandparents, or siblings if you can give them a hand with anything (tell them you’re feeling bored and you’re looking for something to do); call up a friend who may be lonely and offered to take them out to lunch; sign up for a volunteer group.
  • pay attention to other people – go to a shopping center or coffee shop just sit and watch other people, watch what they do or say and try to imagine what is going on in the conversation, pay attention to as many details as you can, figure out how you would describe the person to a friend or how you would write about what is happening in a book.
  • think about someone you care about – keep a picture of them in your wallet door on your phone and take out the picture and say to yourself “I give love to you” and notice also that they care for you, imagine what they might tell you right now in this current situation.
  • go to a support meeting and express appreciation or support for someone else in trouble (narcotics anonymous, alcoholics anonymous, overeaters anonymous)
  • sign up for a suicide prevention or other crisis hotline

Distract yourself with thoughts

it’s not possible to stop oneself from thinking negative thoughts, the more you try to not think about something the more immersed to get in the tangle of those thoughts, so instead of trying to force yourself to forget a thought memory, turn your attention to other thoughts. Here are examples:

  • imagine sexual thoughts or situations or fantasies that you might have about someone you know, try to think of as many details as possible.
  • take a look at what is going on around you and think about why people are acting the way they are or animals are behaving the way they are, what is the motivation?
  • imagine that you’re a hero or heroine going back in time to correct some past mistake or harmful situation, what would you do, what would people say to you?
  • think of your wildest fantasy coming true, what would it be, how would it turn out?
  • keep a copy of a favorite prayer or meditation nearby and read it to yourself, think about how the words calm and soothe you.

Distract yourself with tasks or chores

We already mentioned above the idea of working on a car or bicycle as a way of distracting yourself but here’s a list of things that people can do that are not only distracting but also a source of positive feelings:

  • wash the dishes
  • clean your room or house or bathroom
  • clean or organize a closet door the garage
  • organize your books, computer desktop, pictures, etcetera
  • make a list of steps to find a job or complete some other project
  • get a haircut
  • wash your car
  • garden or mow the lawn
  • wash the laundry
  • do your homework
  • polish your shoes

Create a distraction plan

Identify the skills that you want to practice and that you’re willing to do the next time you’re in a situation that’s causing you pain or emotional upset and write them down on the list. You won’t be able to come up with that plan in that moment so having something written down on one or more index cards and carrying it with you is an important step that you can do right now that will make you feel better in the future.


Self-soothing helps you to feel safer and better able to deal with a difficult situation or problem. They help you to feel stronger and put you in touch with your competent self. They also help you to practice and learn how to treat yourself with care and love. Many people who have overwhelming emotions may have not had the best parenting and so did not learn how to care for themselves emotionally. The second goal of learning self-soothing is helping you to treat yourself more kindly and lovingly.

Self-soothing using your sense of smell

Smell is probably the sensation that most closely connected to emotions. Smell memories can take us back to a time, place and a feeling, better than almost any other kind of sensory experience. Which of these would you be willing to do?

  • burn scented candles or incense
  • wear a perfume that makes you feel happy or confident
  • go someplace where there is a smell that makes you feel positive like a bakery or a garden
  • lie down in a park or in your garden and smell the grass and outdoor smells
  • go to a flower shop and smell the flowers or go for a walk and find the flowers in your neighborhood

Self-soothing using your sense of vision

Vision is the sense that we devote more of our brain to than any other so images can have a powerful effect as well.

  • go through magazines or books or go on to the Internet and make a collage of images or look through your own file of pictures and find ones that are particularly pleasing
  • find a place that soothing for you to look at like a Parker Museum or go outdoors
  • go to the bookstore and find a collection of photographs or paintings or go to the museum
  • draw or paint a picture that’s pleasing to you

Self-soothing using your sense of hearing

Sounds and music can take us away to another time or place as well, and songs activate a part of our brain that is different from thinking.

  • create a playlist of soothing music, classical, opera, New Age, jazz, whatever works for you
  • listen to books on tape
  • listen to the radio
  • open your window and focus on the peaceful sounds outside
  • listen to and recording of nature sounds
  • listen to relaxation exercises (did we mention Calm.com?)

Self-soothing using your sense of taste

Try not to eat things that might make you feel bad because they’re not healthy, but food is one of the most powerful ways of soothing yourself:

  • enjoy a healthy meal
  • focus on really tasting a favorite food
  • drink something soothing like tea or coffee
  • by a piece of ripe and juicy fruit and eat it slowly

Self-soothing using touch

We often forget about our sense of touch, but human touch can be one of the most reassuring things.

  • carry something soft or velvety in your pocket
  • take a warm or cold shower or bath
  • get a massage or massage yourself
  • play with a pet
  • pleasure yourself sexually

Create your own plan

What are your favorite self-soothing skills. Write down a list and keep it close to you. You don’t need to wait for a crisis to practice these, in fact that work better if you’ve done them before you get into a place of emotional upset

More Information

Distress tolerance

Our relationship to pain matters