These are for when we are experiencing a high level of distress (like feeling really anxious, sad, or angry inside and/or having intense and disturbing negative thoughts) and we need to get some space from and time away from the distress, at least to some extent. They are not practices designed to solve the problems that are contributing to our distress level, though they can help us regroup more quickly so that we can start to solve the problem. Think of distress tolerance practices as a brief, necessary vacation from the storms and turbulence that periodically emerge in life.*
We generally use distress tolerance practices when we anticipate that applying mindfulness will not be helpful right now, given the intensity and destabilizing nature of the distress. After we apply distress tolerance practices and feel more stable, then we can approach the trigger situation/problem more mindfully—describing, observing, assessing, and eventually participating in it. By then, we are in a better position to start problem solving.
To see if now is a good time to apply distress tolerance practices, answer the following questions:
- Do I feel overwhelmed or almost overwhelmed? Do I feel behaviorally unstable (not sure what I am going to do next)? Am I considering doing unhealthy behaviors like excessive, poorly timed, or otherwise risky use of alcohol or other drugs, risky sexual behavior, compulsive over-eating, bingeing and purging, self-harm, or behaviors that will significantly damage important relationships?
- If there is a problem that is contributing to my distress, can I take steps to solve it at this time or do I have to wait to start solving the problem?
- Am I in the right frame of mind right now to work on solving the problem right now?
- Am I in the right frame of mind right now to rely on my mindfulness skills to get through this difficult time?
If you answered “yes” to the first question and “no” to any of the next three, and you are feeling in danger of being destabilized by your level of distress, then it is a good time to apply some Distress Tolerance practices.
(If you answered “no” to the first question and “yes or maybe” to the remaining questions, then it is probably a good time to move to problem solving.)
The following practices are designed to replace unhealthy coping behaviors, such as those mentioned in Question 1, above.
As you begin to apply these practices, it can be helpful to consider the following dialectics:
- Attending to the problem vs distracting from the problem
- Attending to the troubling emotions/thoughts mindfully vs introducing more positive emotions into the picture for the time being
As you engage in these practices you are likely to find that you are more ready to move towards the pole of the dialectic that involves problem solving and sitting with our difficult emotions.
You may find that you alternate between problem solving and distress tolerance skills as you move through a complicated, multi-step problem. Do what is most effective for you at that moment.
Distract with ACCEPTS:
The acronym ACCEPTS contains the following elements that help us tolerate distress:
A = Activities
C = Contributing
C = Comparisons
E = Emotions
P = Push Away
T = Thoughts
S = Sensations
Activities: Doing things that engage us physically and mentally help us move through distressing thoughts and feelings. You will need to develop a list of activities that you can do so they are readily available to you. Good candidates are activities that you enjoy (or enjoyed in the past) and that are relatively easy to start. As you develop your list, make sure to identify anything that you will need to prepare or acquire in order to engage in the activity. (For example, if you want to try running as an activity, make sure you have the proper gear available.)
Many times when we are in distress, it can seem challenging to start an activity. Also, we may be dealing with sadness or low energy/interest—these factors can make moving into an activity challenging. Remember that getting started is a choice that you have control over, though it may be the hardest part. It is important to remind yourself that once you get started, it is likely that the activity will feel easier to do and that you are going to start to feel better.
Also, it will be easier to start the activity if you do it regularly, even when not experiencing a high level of distress. Putting the activities you identify into a routine that you follow even when not distressed will make it much more likely that you will make the choice to start the activity when you are in distress. Doing the activity routinely will also help you remember that you start to feel better when you start the activity, even if motivation is low in the beginning.
Contribute: Contributing is a subset of Activities that helps us distract from ourselves because we are focusing on others for a period of time. We benefit from the connection with other people, as well as from a sense that we are helping. Contributing activities can be seemingly very minor. Smiling at someone, holding a door, asking someone at work if they need help, or giving a compliment are all contributing activities. Caring for a living thing or volunteering are more involved forms of contributing. Regardless of the complexity of the activity, when we give to others (and we therefore get out of our own situation for a period of time) we tend to feel better.
Comparisons: We can use comparisons to help us get some perspective on our current distressing situation. For instance, we can recall times where we felt worse or we can recall situations that were more stressful and demanding than the one we are dealing with presently. Many of the distressing situations that we will come across are probably less distressing than some of the big ones we have faced in the past.
A variation of comparison is to think about people who are dealing with situations that may be more stressful than your own. This can be someone else you know, or it can be someone that you heard about on the news. Thinking about another’s distress in comparison with your own does not mean that you invalidate the distress you yourself are feeling—rather that you are putting your current distress into some perspective, as well as feeling empathy for others. You remember that life is hard for many people and that it is part of the human condition to go through tough times. We are all equal in that regard.
Emotions: Seek out activities and experiences that trigger emotions different from the distressing ones you are experiencing now. This could be from listening to music with an emotional tone different from the one you are feeling now. For instance, if you are feeling tired or low-energy, turn on some high-energy music. Or it could be from watching a show or movie that generates emotions different from the ones you are feeling now. If you are feeling sad, sometimes putting on a comedy can distract you from the sadness you are feeling, until the sadness is less destabilizing so that you can get back to problem solving.
Push Away: Use mental imagery to picture locking the problem that triggered the distress into a box so that it stays put and cannot act against you until you are ready to open the box and deal with it. Or, write a little bit about the problem and then actually put the writing into a drawer or box and close it up. Then take it out of the box when you feel less distressed and more ready to start solving the problem. The important part of Push Away is giving yourself permission to not think about the problem for awhile and to then go back to the problem situation when you are feeling less distressed and more able to act on the problem (or hold it in mindfulness if there is nothing you can do directly to act on the problem).
Thoughts: We can only think about one thing at one time. Actively put your mind on another thought or set of thoughts other than the distressing situation. Think of things you want to do in the future. Think about things you did in the past that felt good and were fun. Or get absorbed in a book, puzzle, or game that occupies your thoughts. If the distressing situation creeps back into your mind, gently usher it back out and return to focusing on your activity.
Strong Sensations: This refers to doing something awakens your senses and is likely to a produce a change in your emotional state, at least for a short period of time. These sensations are not relaxing. They are sufficiently strong to introduce a new experience that distracts from the distress you are experiencing. Examples include taking a (not too) hot or cold shower, holding ice cubes in your hands, looking at bright, bold colors, standing outside on a cold day, or eating or drinking something with a strong taste. Just remember that the activity that produces the strong sensation needs to be a safe one.
Distract with Self-Soothing
Self-soothing helps us navigate distress by creating a sense of relaxation through a mindful connection to one or more of the senses. Even though you are not approaching the problem situation mindfully at this point, you will be using your senses mindfully to self-soothe.
Using sight: Mindfully focus on the visual world around you. This could be what is outside your window, it could be what you see when you go for a walk, or it could be what you see in your living space or where you are the moment. Notice what is around you and really focus on the visual details. See the textures, contours, and typically unnoticed detail in everyday objects around you.
Using hearing: Mindfully focus on the sounds around you. Whether it is music that you put on, the sounds of the world outside, or even the sound of the appliances in your home if those are pleasing to you. Really focus on the sounds and the variations and details within the sounds.
Using smell: Mindfully focus on smells around you that you find pleasant. This may involve lighting a candle or incense and focusing on the aroma given off. Or it could involve putting on a favorite perfume or cologne and focusing on the aroma. It could involve smelling the various spices that you keep in your kitchen. You might want to assemble a collection of spices in one easily-accessed location to keep handy when you want to practice this activity.
Using taste: Mindfully focus on tastes that you enjoy. This could be a snack that you like, a piece of hard candy, or a non-alcoholic beverage that you enjoy. Give your full attention to the taste sensations associated with what you are taking in.
Using touch: Mindfully focus on touch sensations that you enjoy. This could be petting your dog or cat or putting on comfortable clothing and getting under a warm blanket. This could involve putting on oil or lotion on your skin. Wash your face with soap and comfortably warm water. Dry off and notice the difference in how you are feeling.
IMPROVE the Moment
IMPROVE, like ACCEPTS, provides healthy distractions.
I = Imagery
M = Meaning
P = Prayer
R = Relaxation
O = One thing at a time
V = Vacation
E = Encouragement
Imagery—When you are feeling distress and you cannot work on problem-solving at the moment, take a little time and focus on a mental image or scene that is comforting or soothing to you. Many people find that they choose one or several go-to images that are relaxing to them. Hold that image in your mind, put yourself into it, and focus on what you see, feel, hear, and smell in the image. Also touch sensations, such as the feel of the sand underneath your feet if you are imagining being on a beach. Allow yourself to spend time and feel at home. You will notice that other thoughts come into your mind. That is normal. Just recognize that you are distracted, let go of the distracting thought, and go back to the image until you are ready to leave.
Meaning—Finding meaning or purpose in a difficult experience can sometimes make the experience feel less distressing. Is there something to be learned from the experience, despite its painful nature? Could we do something differently next time? Was there something that we may have done or not done that might have contributed to the distressing situation. Can we learn more about our coping skills/ability as a result of the distressing situation?
Prayer—Recognize that you are going through a difficult time and pray for strength, resolve, and wisdom to move through the difficult time. The prayer or communication can be held with a higher power, with an admired/loved figure (even if you don’t know the person), or with yourself.
Relaxation—Use your mindfulness breathing exercises, mindful progressive muscle relaxation, or self-soothing skills to move through the distress. If thoughts about the distressing situation intrude into your relaxation, acknowledge the distraction and gently guide your focus back to the relaxation exercise.
One thing at a time—Remember that you can only do one thing at a time or take care of one problem at a time. When you are feeling overwhelmed with multiple demands, focus on the most important one and do what you can with that demand. Focus on the thing that you need to do now to move things forward and avoid telling yourself that everything has to happen at once.
Vacation—This does not mean an actual vacation. Rather it means that when we are in distress, it can be helpful to take some time to take a brief walk, to listen to some music we like, or to go online and read or watch things that interest us. In general, the vacation needs to be brief (usually not more than a day), because we do not want problems to accumulate, but it should be long enough to help you feel a reduction in the sense of overwhelm and destabilization. During your vacation, apply the practices mentioned in ACCEPTS, self-soothing, and IMPROVE. If another activity seems preferable and is a healthy one, that should be fine as well.
Encouragement—Validate your feelings. Encourage yourself that you are equipped to get through this difficult time. Think about other difficult situations that you have gotten through.
* This material is gathered from Marsha Linehan’s Skills Training Manual for Treating Borderline Personality Disorder (1993).