DBT group notes: Distress tolerance vs avoidance


Welcome to the Distress Tolerance Unit! Each week while we cover this unit, I will use the Mindfulness Exercise to introduce a Mindfulness Practice specifically to help manage distress in a crisis. We start with Square breathing. Its this simple, Breath in 4, Hold 4, Breath out 4, Hold 4. Repeat.

I like this guided Square (or Box) breathing video. I find it soothing and the breathing pace is calming.


Distress Tolerance Skills are all about NOT making a BAD situation WORSE.

Distress Tolerance Skills: What are they?

At some point in our lives, we all have to cope with distress and pain. Either it can be physical, like a bee sting or a broken arm, or it can be emotional , like sadness or anger. In both cases, the pain is often unavoidable and unpredictable. You can’t always anticipate when the bee will sting you or when something will make you sad. Often, the best you can do is to use the coping skills that you have and hope they work.

But for some people, emotional and physical pain feels more intense and occurs more frequently than it does for other people. Their distress comes on more quickly and feels like an overwhelming tidal wave. Often, these situations feel like they’ll never end and the people experiencing them don’t know how to cope with the severity of their pain. For the purposes of this book. we’ll call this problem “overwhelming emotions”. (But remember, emotional and physical pain often occur together.)

People struggling with overwhelming emotions often deal with their pain in very unhealthy, very unsuccessful ways because they don’t know what else to do. This is understandable. When a person is in emotional pain, it’s hard to be rational and think of a good solution. Nevertheless, many of the coping strategies used by people with overwhelming emotions only serve to make their problems worse.

Matthew mckay, the dialectical behavior therapy skills workbook


It can be helpful for a deeper understanding of DBT to get to know the woman that created DBT. This is Marsha Linehan talking about how she realized that clients needed distress tolerance skills.

Marsha Linehan, founder of DBT, introduces the Distress Tolerance Unit.


Everyone has them. In DBT we call them “unskillful” behaviors. Things we do to make ourselves feel better in the moment (or at least trying to to feel worse) that create short term and long term problems. Here is the kicker though! We wouldn’t do them if they didn’t work! And sometimes they work pretty well and immediately. So much so that they become self-reinforcing. Numbing yourself with alcohol works. Self-harm releases endorphins and can ease emotional pain. Isolating can relieve social pressure or reduce feelings of shame or embarrassment. Suicidal ideation is an escape hatch that says “you have a way out.”

Most people who end up in DBT are here because at some point their unskillful behaviors started to ruin their lives–or at the very least make a difficult life even worse.

Distress Tolerance skills are a whole set of skills meant to replace Unskillful behaviors with Skillful behaviors. Behaviors that help and won’t harm.

Before we launch into asking you to release from your unskillful behaviors, lets take a moment to acknowledge them.


I invite you to work through the checklist below. Note the items that are strategies you have used.

Then write down your thoughts about possible costs in the future, as well as what those strategies have cost you in the past.

Remember its important to honor these painful habits and acknowledge why you turned to these behaviors.

Its a sort of farewell, as you let old self-destructive coping go and open yourself to practicing Skillful replacement behaviors.


This little story illustrates the importance of choosing skillful means instead of habitual self-destructive behaviors.

It starts with a text.

A break up text.

Stacey was getting ready for her date with Sam. Another fun friday night, when her phone chirped. “I can’t see you anymore. I’m done. Sorry. I wish you all the best. Goodbye.” Just like that after three months of hanging out, great sex and good times.


Fear of abandonment is at its worst when you are actually being abandoned.

Stacey texted back, “What? I don’t understand? I am just getting ready to meet up with you. Are you canceling our plans?”

No response.


No response.

“Sam? What are you doing? Why did you send that text?????? Are you breaking up with me????? by Text???? Seriously?”

And so it began. Emotion Mind took over and Stacey grabbed a bottle of wine and kept texting. And texting. The texts ranged from begging to screaming to appeasing, flattering, threatening, insulting. But nothing she did elicited a response. The intensity of her panic and despair only increased as his silence when on. And she opened a second bottle.

There was a decision point further back. When she got his breakup text, before she started drinking. Before her texting would legally count as harassment. There was a choice point where she could have used Distress Tolerance skills and the night would have had a completely different outcome. Take a moment….What skillful thing could she have done when she was still sober? (As we carry on with the distress tolerance unit, you will have so many ideas for getting through this kind of crisis.)

Half way into the second bottle, she decided to take matters into her own hands. If he wouldn’t text back, then she would go to his house. And talk to him in person. Maybe there was something wrong with his phone? Or something he needed help with? Or at least then he would have to face her!

This is the next decision point where distress tolerance skills would have led to a different outcome.

She jumps in the car and drives to his house. Driving under the influence, very unskillful.

When she arrives, she has reached another decision point. The choice she makes: Bang on his door yelling…for hours.

Eventually someone calls the police. When she sees the police lights, she runs for her car in an effort to drive away, but she gets pulled over.

Now a really bad, painful situation has gotten much much worse.

The police take her to the station and charge her with driving under the influence, resisting arrest, drunk and disorderly and disturbing the peace. And its friday. So she will be spending the weekend in jail before she has a chance to see the judge.

She is offered one phone call. She declines. Thoughts about why she would decline?

She is embarrassed, humiliated and doesn’t want anyone to know what has happened.

Stacey has a pregnant sister. Her sister is single and Stacey had signed on to be her labor coach and companion. They had completed the natural childbirth class together. Her sister went into labor early that weekend. No one in the family knew where Stacey was. You can imagine the impact this had on Stacey’s relationship with her sister…irreparable damage. Not only was Stacey MIA for the labor, her sister was also terrified about what had happened to her.

When you choose to use Distress tolerance skills, you get to choose your own ending to the story.

(That’s the moral of the story…in case you missed that…)


Alot of the distress tolerance skills have to do with distraction. They are ways of soothing yourself and getting through a crisis without making it worse. Marsha points out in the DBT skills training Handouts and Worksheets that these skills are NOT for everyday problems (that can be solved); they are not for solving all your life problems; and they are not for building a life worth living.

Distress tolerance skills are meant to help you survive an unbearable moment.

From The DBT Skills Training Handouts and Worksheets:

YOU ARE IN A CRISIS when the situation is:

  • Highly stressful
  • Short-term (that is, it won’t last a long time)
  • Creates intense pressure to resolve the crisis now


  • You have intense pain that cannot be helped quickly.
  • You want to act on your emotions, but it will only make things worse.
  • Emotion mind threatens to overwhelm you, and you need to stay safe.
  • You are overwhelmed, yet demands must be met (like at work or school).
  • Arousal is extreme, but problems can’t be solved immediately .


The downside of learning so many distress tolerance skills is clients using them as a way to avoid problems. Being able to skillfully distract is an incredible resource for surviving crisis, but it can be problematic when escapism becomes a way of life.

The key to all of this is knowing when to expose and when to distract. When is it skillful to expose yourself to the problem? To the difficult emotions? And when does it make sense to distract?

I favorite strategy for making that decision is these three questions:

  1. Is this a Problem That Can be Solved?
  2. Is this a Good Time to Solve the Problem?
  3. Am I in Wise Mind enough to solve the problem?

If the answer to all of those is yes, then solve the problem.

If the answer to any of those questions is no, then use distress tolerance.



  1. Think of a situation you have been in that felt like a crisis –perhaps recently. And go through the three questions:

Was this a problem that could be solved?

Was this a good time to solve the problem?

And were you in wise mind enough (at the time) to solve the problem?

2. This week, as you encounter crisis, large and small, apply these three questions to the situation as part of your decision tree to navigate the crisis.

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Diana is a licensed professional counselor based in Nashville. She has been teaching DBT skills for the last ten years after writing her master's thesis about making DBT skills training interesting and engaging. She loves using story telling to help illustrate how skills can be used.

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