The Beginners Guide to DBT with ADHD, Part 4: Distress Tolerance Skills

Photo by Braden Young

This is part 4 of a series. Part 1, Part 2, Part 3

In the last article, we talked about emotional regulation skills. But sometimes, those of us with ADHD don't realize we need to use these skills until we're past the point of no return and in so much pain that our minds can't focus on anything else. Because of this, we get stuck in a downward spiral that takes us to some pretty bad places. Dialectical Behavioral Therapy (DBT) emphasizes how important it is to learn how to deal with pain in a healthy way. Tolerating and accepting pain is a very important mental health goal for at least two reasons. First of all, pain and suffering are natural parts of life that can't be completely avoided or eliminated. Not being able to accept this unavoidable truth causes more pain and suffering. Second, at least in the short term, if you want to change yourself, you need to be able to deal with pain and distress. If you can't, your attempts to avoid pain and distress (like by acting on impulse) will get in the way of your efforts to change in a good way.

DBT distress tolerance skills build on emotional regulation and mindfulness skills to help people deal with and survive crisis situations and accept life as it is right now.

Crisis Management Skills

Crisis survival skills are short-term ways to deal with painful situations. Their goal is to make a painful situation easier to deal with so that you don't do something rash that could make things worse. There are five main distress tolerance skills that DBT focuses on. These skills help people handle difficult situations and feel upset without making it worse. These skills are:

• STOP skill

• Self-soothing skill

• Distracting skill

• Improving the moment

• Focusing on the pros and cons

Using these five skills (plus the bonus TIPP skills) can assist you in de-escalating your emotions and starting a better internal dialogue with yourself. After all, those of us with ADHD already have a hard enough time keeping our self-talk positive.

STOP Skill

One way to keep ourselves from going into full meltdown mode when we are in a crisis is to picture a STOP sign in our heads. We can use the word STOP to help ourselves stay reined in and in control of ourselves. S -stands for "Stop!" Don't react to any stimuli that come your way. Maintain control over your emotions as well as your physical body. Stay as still as possible.

T - Take a deep breath and take a step back! Removing yourself from the situation is the best thing you can do. Take a big breath or a little break. Don't act rashly based on your emotions.

O - Observe: Pay attention! Spend time using the mindfulness skills and embrace your environment and surroundings, on the inside and out. What are your thoughts? What are the actions and words of others?

P - Proceed with caution! Consider your objectives at the moment and act with complete awareness. What actions may you take to improve the situation, and which ones will aggravate it?

This technique is a great tool to quickly put the brakes on the crisis so that we can better manage ourselves and our emotions going forward.

Self-Soothing Skill

The whole point of the self-soothing skill is to teach you to respect yourself and be kind to yourself. It includes using your five senses to do anything that helps you build a good image of yourself. For example, seeing a beautiful view from the window, hearing the sounds of nature like birds chirping, lighting a scented candle (smell), eating a hearty meal (taste), and petting an animal (touch) are all examples of sensory experiences. They consist of sensual activities that feel comforting, nurturing, and soothing. Many of the mindfulness exercises can be used for this, as many of them are designed to use your five senses to observe the world around you. This helps you build resilience and makes it easier to bounce back from difficult situations.

Distracting Skill (ACCEPTS)

Distractions help us shift our attention from upsetting feelings and thoughts to things that are neutral or fun. It's basically anything that can take our minds off of what's bothering us, like a hobby, a quick walk in the park, helping other people, or watching a movie. These things help us get away from a difficult situation or a troubled state of mind. We can use the acronym ACCEPTS to remember the steps. Activities: Use positive activities to get over the distressing situation. For those of us with ADHD, getting the dopamine from doing our current hyperfixation thing is a great way to distract ourselves. Contribute: Helping people around you or your community is also a great dopamine source for ADHDers.

Comparisons: Comparing ourselves to those who are worse off or even to ourselves at our worst can be humbling enough to snap us out of the spiral. Emotions: Making yourself feel different by doing things that make you happy or laugh Push away: Pushing your situation to the back of your mind for some time and replacing it with something less stressful on a temporary basis

Thoughts: Trying to forget what's bothering you and thinking about something else

Sensations: Doing something intense to give yourself a feeling that is different from the one that you are already going through. For example, eating something spicy or taking a cold shower

Remember that these skills and techniques are only meant to be temporary solutions to prevent meltdowns, which could make the situation worse. Distracting yourself should be used in moderation, as it does us no good to just distract ourselves from every bad situation every time. The goal here is to break our patterns of self-destructive behavior so that we can better manage our emotions when we come back to the situation.

Improving The Moment

The main goal of this skill is to use positive mental forces to improve your current image in your own mind. This can help you to reframe the situation, and help you realize what story you are telling yourself. You can practice this skill by remembering the letters "IMPROVE." Imagery: This means imagining anything that calms you down so that you don’t think negative thoughts. Meaning: This means finding meaning or a purpose in pain or a difficult situation. In simple terms, it all comes down to looking for the good in everything. This helps us see the good in every situation and learn something from it. Prayer: This means praying to God, or whomever you worship. I know this one will not be for everybody, but that doesn’t mean we can’t look inside and ask for strength and confidence, if not from God then at least from ourselves. Prayer tends to strengthen the spiritual side of many people and can help to pacify us. Relaxation: This means doing things to calm down your body and muscles, like listening to music, drinking warm milk, or getting a massage. One thing in the moment: This means being aware and keeping your attention on something neutral going on at the moment. Vacation: This includes taking a mental break from a difficult situation by thinking about something nice or doing something that makes you happy. It can be anything, for example, taking a drive or simply ignoring all phone calls for some time. Encouragement: This means talking to yourself in a positive and helpful way to help you get through a hard time.

The IMPROVE skill is especially useful in situations that are hopeless and beyond our control. We can't do anything to fix these serious problems, so we feel helpless, hurt, and sad. Many of us may feel like this is a constant crisis, so using the IMPROVE skill helps us get through it and regain our confidence.

Focusing on the pros and cons

With this skill, we are usually asked to make a list of all the pros of putting up with a stressful event and compare it to the cons of not putting up with it (like dealing with it by doing things that are bad for us). For those of us with ADHD, I would say pick an event that you still feel shame for and that seems to repeat itself. The main point of this is to help us remember how avoiding confrontation in a difficult situation in the past hurt us and to help us imagine how it will feel to deal with stress now without turning to bad habits. This makes us less likely to act on impulse. Make a list of the pros and cons of giving in to your impulses. Acting on your impulses means doing things that are harmful, dangerous, or addictive and giving in, giving up, or just putting off what you need to do. Make a different list of the pros and cons of resisting those impulses. Keep your list with you and look it over often. If you're in a crisis or feel like you have to act quickly, you can look at your list. Look at what really happened when you went with your impulses in a tough situation. This time, use your list of pros and cons to help you choose a new way to move forward.

TIPP Skills

The Anterior Cingulate Cortex (ACC) is a part of our brain that has the job of holding back our emotions and actions when we need to. Normally, this part of the brain would activate when we were about to do something that we might later regret. Jessica McCabe, creator of the YouTube channel “How to ADHD,” describes this as “the friend that holds you back while the other tries to talk some sense into you.” Unfortunately, for those of us with ADHD, that part of the brain seems to do nothing. So, when our emotions get all fired up, our brain might be screaming at us not to hit the red button, but without our friend there to hold us back, we don’t even get the chance to hear it. Fortunately, there is one more distress tolerance skill that I didn’t include in the 5 main skill sets because this one is mostly physiological. When you think about it, our emotions are really just a physical reaction to the chemicals our brain is releasing into our bodies. Our bodies get flooded with hormones when we are in a crisis situation, which sends our bodies into fight or flight mode. Because our ADHD brains have difficulty pausing to weigh whether or not we are actually in imminent danger, our bodies tend to go into full gear as if we are fighting for our lives. This is why we often go into full meltdown mode and lose our ability to think logically. Thankfully, the TIPP skills give us a natural way to create that friend that holds us back. They alter the chemistry in our brains to calm us down naturally. You can alter your ideas by altering your body chemistry. It is one of the most effective techniques to immediately calm down intense emotions.

T: Turn down your temperature.

Place your face in a bucket of ice water or apply ice to your forehead, cheeks, temples, and eyes with a zip-lock bag full of ice. This causes your brain to react in a way known as the "dive response." In other words, your brain thinks you're plunging underwater. Your brain reduces your heartbeat to regulate and protect your body. The flow of blood to your extremities is reduced, and blood is rerouted to your heart and the brain’s essential parts. I: Intense Exercise Channel all your emotions and stored physical energy into something like jogging, lifting weights, or participating in a physically demanding activity. Get a good sweat going.

P: Paced Breathing Slow down the rate at which you're breathing. Take a deep breath in through your nose for 5 seconds and a deep breath out through your mouth for 7 seconds. Pay attention to your breathing, and make sure your exhale lasts longer than your inhale. When you exhale, your parasympathetic nervous system activates, releasing hormones that relax the mind and body and slowing many high-energy body functions, including your heart rate. P: Paired Muscle Relaxation

Tense your muscles when breathing in. Take note of its tension. Notice how your body changes when you exhale and release tension. Start with your legs and work your way up to other muscle groups.

Reality Acceptance Skills

The goal of crisis survival is to get through the crisis without making it worse. The goal of developing reality acceptance skills is to reduce suffering and increase freedom when painful facts can't be changed right away or ever. I really feel that this is an important skill to learn for those of us with ADHD or any other neurodivergence, as it’s often hard for us to accept the reality that there are going to be some aspects of our brains that just don’t work as well as neurotypical brains. As such, we try to tell ourselves that we should be able to do things and perform in the same ways as our neurotypical counterparts. This is a path that will only lead to depression and more suffering. Once we accept our own reality, we can learn to forgive ourselves for our past mistakes and give ourselves permission to own our neurodiversity. There are 5 reality acceptance skills for distress tolerance, which could be a blog post in and of itself, so I will try to keep these to the basic concepts.

Radical Acceptance

Radical acceptance is the deep-down acceptance of the facts of reality as they are. It means accepting facts as they are and giving up the fight against them. Acceptance is often confused with approval or resistance to change, which it is not. It does not mean that you don’t want change; it only means that you accept that this is the current reality.

Turning the Mind

It takes multiple attempts to accept an unacceptable reality. To accept reality is to turn the mind toward acceptance. It's not acceptance, but it's the first step toward it.

Half Smiling and Willing Hands

Facial expressions and body language can help us control some thoughts and emotions. When half-smiling, facial muscles relax and the lips slightly upturn at the corners. This facial expression helps us feel more accepting because emotions are partially controlled by facial expressions. Willing hands have palms up and fingers relaxed. Willing hands are the opposite of clenched hands, which indicate anger and a desire to change reality. Keeping them open shows acceptance of reality.

Mindfulness of Current Thoughts

Mindfulness of current thoughts means observing thoughts as thoughts rather than as facts about the world. This skill teaches clients to distinguish thoughts from facts and to let them come and go without reacting. The approach is different from that of cognitive therapy, which emphasizes analyzing thoughts and changing them when they are irrational or inaccurate.

Keeping Your Cool

Hey look, you’re still here! I’m glad that you were able to make it through to the end of this article. I know there was a lot of information to absorb here. I talked about a lot of different techniques and I know that we’re never going to be able to do all of them. The important part though is to find what resonates with you and try it next time you feel yourself losing control.

Those of us with ADHD can find it all too easy to fall into the trap of letting our emotions take the steering wheel during heated moments and it’s really important that we find a way to take back control. Whether that is by reining yourself in during those heated red zone moments, or simply accepting that things are not the way you would like them to be for now so that you don’t go down that spiral. Remember, we all have the power to change our own reality, but before we can change it, we have to accept it as it really is.

Is there something in your reality that you need to accept in order to change it? What are some areas of your life that you think you could apply some of these techniques to? Change doesn’t happen right away; it takes hard work and perseverance. But if there is anything I’ve learned since starting this journey, it’s that neurodivergent brains are some of the strongest minds out there. So, I know that with a little guidance and practice, we can master emotions and take control of our futures.

As we learn these skills, we will begin to build confidence in how we interact with other people. In the next article, we will talk about interpersonal effectiveness skills and how we can learn to strengthen our relationships, create new ones, and end toxic ones. See you in Part 5!

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If you find this article interesting and want to learn more or have a comment, feel free to leave a comment below. Or better yet, come talk to us about it on our Discord server! We have a lot of great people who love to talk about ADHD, neurodivergence, nerdy stuff, and all the other things. We've also got a lot of links to resources for further reading and personal growth.