Distress tolerance is a module in Dialectical Behavioral Therapy (DBT) that teaches several skills that may prove valuable during residency training. The skills are sometimes referred to as “crisis survival skills” because they can help you navigate perceived or actual crises. 

Distress tolerance skills are adaptive (rather than maladaptive) behaviors that trainees can use to survive an immediate emotional crisis without making it worse. They can help you accept the reality of a situation if you cannot change the situation, and feel out of control.

There is a relatively high risk for trainees to develop maladaptive behaviors when coping with the extreme stresses, hours and burnout of the workplace. These can include substance abuse (alcohol or drugs), self-harm behaviors, or suicidal ideation. When acutely distressed, people will often do whatever they need to in order to manage their pain. Distress tolerance skills can help lessen the intensity of the emotional pain in the moment. In the emotionally charged resident workplace, these tools are both practical and healthy, functional ways to cope or respond.

Radical Acceptance

Feeling out of control can easily lead to feelings of emotional distress. Radical acceptance means accepting the state of things as they are, without working to change them. “It is what it is.” This involves observing a situation without emotion and acknowledging that some things are simply out of our control. In other words, accept reality as it is, without judgment or resistance. 

Two tools to help augment your practice involve half smile and willing hands. Half smile is as straightforward as it sounds – and can be done anywhere. Simply curl up the edges of your mouth into a half smile. This can be done without breaking scrub, which makes it a particularly useful tool for trainees in the operating room. Willing hands can also be done in a variety of positions or circumstances. Hold your hands with palms facing up (inside the box, if you’re scrubbed and not holding onto a retractor), in a physical gesture representative of radical acceptance.

TIPP Skills

What about when you need a solution immediately? TIPP stands for “Temperature, Intense Exercise, Paced Breathing, and Paired Muscle Relaxation.” TIPP skills work quickly, within seconds to minutes, calming the limbic system and decreasing your state of emotional arousal. They are easy and safe to do, nearly anywhere. 

1. Temperature with cold water: there are multiple options for this, ranging from splashing cold water on your face in the work bathroom, or taking a cold shower, to dunking your face in a bowl of ice water. Works nearly immediately. There are people who also swear by the ice bowl technique for a quick hangover cure as well.
2. Intense exercise: if you have the time or ability to fit this in, it can work relatively quickly to provide an adrenaline rush and combat acute distress.
3. Paced breathing: a controlled breathing technique that helps you regain a sense of control through focusing on the breath. There are variations on controlled breathing, but for instance the Navy Seals have their famed box breathing. To try box breathing, follow these steps – 

Step 1: Breathe in while counting to four slowly. Feel the air enter your lungs.

Step 2: Hold your breath for four seconds.

Step 3: Slowly exhale through your mouth for four seconds.

Step 4: Hold your breath for four seconds.

Repeat steps one through three until you feel re-centered.

Self Soothing By Grounding In Your Senses

Ground yourself mentally using all 5 of your senses. A common form of this meditation involves naming 5 things that you can see (including their colors, shapes, textures), 4 things that you can hear (including for instance ambient noise, the sound of your breathing, the sound of a neighbor), 3 things that you can touch (the seat you’re sitting in, the floor under your feet), 2 things that you can smell, and 1 thing you can taste.

You can practice sensory grounding skills with a snack or piece of candy from the doctor’s lounge. Take for instance a Fig Newton (a longtime favorite of doctor’s lounges everywhere): smell the Newton, touch its smooth surface, look at the juxtaposition of the inner fig with the outer crust, taste the Newton, and hear what it sounds like when you swallow the Newton. 

Pros & Cons of Distress Tolerance Skills

In a crisis situation, when the limbic system is activated and you are in fight or flight mode, it’s easy to make a rash decision or unmeasured reaction. Instead, give yourself a breath, and enough space (often, a moment is enough!) to think logically about the situation and pros and cons of your next step. 

When able – of course this is impractical if you’re on rounds or scrubbed in – write down the pros and cons. In situations where you are, say, scrubbed into a case in the operating room, merely taking the breath to consider your pros and cons internally, may lead to a more balanced response than your initial instinct under duress.

Improving The Moment

Do things that bring joy or pleasure in the moment. Examples may include listening to music, taking a walk in nature, or eating a favorite food. The IMPROVE skills stand for the following:

• Imagery: visualize a different situation
• Meaning: find a sense of purpose from the traumatic event
• Prayer: religious/spiritual or a mantra to recite
• Relaxation: deep breathing, progressive muscle relaxation
• One thing in the moment: slow down and break down the problem into smaller points, addressing each part one at a time (rather than being overwhelmed by the entire situation)
• Vacation: take a break from the stress or a vacation from your thoughts
• Encouragement: self talk, a reminder that the distressing state of mind is merely temporary

Distracting

Engage in activities (exercise, hobbies, socializing) to take your mind off difficult emotions. This can allow you to take a break from the acute stressor and return to it when you feel that you can deal with it calmly. Distractions can involve physically leaving a location or an action such as calling a friend, playing with pets, etc.

Improving Self-Validation

Accept and validate your emotions and experiences, instead of criticizing or denying them. Having trouble regulating emotions can also be associated with having a hard time accepting them as well. Author Seri Van Dijk (DBT Made Simple) broke down the self-validation skill into 3 steps: acknowledging, allowing and understanding. 

For example: 

Step 1: Acknowledging 

“Right now, I feel frustrated and disappointed with myself.”

Step 2: Allowing 

“This feels uncomfortable, but right now it is what it is.”

Step 3: Understanding 

“I am frustrated and disappointed with myself because I didn’t know the answer to that question on rounds. I am not going to judge myself for this, because I’ve been feeling very overwhelmed and mildly depressed. That’s enough with the negative feelings, I don’t need to make it harder on myself. For starters, today I will read 1 article on this topic.”

DBT & Distress Tolerance For Residents

There is a beneficial role for DBT techniques in the life of any resident physician. Due to the high stress nature of the job, improving distress tolerance as well as emotional regulation and interpersonal effectiveness, is a secret weapon that many trainees may not be familiar with. Rethinking Residency aims to give you practical tools that can be used on the job for everyday high stress situations.

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