What is distress tolerance?
Distress tolerance is the ability to experience painful feelings, at least for short periods, and to cope in ways that do not involve infliction of further suffering. 

No matter how skilled we are at managing our lives there will be times when painful events occur. People vary substantially in how they respond to painful events. Some people seem to tolerate or cope with negative experiences and emotional pain better than others. They can feel high levels of pain or distress but somehow they seem to cope, manage to contain it, and carry on with their usual day-to-day activities. At the other end of the spectrum, some people have great difficulty coping with the painful feelings that accompany negative experiences, and they develop maladaptive strategies to cope with these feelings such as self-harm, substance abuse, and suicide attempts.

Distress tolerance is connected to emotional regulation but has a different focus. Good emotion regulation skills may reduce the intensity of painful feelings that are experienced in response to painful events, while poor emotion regulation skills may contribute to higher intensity of distress. But independent of how intense the painful feelings are, it is possible to tolerate that distress well or poorly. Distress tolerance skills are focused on the process of coping with the distress, as it is, not with the process of reducing its intensity.

Most individuals learn to tolerate distress in childhood and this ability improves through adolescence and into adulthood. We learn that experiencing painful events, memories, feelings and thoughts is inevitable and we learn ways of going through these experiences without reacting adversely. From interactions with parents and significant others we learn that painful experience is universal and role models demonstrate ways of coping effectively. Clear, predictable and respectful feedback from others helps us learn.

A person may not develop the skills to tolerate distress if childhood environments do not provide adequate learning opportunities. Young people with poor distress tolerance often experience chaotic family situations in which adults demonstrate poor distress tolerance themselves and do not provide clear, predictable and respectful feedback.

Interventions to enhance distress tolerance provide alternative learning opportunities in which individuals can acquire the skills involved. In addition to providing clear, predictable and respectful feedback in response to maladaptive coping responses, explicit instruction and guided practice is offered in order to enhance conscious awareness and proactively build new skills.

Where does this module come from?
Many of the practice elements in this module are drawn from Dialectical Behaviour Therapy (DBT) (see Box 1). DBT contains four skill-based modules, one of which is Distress Tolerance.

Dialectical Behaviour Therapy (DBT) is designed specifically for clients who experience overwhelmingly painful emotions and have developed maladaptive coping strategies such as self-harm and suicide attempts. A central proposition is that if clients can come to accept that emotional pain is inevitably a frequent visitor in life, and if they learn alternative skills for coping with it, then unhealthy responses will be reduced. DBT teaches three (3) main types of skills for tolerating distress: (i) radical acceptance; (ii) distraction, and (iii) self-soothing and relaxation.

The content presented in this module is drawn from material written by McKay, Wood and Brantley (2007) but has been adapted where appropriate and supplemented with observations and notes designed to make the material more relevant for practitioners working with young people in AOD service settings.  These adaptations have been informed by the wisdom of practitioners working in Victorian youth AOD services and related sectors (Bruun & Mitchell, 2012; Mitchell, 2012b).

The current module presupposes that therapeutic interventions targeting distress can be delivered independently of DBT as an integrated treatment program. Many clients who experience problems with distress tolerance do not have a diagnosis of Borderline Personality Disorder or experience persistent suicidal behaviour or ideation. These clients will not necessarily benefit from a full course of DBT. The principles of client-centred care and cost-effectiveness suggest that it is more appropriate to provide practice elements focused on their particular issues (Mitchell, 2012a) .

Used within a modular practice elements approach (Mitchell, 2012b), these practice elements on distress tolerance can be included in care plans that also include case work, foundation counseling and other therapeutic modules selected on the basis of individual needs.

Box 1: About Dialectical Behaviour Therapy (DBT)

DBT was originally developed as a comprehensive treatment for adult women with borderline personality disorder (BPD), particularly those with persistent self-harm and suicidal behaviour.

It was developed by psychologist Marsha M. Linehan, PhD of the University of Washington, who herself suffered from BPD when she was young. Revealing her personal story for the first time in 2011, Dr Linehan explained that she “developed a therapy that provided the things I needed for so many years and never got”. During her own hard won recovery she came to understand that learning to cope well with overwhelming emotions involved balancing and integrating the work of change with the work of acceptance.

DBT it is a highly structured program involving weekly individual psychotherapy, weekly group skills training, and telephone coaching between sessions (McMain & Korman, 2001; Robins & Chapman, 2004).

Therapy usually extends over 12 months. Individual psychotherapy includes supportive counseling and therapy focusing on the client’s personal experiences of dysregulated emotions, behavioural responses, and current crises. The group-based skills are taught in four modules: mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness.

Modifications have been made to adapt DBT to the specific needs of adolescents. The program was shortened to 15 weeks, a family therapy component was added, and the adult skill development lessons were simplified and adapted to fit the developmental needs and interests of adolescents (Miller, Rathus, Linehan, Wetzler, & Leigh, 1997). Unless clinically inappropriate at least one caregiver is asked to commit to 15 weeks of skills training. A key aim of including parents or caregivers is to help them coach their adolescent and to improve their own skills in interacting with adolescents.

More information about DBT in the context of youth AOD services can be found in Bruun and Mitchell (2012; Section 4.6, p97-102).