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PTSD: Distress Tolerance
Learning to tolerate distressing emotions and sensations is crucial not only for healing from PTSD, but also an essential skill to cope with the inevitable challenges of life. When we persistently react to negative thoughts, emotions and sensations, we can get stuck in a cycle of chronic distress. Building tolerance towards negative affective states, on the other hand, can alleviate feelings of being overwhelmed, prevent uncontrollable outbursts and panic, reduce fatigue, and enhance our capacity to respond to distress effectively.
While learning to acknowledge, feel, remain equanimous or express negative emotional states can be difficult for most, for PTSD sufferers affected by unaddressed trauma, it can be particularly challenging, although entirely achievable. In this months blog article, I will outline the nature of distress tolerance, discuss its importance, and share straightforward tips and strategies to develop tolerance to distress for purposes of improving psychological functioning.
What is Distress Tolerance?
While a key feature of mental health disorders, there appears to be no precise definition of the word distress provided by the DSM. Generally however, distress is understood to encompass unpleasant emotional states. According to Dialectic Behaviour Therapists like Marsha Linehan (2014), distress tolerance is a person’s ability to cope with emotional incidents without feeling overwhelmed or resorting to harmful behaviours. Similarly, Siegal (1999) refers to an optimal zone of tolerance, wherein individuals can regulate their emotions effectively.
For the purposes of the present article, distress is defined as any negative affective state, such as anger, sadness, fear, or other negative energies felt in the body, with tolerance being the ability to acknowledge, feel, remain equanimous towards, or express these states effectively.
Why is Distress Tolerance Important?
Experiencing negative emotions such as anger, sadness, fear, frustration or irritability is a normal part of life. However, when we don’t respond effectively to these states, it can create an imbalance in both mind and body. This imbalance may manifest as heightened anxiety, anger or even lethargy. Moreover, your ability to solve problems, make decisions, and pay attention can become impaired. Avoiding, resisting or reacting negatively to emotional pain can also disrupt daily functioning, and exacerbate mental health issues. Unfortunately, humans tend to seek positive feelings and avoid or negatively react to negative ones, which can further fuel aversion to negative emotions and cause psychological imbalance.
Distress in the context of PTSD however, is different from the distress arising from the normal vicissitudes of life, or the pursuit of hedonic happiness. PTSD related distress is chronic and typically associated with horrific events that are outside the range of normal human experience. Nevertheless, it is equally as important to acknowledge, feel and try to remain equanimous to negative emotions and sensations. While effective PTSD healing requires the processing of cognitions and transformation of core beliefs, working with the ‘felt sense’ of the traumatic response is essential. The absence of a focus on the embodied experience of trauma is akin to changing three tyres of a car, when all four need changing.
Peter Levine and others have illustrated the importance of somatic experiencing for trauma healing. Unexpected shocking incidents can cause freeze reactions, leading to a constriction of the energy body and manifesting states of helplessness and collapse. When not properly processed, this response is experienced as trapped or stuck energy in the body. Titration, a gradual building of distress tolerance, can release this energy and provide symptom relief. Slow awareness of sensations and emotions in the body is key, especially with severe symptom presentation, to avoid overwhelming distress.
If you’ve consistently tried to push away negative emotions, sensations, or thoughts through unhealthy coping strategies such as excessive working, perfectionism, or abuse of food or substances, then the sudden acknowledgment and feeling of this distress can cause psycho-biological crisis. Therefore, attending to the pain in manageable small steps, especially so if you have CPTSD, will build your ability to respond effectively, and eventually bring about states of awareness, calmness and clarity.
How to Build Distress Tolerance Skills
Building distress tolerance varies depending on the individual’s symptoms. For those without a mental disorder, an effective approach is to learn to acknowledge and feel positive, negative or neutral sensations and emotions in the body, and gradually learn not to react to them. This involves staying clam, feeing the emotions, and letting them pass naturally without aversion. However, this approach may not be as effective for individuals with CPTSD. For this, it is crucial to get proper therapeutic support, which may include short-term prescription medicines, or even hospitalisation. Personalised guidance is advised when applying any technique to address chronic distress.
That said, here are some general self-care suggestions on ways to regulate distressing emotions. I draw on a range of techniques from diverse therapeutic approaches, some of which include external strategies to cope with distress, whilst others are body based methods.
Techniques For Distress Tolerance
- Engaging in Distraction: Participating in activities that divert your attention from distress can be effective. This could include working on a task, helping others, watching a humorous or thought-provoking movie, or even holding an ice cube to shift focus.
- Utilise Sensory Awareness: Redirecting your attention to sensory experiences can help manage bodily distress and prevent overwhelm. Focus on what you can see, hear, smell, taste, or touch. For instance:
- Listen to external sounds or music.
- Notice the scents around you or use aromatherapy oils.
- Drink water or a soothing beverage, paying attention to its taste
- Feel the texture of an ice cube, rub your hands together, or press your feet into the ground.
- Observe your environment, such as the artwork or plants around you.
3. Practice Visualisation: Visualisation techniques can help shift focus away from distress. Imagine yourself in a peaceful place, like walking along a beach or being in a serene green space. Alternatively, recall a happy memory involving a person, place, or pet. You might also visualise placing your distress into a box to address later or imagine releasing it entirely.
4. Gradually Increase Body Awareness: Start by bringing awareness to different sensations in your body. For example:
- Focus on the feeling of your feet pressing into the ground, wriggle your toes, or notice the material of your shoes.
- Pay attention to the parts of your body in contact with your seat.
- Practice mindful movements, such as during yoga, or any exercise where you can be aware of physical sensations, like lifting weights and feeling the release.
5. Deliberately Focus on Distress: Gradually build tolerance by intentionally focusing on distressing sensations without judgment. Set a time limit, such as one minute, to concentrate on the characteristics of the discomfort (its location, weight, temperature, texture, etc.). Keep your attention focused on the sensation in the body, ignoring any thoughts that might manifest. After this period, shift your attention to a positive or neutral activity, such as reflecting on a favourite movie, reading a book, or going for a walk. Adjust the time as needed based on your comfort level and observe any changes afterward.
Conclusion
Building effective distress tolerance is crucial for overall health and well-being, but it takes time and practice. Find the techniques that work best for you and practice them consistently. Whether working with a practitioner or applying self-care methods independently, increasing your distress tolerance can help you manage anxiety and prevent overwhelming crises.
I hope you found this article useful. If you have any questions, or to discuss treatment and support options then feel free to get in touch.
With best wishes,
Sadaf
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