Distress Tolerance: STOP and Pros and Cons Skill in DBT

Dr. Elisheva Jakobov-Assouline

In Dialectical Behavioral Therapy (DBT), distress tolerance skills allow us to survive immediate crises, without making things worse and resorting to maladaptive behaviors. These skills are necessary when we cannot immediately change a situation to be better or when we are unsure about what changes we may need to implement in order for our feelings to change. Another important aspect of distress tolerance is about accepting reality as it is in the moment when we are unable to change it and it is not what we want it to be. We all go through difficult moments. However, living one’s life in constant crisis mode is unhelpful and interferes with problem solving.  Finally, another goal of distress tolerance skills is to become free of having to give into our urges (unhealthy), desires, and intense emotions. This blog will further explore what defines a crisis, when you should use distress tolerance skills, and the STOP and pro and cons skills in DBT.

How do I know if I am in a crisis?

By definition, crises are short-term. When the situation is very stressful with the potential of negative outcomes occurring, you most likely are experiencing a crisis. For example, you lose your health insurance and are unable to get a refill on a prescription you need to take for your mental health. Money is tight, and so you decide to stop taking it until you figure out your health insurance. In the meantime, you befriend a negative group of friends and start to heavily drink. Drinking in this situation, will most likely make things worse (and sometimes, may even create a whole new crisis than the one you began with). Finally, a crisis causes you immense pressure to resolve it quickly. There are two different kinds of crisis that require distress tolerance skills. One type of crisis is if you have a strong desire to engage in a destructive behavior, but acting on it, is not effective (for example, you want to quit your job, but if you do, you will be left with no financial security). Another type of crisis exists when there is a demand you need to meet, and if it goes unmet, you will experience negative consequences (for example, you must submit your dissertation at a certain time, otherwise you will not graduate).

When should I use distress tolerance skills?

  • If you are experiencing a lot of pain that cannot be helped quickly, engage in distress tolerance skills so that you can bring your pain down to a more manageable level, and avoid engaging in destructive behavior. For example, you recently had your wisdom teeth pulled out and are experiencing a lot of pain. You are taking your medication but find that it is not fully helping. You then decide perhaps you should drink to ease your pain. Doing the latter won’t serve you well. Rather than engaging in this behavior, try using a distress tolerance skill.
  • When you want to act on your emotions, but it will only make things worse if you do, engaging in these skills can be helpful.
  • When your emotion mind threatens to overwhelm you, but you still need to stay skillful.
  • You are feeling overwhelmed, yet you still have demands to meet.
  • When your emotional arousal is severe, but you cannot solve the problem immediately, often engaging in distress tolerance skills can be helpful.

If a problem is a long-term issue, by definition, it is not considered a crisis. We do not want to use crisis survival skills for long-term issues. This is because if you do so, your problems will never be addressed, and you are most likely just engaging in avoidance and distraction techniques. You also do not want to use distress tolerance skills to make your life worth living. To determine whether the use of these skills are helping you, notice if time passes and you have not engaged in things to make the situation worse. If that is the case, the skills are positively contributing to your life and working. Further, when you are able to tolerate the crisis and are able to utilize other skills as well, know that these skills are working.

The STOP skill in DBT helps refrain one from acting impulsively on their emotions. When you are in emotion mind, it may be difficult to be effective in using your skills. This is why the STOP skill is crucial as it allows you to take the first step by stopping before reacting.

What is the STOP skill?

STOP is an acronym that stands for the following:

  • Stop– whenever you feel that your emotion mind is taking control, simply stop and freeze. Doing so will prevent you from acting on your emotions. For example, a stranger at the supermarket bumps into your shopping cart and you get upset. You may be inclined to want to say something rude. However, acting on your emotions in this case may not serve you well. The person may get really nasty back. Here, you’d want to stop and freeze and not react.
  • Take a step back– when you are in a difficult situation, it may be hard to figure out how to effectively deal with it. Instead of acting on your emotions, take a step back from the situation to calm down and think more clearly. Try to breathe deeply or physically remove yourself from the situation. For example, your driving in the car, and someone starts to tailgate you. You start becoming frustrated and have the urge to keep breaking as to annoy him. Doing so may not be effective and may even escalate the situation. You would stop and take a step back in this situation.
  • Observe– observe what is going on around you both externally and internally. Consider the situation, who is involved, your thoughts and feelings. Gather the facts of the situation instead of jumping to conclusions.
  • Process mindfully– try to act with awareness by asking your wise mind which behaviors will make the situation better or worse. Ask yourself what do I want from this situation and what are my goals. Acting mindfully is the opposite of being impulsive.

Often, individuals may struggle with making healthy decisions when they are feeling stressed or overwhelmed.  Accepting your reality (despite how difficult it may be) and tolerating your distress will lead to improved outcomes.  In DBT, the pros and cons skill can provide insight into making decisions that are helpful when you are trying to decide between two courses of action.

The pros and cons can be helpful in resisting your urges to act impulsively or engage in behaviors that are destructive.

How do I do the pros and cons skill?

This skill involves writing down the positive and negative consequences of tolerating your distress by resisting impulsive behaviors, as well as the positive and negative consequences of not tolerating distress by engaging in impulsive behaviors.

  • Describe the crisis behavior (anything that is damaging in the short-term, long-term, or both) that you are trying to stop
  • Examine the advantages and disadvantages of the behavior
  • Consider the short and long-term consequences of the behavior
  • Create separate pro and cons list for different behaviors
  • Rehearse the advantage of resisting your urges and disadvantage of giving into your urges
  • Say no to crisis urges

When your emotions get the best of you, before things get worse, using the STOP and pro and cons skills can be helpful. While in theory they may sound simple, I’d recommend first practicing them when you are in an emotionally healthy place and not experiencing a real crisis. This is so that when you are actually in a crisis, you will know what to do. If you or a loved one is struggling, feel free to reach out for support.

Dr. Aryeh Berlin is a New Jersey licensed clinical psychologist and founder of Aspire Psychological Group. Dr. Berlin has vast clinical training experiences including a residential adolescent addiction treatment center in Israel, community mental health centers, and youth detention centers. Dr. Berlin has lectured on parenting children with emotional and behavioral difficulties, child development, helping children with school-related challenges and trauma. Audiences included attorneys, mental health professionals, parents, and educators.

Distress Tolerance: STOP and Pros and Cons Skill in DBT