DBT Expert Interviews: From Trauma to Eating Disorders

Practical DBT tips on substance use, trauma, chronic pain, and other conditions.

DBT for Chronic Pain: Distress Tolerance and Emotion Regulation

By Dr. Kirby Reutter, Ph.D., DBTC, LMHC, MAC & Dr. Mark Carlson and Dr. Dennis Hannon.

This presentation is an excerpt from the online course DBT Expert Interviews: From Trauma to Eating Disorders“.




In this section, Dr. Mark Carlson and Dr. Dennis Hannon apply the concepts of distress tolerance and emotion regulation to chronic pain. In particular, they explain the terms behavioral activation, just noticeable change, skills implementation plan, and SMART goals.

Throughout this segment, Mark and Dennis emphasize the importance of utilizing games, metaphors, and creativity when teaching DBT skills and concepts.

Applying Distress Tolerance to Clients With Chronic Pain

Kirby: How do you apply distress tolerance to clients with chronic pain?

Dennis: The distress tolerance skills are a particularly salient and helpful skill set for this population. It’s a difficult skill set to teach.

Clients experience emotional pain that we would sometimes see in a typical adherent-style DBT program, but also extreme physical pain. Oftentimes, this is coupled with existential and spiritual pain, a demoralization process, and the directionlessness that sometimes we see with these clients. It’s an integral and holistic type of pain that goes throughout their entire existence.

We have to look at the entire person as we’re treating and working with clients with chronic pain. Starting with a conversation about existential pain can be extremely helpful. What is the life that they want to be present in? How do we support them in getting there? I sit down with them and take a look at what they’re doing now that’s working and what isn’t working.

It’s important to help them institute some of these skills in their life in a more reactive way initially and move that towards a process of proactive engagement with these skills. This can allow them to see, in hindsight, moments where they could’ve used these skills and begin to use them when anxiety, pain, or anger pops up. Eventually, they get a proactive use of the skills.

Skills implementation plans help facilitate this type of change, where we’re asking them to take a look at the different intensities of various emotions and sensations, including pain. “When pain is at a 10, what are the different skills that you can utilize to help support yourself at that moment?”

We’ll break that down. We’ll start with physical pain because typically it’s the most salient thing. Then we will branch off into the emotional and existential pains that they might be experiencing too.

Mark: Most DBT therapists use distress tolerance with clients with chronic pain. We have a scale of distress that goes from 0 to 10; 10 being high. In the 8 to 10 range, individuals are experiencing distress.

The first thing that I teach people is rule number one is always safety. If you’re in phases 8 to 10, stay safe. Don’t make it worse. Most things will improve if you go by rule number one. If you stay safe and don’t actively make it worse, oftentimes, distress will just come down.

When we’re teaching distress tolerance we have a lot of our clients say, “I’m already doing all this stuff.” Yes, most people are, but they are doing it in the realm of avoidance. We have to teach the difference between skills and avoidance.

Avoidance is using escape to avoid, alter, or modify your experience so you feel less pain. A lot of these skills will do that because we’re distracting people; we’re engaging in other things.

Distress tolerance is a very mindful-based approach. I’m going to try to be skillful and bring my distress down while staying safe and not making it worse. When I bring my distress down, it’s different from avoidance. I intend to go in and actively problem solve what was triggering my distress because now I can see things clearly. I’m not in high enough distress where my functioning is significantly impaired. I can engage in higher-order problem-solving.

Distress tolerance is also taught in the vein of using it as a gateway to the other skill sets or modules in DBT. Stay safe. Don’t make it worse. It can be a gateway to problem-solving.

We have to teach the difference between avoidance and distraction or skill-based interventions to be able to take a strength-based approach. That is a big difference for distress tolerance.

A SIP, or skills implementation plan, means mapping out somebody’s distress from 0, meaning I have none, up to 10, where either I have the most distress possible or I’m unsafe. We have skill-based interventions at every numerical value from 0 to 10. Some of the skill sets are reactive, as in distress tolerance, but we teach it very differently.

We’ll teach distress tolerance at levels 8 to 10 to use it reactively, but we’ll also teach it at levels 0 to 3, where we can use it proactively. When clients are engaged in distress in those middle areas, they can be reactive and proactively use skills as well.

Kirby: DBT, in some ways, is a reactive approach, but it’s teaching skilled or mindful reactions. It’s also a proactive approach that speaks to the cope ahead skill. Our clients need both.

Emotion Regulation and Chronic Pain

Kirby: How do you apply emotion regulation to chronic pain? Do you find that helping someone with depression, anxiety, or some other emotional anguish is related to and helps ameliorate their physical pain?

Mark: Absolutely. One of the primary tools of this emotion regulation is creating positive experiences in somebody’s life.

Probably 90% of clients you’re working with are coming in with some degree of demoralization. This is a primary issue where the clients don’t have a lot of positives to look for. It’s a very miserable experience day in and day out, and they’ve been worn down. Oftentimes, they have to defend that they feel their pain because you can’t see it. A lot of people are looking at them and refer to them as malingering, or making something up, or trying to avoid and getting out of responsibility. It constantly wears people down.

Emotion regulation skills can be taught for people to create some positive experiences in their life, create a life that is worth living, and going through the experiences that they have every day. If we’re going to look for sustainable change in somebody’s life, emotion regulation can be a great springboard for that.

I want to create some momentum in my life by doing something masterful, something where I can feel I can make a difference in my life and then step back and appreciate the step that I took.

Another skill that I teach, oftentimes, in emotion regulation is called just noticeable change. “If you’re going to do one small thing in your life that would lead to a positive or neutral experience, what small step could you take?” Then I want a firm commitment that you can take to it. Now let’s take that step and let’s see where we got from that.

There are times in life when staying neutral is very important. Sometimes clients express, “You talk about building a life worth living or getting something positive in my life. I just want the pain to go away.” Something positive is beyond their reach.

We can step back and use the skill sets in emotion regulation to create something neutral. The client can get a space that’s not necessarily free from pain, but where pain is not in the driver’s seat and it’s not the only thing they’re experiencing.

Emotion regulation can help us create a dual experience where I have pain and something else that I’m creating. We can start to focus with mindfulness on the fact that what the client created is different from his pain, and start building on that. We agree he still has pain, but that doesn’t have to be the primary focus.

Emotion regulation and the skills taught in these modules can help us take those initial steps.

Dennis: Of all the skill sets in DBT, emotion regulation may be second to interpersonal effectiveness. We want to pull in more of that life that the client wants to be present in. We want to be proactive in terms of creating that space rather than being just in a constant space of pain and suffering.

This is where we focus on SMART goals. We’re able to integrate a lot of different types of therapies, including behavioral activation, to start to create that change for the client.

This is one of the places where we start to see some initial movement and energy from clients. It allows us to build on that to create that momentum.

Mark: We created some additional worksheets. We talk about the concept of my story and we have clients map out the first part. “What got you to this point in your life where you’re meeting me? How do you start envisioning that story to potentially change? What are some options that you would hope or wish for? Let’s start adding that to the story.” Then through the skill sets, goals, and objectives, we start to operationalize those small steps to start making some noticeable change in their life.

We call the just noticeable change skill set the What About Bob? skills. The movie What About Bob? is about taking the smallest steps towards something that you want in your life. And pretty soon, you’re starting to build momentum towards something instead of trying to run away.

Sometimes, it makes the skills much easier to teach if you can find stuff in pop culture to relate it to.

We try to do skill training in a very reflective and reciprocal manner to where they’re constantly interjecting themselves into the skills teaching stories. The skill training components of DBT need to be very interactive and reciprocal because they’ll tell us what they’re learning, their barriers, and why they don’t want to work on something. That way we can help problem solve.

With emotion regulation, risk vs reward plays out. If the reward isn’t worth the risk, the client won’t take the step toward change. That reward has to be big enough for them to take those What About Bob? baby steps or the just noticeable change steps.

Dennis: That’s where mindfulness is integral to this process of emotion regulation because oftentimes, we have to support the clients and their process of redefining what change looks like. We work on being aware of their relationship with the idea of change, what they expect in terms of their ability to change, and what changes they want in their lives.

We try reworking that with them towards this idea of just noticeable change. We want them to take those baby steps in support of emotion regulation, adapting the idea of what exercise can mean, and what healthy eating or healthy sleep looks like.

When we’re living with chronic pain, it permeates all of those different areas. Many times, clients go through their journey of re-adapting and re-modifying that process and definition of change to themselves.

Mark: I’m a big proponent of “You need to be tracking the outcome.” If you’re not tracking the outcome, how do you know what you’re doing is effective or not?

We have seen our effectiveness increase when we take creative approaches and we’re active in this. There isn’t one right way to do therapy. There’s an effective way to do therapy. That’s where we take it back to the creative side.

You have creative ways to cope with your pain. Let’s learn from that. Figure out where it’s working and repeat that. Where it’s not working, let’s start accidentally. Oftentimes, we have to get creative. One of the ways that we do it is I’ll say, “I want you to try this skill.” Accidentally, if it worked, how would we know?

Oftentimes, people will take a risk because the accident may work. They’re afraid that it wouldn’t work and they’re stuck with what they’re doing. We also need to address the fear of what happens if it works and it’s effective.

People will increase their expectations and pressure on you. If we don’t find some lighthearted and creative ways of doing this, we miss opportunities to talk about the fear and how difficult it is to make a targeted change in their life.

We need to be creative and stop, focus on “Is there a right way to teach this skill?” I have no idea. Why don’t you consult the expert in the room? That’s the client.

“Here’s what the skill is in the book or what this person wrote. How do you make sense of that? How are we going to work on that together?”

When you have that togetherness, you’re not talking about right or wrong. You’re talking about what works and what doesn’t. I’d rather focus my therapeutic energy there than focus on the right way to teach or to do something.

Kirby: Even if a client is showing up with chronic physical pain as their presenting problem, do you think that chances are that chronic physical pain is a symptom of deeper emotional pain?

Mark: I wouldn’t get into one causes the other. Chronic pain is very complex in how it presents.

If somebody says, “I just have physical pain,” let’s explore a little bit where you’re at on the relational, psychological, spiritual, and emotional aspects of pain, and then the meaning and purpose aspect of pain. Oftentimes, it’s easier to talk about physical pain than it is to talk about any other level of pain. Usually, if there’s physical pain, there’s other pain that tends to be attached.

We don’t talk about it because when we’re talking about CBT or DBT for chronic pain, we’re rethinking the entire approach to pain. Before we started to target chronic pain with CBT and DBT as one of the parts of the third wave, there was a Cartesian model of pain.

You have an injury. If there’s some form of tissue damage then there’s pain. When there’s pain, there’s a loss of functioning. We target the tissue damage and we target the physical aspect of pain only. When that is removed, all pain is gone.

What we know about pain in a biopsychosocial format is starting to change the way we look at it and rethink our entire approach to chronic pain. It’s more complicated than just physical pain. I wouldn’t say if you have physical pain, then you have this other pain. It could just be physical pain and there’s nothing else.

Dennis: There are cases and situations where that physical pain will lead to that emotional and existential pain. As well, existential and emotional pain can lead to physical pain.

We have seen that across time. Most of the clients that come to our program have already gotten to a place where maybe they went through the healthcare system and received a chronic pain diagnosis.

There is a physical sense of pain. The work that we do is less concerned about what caused or led to the onset of that pain and is more focused on the current adaptations and functioning with that pain. That goes for all types of pain: physical, emotional, and existential. We are focused on helping the person re-adapt their relationship to all types of pain.

Main Points

  • DBT distress tolerance is about staying safe without making things even worse. The purpose is to replace ineffective reactivity with more effective reactivity. Distress tolerance is applied mindfulness and it’s a gateway to other DBT skills. If clients can first survive the moment without making it worse, they are more likely to access their capacity for higher-order problem-solving. A skills implementation plan helps clients quantify their distress on a scale of 0 to 10 and then determine a specific skills-based intervention for each level of intensity.
  • Whereas DBT distress tolerance refers to short-term interventions, DBT emotion regulation refers to long-term lifestyle changes that foster a healthier emotional baseline. The ABC acronym helps clients develop healthier emotional habits by adding positives, building mastery, and coping ahead. SMART is another acronym that helps clients activate healthier behaviors by setting goals that are specific, measurable, attainable, relevant, and time-bound. Behavioral changes don’t need to be massive. They simply need to be just noticeable to initiate the necessary momentum for change.
  • Additional techniques for stimulating behavioral activation include:
  1. Having the client promise to do something they would have done anyway.
  2. Prescribing the client a positive behavior that they’re already doing.
  3. Helping clients evaluate the risks vs rewards of attempting a new behavior.
  4. Using creativity to teach new skills, such as games and metaphors.
  5. Asking clients, “What would happen if you accidentally used this skill?”

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