The Poetry of Distress Tolerance

By Michael Mirarchi, LSW, JD at Perez Therapy, LLC

Poetry has been a lifelong passion of mine. I love reading it, and I read it voraciously.

From time to time, I’ll try my hand at writing a poem. I think I’ve written a handful of poems

that pass the straight-face test, meaning you could read them and not laugh at how bad they are.

Two of my poems have been published online. One is a prose poem about my experience giving out free dad hugs at Philly Pride:

Another is a poem I wrote about proposing to my wife at the Grand Canyon at sunset:

Because I love poetry, I am always looking for ways to use poems in therapy sessions, either to illustrate concepts in therapy, to give clients something they might be able to relate to that shows them they’re not alone, to help clients put into words feelings they may be having trouble articulating, or to give clients words of encouragement as they face whatever struggles they’re dealing with.

There are a few poems in particular that I believe powerfully illustrate the concept of

distress tolerance in Dialectical Behavior Therapy (DBT). DBT is an evidence-based modality

developed in the 1980s by the psychologist Marshal Linehan. Originally created to treat

borderline personality disorder, DBT has been adopted over time to treat a wide range of other disorders such as PTSD, mood disorders, and substance use disorders. DBT blends cognitive behavioral techniques with mindfulness and acceptance practices. One set of skills taught in DBT is distress tolerance. These skills are strategies clients can use to cope with distressing emotions and circumstances without resorting to maladaptive coping mechanisms such as self- harm or substance use or otherwise exacerbating an already difficult time. When I work with clients on distress tolerance, I often use poems that illustrate the concept. Through psychoeducation, I can explain to clients how distress tolerance works, but poetry can illustrate the concept more vividly than I can with my prosaic words.

This poem powerfully depicts the usefulness of distress tolerance skills and how those

skills promote mental health:

Tools

After I asked about your scars,

you sat me down and

showed me the razor blade

you kept for years

in your bedside table.

You showed me

the sewing needle,

the lighter, the alcohol,

the hook — a whole box full

of knives and fire.

You said, “These are the tools

some children use

to pull pain out of themselves

when no one teaches them

a safer way how.”

Your scars are healed over now.

Your scars are healed over and

you have healed beneath them.

When I asked why

you would ever want to keep

this collection of hurtful things,

you closed the box

and put it away.

You said, “I keep them

to remind myself

I know safer ways now.”

-- Gabriel Gadfly

In this poem, the razor blade, sewing needle, the lighter, the hook are all tools the person used to cope with distressing emotions. The description of the box containing these tools as “a whole box / full of knives and fire” shows their maladaptive nature. In an effort to escape pain, the person who uses these tools ends up hurting themself — either by self-harm, such as cutting themself, or by intoxicating themself with alcohol or drugs. At the root of most addiction is a person’s use of the addictive substance or behavior to escape pain. The addictive impulse is an impulse to self-medicate, to anesthetize, to numb uncomfortable feelings. People who compulsively cut themselves do so because the physical pain from the cut temporarily distracts them from the intense emotional pain that they’re feeling and thus brings them some temporary relief. The goal of distress tolerance in DBT is to teach a client to replace maladaptive coping strategies with adaptive coping strategies so that, in the words of the poet, the client “know[s] safer ways now.”

This poem particularly illustrates the distress tolerance skill of comparison. In DBT,

comparison invites a client who is experiencing distress and considering maladaptive coping

strategies to instead compare themself to their past self so see how far they have come. By

keeping the box of self-harm tools to remind themselves that they know safer ways now, the poem’s subject is using the comparison strategy to resist the impulse to resort to self-harm as a way of coping with distress.

Here’s another poem that I read as treating the subject of distress tolerance:

Trough

There is a trough in waves,

a low spot

where horizon disappears

and only sky

and water

are our company.

And there we lose our way

unless

we rest, knowing the wave will bring us

to its crest again.

There we may drown

if we let fear

hold us in its grip and shake us

side to side,

and leave us flailing, torn, disoriented.

But if we rest there

in the trough,

in silence,

being in the low part of the wave,

keeping our energy and

noticing the shape of things,

the flow,

then time alone

will bring us to another

place

where we can see

horizon, see land again,

regain our sense

of where

we are,

and where we need to swim.

— Judy Sorum Brown

Whenever I have a client in severe emotional distress, I promise them that they won’t be feeling this way for the rest of their life. Even the most painful feelings will pass eventually. They may pass like a kidney stone, but they’ll pass. This poem embodies that idea that life has natural ebbs and flows, like waves on the ocean.

I read this poem as a lesson in mindfulness. Mindfulness in DBT is a module separate from distress tolerance, but mindfulness is also incorporated into all of the DBT modules. The poem’s description of “being in the low part of the wave, / keeping our energy and / noticing the shape of things, / the flow” is an example of mindfulness. Rather than panicking when a

distressing emotion hits, it is possible to sit with emotion, to notice it, to notice how you’re

feeling, and the ride it out. I have a good friend who’s a recovering alcoholic, who says that in recovery, he has learned that a big emotion is not an emergency.

When he was active in his alcoholism, big emotions such as anger, shame, sadness, or anxiety, felt like an emergency, and he would turn to alcohol to self-medicate, to put out the fire. Today, he has learned that he doesn’t need to panic when he feels a big emotion, and that with time, the emotion will pass. On an artistic level, I admire how well-crafted this poem is. The line breaks and varied line lengths give me the sensation, as I read the poem, that I’m slowly rising and falling in the ocean with the incoming waves.

The final poem on the subject of distress tolerance that I will share with you is a poem

that stopped me dead in my tracks the first time I read it. After I read it for the first time, I

immediately reread the poem. Five or six times. I’ve often felt bad about myself for feeling like I’ve never really gotten over my most painful losses and feeling like I should have. This poem helped me to see things from a different point of view:

The Cure

We think we get over things.

We don’t get over things.

Or say, we get over the measles

but not a broken heart.

We need to make that distinction.

The things that become part of our experience

never become less a part of our experience.

How can I say it?

The way to “get over” a life is to die.

Short of that, you move with it,

let the pain be pain,

not in the hope that it will vanish

but in the faith that it will fit in,

find its place in the shape of things

and be then not any less pain but true to form.

Because anything natural has an inherent shape

and will flow towards it.

And a life is as natural as a leaf.

That’s what we’re looking for:

not the end of a thing but the shape of it.

Wisdom is seeing the shape of your life

without obliterating (getting over) a single

instant of it.

— Albert Huffstickler

This poem helped to see that it’s ok that I’ve never fully gotten over my most painful losses. The poem’s instruction to “let the pain be pain” cuts to the core of distress tolerance, which teaches clients how to sit with their pain, rather than try to run away from it. The poem’s final sentence — “Wisdom is seeing the shape of your life / without obliterating (getting over) a single / instant of it” — speaks to distress tolerance and in particular the mindfulness theme that runs throughout the distress tolerance skills and DBT in general.

Seeing the shape of your life requires mindfulness — it requires you to pay attention, to notice what’s happening, and rather than trying to destroy the uncomfortable feelings, to sit with them and feel them, however uncomfortable they may be.

This poem also embodies the principle of radical acceptance. In DBT, radical acceptance

means total acceptance of your present circumstances. It doesn’t mean that you have to like your present circumstances. Nor does it mean that you need to give up on trying to change your present circumstances. Rather, it simply means that resisting your circumstances will not help you move forward. When you suffer a painful loss, you may commit to the idea that it should not have happened and fight that loss internally. That’s not radical acceptance. Radical acceptance asks you to accept the loss, however painful, unfair, or unexpected, without resistance. Radical acceptance reduces our suffering, because when we resist painful facts, such as loss, betrayal, or trauma, we often get stuck in despair, bitterness, or rage. Pain without acceptance leads to suffering, which can be endless. Radical acceptance offers us emotional freedom in which we can take steps toward change or healing.

This poem offers a model of grief in which the goal of grief is not to get over the loss, but

to accept the loss and integrate it into the shape of your life. As we grieve our losses, they

become more right sized and take their place in the larger shape of our lives, which continue to flow around them. The pain of my most significant losses will always be there, but my life has taken shape around those losses.

In my own life, reading, writing, and listening to poetry has been a powerful comfort to

me during distressing times. In my therapy practice, I have been fortunate to be able to share this comfort with clients if they are receptive to poetry as a way of finding solace. My goal in sharing poetry with clients is ultimately to empower them to find similarly effective coping skills in their own lives.