Picture yourself as a junior resident on morning rounds with a senior and a rotating intern. You’ve been up almost all night on call, and you’re almost at the end of the patient list. Your senior asks you about the next patient, and you stumble. You can’t find your notes, and you’re blanking on the answer. Your senior becomes impatient and starts to raise their voice. How do you react?
If you’ve ever been a resident, you know what it’s like to feel distressed.
Residency training is an incredibly unique, often grueling trial that can seriously affect your physical and mental health. Our training system is designed to teach medical knowledge, but not necessarily how to deal with the intense situations and complicated interpersonal issues that often arise during training. So how should our residents go about learning the skills they need to handle their new environment?
We know that resident physicians love evidence-based practices, and a plethora of evidence-based research supports the effectiveness of DBT (dialectical behavior therapy). While DBT was originally developed to treat suicidal ideation, self-harm behaviors, and borderline personality disorder, it has also demonstrated effectiveness for treating mood disorders and substance use disorders.
In this article, we will focus specifically on one aspect of DBT training – increasing distress tolerance. Distress tolerance is a dialectical behavioral therapy (DBT) module that teaches several skills that may prove valuable during residency training. The skills are sometimes referred to as “crisis survival skills” because they can help you navigate perceived or actual crises.
Distress tolerance skills are adaptive (rather than maladaptive) behaviors that trainees can use to survive an immediate emotional crisis without making it worse. They can help you accept the reality of a situation if you cannot change the situation and feel out of control.
There is a high risk for trainees to develop maladaptive behaviors when coping with the workplace’s extreme stresses, hours, and burnout. These can include substance abuse (alcohol or drugs), self-harm behaviors, or suicidal ideation. When acutely distressed, people will often do whatever they need to in order to manage their pain. No judgment there. Distress tolerance skills can help lessen the intensity of the emotional pain in the moment. In the emotionally charged resident workplace, these tools are both practical and healthy, functional ways to cope or respond.
Without going into great detail on each aspect of distress tolerance skills within the scope of this article, I will provide an overview of the most readily available and practical techniques that residents can use today.
Radical acceptance. Radical acceptance means accepting the state of things as they are without working to change them. Two tools to help augment your practice involve a half smile and willing hands. Half smile is as straightforward as it sounds – and can be done anywhere. Simply curl up the edges of your mouth into a half smile. This can be done without breaking scrub, which makes it a particularly useful tool for trainees in the operating room. Willing hands can also be done in a variety of positions or circumstances. Hold your hands with palms facing up (inside the box, if you’re scrubbed and not holding onto a retractor) in a physical gesture representative of radical acceptance.
TIPP skills (temperature, intense exercise, paced breathing, and paired muscle relaxation). TIPP skills work quickly, within seconds to minutes, calming the limbic system and decreasing your state of emotional arousal. Splash cold water on your face, or dunk your face into a bowl of ice water. If you have the time or ability to fit in a quick exercise, an adrenaline rush can combat acute distress. Paced breathing is a controlled breathing technique that helps you regain a sense of control through focusing on the breath. An example of this is the Navy Seal box breathing method.
Self-soothing by grounding in your senses. Ground yourself mentally using all 5 of your senses. A common form of this meditation involves naming 5 things that you can see (including their colors, shapes, and textures) and 4 things that you can hear (including, for instance, ambient noise, the sound of your breathing, the sound of a neighbor), 3 things that you can touch (the seat you’re sitting in, the floor under your feet), 2 things that you can smell, and 1 thing you can taste.
There are several other helpful techniques under the distress tolerance module as well, such as “I.M.P.R.O.V.E.,” distracting, and self-validation. These techniques may take a bit of practice to master and are not quite as in-the-moment as the 3 mentioned above, but incredibly useful for long-term improvement of distress tolerance.
DBT skills, and specifically distress tolerance skills, are incredibly practical and often immediate methods for helping a resident stay cool in an acutely stressful situation. Due to the high-stress nature of the job, improving distress tolerance, emotional regulation, and interpersonal effectiveness is a secret weapon that many trainees should add to their toolbox.
Frances Mei Hardin is an otolaryngologist.