Facing Your Feelings
Facing Your Feelings
Module 1
Understanding Distress Intolerance
Introduction
2
What Is Distress Intolerance?
2
The Paradox…
3
Am I Distress Intolerant?
4
Healthy Distress Tolerance
5
How Does Distress Intolerance Develop?
5
Distress Intolerant Beliefs
6
Distress Escape Methods
7
Distress Intolerance Model
8
My Distress Intolerance Model
9
The Good News…
10
Module Summary
About the Modules
11
12
Facing Your Feelings
The information provided in the document is for information purposes only. Please refer to
the full disclaimer and copyright statements available at www.cci.health.gov.au regarding the
information on this website before making use of such information.
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Module 1: Understanding Distress Intolerance
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Introduction
We all experience emotions. Emotions are an important part of being human, and are essential to our
survival. As humans we are designed to feel a whole range of emotions, some of which may be comfortable
to us, and others may be uncomfortable.
Most people dislike feeling uncomfortable. There are many different ways that humans can feel
uncomfortable…we can be hot, cold, tired, in pain, hungry, unwell, and the list could go on. The type of
discomfort we will be talking about in these modules is emotional discomfort, or what is often called
distress. We may not like it, but experiencing uncomfortable emotions is a natural part of life.
However, there is a difference between disliking unpleasant emotions, but nevertheless accepting that they
are an inevitable part of life and hence riding through them, versus experiencing unpleasant emotions as
unbearable and needing to get rid of them. Some people tell us that they “can’t face”, “can’t bear”, “can’t
stand”, or “can’t tolerate” emotional distress. Being intolerant of experiencing emotional discomfort can
actually breed a whole bunch of problems, as it interferes with living a fulfilling life, and can make worse any
emotional discomfort we might be experiencing. If difficulty facing your feelings or tolerating distress
sounds like you, then read on to learn ways to overcome this pattern.
What Is Distress Intolerance?
There are many different definitions of distress intolerance. What we mean by distress intolerance is a
perceived inability to fully experience unpleasant, aversive or uncomfortable emotions, and is
accompanied by a desperate need to escape the uncomfortable emotions. Difficulties tolerating
distress are often linked to a fear of experiencing negative emotion. Often distress intolerance centres on
high intensity emotional experiences, that is, when the emotion is ‘hot’, strong and powerful (e.g., intense
despair after an argument with a loved one, or intense fear whilst giving a speech).
However, it could also occur for lower intensity emotions (e.g., nervousness about an upcoming medical
examination, sadness when remembering a past relationship break-up). It is not the intensity of the
emotion itself, but how much you fear it, how unpleasant it feels to you, how unbearable it seems, and how
much you want to get away from it, that determines if you are intolerant of distress.
There are varying types of negative emotions that could potentially be distressing for people. We thought
it might be helpful to categorise these emotions into the following 3 clusters:
The Sad
This group includes emotions that reflect sadness at varying degrees of intensity. This would include
disappointment, hurt, despair, guilt, shame, sadness, depression, grief, misery, etc. These emotions
can be accompanied by either low physiological arousal (e.g., low energy, fatigue, heaviness) or
heightened physiological arousal (e.g., intense crying, restlessness), thoughts of hopelessness, loss,
regret and inadequacy, and the urge to hide away from life.
The Mad
This group includes emotions that reflect anger at varying degrees of intensity. This would include
irritation, agitation, frustration, disgust, jealousy, anger, rage, hatred, etc. These emotions are
usually accompanied by high physiological arousal (e.g., tension, increased heart rate, feeling sweaty
or hot, etc), thoughts of unfairness, injustice and wrong doing, and the urge to lash out in some way.
The Scared
This group includes emotions that reflect fear at varying degrees of intensity. This would include
nervousness, anxiety, dread, fear, panic, terror, etc. These emotions are usually accompanied by
high physiological arousal (e.g., increased heart rate, increased breathing, tension, sweating, shaking,
butterflies in stomach, etc), thoughts of threat, vulnerability and helplessness, and the urge to avoid
or escape.
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For some people their distress intolerance might be very broad, in that they find all negative emotions
distressing, for other people their distress intolerance might be very select to just one type of emotion
(e.g., anxiety). How about you? What Negative Emotions do you find difficult to deal with?
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Note: Some people can be distressed by positive emotions, not just the negative ones. It is not uncommon for people to be
concerned that positive emotions will make them lose control in some way. These modules will only focus on intolerance related
to negative emotions, but some of the strategies may be relevant if you have trouble experiencing positive emotions too.
It is important to realise that the term distress that we are using throughout these modules, refers to
emotions that are experienced as aversive, unpleasant, uncomfortable and upsetting. Now, the 3 clusters
of negative emotion previously mentioned, are not necessarily in themselves distressing. For example,
some people like the empowering feeling of being angry, and don’t find it at all an upsetting emotion. Some
people like watching horror movies because they enjoy the feeling of being scared. Some people don’t
mind feeling sad, because it gets their creative energy going when it comes to art, music or writing, or they
may hold the attitude “it’s good to have a cry every now and then”. These examples show that negative
emotion in itself is not necessarily distressing, and as you will see in the next module, these emotions
are normal and often helpful to us. We only begin to feel distressed when we evaluate our
emotional experience as a bad thing.
The Paradox…
Now, it makes a lot of sense to try to get away from things that feel unpleasant. This strategy seems to
work for other things that make us uncomfortable (e.g., heat, cold, pain, hunger, etc). However, when we
apply the same strategy to our emotions, it seems to backfire. This is the paradoxical nature of distress
intolerance. That is, the more we fear, struggle with, and try to avoid any form of distress,
generally the worse that distress gets. Our fear and avoidance of the distress actually magnifies the
distress.
Imagine your emotional distress is a puddle of water blocking your path. If you can recognise that
emotional distress is not something to be feared, nor something to run away from, then all you have is a
puddle of water. If you just wait there it will eventually dry up enough to jump over it, or you could just
splash through it and keep on going. However, if instead you fear your distress, struggle with it and try
everything to escape from it, all you do is add more and more water to the puddle, and very soon you are
faced with a deep pond that it impossible to jump over or splash through. The bigger the pond, the harder
to find a way through it, and hence the longer you will feel stuck and unable to move forward.
Distress
puddle
Fear
Escape
Distress
pond
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Module 1: Understanding Distress Intolerance
Facing Your Feelings
Am I Distress Intolerant?
If yo
u are still a bit unclear as to whether distress intolerance is a problem for you, take a look at the
following statements. Put a tick next to the statements you strongly agree
with.
Fee
ling distressed or upset is unbearable to me
When I feel distressed or upset, all I can think about is how bad I feel
I can’t handle feeling distressed or upset
My feelings of distress are so intense that they completely take over
There is nothing worse than feeling distressed or upset
I don’t tolerate being distressed or upset as well as most people
My feelings of distress or being upset are not acceptable
I’ll do anything to avoid feel distressed or upset
Other people seem to be able to tolerate feeling distressed or upset better than I can
Being distressed or upset is always a major ordeal for me
I am ashamed of myself when I feel distressed or upset
My feelings of distress or being upset scare me
I’ll do anything to stop feeling distressed or upset
When I feel distressed or upset, I must do something about it immediately
When I feel distressed or upset, I cannot help but concentrate on how bad the distress actually feels
The above statements are an adaptation of the Distress Tolerance Scale (Simons & Gaher, 2005)
If yo
u find yourself agreeing with a lot of the above statements, then this can be a sign of having difficulties
with tolerating emotional distress.
To
get an even better idea if distress intolerance is a problem in your life, keep a tally over the next week
or so of any negative emotions you feel. Then make a rating of how intolerable (i.e., unbearable,
unmanageable) these feelings were for you. Also note how you reacted to these emotions (i.e., Did you
frantically try to stop the feeling? Did you ride it out? Did you do things that seemed helpful or unhelpful to
coping with the emotion?). You could use a notepad to keep track of these things, and it might look
something like the example below. After having tuned in closely to how you tolerate negative emotions,
you may then be in a better position to assess if distress intolerance is a problem for you.
Da
y/Time Negative Emotion Intolerable (0-5)
0 tolerable 5 intolerable
My reaction to the emotion
Monday 8am
Mo
nday 2pm
Monday 8pm
Anxious
Angry
Sad
4
3
5
Sto
pped the anxiety by calling in sick
to work. This was unhelpful given how
many sick days I have had, and I will
just have to face work tomorrow
Did
some breathing, watched TV, the
feeling passed
Dr
ank, felt worse, hungover
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Module 1: Understanding Distress Intolerance
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Healthy Distress Tolerance
A
n important thing to consider when assessing your own level of distress tolerance, is that like many things
in life, doing anything at the extreme can be unhelpful. Think of distress tolerance as a continuum where at
one end people can be extremely intolerant of distress, and at the other end people can be extremely
tolerant of distress. Sitting at either end of the spectrum isn’t good for you.
I
f you were always overly tolerant of experiencing all unpleasant emotions, then problems might result such
as tolerating bad situations or bad people in your life. If you were tolerant in the extreme, you would
never take action to change unhappy circumstances in your life that need to be changed. As you read
through the rest of this module, you will get a sense of all the negative consequences that occur on the
other side of the spectrum when people are intolerant of distress. When working through these modules
we will be aiming for somewhere in the middle of the continuum, so that you learn to balance tolerating
emotional discomfort when it does arise, with taking action to improve your emotional experiences.
Y
ou might like to put a cross to mark where you think you are on this continuum at the moment.
Extremely Intolerant of
Distress
Healthy Distress Tolerance
Extremely Tolerant of
Distress
How Does Distress Intolerance Develop?
I
t is likely a combination of biological and environmental factors that lead some people to be more
intolerant of emotional distress than others.
T
here is some suggestion that biologically some people are more sensitive to negative emotions,
experiencing negative emotions more easily, at a higher level of intensity, and for a longer duration than
other people. This may mean that some people experience negative emotions as more painful, and hence
have greater difficulty coping with the experience.
It
is likely your experiences growing up through childhood, adolescence and through adult life, may shape
how you deal with emotions. Some people may not have been shown ways to tolerate emotional
discomfort appropriately, for example being punished for expressing normal emotions like crying when they
were sad. Others may have only been shown unhelpful ways of dealing with their emotions, such as seeing
a loved one use alcohol to deal with their own emotions.
F
inally, if we have stumbled upon unhelpful ways to escape our emotions, these methods may have been
reinforced by temporarily making us feel better. As such, we keep using unhelpful methods and don’t have
a reason to look for other more helpful ways of dealing with our distress.
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Module 1: Understanding Distress Intolerance
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Distress Intolerant Beliefs
R
egardless of how a person’s distress intolerance emerged, we take the view that this intolerance keeps
having a hold over people’s lives due to certain beliefs they have developed about experiencing negative
emotions. These beliefs tend to centre on the notion that negative emotion is bad in some way,
unbearable, unacceptable, or will lead to disastrous consequences. These beliefs tend to make any negative
emotion that we may feel, become a highly distressing emotional experience. Below are some of the
common beliefs that people with distress intolerance have when they start to experience negative emotion:
I
can’t stand this
It’s unbearable
I hate this feeling
I must stop this feeling
I must get rid of it
Take it away
I can’t cope with this feeling
I will lose control
I’ll go crazy
This feeling will keep going on forever
It is wrong to feel this way
It’s stupid and unacceptable
It’s weak
It’s bad
It’s dangerous
Let’s try to uncover your common Distress Intolerant Beliefs. Firstly, do any of the statements above
ring true for you? If so, jot down the statements relevant to you. Secondly, ask yourself the following
questions:
W
hat does it mean to me when I start to feel uncomfortable emotions? What do I think will happen if I let
myself feel distressed? What must I do when I feel any emotional discomfort?
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I can’t stand it!
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Module 1: Understanding Distress Intolerance
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Distress Escape Methods
A
s mentioned earlier, a clear sign of distress intolerance is when someone takes desperate urgent
measures to escape or get rid of uncomfortable emotions. This can be done in a number of different ways,
and each way can lead to significant problems in a person’s life.
A
voidance
One method is via avoidance, and avoidance can take many forms. Firstly, there is
situational avoidance. This is when you avoid any situation, scenario, place,
person, cue or activity that you know is likely to bring on distressing emotions.
Examples of this might be avoiding a particular family member with whom you
become angry, avoiding studying because you become frustrated, avoiding
socialising or leaving the house because you become anxious, avoiding things that
change your physical state because you feel nervous (e.g., sitting in a hot car,
drinking caffeine), avoiding medical appointments or tests because you are
frightened, or avoiding reminders of the past or certain topics of conversation because they sadden you.
A
second method, is a more subtle form of avoidance known as reassurance seeking or checking. This
is when you try to quickly allay your distressing emotions by excessively
seeking reassurance from other
people or engaging in some repetitive checking behaviour. Checking or reassurance seeking temporarily
brings you comfort and takes away your distress, but the relief is short lived and you have to keep doing
these things the next time you feel distressed. Examples might include having to repetitively check things
on your body (e.g., a physical sensation, symptom or feature) or in your environment (e.g., around the
home), over-preparing for things (e.g., projects, work, social events), keeping things in excessive order, or
overly questioning or consulting other people’s opinions to calm you down (i.e., family, friends, medical or
mental health professionals, internet research).
Fin
ally, there is a third method called distraction and suppression which involves trying to push away
the distress, rather than sitting with the emotion and feeling what needs to be felt (i.e., telling yourself to
“stop it” as soon as you feel any distress, finding any mental or physical activity to distract yourself from the
slightest hint of emotion such as counting or repeating positive statements, etc). The problem with
distraction and suppression is that you can’t keep it up for long, and the emotion ends up being like a beach
ball you are trying to hold under the water with your hands. You can only hold it at bay for so long, it
becomes exhausting, and eventually it pops back up and hits you in the face!
Numbing & Withdrawing
Numbing and withdrawing capture things you do to tune out from the distress. The most common ways of
doing this would be by using alcohol or drugs to escape emotional discomfort. Binge eating is also a
common method used to try to alleviate distress. Excessive sleep can also be used in an unhelpful way to
zone out from and escape unpleasant emotions.
H
armful Releases
We have used the term ‘harmful releases’ to capture behaviours we might engage in to release or vent our
distress, that are also directly physically damaging to ourselves. Rather than allowing our emotions to run
their natural course, we might injure or harm ourselves as a way of stopping the emotional discomfort.
Such behaviours might include scratching, picking, biting, punching, hair pulling, head banging, cutting or
burning. The degree of harm we cause to ourselves could be minor or major, but the key is that doing
harm to ourselves is being used to get rid of distressing emotions.
Pl
ease Note
: Whilst these modules may be helpful to people who use drugs, alcohol or self-
harm as a means of tolerating emotional distress, it is important to recognise that these are
very serious problems in their own right that can cause a person significant harm. We
strongly advise seeking help from a GP or mental health professional to address these
concerns, rather than relying solely on these Modules to overcome the problem.
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Module 1: Understanding Distress Intolerance
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W
e have just outlined the most common ways people escape their distress. You may be able to think of
other unhelpful methods. The important thing is to recognise your common Distress Escape Methods.
Ask yourself, what do I do to get rid of unpleasant emotions? Take some time to jot these down now.
______________________________________________________
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______________________________________________________
______________________________________________________
The issue with each of these escape methods is that they only work in the short-term. In the short-term,
as soon as you avoid or numb or release yourself, you experience instant relief from whatever distressing
emotion you are trying to flee. In this way it may seem like a really good strategy, and that is probably why
you have been using it, because there is some pay off. However, over the longterm it all falls apart because:
T
he escape strategy itself is damaging and causes other problems in your life
,
Y
our negative emotions usually worsen because you feel you haven’t coped well,
B
y continually using your escape strategy, you never learn other more helpful ways of toleratin
g
e
motional distress, and
B
y continually using your escape strategy you never have the opportunity to stay with the emotional
distress and therefore challenge the beliefs you hold about not being able to tolerate negative emotions
(maybe you can tolerate them, but you have just never given yourself the chance???)
Distress Intolerance Model
W
e have covered a lot of issues surrounding distress intolerance. Let’s put together everything we have
covered so far to help make sense of what is going on when you are having difficulties dealing with
emotional distress.
D
istress usually starts with some sort of trigger which can be big (e.g., a relationship break-up) or small
(e.g., watching a distressing story on TV), internal (e.g., noticing a thought, image, memory, emotion,
physical sensation, etc) or external (e.g., a certain situation, event, person, place, cue, etc). We will look at
your triggers in more detail in Module 4. For now, think back to past times you haven’t coped well with
distress, what sorts of things were your Triggers?
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______________________________________________________
W
hatever the trigger, we start to feel some sort of negative emotion. Now the emotion in and of itself is
not necessarily distressing, unless we also hold distress intolerant beliefs which tell us the emotion is bad in
some way and must be stopped. As a result of our beliefs, we start to experience the emotion as highly
distressing and upsetting to us, and therefore engage in our unhelpful escape methods to stop it. In the
short-term this takes the emotional pain away, but in the longterm makes everything much worse.
T
his chain of events captures what we mean by distress intolerance, and is mapped out in the model on the
next page. Try filling in each box to make the model specific to you, so you can see your distress
intolerance ‘chain’. You will be able to fill in the Triggers, Negative Emotion, Distress Intolerant Beliefs,
and Distress Escape Methods sections from what you have already written earlier in this module.
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Module 1: Understanding Distress Intolerance
Facing Your Feelings
My Distress Intolerance Model
Triggers
(big, small, internal, external)
Negative Emotion
e.g., sad, fear, anger, etc
Distress Intolerant Beliefs
e.g., “I can’t bear this feeling…it’s bad…it must stop
Distress Escape Methods
e.g., avoidance, numbing & withdrawing, harmful releases
Consequences
S
hort Term = relief
Long Term = more distress, more life problems, by escaping I miss the opportunity
to practice other helpful ways of tolerating distress, by escaping I miss the
opportunity to stay with the distress and hence test if my distress intolerant beliefs
are actually true. So next time I face a trigger the cycle starts again…
Distress
Negative emotion is experienced as
highly upsetting & uncomfortable
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Module 1: Understanding Distress Intolerance
Facing Your Feelings
The Good News…
The good news is that it doesn’t have to be this way! No matter how
your distress intolerance has come about, no matter what emotions you
have trouble dealing with, and no matter how unhelpful your escape
methods are, you can learn ways of tolerating distress.
Distress tolerance is a good life skill for anyone to learn. Instead
of fearing and fighting uncomfortable emotions and desperately trying to
get rid of them, these modules we will teach you how to sit with and
tolerate emotional distress, such that you learn the emotion will pass and
that you can cope.
We will focus on things you can change in the here and now, particularly your escape methods and distress
intolerant beliefs. Modules 2 & 3 will teach you specific techniques for tolerating distress that focus on
both accepting distress and improving distress. Module 4 will draw all this work together in a Distress
Tolerance Action Plan, and give you ideas for how to practice this plan, which over time will tackle the
distress intolerant beliefs that are driving the problem.
When using self-help materials, some people might skip sections or complete things in a different order.
The modules in this information package have been designed to be completed in the order they appear.
We recommend that you work through the modules in sequence, finishing each module before moving on
to the next one in the series. We believe that by doing this, you will maximise the benefits you might
receive from working through this information package.
Emotional discomfort is impossible to get rid of, as it is an inevitable part of being human. So we all need
to learn how to live with it, and not let our fear of distress restrict how we live our lives. You may have
been telling yourself for some time now that you “can’t stand it!” But stick with us to find out how you can
face your feelings and learn to tolerate your distress.
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Module 1: Understanding Distress Intolerance
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Module Summary
Distress intolerance is a perceived inability to fully experience unpleasant, aversive or
uncomfortable emotions, and is accompanied by a desperate need to escape the uncomfortable
emotions.
Sadness, anger and fear are the 3 clusters of negative emotion people may find distressing, and
people may have trouble with all negative emotions or just one specific type.
Negative emotion in itself is not necessarily distressing. We begin to feel distressed when we
evaluate our emotional experience as aversive.
Distress intolerant beliefs are central to this problem, as people commonly hold beliefs that
negative emotion is bad in some way or that experiencing negative emotion will be unbearable or
will lead to disastrous consequences.
Avoidance (e.g., situational, reassurance seeking, checking, distraction, suppression), numbing &
withdrawing (e.g., alcohol, drugs, binge eating, excessive sleep), and harmful releases (e.g., self
injury) are common unhelpful escape methods people use to get rid of emotional distress.
Escaping from distress only works in the short-term. In the long-term the distress gets worse, it
creates bigger life problems, and the opportunity is missed to learn healthy ways to tolerate
negative emotion or to test if your fears about experiencing negative emotion are truly valid.
Emotional distress is impossible to get rid of, as it is an inevitable part of being human. Learning
how to tolerate emotional discomfort is an important skill for everyone to learn.
Coming up next
In Module 2, you will learn specific
techniques to help you accept
emotional distress…
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About The Modules
CONTRIBUTORS
Dr Lisa Saulsman (MPsych
1
; PhD
2
)
Centre for Clinical Interventions
Paula Nathan (MPsych
1
)
Director, Centre for Clinical Interventions
Adjunct Senior Lecturer, School of Psychiatry and Clinical
Neuroscience, The University of Western Australia
1
Masters of Psychology (Clinical Psychology)
2
Doctor of Philosophy (Clinical Psychology)
BACKGROUND
The concepts and strategies in these modules have been developed from evidence based psychological
practice, primarily Cognitive-Behavioural and Mindfulness-Based Therapies. These modules are based on
the approach that distress intolerance is a result of problematic cognitions (thoughts) and behaviours.
REFERENCES
These are some of the professional references that informed the development of modules in this
information package.
Allen, L.B., McHugh, R.K. & Barlow, D.H. (2008). Emotional disorders: A unified approach. In D.H. Barlow
(Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (4
th
ed., pp. 216-249).
New York: Guilford Press.
Clen, S.L., Mennin, D.S. & Fresco, D.M. (2011). Major depressive disorder. In M.J. Zvolensky, A. Bernstein
& A.A. Vujanovic (Eds.), Distress Tolerance: Theory, Research, and Clinical Applications (pp. 149-170). New
York: Guilford Press.
Gratz, K.L. & Tull, M.T. (2011). Borderline personality disorder. In M.J. Zvolensky, A. Bernstein & A.A.
Vujanovic (Eds.), Distress Tolerance: Theory, Research, and Clinical Applications (pp. 198-220). New York:
Guilford Press.
Leahy, R.L. & Tirch, D., & Napolitano, L.A. (2011). Emotion Regulation In Psychotherapy: A Practitioner’s Guide.
New York: Guilford Press.
Lynch, T.R. & Mizon, G.A. (2011). Distress overtolerance and distress intolerance: A behavioral
perspective. In M.J. Zvolensky, A. Bernstein & A.A. Vujanovic (Eds.), Distress tolerance: Theory, research,
and clinical applications (pp. 52-79). New York: Guilford Press.
Simons, J.S., & Gaher, R.M. (2005). The Distress Tolerance Scale: Development and validation of a self-
report measure. Motivation and Emotion, 29, 83-102.
“FACING YOUR FEELINGS”
We would like to thank Bruce Campbell for the title of this module that forms part of the InfoPax series.
Saulsman, L., & Nathan, P. (2012). Facing Your Feelings: Learning to Tolerate Distress. Perth, Western
Australia: Centre for Clinical Interventions.
ISBN: 0 9757995 7 6 Created: May 2012
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