By: Jennifer McMillen Smith, LISW-S, HIV Social Worker at MetroHealth Medical Center and medically reviewed by Ann K. Avery, MD, Infectious Disease Physician at MetroHealth Medical Center
Something bad happens, and on the inside, your immediate response is "NOPE." Your heart races, thoughts spin, and you just want to run, scream, or hide under a blanket until it resolves.
That, in a nutshell, is distress. And unfortunately, there is no OFF button. But we can learn how to ride out the horrible wave without letting the moment take us under.
Distress tolerance
Distress tolerance is the ability to stay with difficult emotions without immediately trying to escape them, act on them, or make them disappear. You don't have to love the moment, find the silver lining, or pretend everything is fabulous. It simply means learning to experience a difficult emotion fully and giving yourself enough space to decide what comes next.
For people living with HIV, that space can be especially important when stigma sneaks into your inner monologue.
When stigma becomes an inner voice
We are all shaped by the messages we hear around us:
- “People like us don’t do that.”
- “What will people think of you?”
- “You're gonna date them?”
And somewhere along the way, we may forget to ask the obvious question: Who asked you?
Those little comments we hear, over and over again, can stick with us. After a while, we may start saying the same things to ourselves without even noticing where they came from. Almost like sound bites, they can start to sound like our own thoughts.
For people living with HIV, that can mean internalizing the stigma that surrounds it. Messages that once came from the outside can begin to influence how we think about ourselves.
This is called self-stigma. Experiencing it does not mean something is wrong with you. It’s a very human response to the world around us. Understanding why it happens can be the first step toward recognizing those messages for what they are. After we notice them, we can create some space between the actual stigma we experience and how we truly see ourselves.
Making space for difficult feelings
We absorb messages from everywhere: family, friends, school, coworkers, TV, ads, movies, news, and social media. Some tell us that we're loved, capable, and worthy of respect. Others teach us what we're supposed to look like, how we're supposed to live, who we're supposed to love, and where we're supposed to belong. We absorb these messages without ever consciously deciding whether we believe them.
And some of those messages come with a lot of rules. Wear this. Act like that. Don't be too much. Don't stand out. OMG, who made all these rules?
When the negative messages get activated, they can bring up difficult emotions, including shame, fear, sadness, or anger. Distress tolerance is about learning to sit with those feelings without needing to immediately make them go away, act on them, or believe everything they tell us.
With a little practice, it’s possible to actively decide how to respond to the negativity.
HIV brings extra layers
Living with HIV can bring emotional challenges that go beyond the diagnosis. There are decisions about disclosure, reactions from others, relationships to navigate, medical appointments and treatment, and periods of uncertainty about the future. The hardest part is not just the diagnosis, but all the big feelings that come along with it.
When those feelings become overwhelming, distress tolerance can help you push “pause,” stay present, and care for yourself.
Distress doesn't mean you're failing
Living with HIV does not mean you are supposed to handle every moment with strength, patience, or Beyoncé-like confidence. There may be times when you feel overwhelmed, angry, afraid, exhausted, or simply tired of having to deal.
Those feelings don't mean you're failing. Distress is an internal alarm bell. When you feel threatened, uncertain, or overwhelmed, your brain and body react in ways designed to get your attention. The alarm lets you know that something needs your attention, even if it doesn't tell you exactly what’s wrong.
Learning distress tolerance is about learning how to hear the alarm and, instead of taking action right away, deciding what needs—and what deserves—our attention.
Six ways to handle a difficult moment
Distress tolerance offers a few simple tools for getting through the immediate moment and creating enough space to decide what to do next.
Here are six tools that help you step out of the emotional vortex and give yourself a little room to breathe.
1. Pause before you react. “STOP” is a reminder to slow down before acting on an intense emotion or urge.
- Stop: Pause before reacting.
- Take a step back: Give yourself some space from the situation.
- Observe: Notice what you're feeling, thinking, and wanting to do.
- Proceed mindfully: Decide what to do next rather than acting on the immediate urge.
2. Change what your body is experiencing. “TIP” uses physical sensations, such as cold water, movement, or paced breathing, to help reduce the intensity of an emotion.
- Temperature: Use a change in temperature, such as an ice-cold drink or splashing cold water on your face, to help lower emotional intensity.
- Intense movement: Use brief physical activity, such as walking or stretching, to help release some of the body's emotional energy.
- Paced breathing: Slow your breathing to help your body settle.
3. Comfort yourself. Self-soothing uses your senses to create comfort and safety when you need them. Grab a soft blanket and a warm cup of tea, then cuddle up with yourself.
4. Temporarily shift your attention. “ACCEPTS” can help you distract yourself when an emotion is simply too intense to sit with right now.
- Activities: Get your mind off how you feel with a video game, take a walk, or anything that distracts you for a bit.
- Contributing: Be helpful to someone else.
- Comparisons: Remind yourself that difficult moments are temporary and that others have faced hard moments too.
- Emotions: Shift toward a different emotion through music, a movie, humor, or anything else that changes how you feel.
- Pushing away: Give yourself permission to set the problem aside temporarily when you need a break.
- Thoughts: Shift your thinking by doing something else. Focus on a word puzzle, a quick game of Candy Crush, or washing some dishes.
- Sensations: Engage your senses with a cool drink, a warm shower, music, or another physical sensation.
5. Think about the urge before acting on it. Looking at the pros and cons can help you consider where a particular reaction might lead.
6. Acknowledge what is happening. Radical acceptance means recognizing reality as it is, without saying that you like it, agree with it, or approve of it.
Sometimes, the most useful step is to wait. Once the emotional intensity subsides, you may be in a better position to ask, "What can I actually change?" That's where problem-solving comes in.
Practice before you need it
Distress tolerance skills are easier to use when you've practiced them before you need them. Don't wait for a difficult moment to try them for the first time.
Try one of the above tools on an ordinary day. Start when you realize you’re just feeling a little annoyed about something. Maybe it’s raining out, and you planned on going outside on a walk, or a barista wrote your name wrong at the coffee shop. Notice what helps you feel calmer, more grounded, or more in control. You might find that some skills work better for you than others.
When you need more support
Distress tolerance skills can help you get through difficult moments, but you don't have to handle everything on your own. These skills are one tool for coping, not a replacement for professional support.
If difficult emotions are making it hard to get through your day, impacting your relationships, or simply feeling like more than you can manage, reaching out can help. Your HIV doctor, mental-health professional, social worker, case manager, or support group can offer support that goes beyond what a coping skill can provide.
Asking for help isn't a sign that you're not coping well. Sometimes taking care of yourself means letting someone else help. There is no prize for doing this the hard way.
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