Defining Crisis in DBT

Most people assume a crisis means life or death. In DBT it means something more specific and more common.

The word does a lot of work in the treatment, because it determines which set of skills applies. Getting the category right is not a matter of vocabulary, it changes what you are supposed to do in the next twenty minutes.

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In DBT, we define a crisis as firstly something that is highly stressful with the potential for some very negative outcomes.

Dr. Jesse Finkelstein anticipates the objection directly.

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Some of you might be thinking, well, aren't crises meant to be like life or death situations? I guess that's one definition of a crisis. And in DBT, we think about crises as situations that tend to elicit really strong emotions where we may have the urge to get some very quick relief by doing something that is going to harm our interests in the long term.

That is the working definition, and it is built around behavior rather than severity. A crisis in DBT is any situation where the pull toward immediate relief is strong enough to cost you something you care about.

Defined that way, most people have several a month. They do not look like emergencies from the outside, which is part of why they are so expensive. Nobody prepares for them.

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Two examples

Both are deliberately ordinary, and that is the point of choosing them.

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You're on a plane and you're about to lose cell reception and someone just broke up with you. Or you are trying to remain abstinent from alcohol and you're at a party where everyone is drinking.

Neither is life threatening. Both carry a real risk of doing something in the next twenty minutes that you will still be dealing with next month. That is the category.

Notice also that in both cases the situation has an end. The flight lands. The party finishes. Nothing about the underlying problem is resolved by that, but the window in which you are most likely to act against yourself does close on its own.

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The three elements

One: high stress with the potential for very negative outcomes. The situation is genuinely difficult and the available responses include some that are genuinely costly. Both halves are required. A difficult situation with no destructive option available is just a bad day.

Two: it is short term. This is the element people skip, and it changes what you are supposed to do.

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Crises are short term. The skills that we have to help get us through a crisis without making it worse, these are not skills that we want to use to solve the problem. We want to use these skills to just get through a crisis so that we don't make what is already a painful situation a lot worse.

Crisis survival skills are not problem solving. They are not meant to fix the breakup, resolve the conflict, or address the underlying issue. Their entire job is to get you to the other side of a window of time with your options intact.

This is a real constraint and it is worth respecting. Trying to solve a problem at peak arousal produces decisions you would not make at rest, and those decisions then become the new problem. The sequencing is deliberate: survive first, decide later.

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This party won't last forever. You'll be there for maybe an hour or two. How do we get through it without breaking your goal of abstinence?

An hour or two is a tractable problem. The rest of it is a different conversation, for a different day, with a clearer head.

Three: intense pressure for quick resolution. The situation does not feel like it can wait, and that feeling is itself part of the problem.

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Maybe you're in a fight with someone, a partner, a loved one, and your urge is just to send them a really mean text. Maybe you failed an exam and your urge is to get some relief by getting stoned.

In both cases the urge promises resolution and delivers relief. Those are not the same thing, and under pressure they are very hard to tell apart.

The tell is usually the time horizon. Relief arrives immediately and is aimed at how you feel. Resolution takes longer and is aimed at the situation. When something offers to fix everything within the next minute, it is almost always the first one wearing the language of the second.

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Why the definition is useful

Naming a moment as a crisis does two things at once.

• It tells you which toolkit to reach for. Crisis means survive the window, not solve the problem.
• It tells you what success looks like. Success is arriving at the other end without a new problem attached, not feeling better.

That second point relieves a lot of pressure. People often judge a crisis skill as having failed because they still felt terrible afterwards. Feeling terrible was never the target. The target was not making it worse.

It also works in the other direction. If a situation is not short term and has no window, crisis skills are the wrong tool and using them repeatedly turns into avoidance. A job that is making you miserable every day is not a crisis, it is a problem, and problems get solved rather than survived.

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What to actually use

Once you have identified a moment as a crisis, the DBT crisis survival skills are the direct answer, with part two here. When arousal is very high, the TIP skills work on the body in a minute or two, and the STOP skill inserts a gap before the urge becomes an action.

Dr. Jesse Finkelstein teaches these skills in individual therapy and the DBT skills group at Axis Psychological Services in New York City. You can book a free consultation.

If you want to build a crisis plan with support, learn about DBT therapy in NYC, or practice these skills in the DBT skills group in NYC.