DBT Distress Tolerance: Skills List & Module Guide

Dialectical Behaviour Therapy (DBT) is a therapeutic approach that empowers individuals to regulate their emotions, improve relationships, and navigate life’s challenges with resilience.

One of the four pivotal modules of DBT is Distress Tolerance, which equips individuals with invaluable skills in order to to cope with overwhelming emotions and crisis situations effectively.

In this article, I’ll delve into this core module of DBT. The DBT Distress Tolerance module consists of 4 main skills, which I’ll cover in more detail throughout this guide.

Understanding DBT Distress Tolerance: What is it For?

In DBT, Distress Tolerance is about learning to cope with distress and emotional pain skillfully. It focuses on developing the ability to tolerate distress without making the situation worse, rather than eliminating or avoiding pain altogether, via a number of different strategies.

These skills are particularly crucial during intense emotions, crisis situations, or extreme stress, which can be common if you are living with BPD or healing from trauma.

One important factor to note with Distress Tolerance skills is that they are short-term strategies for navigating extreme distress. If you use these skills alone and for minor stressors, it can result in longer-term avoidance, which is not the purpose of this module.

Distress tolerance skills are there for those moments when our distress is too high to use skills from the previous three DBT modules: DBT Mindfulness, DBT Interpersonal Effectiveness, and DBT Emotional Regulation,

You might find that you use these skills a lot more in the earlier stages of your recovery, so don’t judge yourself for that! Just be mindful if you start relying on them to get through everyday inconveniences instead of those moments of real distress for you.

For me, I relied on these heavily to heal my self-destructive urges (self-h*rm, drinking, avoidance) in the early days of DBT. It wasn’t until I got through some of the trauma work and started feeling safer with mindfulness and learnt how to regulate my emotions that I could really start letting go of these techniques as a regular practice.

I do, however, still use these skills when I’m feeling extremely anxious or uncomfortably restless. The cold water works wonders, and a rigorous dance workout in my room always helps me move some of that energy around and clear it a bit.

List of Distress Tolerance Skills in DBT

Distress Tolerance Skill Name	Example/Description
TIPP	Uses body-based strategies (Temperature, Intense Exercise, Paced Breathing, and Progressive Muscle Relaxation) to quickly regulate emotions.
ACCEPTS	A set of distraction tools for short-term distress: Activities, Contributing, Comparisons, Emotions, Pushing Away, Thoughts, Sensations.
Self-Soothing Techniques	Uses the five senses (sight, sound, touch, taste, smell) to calm and comfort yourself in the moment.
IMPROVE the Moment	Mental strategies to get through hard moments: Imagery, Meaning, Prayer, Relaxation, One Thing at a Time, Vacation, Encouragement.
Crisis Survival Strategies	Short-term coping tools for when you’re in emotional crisis, aimed at getting through the moment without making it worse.
STOP	A mindfulness-based pause button: Stop, Take a step back, Observe, Proceed mindfully.
Pros & Cons of Acting on Distress	Helps you weigh the short-term urge vs. long-term goals, clarifying the benefits of tolerating distress rather than reacting impulsively.

Core DBT Distress Tolerance Skills

The core DBT Distress Tolerance Skills include:

• TIPP
• ACCEPTS
• Self-Soothing Techniques
• IMPROVE the Moment

Let’s explore these core skills that constitute Distress Tolerance in DBT in some more detail.

TIPP

TIPP is the first DBT distress tolerance skill, and is an acronym that stands for the following four steps: temperature, intense exercise, paced breathing, and paired muscle relaxation. This DBT Distress Tolerance skill that utilises the biological functions of our nervous system to reverse the firing of fight or flight responses and lowering our levels of distress.

The four steps of the DBT TIPP skill are as follows:

1. Temperature: When experiencing heightened distressing emotions, the body often feels hot. You can counteract this by splashing your face with cold water, jumping in a cold shower for 30 seconds, holding an ice cube, or allowing cool air from a car’s AC to blow on your face. Altering your body temperature helps in cooling down both physically and emotionally.
2. Intense Exercise: Engage in intense exercise that matches the intensity of your emotions. It doesn’t require marathon-level fitness—sprint down the street, swim a few laps, or perform jumping jacks until fatigue sets in. Intense exercise increases oxygen flow, effectively reducing stress levels. Exhaustion makes it challenging to sustain heightened upset feelings.
3. Paced Breathing: Control your breath to significantly reduce emotional pain. Various breathing exercises can be employed, or try the “box breathing” technique: Inhale for four seconds, hold for four seconds, exhale for four seconds, and then hold for another four seconds. Repeat this pattern until you feel a sense of calm. Consistent, controlled breathing diminishes the body’s fight or flight response.
4. Paired Muscle Relaxation: Utilise the fascinating science of paired muscle relaxation. Tighten a voluntary muscle, then consciously relax it and allow it to rest. Relaxed muscles demand less oxygen, leading to a slowdown in breathing and heart rate. This contributes to an overall sense of calmness.

By implementing these TIPP techniques, individuals can actively engage with their body’s physiological responses to distress, promoting emotional regulation and a reduction in overall stress levels.

Positive Psychology explains:

When the limbic system is in a state of extreme arousal, it may be difficult for a person to regulate their emotions (Koons, 2016). Similarly, when a computer is working so hard that it is overheating, it will eventually become overloaded and freeze. The only way to recover from this is to restart the system, thereby returning it to a working state.

A comprehensive list of self-regulating and self-soothing skills are listed below. In an extreme emotional crisis, TIPP skills are the fastest way that a person can restart their body chemistry to return to a calmer state of mind (McKay et al., 2007). Again, this is similar to restarting a computer when nothing else works.

The purpose of distress tolerance, self-soothing, and TIPP skills is to prevent the emotional crisis from worsening.

ACCEPTS

The second distress tolerance skill taught in DBT is ACCEPTS, an acronym representing distraction techniques. This skill plays a fundamental role in shifting focus from distressing emotions. Expanding on this, we can further explore each element of ACCEPTS:

• Activities: Actively participating in positive and enjoyable activities can be a powerful distraction from distressing thoughts and emotions.
• Contribute: Engaging in activities that contribute positively to others can divert attention away from personal distress.
• Comparison: Reflecting on the challenges faced by others less fortunate can provide a perspective shift and reduce personal distress. (Note: Use discernment on whether this is appropriate to your situation or whether it may feel invalidating. You don’t have to use this is it isn’t helpful to you.)
• Emotions: Actively cultivating emotions opposite to those causing distress can help in changing the emotional state. (I liked to watch horror films as the ultimate emotional distraction if things were bad short-term!)
• Pushing Away: Temporarily putting aside or pushing away distressing emotions can help provide some space between you and the distress or destructive urges until your nervous system has regulated.
• Thoughts: Developing strategies to redirect and put aside distressing thoughts while in high emotion can create mental space for more effective problem-solving later.
• Sensations: Engaging and distracting the senses in various ways, such as holding an ice cube or smelling soothing scents, can divert attention from emotional distress.

Self-Soothing Techniques

The third core distress tolerance skill of DBT is self-soothing. Practicing self-soothing regularly contributes significantly to building emotional resilience, and it involves activities that stimulate the five senses, bringing you back to the present moment. This could include:

• Vision: Surrounding oneself with visually comforting elements or engaging in art.
• Hearing: Listening to calming music, nature sounds, or a favourite podcast.
• Smell: Using scented candles, essential oils, or enjoying the aroma of favourite foods.
• Taste: Indulging in favourite, flavoursome foods or non-alcoholic beverages.
• Touch: Engaging in activities that provide a comforting tactile experience, such as a warm bath, soft blankets, or a comforting hug.

IMPROVE the Moment

Finally, the IMPROVE distress tolerance skill offers strategies to improve and enhance the current moment during distress. Expanding on this, we can delve into each component:

• Imagery: Creating a peaceful mental image can serve as a powerful tool to improve the emotional state.
• Meaning: Finding purpose or lessons in the moment can contribute to a sense of meaning and reduce distress.
• Prayer: For individuals with spiritual inclinations, prayer can offer solace and connection during difficult times.
• Relaxation: Engaging in calming activities, such as deep breathing exercises or progressive muscle relaxation, can be instrumental in improving the moment.
• One Thing in the Moment: Focusing on one thing at a time can prevent overwhelming feelings and improve coping ability.
• Vacation: Taking a mental break, even if only momentarily, allows the mind to reset and approach challenges with a fresh perspective.
• Encouragement: Providing oneself with supportive statements fosters a positive internal dialogue, contributing to improved distress tolerance.

Additional DBT Distress Tolerance Skills: Crisis Survival Strategies

Navigating through moments of intense distress can be challenging, but having a set of crisis survival strategies to hand can truly be a lifesaver in these moments. From crafting a personalised safety plan to leaning on the support of trusted individuals such as friends, family, or mental health professionals, mastering the art of crisis management can significantly enhance our resilience in facing life’s toughest challenges.

DBT’s Distress Tolerance module also outlines a few key crisis survival skills for when:

1. You have intense emotional pain that cannot be helped quickly.
2. You want to act on your emotions, but it will only make things worse.
3. Emotion mind threatens to overwhelm you, and you need to stay skillful.
4. You are overwhelmed, yet demands must be met.
5. Arousal is extreme, but problems can’t be solved immediately.

STOP (Stop, Take a Step Back, Observe, Proceed Mindfully)

In moments of intense emotional turmoil, it’s crucial to halt before reacting impulsively. Remember the acronym STOP:

• Stop: Freeze and resist the urge to act immediately. By pausing, you regain control over your emotions and actions.
• Take a Step Back: Create space between yourself and the situation. Take a breather, allowing yourself to disengage from the intensity of the moment.
• Observe: Take note of your inner experiences and external surroundings. What thoughts and emotions are present? What’s happening around you? This awareness lays the foundation for informed decision-making.
• Proceed Mindfully: With a clear understanding of the situation and your emotional state, proceed with mindfulness. Consider your goals, the potential impact of your actions, and consult your Wise Mind to discern the most skillful course of action.

Pros & Cons

An urge is a crisis when it is very strong and when acting on the urge will make things worse in the long term. When faced with overwhelming urges during a crisis, evaluating the pros and cons can provide clarity and guide your response:

• Evaluate Urges: Recognise when an urge becomes a crisis by its intensity and potential long-term impact. Whether it’s a desire to engage in harmful behaviours or to avoid necessary actions, acknowledge the significance of the urge.
• List Benefits and Drawbacks: Create two lists outlining the advantages and disadvantages of giving in to the crisis urges versus resisting them. Consider the short-term relief versus the long-term consequences for each scenario.
• Weigh Your Options: Compare the lists to assess which course of action aligns with your values and goals. By carefully weighing the pros and cons, you can make an informed decision that promotes your overall well-being and resilience.

Journal Prompts for Using DBT Distress Tolerance Skills

1. Reflect on ACCEPTS Techniques: Think back to a recent situation where you felt overwhelmed by distress. How could you have applied the various ACCEPTS techniques, such as engaging in enjoyable Activities or Contributing to others, to shift your focus and manage the situation more effectively? Consider how employing these distraction strategies might have influenced your emotional state and coping ability during that challenging moment.
2. Explore Self-Soothing Activities: Identify self-soothing techniques that resonate with you on a personal level. Reflect on activities that stimulate your senses and bring comfort during times of distress. How can you incorporate these self-soothing practices into your daily routine or action plan for coping with heightened emotional states? Whether it’s indulging in your favorite music to soothe your Hearing sense or surrounding yourself with visually comforting elements to please your Vision, explore ways to integrate these activities into your distress tolerance toolkit.
3. Apply IMPROVE Strategies: Recall a recent challenging moment where you struggled to cope with intense emotions. How might applying the IMPROVE strategies have enhanced your ability to navigate that distressing situation? Consider incorporating techniques such as Imagery to create a peaceful mental image or Relaxation exercises to promote a sense of calmness. Reflect on how implementing these strategies could have improved your emotional regulation and overall well-being in that moment. Can you develop a plan for using these IMPROVE techniques in future instances of distress to bolster your resilience and coping skills?
4. Integrate Crisis Survival Strategies: Delve into the crisis survival strategies outlined in DBT’s Distress Tolerance module. Reflect on situations where you’ve experienced intense emotional pain or overwhelming urges. How could employing the STOP technique have helped you regain control and approach the situation mindfully? Explore the process of evaluating Urges as crises and weighing the Pros & Cons of acting on those urges versus resisting them. Consider how mastering these crisis survival skills can enhance your ability to navigate challenging moments with resilience and effectiveness.

By engaging with these journal prompts, you can deepen your understanding and application of distress tolerance skills, empowering yourself to navigate life’s challenges with greater ease and resilience. Remember to approach the journaling process with self-compassion and openness to growth and learning.

24 DBT Mindfulness Journal Prompts For Deeper Healing (8-Page Journal PDF)

Conclusion

Distress Tolerance stands as a core element of DBT, offering practical skills to manage overwhelming emotions and crisis situations. By delving into the nuanced aspects of ACCEPTS, self-soothing techniques, and IMPROVE, individuals can build resilience and navigate life’s challenges with greater ease.

The integration of these skills into your coping toolbox empowers individuals to face distress skillfully and emerge truly stronger from challenging situations.

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DBT Distress Tolerance FAQs

What are the four core distress tolerance skills in DBT?

Distress Tolerance Skills in DBT involve learning to bear pain skillfully, focusing on tolerating distress without exacerbating the situation. These skills are crucial during intense emotions, crises, or extreme stress. The 4 Core DBT Distress Tolerance Skills include: TIPP (Temperature, Intense Exercise, Paced Breathing, Paired Muscle Relaxation), Distract with ACCEPTS (Activities, Contribute, Comparison, Emotions, Pushing Away, Thoughts, Sensations), Self-Soothing through the 5 senses, and IMPROVE the moment (Imagery, Meaning, Prayer, Relaxation, One Thing in the Moment, Vacation, Encouragement).

What is the best therapy for distress tolerance?

Dialectical Behaviour Therapy (DBT) is considered one of the best therapies for distress tolerance. It equips individuals with practical skills, including ACCEPTS, self-soothing, and IMPROVE, to effectively manage overwhelming emotions and crisis situations.

What is the meaning of distress tolerance?

Distress tolerance refers to the ability to withstand and manage distressing emotions or situations effectively without resorting to harmful or impulsive behaviours. It involves learning to tolerate uncomfortable feelings without making the situation worse, focusing on short-term strategies to navigate intense emotions or crises.

How do I get better at tolerating distress?

Improving distress tolerance involves practicing and implementing various coping strategies and skills. Engaging in therapies such as Dialectical Behaviour Therapy (DBT) can be highly beneficial, as it equips individuals with practical techniques like TIPP, ACCEPTS, self-soothing, and IMPROVE to manage distress effectively. Additionally, building mindfulness through meditation and self-awareness exercises, as well as developing a strong support network, can aid in enhancing distress tolerance over time.

What are the symptoms of distress intolerance?

Symptoms of distress intolerance can manifest in various ways and may differ among individuals. Common signs include difficulty managing intense emotions, engaging in impulsive or self-destructive behaviours when experiencing distress, feeling overwhelmed or unable to cope during challenging situations, and experiencing physical symptoms such as panic attacks or agitation in response to stressors.

What causes low distress tolerance?

Low distress tolerance can stem from various factors, including past traumatic experiences, a lack of taught emotional regulation skills, underlying mental health conditions such as BPD, anxiety or depression, and environmental stressors. Additionally, genetics, upbringing, and learned behaviours can also contribute to one’s level of distress tolerance. Seeking therapy and developing coping strategies can help address and improve low distress tolerance.