Whether perceived or actual, emotional stress is challenging to deal with, especially for some people with a trauma history.
This inability may significantly worsen during a crisis, when people feel helpless and out of control. A person’s ability to manage an emotional incident without feeling overwhelmed is called distress tolerance (Linehan, 2014).
Being able to handle difficult emotions can help a person more quickly return to a state of equilibrium when new stressors arise (Chapman, Gratz, & Tull, 2011). It is possible to assist people in improving their distress tolerance, and for that reason, we will discuss distress tolerance skills in this article.
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Distress Tolerance Skills Explained
Distress tolerance skills allow a person to survive an immediate emotional crisis without making it worse (Linehan, 2014). They also help them accept the reality of the situation when they feel out of control because they cannot change the situation (Chapman et al., 2011).
Another benefit is that distress tolerance skills also help people cope with their feelings when they don’t know exactly what they want or need at that moment.
Distress Tolerance is a module in Dialectical Behavior Therapy (DBT), and there are several skills taught as a part of this module (Linehan, 2014). These skills are often called “crisis survival skills” because they help a person navigate a (perceived or actual) crisis (Linehan, 2014).
The most frequently taught distress tolerance skills are:
- Self-soothing techniques;
- TIPP skills;
- The STOP skill, to stop yourself from engaging in impulsive behavior;
- Pros and cons;
- Radical acceptance;
- Distraction; and
- Improving the moment (Van Dijk, 2013).
Crisis survival skills are short-term coping strategies that help manage emotional pain to avoid destructive behavior. Sometimes when a person feels extreme emotional distress, they will do whatever they can to avoid feeling that pain.
Such actions may include self-harm behaviors (cutting, burning, etc.), running away or avoiding the situation, using alcohol or drugs, or denying that the stressor is real (McKay, Wood, & Brantley, 2007). The avoidance of emotional pain may lead to more harmful or risky behaviors that have serious long-term consequences (Van Dijk, 2013).
During a perceived or actual crisis, a person’s limbic system gets activated, and they become on high-alert (Koons, 2016). It is difficult to practice adaptive coping techniques when a person is already in an agitated state of mind (McKay et al., 2007).
Using a distress tolerance skill can help a person lower the intensity of the emotional pain. The person can then utilize other DBT coping skills such as emotional regulation, mindfulness, and interpersonal skills.
A Look at Self-Soothing Techniques
Distress tolerance skills help us cope with complicated feelings, including feeling out of control (McKay et al., 2007).
When most people are anxious or in a stressful situation, the most adaptive way to cope is to utilize self-soothing techniques.
Most people develop their own ways to calm themselves when feeling distressed. This is similar to a child stroking a favorite stuffed toy or sucking their thumb. Those are developmentally appropriate ways to help calm yourself when you are a young child. As an adult, we modify those feelings to techniques that are socially appropriate for adult behavior.
Some young children never learn how to adapt these self-soothing behaviors to developmentally appropriate adult calming behaviors. These people struggle most with distress tolerance, and they must learn new adaptive self-soothing techniques to help them with new emotional stressors.
Self-soothing using your senses
Some adaptive self-soothing techniques include using all of your senses to mentally and emotionally ground yourself (Chapman et al., 2011). This means that you would instruct your client to:
- See: look at all the colors and textures in the environment;
- Hear: listen to the sounds around them, to their own breathing;
- Touch: ask them what the seat feels like under their legs, the clothes on their skin, the breeze in their hair, etc.;
- Taste: have them eat a small piece of food and pay attention to the way it tastes in their mouth; and
- Smell: have them acknowledge the smells in the room, light a candle, or use aromatherapy.
Providing a raisin to the client is an excellent way to teach sensory grounding (self-soothing) skills. They can smell the raisin, touch the bumpy surface, look at the ridges and color, taste the raisin, and hear what it sounds like when they swallow the raisin.
Weighing the pros and the cons
Although this sounds like a simple technique, when we are in a crisis situation, we often make emotional, rather than rational, decisions (Linehan, 2014). Our body and mind are in the fight or flight mode, and we want to get out of the distressing situation as quickly as possible.
When we do not stop and weigh our choices carefully, we may make rash and impulsive choices that can lead to harmful consequences (Chapman et al., 2011). Weighing the pros and cons simply means that a person should pause and take a moment to think logically about their situation and the next steps.
Writing down a list of pros and cons for their plans may help them see the logic when they feel particularly emotional. It is a way to return someone to the “wise mind” (middle path) state of DBT (Koons, 2016).
Radical acceptance is a technique that sometimes requires a lot of practice but, when implemented, can be extremely useful. People often feel out of control, which increases their anxiety and feelings of distress (Chapman et al., 2011).
Radical acceptance means merely accepting the state of things as they are, without working to change them. Basically, “it is what it is.” When we relinquish the need to control a situation and understand that there is nothing we can do to change it, the pressure to fix things often subsides.
Radical acceptance merely means observing a situation, without emotion, and accepting that we are not omnipotent beings and some things are simply out of our control (Chapman et al., 2011).
When we try to control things, we may feel an increase in distress if we fail. If we stop trying to control and just accept that things are as they are, then we can move forward without getting emotionally stuck (Linehan, 2014). It is no longer our responsibility to change the situation.
When all else fails, the best skill to practice may be distraction. Although humans like to think that we can multitask, our working memory limits how much information it can process at a time.
If someone is feeling particularly overwhelmed, it may help them to temporarily do something else to distract themselves from the distressing situation, until they are able to return to deal with it calmly (Chapman et al., 2011). Distraction can involve physically leaving a location or an action such as calling a friend, watching tv, reading a book, playing with pets, etc.
Improving the moment
The IMPROVE skills stand for:
- One thing in the moment,
- Vacation, and
- Encouragement (Linehan, 2014).
These are smaller distress tolerance skills that can be utilized as needed by the client. The client can visualize (Imagery) a different situation or find a sense of purpose (Meaning) from the traumatic event.
Prayer doesn’t have to be religious but can involve reciting a mantra or quote to connect to the world spiritually.
Relaxation can be things like deep breathing or Progressive Muscle Relaxation, which will be discussed further below.
“One thing in the moment” means to slow down and partialize a problem, addressing each part at a time rather than feeling overwhelmed by the whole situation.
Vacation is similar to the distraction skill, taking a break from the stress (a vacation from your thoughts). At the same time, Encouragement is a form of self-soothing that involves self-talk and a reminder that this distressing state of mind is merely temporary.
Resetting the system
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.
What Are TIPP Skills?
TIPP is an acronym for Temperature, Intense Exercise, Paced Breathing, and Paired Muscle Relaxation (some people refer to this only as TIP, despite the two “P” skills; Linehan, 2014).
TIPP skills work very fast, usually within a few seconds to a few minutes, to calm the limbic system and lower the state of emotional arousal. They are easy to do and available anywhere (you can even do them in public), without the side effects or cost of psychiatric medication (Linehan, 2014). With practice, TIPP skills can become an adaptive coping technique that can be used anywhere by anyone.
Comprehensive List of the Skills
TIPP skills include:
1. Temperature with cold water
Cold water provides a shock to the system. If a client is having difficulty regulating their emotions, suggest that they splash cold water on their face, take a cold shower, or hold ice cubes in their hands.
These are tasks that will not hurt the client, but the cold temperature will prevent them from remaining in an elevated emotional state.
2. Intense Exercise
Similar to cold temperatures, intense exercise changes the biochemistry of the system adaptively. During intense exercise, the heart rate is up and adrenaline is pumping. When adrenaline floods the system, it provides a euphoric feeling.
Intense exercise is useful as it is difficult for a person to feel distressed and elated simultaneously.
3. Paced Breathing
With paced breathing, instruct the client to inhale through their nose slowly for a count of two, hold the breath for three seconds, and then exhale slowly through their mouth for a count of five.
Paced breathing is counted and regulated breathing that helps clients regain a sense of control by controlling their most basic biological function: their breath.
When the client learns to breathe slowly and calmly, their blood pressure will lower, and they will feel more relaxed and less stressed. This can help address the effects of anxiety, insomnia, and fatigue, among other problems.
4. Paired Muscle Relaxation
In Paired Muscle Relaxation (PMR), a pair of muscles, such as the toes on both feet, are tensed while breathing in and then relaxed while breathing out. Work on the muscles in a particular order, from the top of the head to the feet or vice versa.
When the body is physically relaxed, it is difficult to be emotionally agitated.
The mind–body connection is very strong, so to calm the mind, calm the body. PMR also teaches mindfulness of the body and self-awareness. Some people believe guided PMR, such as with a practitioner or an audio recording, is helpful when starting PMR until you are familiar with the practice.
5 Ways to Teach These Skills
There are various ways to teach these skills to clients.
Handouts and worksheets
Tools such as worksheets can be integrated into a therapy session, where the practitioner would lead a client in guided skill instruction.
The PositivePsychology.com Toolkit has resources for a practitioner who wants to teach distress tolerance skills to the client. These can initially be taught during a group, individual, or family session, and then the client can practice the skill at home with the help of the therapy worksheet.
Clients can practice skills alone at home using guided audio recordings. There are many audio recordings that clients might wish to purchase, many of which accompany workbooks or come as guided audio meditations.
Alternatively, practitioners may wish to pre-record their own audio that guides their clients through the use of DBT skills and techniques. Clients may then listen to these recordings when needed.
For instance, using the blended care platform Quenza, therapists can design audio-based activities for their clients to complete on their Apple or Android device. The therapist can then track the completion of these activities from their own devices, potentially providing useful content for exploration during in-person therapy sessions (e.g., regarding the frequency and types of activities clients use to self-soothe).
The most often recorded skill is the Progressive Muscle Relaxation technique, since it is helpful to listen to this guide the first few practice times.
Therapy books such as The Dialectical Behavior Therapy Skills Workbook by McKay, Wood, and Brantley (2007) can be recommended to the client, and homework can be assigned to do between sessions.
This book is handy because it describes why we need to learn DBT skills, how they help, and how they should be practiced. The book allows for individual variations in how the techniques are applied.
Some clinicians use the book in group therapy or individual sessions; other clinicians recommend it as homework. Clients who are already familiar with DBT skills can use the book independently as a refresher course.
Available on Amazon.
Distress tolerance skills can be taught in DBT group therapy sessions as part of the Distress Tolerance module or integrated into any group or family therapy format to help regulate client emotions.
When clients come to therapy sessions in a more grounded mindstate, they are more receptive to the therapeutic process. The skills also help strengthen the therapeutic alliance since the therapist reinforces a peaceful and calm mindstate during sessions.
Individual therapy sessions
These techniques can also be taught in individual therapy sessions. When used in individual therapy, they can be tailored by the clinician to adapt to the client’s specific needs. Therapy sessions can consist primarily of skill-based learning or adjuncts to psychodynamic psychotherapy and other treatment models.
Although Distress Tolerance is part of the Dialectical Behavior Therapy treatment model (Linehan, 2014), distress tolerance skills such as self-soothing, grounding techniques, mindfulness meditation, and TIPP skills can be taught to clients, as needed. You do not have to be certified in DBT to help your clients learn to calm themselves in an emergency.
4 Helpful Handouts and Worksheets
- The Raisin Meditation: As briefly described above, the Raisin Meditation is the most frequently used technique to teach clients how to use their five senses to ground themselves and maintain a calm affect through mindfulness. It involves using a raisin to teach the skills. Once the client learns how to use their senses to tolerate distressing situations, the skill can be generalized to other situations.
- Nature Play: This handout helps clients learn how to use their sense of sound to regulate their emotions, no matter where they are located. It teaches mindful listening skills that can be used to self-soothe.
- Breath Awareness: This handout guides a client on how to be mindful and focus on their breathing to ground themselves. It is a beneficial self-soothing skill that can be practiced anywhere.
- The Five Senses Worksheet: Like the Raisin Meditation, this handout helps clients practice mindful meditation using their five senses. When we focus on our senses, it helps calm our nervous system and helps us self-soothe and relax when stressed or distressed.
Several excellent tools are available in the PositivePsychology.com Toolkit that may help clients and practitioners learn more about distress tolerance skills:
- The Practicing Acceptance with Ice Cubes tool is a DBT Distress Tolerance TIPP skill.
- Progressive Muscle Relaxation is a self-soothing tool that may help clients cope with distressing feelings and thoughts.
- The Eye of the Hurricane Meditation is a tool to help clients calm themselves while practicing radical acceptance.
A Take-Home Message
Everyone deals with stress differently. Some people learned how to cope with stressful situations as children, while others never developed adequate coping skills.
Distress Tolerance skills, as a module in Dialectical Behavior Therapy, can be taught to any client that needs to improve their crisis coping techniques.
There are many resources that a practitioner can use to teach these skills. When clients feel severe distress, they may act irrationally, but when they practice distress tolerance skills, they return to a state of “wise mind” where they can make healthier decisions.
With the tools and guidance shared above, you should be able to assist any client with practical coping skills, without having to be DBT certified.
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- Chapman, A., Gratz, K., & Tull, M. (2011). The dialectical behavior therapy skills workbook for anxiety: Breaking free from worry, panic, PTSD, and other anxiety symptoms. New Harbinger Publications.
- Linehan, M. M. (2014). DBT skills training handouts and worksheets. Guilford Publications.
- Linehan, M. M. (2014). DBT skills training manual. Guilford Publications.
- Koons, C. R. (2016). The mindfulness solution for intense emotions: Take control of borderline personality disorder with DBT. New Harbinger Publications.
- McKay, M., Wood, J. C., & Brantley, J. (2019). The dialectical behavior therapy skills workbook: Practical DBT exercises for learning mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. New Harbinger Publications.
- Van Dijk, S. (2013). DBT made simple: A step-by-step guide to dialectical behavior therapy. New Harbinger Publications.