DBT distress tolerance skills

Some moments hurt so much that you just need to get through the next hour. Distress tolerance skills are for those moments. They come from dialectical behavior therapy (DBT), and their goal is simple: survive a crisis without making things worse.¹

These skills do not fix the problem. They help you ride out the wave so you do not act in ways you later regret. This lesson walks you through four of the main skills, step by step: TIPP, STOP, self-soothing and radical acceptance.

What distress tolerance means

Pain is part of life. Distress tolerance teaches you to bear pain in hard situations when you cannot change them right away.¹ The aim is to get through a crisis without self-harm, drugs or other acts that make things worse.¹

DBT sorts these skills into two groups:¹

• Crisis survival skills help you get through a short, intense moment. TIPP, STOP and self-soothing are in this group, along with others such as distraction.²
• Reality acceptance skills help with painful facts that cannot be changed now, or maybe ever. Radical acceptance and willingness are in this group.

Use crisis skills when your emotion is very strong and you cannot solve the problem right now. When you feel calmer, you can turn to problem-solving, the emotion regulation skills or help from others.

TIPP: calm your body fast

When emotion is extreme, it is hard to think clearly. TIPP works on your body first. Linehan based these skills on research about lowering the body's arousal through temperature, exercise, breathing and muscle relaxation.¹ You do not need to use all four. Pick the one that fits the moment.

T: Temperature

Cold water on your face sets off the dive reflex. This is a built-in body response that happens when you hold your breath with your face in cold water. Your heart rate slows down and blood moves toward your heart and brain.⁸

1. Fill a bowl or sink with cold water. Cold tap water is enough for most people. It does not need to be icy.⁴
2. Take a breath and hold it. Lean forward and put your face in the water so your eyes and nose are covered.⁴
3. Stay for about 30 seconds, or as long as is comfortable.⁴
4. Come up and breathe slowly. Make each breath out longer than the breath in.⁴
5. Repeat if needed until you feel the edge come off.⁴

Gentler options. Hold a cold pack or a bag of frozen vegetables, wrapped in a damp cloth, over your eyes and cheeks while you hold your breath. You can also put a cold, wet cloth on the back of your neck, hold an ice cube or drink a glass of cold water.⁴

I: Intense exercise

A short burst of hard movement can burn off the stored energy of a strong emotion. Right after moderate to vigorous activity, adults tend to feel less anxious for a while.¹¹

Move hard enough to raise your heart rate for several minutes: a brisk walk, marching in place or dancing to a fast song. Seated exercises count too. If you have heart, joint or balance problems, ask your doctor what level of effort is safe.

P: Paced breathing

Slowing your breath, and especially making your breath out longer, helps switch on the body's calming system.⁵ A review of 15 studies found slow breathing was linked to more relaxation and changes in heart rhythm that point to a calmer body. The authors said the evidence was still limited, and results for anxiety were mixed.⁹

1. Sit or lie down and put one hand on your belly.
2. Breathe in slowly through your nose for a count of about 5. Let your belly rise.⁵
3. Breathe out slowly through pursed lips, as if whistling, for a count of about 7.⁵
4. If that feels too long, try 2 counts in and 4 counts out. What matters most is that the breath out is longer.⁵
5. Keep going for a few minutes, or until you feel steadier.

You can also try our guided cyclic sigh or box breathing practices.

P: Paired muscle relaxation

This skill comes from stress training for athletes.¹ It is a quick form of progressive muscle relaxation, where you tense a group of muscles and then let them go.¹⁰

1. Breathe in and tighten one group of muscles, such as your fists, shoulders or face. Tense firmly but not to the point of pain.
2. Hold for about 5 seconds and notice the tension.
3. Breathe out slowly and let go all at once. You may silently say "relax."
4. Notice the difference between tight and loose, then move to another muscle group.

For a longer guided version, see progressive muscle relaxation. Relaxation methods are generally safe. A few people feel more anxious at first. If that happens, open your eyes and try a different skill.¹⁰

STOP: pause before you act

Strong emotions push us to act right now: to yell, drink or worse. STOP, from Linehan's DBT handouts, puts a gap between the urge and the action.²

1. S: Stop. Freeze. Do not move, speak or act yet.²
2. T: Take a step back. Step away, even just one step or into another room. Take a slow breath.²
3. O: Observe. Notice what is going on inside you and around you. What are you feeling? What are you thinking? What are the facts?²
4. P: Proceed mindfully. Ask what action will help, or at least not make things worse. Then choose with your goals in mind.²

An example. A daughter tells you on the phone that she cannot visit this weekend after all. You feel a rush of hurt and want to hang up on her. Stop. Say, "I need a minute." Step away from the phone and breathe. Notice: "I am disappointed and lonely." Then decide what you want: maybe to say how you feel and plan another day.

Self-soothe with your five senses

Self-soothing means being kind to yourself through your senses. You pick things that comfort or relax you.⁵ If you are very worked up, use a TIPP skill such as cold water first, then self-soothe.⁵

Combining senses can help.⁵ If your vision or hearing has changed with age, lean on the senses that work best. Use self-soothing on calm days too.⁵

Radical acceptance: facing what you cannot change

Some pain comes from facts we cannot change: a death, a diagnosis, a past mistake, a loss of independence. Radical acceptance means fully accepting the facts of the present moment.¹ Linehan drew on the writings of Viktor Frankl, a psychiatrist who survived the Nazi death camps.¹

1. Notice when you are fighting reality. Watch for thoughts like "This should not have happened" or "It is not fair."⁶
2. State the facts in plain words. For example, "My husband has dementia." "I can no longer drive."⁶
3. Let yourself grieve. Cry, write, pray or talk with someone. Feeling the loss is part of accepting it.⁶
4. Use your body. Relax your face and shoulders. Try willing hands: rest your hands on your lap, palms up, with fingers loose. This posture tells your body you are willing to face what is true.⁷ A soft half-smile can help too.⁷
5. Turn your mind. Acceptance is not a one-time event. When you notice yourself fighting again, gently turn back toward accepting. This "turning the mind" is a skill in itself.^2,6
6. Start small. Practice with small annoyances, such as a traffic jam, before big losses. Short bursts of a few minutes are fine.⁶

DBT also teaches willingness over willfulness. Willingness means being ready to respond to life as it is. Willfulness is the opposite: refusing to accept the moment as it is.¹ Acceptance and Commitment Therapy teaches a similar idea; see making room for feelings.

Build a distress tolerance kit

In a crisis, it is hard to remember what helps. A kit puts your skills in one place, so you do not have to think.³

What the research shows

Most research looks at DBT as a whole package, not single skills. See the DBT overview for those results. Here is what we know about the parts of this lesson.

Tips for older adults and caregivers

Later life brings its own hard moments: a new diagnosis, chronic pain, the death of a spouse, or caring for someone with dementia.

• Check with your doctor before cold water or hard exercise if you have heart problems or take heart medicines.⁴
• Caregivers can use STOP when a loved one's behavior is upsetting. A short pause can prevent words you regret. See caregiver burnout.
• Radical acceptance can help families facing a dementia diagnosis. It frees energy for the care you can give.

Common problems

The skills don't work when I'm really upset.

That is normal at first. Skills work better when you have practiced them on calmer days. Start with TIPP, because it works through your body, not your thinking. Then try another skill.

I use these skills every day, and I'm still in crisis a lot.

These skills are meant for short-term survival. If you face crises often, you deserve more support. Full DBT with a trained therapist offers individual sessions, a skills class and coaching between sessions. See how to find a therapist.

When to get help

Reach out to a doctor or therapist if strong emotions are getting in the way of daily life, if you are using alcohol or drugs to cope, or if you have urges to hurt yourself. If you or a loved one is in crisis, call or text 988 any time. Call 911 if there is immediate danger.¹³ For family members, see when a family member is in a mental health crisis.

Next lesson: DBT emotion regulation skills teaches ways to lower how often and how strongly painful emotions show up.

Education only. This page is general information written from the sources listed. It is not medical, legal or financial advice and does not replace a doctor, therapist or lawyer who knows your situation. How we write and check pages.