Distress tolerance skills help a client get through a moment of intense pain without doing something that makes their life harder, and live with facts they can't change yet. This guide is for clinicians who teach them. It takes each crisis survival skill (STOP, pros and cons, TIP, ACCEPTS, self-soothe and IMPROVE the moment) and each reality acceptance skill (radical acceptance, turning the mind, willingness, half-smiling and willing hands, and mindfulness of current thoughts) and covers what it's for, when it fits, how to teach it and what to watch for, including the medical cautions for cold water and hard exercise. Then come a crisis survival plan your client can copy, teaching tips, the mistakes that turn distraction into avoidance, what research says about distress tolerance itself, and how to note skills practice.
For a one-line summary of every DBT skill in all four modules, with an acronym key, see our DBT skills list. This page goes deeper on one module.
About this guide. The skills come from Marsha Linehan's DBT Skills Training Manual, 2nd edition (Guilford Press, 2015); Guilford's 2025 revised edition keeps the same skills. Linehan's handouts and worksheets are copyrighted, and we don't reproduce them or their layouts. Every description, example and the plan below are written in our own words. If you want printable STOP and TIPP worksheets of our own, they're on our DBT worksheets page.
Every client and example in this article is invented. Any resemblance to a real person is a coincidence.
What distress tolerance skills are for
The Linehan Institute describes this DBT module as "building the ability to tolerate and survive painful situations without making them worse" (Linehan Institute). Two sets of skills do that work:
- Crisis survival skills are for short, intense moments when the urge to act is strong and acting would make things worse. They get the client through the next minutes or hours. They don't solve the problem.
- Reality acceptance skills are for pain that comes from facts the client can't change, at least not now: a death, a diagnosis, the past, someone else's decision. They reduce the extra suffering that comes from fighting those facts.
The module sits on the acceptance side of DBT. Emotion regulation tries to change an emotion. Distress tolerance assumes the emotion is going to stay for a while and asks how to get through it without adding a new problem. The two work as a pair: when an emotion is too intense for check the facts or opposite action to land, the client uses a crisis skill to come down, then goes back to emotion regulation.
What counts as a crisis here. Crisis survival skills are meant for situations that are short-lived, highly stressful and pushing hard for an immediate fix. They aren't meant for every uncomfortable feeling, and they aren't a way of living. A client who reaches for them all day, every day, for the same problem is usually avoiding it. There's more on that under common mistakes.
They don't replace risk work. If a client has thoughts of suicide, assess risk (our C-SSRS screener guide covers one common screen) and build a written safety plan. Crisis survival skills can be one step on that plan. They're never the whole of it.
How to print this page or save it as a PDF
To save this guide or the crisis survival plan as a PDF, press Ctrl+P (Windows) or Cmd+P (Mac), or open your phone browser's share menu and choose Print, then pick "Save as PDF". For the plan alone, copy the text from the box below into a document, or straight into the client's phone notes during the session.
Which distress tolerance skill fits when
A quick map from what's in front of you to the skill that usually fits. It assumes you've already assessed risk.
- The urge has just hit and the client is about to act (send the text, say the cutting thing, walk out, drink, hurt themselves): STOP. It takes seconds and needs nothing.
- Arousal is so high the client can't think, talk or follow steps: TIP. Skills that work through the body still work when thinking skills can't, as long as the medical screen is clear.
- The same crisis urge keeps coming back (the drink after a fight, quitting after criticism): pros and cons, written in advance while calm and read at the first sign of the urge.
- The urge will pass, but not soon (an evening alone, a long wait for news): ACCEPTS to pass the time without acting, then self-soothe.
- The client feels lonely, raw or exhausted, and comfort is what's missing: self-soothe.
- The pain will last hours or days and the client has to function through it: IMPROVE the moment, especially one thing in the moment and encouragement.
- The pain comes from a fact that can't change, and the client keeps fighting it ("this shouldn't have happened", "it's not fair"): radical acceptance and turning the mind.
- The client is refusing what the situation needs, or trying to force an outcome: willingness, with willing hands as a body cue.
- The client is caught in a loop of the same thoughts: mindfulness of current thoughts.
- The client is dissociating or flooded by trauma reminders: grounding first, such as our 5-4-3-2-1 grounding worksheet, then a crisis skill once they're back in the room. Our window of tolerance worksheet helps clients notice when they're too far outside their zone for any skill to land.
Crisis survival skills, one by one
STOP
What it is. Four quick moves for the gap between an urge and an action. Stop: freeze, don't speak, type or move yet. Take a step back: get some distance, in the body or in the mind, and breathe. Observe: notice what's going on inside and outside, and what the facts are. Proceed mindfully: ask what you want out of this situation, and pick the action most likely to get it.
When it fits. Fast urges: an angry reply, an impulse to leave, quit, buy, use or self-harm. It's usually the first skill on a crisis plan because it comes before every other choice.
How to teach it. Practice the freeze for real in session, standing up if you can. Ask the client to choose one physical "stop" (hands flat on the table, phone face down) and one way to step back (leave the room, three slow breaths). For observe, have them say the urge out loud as an urge: "I have the urge to send this." For proceed mindfully, agree on one question they'll ask themselves, in their own words, such as "What do I want this to look like tomorrow?"
What to watch for. Some clients treat "proceed" as permission to do the same thing after a pause. Proceeding mindfully means acting from wise mind, and sometimes the wise action is to do nothing until morning. In arguments, stepping back can include a sentence that leaves the door open ("I need ten minutes, and then I'll come back"). When the urge is to say something to someone, our DEAR MAN guide helps with what to say once the client is calm.
Pros and cons
What it is. A way to weigh acting on a crisis urge against resisting it, in the short term and the long term. The long-term costs of acting are exactly what emotion mind forgets, so the skill puts them in writing ahead of time.
When it fits. Crisis urges with a pattern: drinking after conflict, self-harm after shame, ending relationships after a perceived rejection. It needs a client who can read and think, so it comes after STOP or TIP when arousal is very high.
How to teach it. Write it in session, while the client is calm, about one specific urge. Start with an honest list of what acting on the urge does for them (relief, a sense of control, being taken seriously). Clients who skip the benefits don't trust the list, and a list they don't trust won't hold up in a crisis. Then list what acting costs them in a day, a week and a year, and what resisting gives and costs. The client keeps the result where the urge tends to happen and reads it at the first sign.
What to watch for. Lists written by the therapist, costs too vague to feel ("it's bad"), and lists that are never read during an urge. After each crisis, update the list with what actually happened.
TIP skills (often written TIPP)
What it is. Four ways to bring extreme arousal down through the body, quickly enough that the client can then use another skill: temperature, intense exercise, paced breathing and paired muscle relaxation. Linehan puts both P skills under one letter, so the manual says TIP; many clinicians and clients write TIPP. The effect is real but brief. Think of TIP as a bridge to the next step of the plan, not the plan.
The medical screen comes first. Before you teach cold water or intense exercise, ask about:
- heart disease, a heart rhythm problem (including long QT syndrome), or fainting
- a low resting heart rate, or medicines that slow the heart, such as beta-blockers
- anorexia, bulimia or another eating disorder, now or in the past
- asthma or another lung condition, injuries, pregnancy, or anything else that limits exercise
- any condition made worse by cold
If any apply, ask the client to check with their doctor before using those two skills, and teach paced breathing and paired muscle relaxation in the meantime. Write the screen and the answers in your note.
Why the screen matters. Cold water on the face sets off the diving response: the heart slows, blood vessels narrow and the body releases more adrenaline-type hormones (Foster & Sheel, 2005). The slowing is what makes the skill work, and it's also why it isn't for everyone. In a study of 54 healthy 15- and 16-year-olds who put their faces in 10°C (50°F) water, six had extra beats from the heart's upper chambers and two had a ventricular rhythm called bigeminy. The authors judged brief body immersion in ice water low risk for severe arrhythmias in healthy teens, but warned the risk could rise when it's combined with face submersion and breath-holding (Lundström et al., 2025). Anorexia is associated with a slow heart rate and low blood pressure, among other heart changes (Sachs et al., 2016).
T, temperature. Cold on the face calms the body fast. The client leans forward over a bowl of cold water and puts their face in for up to about 30 seconds, holding their breath only as long as is comfortable, or holds a cold pack or a bag of ice wrapped in a cloth over the eyes and cheeks. Sit down afterward, and stop at any dizziness. Never put ice straight on skin, and don't let a cold plunge or ice bath stand in for this skill.
I, intense exercise. A short burst of hard movement uses up the energy a strong emotion builds: fast stairs, jumping jacks, a run in a safe place, dancing hard. Even a few minutes counts. Make it exercise, not rehearsing the fight. In a well-known study, angry people who hit a punching bag while thinking about the person who angered them felt angrier and acted more aggressively afterward than people who did nothing at all (Bushman, 2002). For a client who uses exercise to make up for eating, this isn't the skill.
P, paced breathing. Slow the breath right down and make each breath out longer than the breath in, such as in for 4 and out for 6, for a minute or two. A systematic review of slow breathing (under 10 breaths a minute) in healthy people found more heart rate variability and less reported arousal, anxiety and anger (Zaccaro et al., 2018). Don't add long breath holds. Some clients with panic feel worse when they focus on their breath; try shorter rounds with eyes open, or count something in the room at the same time.
P, paired muscle relaxation. On the breath in, tense one muscle group (fists, shoulders, face) and notice the tension. On the breath out, let go, perhaps saying "relax" silently. This is a short crisis version. Many websites swap in full progressive muscle relaxation for the second P, which works well as daily practice but takes far longer than a crisis allows. Skip injured or painful areas, and tense firmly but not to the point of a cramp.
Distract with wise mind ACCEPTS
What it is. Seven ways to move attention off the crisis until the urge passes. "Wise mind" is part of the name for a reason: distraction is chosen on purpose, for a limited time, with a plan to come back to the problem later.
- A, activities:something that takes real attention, such as cooking from a recipe, a game, sorting a drawer, a walk with a podcast.
- C, contributing:do something for someone else, such as helping a neighbor, sending a friend a message to ask how they're doing, or a chore for a housemate.
- C, comparisons:compare now with a time you got through something harder, or with how you would have handled this a year ago.
- E, emotions:stir up a different emotion on purpose, with a comedy, upbeat music or a moving story.
- P, pushing away:set the problem aside for now: write it down and put the paper in a drawer, or picture it in a box on a high shelf, and choose a time to come back to it.
- T, thoughts:fill the mind, with counting back from 100 by sevens, an animal for every letter of the alphabet, song lyrics or a puzzle.
- S, sensations:a strong but safe sensation, such as cold water on the hands, a sour candy, a strong mint or a hot drink held in both hands.
What to watch for. Comparisons can backfire for clients prone to shame ("other people have it worse, so I have no right to feel this"). Compare with their own past instead, or leave that letter out. Sensations should be strong but never hurt or leave a mark, so leave out substitutes such as snapping a rubber band on the wrist, which still rehearses causing pain. Contributing can turn into caring for everyone except oneself. And pushing away only works if there's a time to come back.
Self-soothe
What it is. Comfort through the five senses: something to look at, listen to, smell, taste and touch, done slowly and with attention. The 2015 edition adds a body scan. The aim is to be kind to yourself through the crisis, not to numb it.
When it fits. Loneliness, grief, exhaustion, and the empty feeling after a crisis has peaked. It matters most for clients who grew up where needing comfort was mocked, punished or ignored, and who never learned to give it to themselves.
How to teach it. Build a soothe kit in session: one item per sense, kept in one place (a small box, a bag, a folder of photos and songs on the phone). Then practice with one item for a few minutes and full attention: the weight of the blanket, the smell of the hand cream, every note of the song.
What to watch for. Clients who feel they don't deserve comfort, or that soothing is weak, may refuse the skill or do it grudgingly; explore the belief and start very small. Smells and sounds can be trauma reminders, so the client chooses every item. With eating disorders or binge eating, keep taste to one small, mindful taste or pick another sense. Alcohol and drugs are never part of the kit. And when what the client needs is another person, self-soothe shouldn't replace reaching out.
IMPROVE the moment
What it is. Seven ways to change how the moment feels while it lasts:
- I, imagery:imagine a safe place in detail, or imagine yourself getting through this well.
- M, meaning:find some purpose or value in the pain, or something the pain shows you care about.
- P, prayer:open to a higher power, to nature, or to your own wise mind, and ask for strength to get through it.
- R, relaxation:loosen the body with a warm bath, a stretch or a slow hand massage.
- O, one thing in the moment:give full attention to only what you're doing right now, so you're carrying this minute, not the whole week.
- V, vacation:take a short, planned break, such as twenty minutes under a blanket with the phone off, then come back.
- E, encouragement:talk to yourself the way a good friend would ("I've done hard things before. This is one evening.") and rethink the situation in kinder terms.
When it fits. Long stretches of pain: a hospital waiting room, the evening after bad news, an anniversary of a loss, a hard shift that can't be left.
What to watch for. Meaning offered too soon is invalidating, especially in fresh grief or after trauma; let the client find it, and never supply the silver lining yourself. Prayer is offered, never required, so ask about the client's beliefs first. For trauma survivors, build the safe place image together in session, check that it isn't tied to a trauma memory, and agree on a way to stop. A vacation that stretches into a day in bed has become avoidance.
Reality acceptance skills
Crisis survival skills get a client through minutes and hours. Reality acceptance skills are for pain that's going to stay because the facts behind it won't change: a death, a diagnosis, an injury, a childhood, a partner who left, a job that's gone. The idea in brief: pain is part of life, but refusing a painful reality adds a second layer of suffering on top of it, such as bitterness, rage, or being stuck replaying it. Acceptance takes away the second layer, not the first.
Radical acceptance
What it is. Accepting, completely and with mind, body and heart, facts of the present or the past that can't be changed right now. "Radical" means all the way, not a grudging "fine".
What it isn't. Approval, forgiveness, giving up, passivity, or pretending it doesn't hurt. Accepting that something happened is different from saying it was acceptable.
When it fits. Losses, diagnoses, the past, other people's choices, and decisions that are final. Small facts make good practice: a canceled flight, rain on the day of an outdoor plan.
When to take care. Never use radical acceptance to keep a client in an unsafe situation, or to ask them to accept ongoing abuse, discrimination or harm they can act on. What they accept is the fact of what's happening, and that often makes action possible: accepting that a relationship is abusive is a step toward planning to leave it safely, not a reason to stay. Accepting this moment and working to change the future go together. That's the dialectic.
How to teach it. Start with low-stakes facts. Help the client spot their signs of non-acceptance: "this shouldn't be happening", "why me", bitterness, replaying the moment. Then have them say the fact plainly in one sentence, notice where the body is fighting it (a clenched jaw, fists), and soften there. Warn them that acceptance often brings sadness before relief, so grief isn't a sign it's failing. Expect to practice the same fact many times.
Turning the mind
What it is. Acceptance isn't a single decision. Turning the mind is noticing that you've slid back into fighting reality and choosing acceptance again, as often as it takes. Many clinicians teach it with the picture of a fork in the road: one path leads toward acceptance, the other toward refusing reality, and the client chooses each time they reach it.
How to teach it. Help the client find their personal sign that they've turned away (a phrase, a tight chest, a mental replay), and a short commitment in their own words, such as "I'm choosing to accept that this happened." At first they may need to turn the mind dozens of times a day.
What to watch for. Clients who feel like failures because they "keep un-accepting". Turning the mind again is the skill working, not failing.
Willingness
What it is. Willingness is doing what the situation calls for, fully and without dragging your feet. Its opposite, willfulness, is refusing, sulking, giving up, or insisting on control: sitting on your hands when something needs doing, or trying to fix what can't be fixed.
How to teach it. Help the client notice willfulness without judging it; everyone does it. They name it, accept that they're being willful right now, turn the mind, and ask what the situation actually needs. Willing hands (below) gives the body a cue. Ask what the willfulness is protecting them from; often it's fear of what accepting would mean.
What to watch for. Willingness isn't doing what other people want or giving in on your values. Sometimes the willing, effective response is a clear no, which is where interpersonal effectiveness skills come in.
Half-smiling and willing hands
What it is. Two ways to let the body support acceptance. For a half-smile, the client relaxes the face from forehead to jaw and lets the corners of the lips turn up very slightly. It isn't a grin, and nobody else needs to see it. For willing hands, they unclench the hands and rest them palms up, fingers loose, on the thighs or at the sides.
Why it might help. Facial expressions feed back into how we feel, but the effect is modest: a meta-analysis of 138 studies found that facial feedback does influence emotional experience, though the effects are "small and heterogeneous" (Coles, Larsen & Lench, 2019). Present these as small supports for acceptance, not a switch that changes mood.
What to watch for. A client who has been told to "smile" by someone who hurt them, or by strangers, may hear the half-smile as one more demand. Explain that it's a relaxed face, private and optional; willing hands alone works too. Don't use either in session as a cue for the client to cover their pain.
Mindfulness of current thoughts
What it is. Watching thoughts as events that come and go in the mind, not as facts, orders or things that must be pushed out. The client notices a thought, names it as a thought ("there's the thought that I ruin everything"), and lets it pass without arguing with it or fighting it.
Why it helps. Trying hard not to think something tends to bring it back. A review of the research on thought suppression found it can be counterproductive, helping to bring about the very state of mind the person wanted to avoid (Wenzlaff & Wegner, 2000).
How to teach it. Practice in session with a familiar image: thoughts as clouds, leaves on a stream or items on a conveyor belt. Have the client add "I'm having the thought that..." in front of a painful thought, or repeat a single word from it slowly until it's just a sound. The idea is close to defusion in ACT; our ACT therapy worksheets include a defusion sheet.
What to watch for. For intrusive trauma memories or obsessional thoughts, this skill sits alongside trauma-focused or exposure treatment, not in place of it.
When the crisis is addiction. The 2015 edition adds a set of distress tolerance skills for addictive behavior, such as dialectical abstinence and burning bridges. Our DBT skills list describes each; they belong alongside treatment for the addiction itself.
A crisis survival plan your client can copy
This plan pulls the whole module onto one page, in the order many clients find easiest to follow in a crisis. Fill it in together while the client is calm, in their own words, and keep only the skills they've tried and found helpful. Then put it where crises happen: phone notes, a photo on the lock screen, a card in the wallet. It goes next to their safety plan, not in place of it.
Building the plan in session:
- Start from a recent crisis. Walk through what happened and find the urge and the first warning signs; they become the top of the plan.
- Do the medical screen before you fill in step 2.
- Try each skill in session before it goes on the plan. If paired muscle relaxation did nothing for this client, leave it off.
- Keep each step to one to three options. A long list is hard to use when the client can't think.
- Decide together where the plan will live, and have the client photograph or type it before they leave.
- Review it at the next session and after every crisis, and change what didn't help.
How to teach distress tolerance skills
- Give the reason first.A client who hears "distract yourself" can feel dismissed. Say plainly what the skills are for: they don't fix the problem; they stop the client adding a new one while the emotion peaks, so the problem can be dealt with later.
- Teach when calm, practice until it's automatic.A skill tried for the first time in a crisis rarely works. Rehearse in session, then daily in small moments (a long line, an irritating email) so it's there when it matters.
- Show it, then measure it.Do the skill with the client: paced breathing together, or a cold pack after the screen. Ask for a 0 to 10 rating before and after. A drop of two points the client felt does more than any explanation.
- Let the client build the menu.Your examples are prompts. Clients use the skills they picked and tried.
- Match the skill to the intensity.At the very top, body skills (TIP). As it eases, attention skills (ACCEPTS, self-soothe), then thinking skills (reading the pros and cons, meaning, encouragement). For pain about facts, acceptance.
- Rehearse in imagination.Have the client picture the last crisis in detail and walk through using the plan, step by step. It's close to cope ahead in emotion regulation.
- Make it portable.A phone note, a lock-screen reminder, a card in the wallet, the soothe kit by the bed or in the car.
- Review every use.Open the next session with it: which skill, when, the ratings, what got in the way. When a skill "didn't work", it was usually used too late, too briefly, or at the wrong intensity.
In a skills group. Activities that work well: each member brings one item per sense and builds a soothe kit; a timed round of paced breathing with ratings before and after; pros and cons in pairs on an invented example, not a member's own crisis; a fork-in-the-road exercise for turning the mind; half-smiling and willing hands during a short mindfulness practice. Keep it a class: members report how practice went, not the details of their crises.
On video. Confirm the client's location and an emergency contact at the start. If you'll practice temperature, ask them before the session to have a cold pack or a bowl of cold water ready, and have them sit down. Do paced breathing with them so you can see and hear the pace.
With teens. Keep it short and concrete, and put the plan on their phone. Bring caregivers into the plan: which skills the teen uses, what helps, and what not to do while they're using one, such as following them when they step out of the room. Do the medical screen with caregivers present, and make a version of the plan that works at school.
Common mistakes with distress tolerance skills
- Using distraction as avoidance. This is the most common one. ACCEPTS, self-soothe and a vacation from the problem are for getting through a crisis, not for steering around every uncomfortable feeling or the problem itself. The signs: the client distracts every day from the same issue, the problem never comes back to session, feelings return stronger later, and you hear "I just don't think about it". The fix: every distraction has a return time; once the peak passes, move to problem solving or emotion regulation; and help the client tell a crisis from ordinary discomfort, which usually calls for mindfulness of current emotions or opposite action instead.
- Teaching crisis skills during a crisis. First teach them calm, then use them in a crisis.
- Skipping the medical screen for cold water and hard exercise, or forgetting to repeat it when medicines change.
- Offering radical acceptance as "get over it". Validate the pain first. Acceptance offered before validation sounds like dismissal.
- Using acceptance where change is possible. If the client can act to change a harmful situation, problem solving comes first.
- Treating the crisis survival plan as a safety plan. A client at risk of suicide needs both.
- Putting full progressive muscle relaxation in the crisis step. It's useful daily practice but too long for a crisis.
- Sensations that hurt and comparisons that shame, both covered above.
- Too many skills at once. One or two a session, practiced until the client can use them without the sheet.
- Not measuring. Without before-and-after ratings, neither you nor the client knows which skills earn a place on the plan.
What the research says about distress tolerance
In research, "distress tolerance" means two related things: a person's capacity to withstand distress, which has been studied across many problems, and the DBT module meant to build that capacity. The evidence for each is different.
- The Distress Tolerance Scale.Simons and Gaher (2005) developed the DTS, a self-report measure of how well a person believes they can withstand emotional distress, in two studies of 642 and 823 participants. Its items grouped into four related factors under one general distress tolerance factor. Scores were stable over six months; lower scores went with using substances to cope and, among men, with later alcohol problems. Men reported higher distress tolerance than women in both studies (Simons & Gaher, 2005). A later validation describes the four factors as tolerance (how bearable the emotion feels), appraisal (whether the person sees the emotional situation as acceptable), absorption (how much the emotion takes over attention and gets in the way of functioning) and regulation (the ability to regulate it). The current version has 15 items rated on a 5-point scale, with higher scores meaning more tolerance, and the authors suggest it may be most useful as a single overall score (Leyro et al., 2011).
- A broad risk factor, loosely defined.A review in Psychological Bulletin found links between distress tolerance and a range of psychological symptoms and disorders, but also "notable conceptual and operational heterogeneity": researchers define and measure it in different ways (Leyro, Zvolensky & Bernstein, 2010).
- Self-report and behavior don't line up.In college students and people in residential substance use treatment, self-reported distress tolerance was most closely tied to negative emotionality, current negative mood, impulsivity and perceived stress. It wasn't significantly correlated with behavioral measures, the lab tasks that test how long someone keeps going under stress (Kiselica et al., 2015). A DTS score tells you how a client sees their own tolerance, not how they'll act in a crisis.
- Distress tolerance can improve with treatment.In a randomized study of 76 people in residential substance use treatment with low distress tolerance on lab tasks, a six-session distress tolerance treatment improved those lab measures more than six sessions of supportive counseling or usual treatment, and more participants reached clinically significant improvement (Bornovalova et al., 2012). That treatment is its own protocol, not the DBT module.
- Practicing skills goes with staying in treatment.In 70 people receiving DBT for borderline personality disorder, those who used skills less at any point were more likely to drop out over the next two months, and more frequent skills use was linked to less self-harm at the same time. The study looked at all DBT skills, not distress tolerance alone, and the authors note the direction of the link isn't settled (Barnicot et al., 2016). Earlier work in 108 women found that skills use fully accounted for the drop in suicide attempts and depression over a year of treatment (Neacsiu, Rizvi & Linehan, 2010).
- The physiology behind TIP is well described; the package isn't well tested.The diving response is well described in physiology research, and slow breathing has a smaller body of studies in healthy people (both cited above). In a PubMed search for this article we found no controlled studies of the TIP skills as a package.
What this means in practice. Tell clients the truth: practicing skills goes with doing better in DBT, and the body-based skills rest on well-understood physiology, but no study shows any single crisis skill works for everyone. Their own before-and-after ratings are the best evidence for which skills earn a place on their plan. If you use the DTS to track change, pair it with behavior (urges acted on, skills used), since self-report and behavior measure different things. The items and scoring are in the 2005 paper.
How to note distress tolerance skills practice
The ACA Code of Ethics asks counselors to take "reasonable steps to ensure that documentation accurately reflects client progress and services provided" (ACA Code of Ethics, A.1.b). For skills work, "reviewed distress tolerance skills" doesn't do that. Record:
- The skill by name and module, and which part, for example "TIP, paced breathing".
- The urge or behavior it targets, tied to a treatment plan goal.
- For TIP, the medical screen, the client's answers, and any referral for medical clearance.
- What you did: explained, modeled or practiced in session, with the client's ratings before and after.
- Practice since the last session: how often, in what situations, and what happened.
- Where the crisis survival plan is kept, and whether the client has a copy.
- Risk: what you asked, the client's answer, and the status of the safety plan.
- The practice assigned for the week.
Example 1: a BIRP note for teaching TIP. Invented client: a 31-year-old restaurant manager we'll call Theo, in DBT-informed individual therapy by video for urges to drink and to quit jobs after conflicts. Our BIRP note examples cover the format in more detail.
Example 2: an excerpt from a DAP note for reality acceptance. Invented client: a 48-year-old office administrator we'll call Rosa, whose job of 15 years was eliminated. Our DAP notes examples show full DAP notes.
Phrases you can adapt:
- "Client completed the TIP medical screen; reports no heart conditions, heart-rate medicines or eating disorder history. Practiced temperature with a cold pack, distress 8/10 to 5/10 (client rating)."
- "Client used ACCEPTS (activities, thoughts) for about 40 minutes during an urge to self-harm on 10/12; urge passed without acting. Returned to the trigger in session using problem solving."
- "Client named three items for a self-soothe kit and agreed to keep it by her bed."
- "Distraction used daily this week to avoid calling his father; discussed the difference between crisis distraction and avoidance; set a time to plan the call."
- "Client described radical acceptance as 'not saying it was fine'; practiced turning the mind four times in session when she began replaying the event."
For more wording, see our progress notes cheat sheet.
How this works in TranqBay
TranqBay is practice software for therapists in private practice: a practice website, online booking, video sessions, session notes and forms in one place. Here's where distress tolerance work fits.
- Your practice website is where people looking for help with intense emotions read how you work. A plain line for its "Services" or "My approach" section: "I teach practical skills from dialectical behavior therapy (DBT) for getting through hard moments without making them worse." Your website and booking page aren't crisis services, so wherever your site says how to reach you, say that too and give 988.
- Services and booking. You can offer individual and couples services, each with its own length and fee, and packages of sessions, for example a short course of individual sessions for building a crisis survival plan. Confirm each booking yourself, which suits a screening call for fit, or let clients book straight away. Returning clients book their next session themselves.
- Video sessions are end-to-end encrypted and HIPAA-ready, and you and the client can check camera, mic and speakers before joining. TranqBay provides a Business Associate Agreement that applies when you accept the Terms, with no separate document to sign.
- Others in the session. You can invite others to a session, so a parent can join a teen's session to learn the plan, or a partner can learn what helps during a crisis. Sessions can also run by audio or in person.
- Forms for a session. The form library has ready-made templates you can send a client for a session, including intake, consent to treat, telehealth consent, release of information, the PHQ-9 and the GAD-7. The client fills them in online and the answers wait with the session. TranqBay doesn't score them; our PHQ-9 and GAD-7 calculators do.
- Session notes come in BIRP, DAP, SOAP or GIRP format, or as a blank note in your own words, so the examples above fit whichever you use. The structured formats are part of the advanced note templates, which some plans include.
At practice.tranqbay.health you can look through the practice website designs, including the "Services" section where you'd describe DBT-informed work, and see the booking page a client would use.
Frequently asked questions about distress tolerance skills
What are distress tolerance skills?
They're DBT skills for getting through intense emotional pain without making the situation worse, and for accepting facts that can't be changed right now. They don't solve the problem; they stop the client adding a new one.
What are the distress tolerance skills in DBT?
Two groups. Crisis survival skills: STOP, pros and cons, TIP, distracting with wise mind ACCEPTS, self-soothe and IMPROVE the moment. Reality acceptance skills: radical acceptance, turning the mind, willingness, half-smiling and willing hands, and mindfulness of current thoughts. The 2015 edition also includes skills for when the crisis is addiction.
What does TIPP stand for?
Temperature, intense exercise, paced breathing and paired muscle relaxation. Linehan writes it as TIP, with both P skills under one letter. Screen for heart conditions, heart-rate medicines, eating disorders and anything that limits exercise before suggesting cold water or hard exercise.
What is ACCEPTS in DBT?
A set of seven distraction skills: activities, contributing, comparisons, emotions (creating different ones), pushing away, thoughts and sensations. They help a client wait out a crisis urge, with a plan to come back to the problem later.
What is IMPROVE the moment in DBT?
Seven ways to make a painful moment more bearable while it lasts: imagery, meaning, prayer, relaxation, one thing in the moment, vacation and encouragement. It suits long stretches of pain that can't be escaped, such as a wait for news.
What is self-soothe in DBT?
Comforting yourself through the five senses (sight, sound, smell, taste and touch), slowly and with attention, plus a body scan in the 2015 edition. Many clients build a soothe kit with one item per sense.
What's the difference between distress tolerance and emotion regulation?
Emotion regulation aims to change an emotion or lower vulnerability to it. Distress tolerance accepts that the emotion is here for now and focuses on getting through it without making things worse. Clients often use a distress tolerance skill to come down from a peak, then an emotion regulation skill once they can think.
Is distraction the same as avoidance?
Not when it's used as DBT intends: on purpose, for a limited time, during a real crisis, with a plan to return to the problem. It becomes avoidance when it's used every day to steer around the same feeling or problem. The fix is a return time and a move to problem solving once the peak has passed.
Are TIPP skills safe for everyone?
No. Cold water on the face slows the heart, and intense exercise speeds it up. Clients with heart conditions, a low resting heart rate, heart-rate medicines, eating disorders, lung conditions, injuries or pregnancy should check with their doctor first. Paced breathing and paired muscle relaxation suit most clients, with the adjustments above for panic and injuries.
Is radical acceptance the same as approving of what happened?
No. It means accepting that something is a fact, not that it was right, fair or acceptable. It's never a reason to stay in an unsafe situation, and accepting the facts of a harmful situation is often what makes changing it possible.
How do you measure distress tolerance?
A widely used self-report measure is the Distress Tolerance Scale (Simons & Gaher, 2005), which has 15 items in its current version. Researchers also use lab tasks that test persistence under stress, but the two don't correlate well. In practice, many therapists track urges, skills used and before-and-after ratings on a diary card.
Is there a distress tolerance skills PDF?
You can make one from this page: press Ctrl+P (Windows) or Cmd+P (Mac), or use your phone's share menu, choose Print, then "Save as PDF". For printable STOP and TIPP worksheets of our own, see our DBT worksheets.
Can I teach distress tolerance skills without offering full DBT?
Yes, many therapists teach them in individual therapy or a skills group. That's DBT-informed work, not comprehensive DBT, and it's clearest to describe it that way, in your notes and on your website. Keep a risk plan in place, since skills-only work has no built-in phone coaching or consultation team.
Before your next session
Pick one client who acts on crisis urges and build the first two steps of their crisis survival plan with them: STOP, and one TIP skill they've tried in session after the medical screen. Write the skill, the screen and the ratings into your note, and open the next session with how it went.
If you're building a practice around skills-based work, see how TranqBay works for private practice: you can browse the practice website designs where you'd describe DBT-informed therapy, and the booking page clients use to book the sessions where you review their plan. If you're deciding whether to join, this page explains how joining TranqBay works.
Sources
Books 1linehaninstitute.org 1link.springer.com 1Research 13Associations 1988 Lifeline 1
linehaninstitute.org1
Research13
- 4Leyro TM et al. Distress Tolerance Scale: a confirmatory factor analysis among daily cigarette smokers. J Psychopathol Behav Assess (2011)pubmed.ncbi.nlm.nih.govhttps://pubmed.ncbi.nlm.nih.gov/23935238/
- 5Leyro TM, Zvolensky MJ, Bernstein A. Distress tolerance and psychopathological symptoms and disorders: a review of the empirical literature among adults. Psychol Bull (2010)pubmed.ncbi.nlm.nih.govhttps://pubmed.ncbi.nlm.nih.gov/20565169/
- 6Kiselica AM et al. The nomological network of self-reported distress tolerance. Assessment (2015)pubmed.ncbi.nlm.nih.govhttps://pubmed.ncbi.nlm.nih.gov/25475104/
- 7Bornovalova MA et al. Initial RCT of a distress tolerance treatment for individuals with substance use disorders. Drug Alcohol Depend (2012)pubmed.ncbi.nlm.nih.govhttps://pubmed.ncbi.nlm.nih.gov/21983476/
- 8Barnicot K et al. Skills use and common treatment processes in DBT for borderline personality disorder. J Behav Ther Exp Psychiatry (2016)pubmed.ncbi.nlm.nih.govhttps://pubmed.ncbi.nlm.nih.gov/27132175/
- 9Neacsiu AD, Rizvi SL, Linehan MM. Dialectical behavior therapy skills use as a mediator and outcome of treatment for borderline personality disorder. Behav Res Ther (2010)pubmed.ncbi.nlm.nih.govhttps://pubmed.ncbi.nlm.nih.gov/20579633/
- 10Foster GE, Sheel AW. The human diving response, its function, and its control. Scand J Med Sci Sports (2005)pubmed.ncbi.nlm.nih.govhttps://pubmed.ncbi.nlm.nih.gov/15679566/
- 11Lundström A et al. Assessment of arrhythmias and heart rate response in healthy adolescents performing face immersion and body submersion in ice-cold water. Physiol Rep (2025)pubmed.ncbi.nlm.nih.govhttps://pubmed.ncbi.nlm.nih.gov/40624837/
- 12Sachs KV et al. Cardiovascular complications of anorexia nervosa: a systematic review. Int J Eat Disord (2016)pubmed.ncbi.nlm.nih.govhttps://pubmed.ncbi.nlm.nih.gov/26710932/
- 13Bushman BJ. Does venting anger feed or extinguish the flame? Catharsis, rumination, distraction, anger, and aggressive responding. Pers Soc Psychol Bull (2002)doi.orghttps://doi.org/10.1177/0146167202289002
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- 15Coles NA, Larsen JT, Lench HC. A meta-analysis of the facial feedback literature: effects of facial feedback on emotional experience are small and variable. Psychol Bull (2019)pubmed.ncbi.nlm.nih.govhttps://pubmed.ncbi.nlm.nih.gov/30973236/
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