Some moments hurt too much to think clearly, and the problem behind them cannot be fixed tonight. Distress tolerance is the part of DBT that teaches you how to get through those moments without making things worse, and how to accept what you cannot change right now.
It is one of the four modules of Dialectical Behavior Therapy, and its skills are among the most practical in the whole treatment. You can see how it fits with the other modules in the full DBT skills list.
What Is Distress Tolerance For?
Pain is part of life. Suffering often comes from what we do to escape it: sending the message, drinking, lashing out, hurting ourselves, or shutting down for days. These actions bring short relief and long trouble.
Distress tolerance does not try to make the pain disappear. It has two parts. Crisis survival skills help you get through the next minutes or hours without adding a second problem to the first. Reality acceptance skills help with pain that lasts longer than any single crisis, by accepting facts you cannot change right now. For what DBT means by a crisis, see defining crisis in DBT.
Crisis Survival Skills
- STOP. Stop, take a step back, observe, proceed mindfully. A pause between the urge and the action.
- TIPP. Temperature, intense exercise, paced breathing and paired muscle relaxation bring extreme arousal down through the body.
- Pros and cons. Compare acting on the urge with resisting it, in the short term and the long term. Write it on a calm day so it is ready for a hard one.
- Wise Mind ACCEPTS. Distract with activities, contributing, comparisons, other emotions, pushing away, other thoughts and sensations.
- Self soothe. Comfort yourself through sight, sound, smell, taste and touch.
- IMPROVE the moment. Imagery, meaning, prayer, relaxing actions, one thing in the moment, a brief vacation and encouragement.
For a walkthrough of how these skills fit together, read DBT crisis survival skills.
Reality Acceptance Skills
Some pain comes from facts that will not change, at least not now. Fighting them can add suffering on top of pain.
- Radical acceptance. Accepting, fully, what you cannot change. Acceptance is not approval.
- Turning the mind. Choosing acceptance again each time you catch yourself fighting reality.
- Willingness. Doing what the situation needs instead of refusing or trying to control it.
- Half smile and willing hands. Softening the face and hands to help the body move toward acceptance.
Know Your Crisis Pattern
Distress tolerance works best when you know what you tend to do in a crisis, so you can plan possible skills for each habit in advance. The short exercise below helps you spot your pattern.
Building a Crisis Plan
- Write it down. Your top urges, the skill for each, and two people you can contact.
- Keep it close. On your phone and on paper, where you will see it.
- Practice on small days. Skills learned only in a crisis are hard to reach. Try TIPP or STOP on ordinary stress first.
- Plan for safety. If urges involve harming yourself, include crisis lines and remove means in advance.
Related skills that help in hard moments: urge surfing, grounding techniques and box breathing.
What If Distress Tolerance Is Not Enough?
Crisis survival skills are for getting through the moment. If crises are frequent, the work is also to build a life with fewer of them, which is what the other DBT modules and therapy are for. If you are in danger right now, call or text 988 or call 911.
Dr. Jesse Finkelstein teaches distress tolerance as part of DBT therapy in NYC at Axis Psychological Services, with the DBT skills group offered through partner clinics. You can book a free consultation.
References
Linehan, M. M. (2015). DBT Skills Training Manual (2nd ed.). Guilford Press.
Linehan, M. M. (2015). DBT Skills Training Handouts and Worksheets (2nd ed.). Guilford Press. Distress Tolerance Handouts 1 to 15.
Common questions about distress tolerance
What are distress tolerance skills?
Distress tolerance skills are a DBT module for getting through intense emotional pain without making things worse. They include crisis survival skills such as STOP, TIPP, pros and cons, ACCEPTS, IMPROVE and self soothe, and reality acceptance skills such as radical acceptance and willingness.
When should you use distress tolerance skills?
When emotional pain is very high and the problem cannot be solved right now, for example late at night, after a fight, or while waiting for news. Crisis survival skills are for getting through the moment, not for solving the underlying problem. Reality acceptance skills help with longer-lasting pain from facts that cannot change right now.
What is the difference between distress tolerance and emotion regulation?
Distress tolerance helps you get through a crisis without acting on harmful urges. Emotion regulation works on the emotions themselves over time: understanding them, reducing vulnerability, and deciding whether changing an emotion or its expression would help.
What are examples of distress tolerance skills?
Splashing cool water on your face (TIPP), pausing before acting (STOP), listing the pros and cons of acting on an urge, distracting yourself with an absorbing activity (ACCEPTS), soothing yourself through the five senses, and radically accepting a painful fact you cannot change.
