Distress tolerance is the part of Dialectical Behavior Therapy (DBT) that helps a person respond skillfully when pain, urges, or emotions are intense and the situation cannot be improved right away. Its goals include surviving crises without making them worse and accepting realities that cannot be changed in the moment. (Linehan, 2015, Distress Tolerance Handouts 1–3)
That definition sets an important limit: distress tolerance is not a way to solve every problem, avoid emotion, or build an entire life. It creates enough room to choose the next effective step, but it does not replace treatment planning or emergency support. (Linehan, 2015, Distress Tolerance Handout 3)
For the broader curriculum context, see the therapist’s guide to DBT’s four skills modules. When a crisis has passed and the work turns to understanding an emotion, changing an ineffective action urge, or addressing vulnerability, the companion DBT emotion regulation skills guide explains those choices.
Crisis survival versus problem-solving
Crisis-survival skills fit situations that are highly stressful, short-term, and difficult to resolve immediately. They are especially relevant when acting on an urge would make the situation worse, emotional arousal is extreme, or a person needs to remain skillful while demands continue. They are not intended for routine problems that can be addressed directly. (Linehan, 2015, Distress Tolerance Handout 3)
A therapist can therefore start with two questions:
- Can anything effective be done about the problem now? If yes, problem-solving may be the better next step.
- Would acting on the current urge make matters worse? If yes, a crisis-survival skill may help the person get through the peak without adding consequences. (Linehan, 2015, Distress Tolerance Handouts 3 and 5)
TIPP: changing physiological arousal
In this guide, TIPP names four concrete practices taught in Linehan’s crisis-survival materials. The second-edition handout groups them under TIP, with both paced breathing and paired muscle relaxation under the final P. Their purpose is to change physiological arousal when emotion mind is extreme—not to guarantee a particular heart rate, speed of relief, or clinical outcome. (Linehan, 2015, Distress Tolerance Handout 6)
- Temperature: apply cold water or a cold pack to the eye-and-cheek area while holding the breath.
- Intense exercise: briefly use vigorous movement to expend physical energy.
- Paced breathing: slow the breath and make the exhale longer than the inhale.
- Paired muscle relaxation: tense muscles while breathing in, then release tension while breathing out. (Linehan, 2015, Distress Tolerance Handout 6)
Temperature and intense exercise require clinical judgment. Linehan’s handout advises consulting a health care provider before using them when a person has relevant heart or medical conditions, a low resting heart rate related to medication, beta-blocker use, cold allergy, or an eating disorder. (Linehan, 2015, Distress Tolerance Handout 6)
ACCEPTS and IMPROVE
Wise Mind ACCEPTS organizes ways to distract temporarily: Activities, Contributing, Comparisons, different Emotions, Pushing away, other Thoughts, and other Sensations. The aim is not permanent avoidance. It is a deliberate shift of attention while a crisis cannot be fixed safely or effectively. (Linehan, 2015, Distress Tolerance Handout 7)
IMPROVE the Moment offers another set of options: Imagery, Meaning, Prayer, Relaxing actions, One thing in the moment, a brief Vacation, and self-Encouragement and rethinking the situation. Clinicians can adapt the menu to a client’s beliefs and circumstances; for example, prayer may mean opening to a higher power or to Wise Mind. (Linehan, 2015, Distress Tolerance Handout 9)
Self-soothing and radical acceptance
Self-Soothe with the Five Senses uses mindful attention to vision, hearing, smell, taste, or touch. A useful plan is specific and available: a familiar song, a pleasant scent, or a soft blanket is easier to try than the instruction “calm down.” (Linehan, 2015, Distress Tolerance Handout 8)
Radical Acceptance belongs to DBT’s reality-acceptance skills. It means acknowledging the facts of the present and past with the whole self, including painful facts a person does not like. It does not mean approval, love, passivity, or opposition to change. (Linehan, 2015, Distress Tolerance Handouts 10–11a)
Acceptance may need to be chosen repeatedly. Linehan describes “Turning the Mind” as noticing nonacceptance and making an inner commitment, again and again, to face reality as it is. (Linehan, 2015, Distress Tolerance Handout 12)
Choosing a skill
Skill selection works best when it matches the function of the moment:
- When arousal is too high for a complicated strategy, consider a medically appropriate TIPP practice.
- When attention is locked onto the crisis, try an ACCEPTS option.
- When the moment needs to become more bearable, choose an IMPROVE or self-soothing practice.
- When the facts cannot be changed now and fighting them adds suffering, practice Radical Acceptance or Turning the Mind. (Linehan, 2015, Distress Tolerance Handouts 3 and 6–12)
Here is one short fictional example: during a painful wait for news that cannot be sped up, Sam notices an urge to send an angry message. Sam postpones the message, uses paced breathing, and then listens to a familiar album. Later, Sam and the therapist can assess what each step changed—and what still needs problem-solving.
Recording attempts and results on a diary card
Dbrief’s therapist dashboard supports reviewing diary cards between sessions. In this context, the value is not a score for using skills “correctly.” It is a shared record that supports a specific review: What did you try? What changed? What should we practice or choose differently next time? This workflow description is not evidence that Dbrief improves clinical outcomes.
Further reading:
- Linehan, M. M. (2025). DBT Skills Training Manual: Revised Edition. Guilford Press. ISBN 978-1-4625-5635-9.
- Linehan, M. M. (2015). DBT Skills Training Handouts and Worksheets, Second Edition. Guilford Press.