Dialectical Behaviour Therapy For Distress Tolerance

  • Isabel Rivera Doctor of Philosophy – PhD, University of Manchester, UK

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Overview of distress tolerance and DBT

Dialectical behaviour therapy (DBT) is a comprehensive treatment that can help you develop distress tolerance. Distress tolerance is one of the main modules in DBT, providing you with practical tools and strategies to survive through current crises you may experience and cannot immediately change.1

DBT is a programme of talking therapy comprising a series of treatments designed to help you address intensely negative emotions caused by distressing situations. Learning distress tolerance in DBT provides you with the tools to navigate your current crises that could lead to extreme emotions and even self-harm. DBT also helps you develop the necessary skills to reduce emotional dysregulation and gain control of your emotional responses.1

The DBT approach addresses your present circumstances and your future. Through the development of distress tolerance and mindfulness, DBT helps you accept your current reality. Through the skills of emotion regulation and interpersonal effectiveness, DBT encourages you to change as a necessity for progress.1

What is dialectical behaviour therapy (DBT)?

DBT is a programme of various individual and group treatments based on cognitive behavioural therapy (CBT). Treatments in this programme include individual therapy, group skills therapy, telephone coaching, and therapist consultations.4

DBT was originally developed by Marsha Linehan for individuals affected by borderline personality disorder (BPD). They experience extreme negative emotions that can lead to self-harm and suicidal behaviours. This treatment method has now been extended to other mental health issues such as depression, anxiety, eating disorders, post-traumatic stress disorder (PTSD), and substance use disorder.1,4

‘Dialectical’ means understanding and embracing opposing or contradicting ideas. In DBT, the concepts of acceptance and change are balanced:

  • Radical acceptance - your reality as you are now is acknowledged through the validation of your thoughts, emotions, and behaviours
  • Change as a necessity - new skills are taught to help you deal with problems through behavioural change and personal growth5

Understanding the impact of distress tolerance

Distress tolerance is the ability to withstand the intense emotional discomfort that arises from distressing situations and circumstances. This skill is one of the four key skills that DBT focuses on to help you get through crises unharmed. DBT also teaches the skills of mindfulness, emotion regulation, and interpersonal effectiveness to provide a comprehensive approach to help you deal with intense emotions.2,3

The impact of having high distress tolerance cannot be undermined. Having high distress tolerance promotes emotional adaptability in response to stress. This enables more productive behaviours like problem-solving in the face of stress. In contrast, low distress tolerance usually leads to unhealthy and unproductive coping mechanisms such as excessive rumination, isolation, lashing out at others, and reckless behaviours. It has been shown to correlate with mental health issues such as anxiety, eating disorders, and substance abuse. As such, developing distress tolerance has been a focal treatment for patients experiencing intense emotion dysregulation to prevent reactions that can lead to harm.2, 6

Distress tolerance and DBT: a symbiotic relationship

Unpacking DBT's core modules

The development of DBT as a practice draws from both Western and Eastern concepts, leading to the 4 core skills:

  • Mindfulness and distress tolerance modules tackle the concept of radical acceptance
  • Emotion regulation and interpersonal modules look at the need for change1

These skills are learned and developed during group skills therapy, while individual therapy sessions motivate you to apply these skills in your daily life.1


Mindfulness is the skill of being fully aware of the present moment in a nonjudgmental manner. It is a core skill of DBT and is applied in every other module. Drawing from Hinduism, Buddhism, and other contemplative practices This module helps you acknowledge your present internal and external experience through behaviour and reality acceptance skills such as:

  • Wordless observing
  • Describing what is observed
  • Participating
  • Being non-judgmental
  • One mindfulness1,5

Interpersonal effectiveness

This module deals with the development of healthier relationship dynamics. People experiencing extreme emotional dysregulation tend to have relational conflicts and interpersonal avoidance. Interpersonal effectiveness skills help with improving your relationships with others and yourself. Improved relationships in turn foster positive reinforcement of healthier interpersonal behaviours. Some skills taught in this module are:

  • Assertiveness
  • Learning how and when to say no
  • Validation
  • Learning positive and negative reinforcement1,5

Emotion regulation

The emotion regulation module dives into the specifics of emotions, which are instinctive, fleeting, and patterned responses that can be regulated. This teaches you to look at your emotions differently giving you the agency to act or not act, based on your emotions, reducing emotional vulnerability. Some skills taught to develop emotion regulation are:

  • Identifying, describing, and changing emotional responses
  • Managing difficult emotions
  • Reducing emotional vulnerability
  • Exploring pleasant activities
  • Developing value-based goals1,5

Distress tolerance

The distress tolerance module teaches you practical tools for surviving life crises, without making things worse. In upsetting situations that cannot be changed or avoided, being able to tolerate the emotional distress experienced helps prevent harmful, risky behaviours like self-harm or substance abuse.5

This module develops skills such as:

  • Self-soothing techniques
  • Activating the nervous system
  • Distraction1,6

DBT’s unique contribution to distress tolerance

DBT treatment offers a comprehensive approach to developing effective distress tolerance skills through the learning modules in this programme. Distress tolerance skills are specifically learned, practised, and developed during group skills therapy. Meanwhile, individual sessions with your therapist enhance your learning by helping you apply these skills in your daily life. During times of crisis, telephone coaching with your therapist can guide and support you through your distress and avoid reckless and harmful behaviours.1

Practical strategies for real-life challenges

Distress tolerance skills: everyday applications

For people who experience negative emotions more intensely and more frequently, it can feel like there is no end to the wave of pain and it can be difficult to see beyond it. Distress tolerance skills are meant to be used in times of overwhelming emotion. As such, they are practical and easy-to-do skills that you can quickly access in your arsenal even in the face of distress. These skills will help you de-escalate the intensity of your emotions, so you are able to see beyond the pain, think more clearly, and take a more level-headed approach to address the distressing situation.6

Simplicity and practicality in DBT's distress tolerance techniques

The distress tolerance module can be seen as a survival kit, equipping you with handy and practical techniques to use at any given moment, particularly in times of life crises. Some practical exercises to help with tolerating distress are explored further in the next sections:

  • Radical acceptance
  • Distraction strategies
  • Self-soothing strategies
  • Advanced distress tolerance skills6

The role of radical acceptance

Precision in radical acceptance: a DBT pillar

Radical acceptance is one of the two core concepts of DBT, with the other being change as a necessity for progress. Radical acceptance is a shift in attitude and perspective of your experiences. During emotional distress, the intuitive initial reaction is to get angry, become overly judgmental, or blame someone else for the pain. Doing this does not address the pain nor does it solve the problem.1,6

Radical acceptance, on the other hand, encourages you to acknowledge the current circumstances without judgement or criticism. Radical acceptance is accepting things as they are and accepting that you cannot change people or the situation. This is a way of refocusing your perspective to what is in your control. This leads to more productive efforts in dealing with the present situation instead of unproductive behaviours like blaming.1,6

Seamlessly integrating radical acceptance: a skill for life's challenges

To start practising radical acceptance, it may be easier to start with smaller events rather than larger, more painful ones. For example, being stuck in traffic, instead of quickly getting upset, learn to be patient as this is beyond your control. Some coping statements you can use when exercising radical acceptance are:

  • The present is the only moment I have control over
  • I can’t change what has already happened6

Tackling distress: the power of distraction in DBT

Practical distraction techniques

During times of crisis, unhealthy coping mechanisms like self-harm are used to deal with the overwhelming emotions. These actions are not only dangerous but can lead to permanent damage to the body and in severe cases, death. A major reason for developing distress tolerance in DBT is to prevent this from happening. One healthy way to tolerate distress is through distraction, which momentarily takes you away from the intense pain until you are ready to face it.6

Incorporating distraction into daily life

Distracting yourself from self-destructive behaviours

When you have the urge to harm yourself as a means of coping with intensely negative emotions, here are some safer alternatives you can do to distract yourself:

  • Gently snapping a rubber band on your wrist provides temporary, less injurious pain
  • Squeezing an ice cube is numbingly cold and distracting
  • Screaming into a pillow
  • Crying releases stress hormones and can make you feel better6

Distracting yourself with pleasurable activities

Doing things that you know make you feel good can distract you from your overwhelming emotions in times of distress. Regularly partaking in pleasurable activities outside times of crisis is also healthy. Some pleasurable activities you can do are:

  • Exercising - weightlifting, pilates, yoga
  • Talking to friends via phone, chat, or in-person
  • Going for a long walk in the park
  • Getting out of the house
  • Going for a drive
  • Watching something - a movie, television show, Youtube video
  • Playing games
  • Listening to music - and singing6

Distracting yourself by diverting attention to someone else

Diverting your attention from yourself and your pain to someone else can help you momentarily take your mind off your overwhelming feelings. Some things you can do are:

  • Running errands with a friend
  • Cleaning the house to help your parents
  • Volunteering at your local shelter
  • Going to the shopping centre
  • Parking to sit and people-watch6

Tips for distraction mastery

Creating a distraction plan that you can easily access will help you apply these techniques in times of distress. Identify the distraction skills that resonate with you, write them down in a notebook you can carry around with you, or record them on your phone. This way, whenever an emotional situation arises, you can easily remind yourself of the distraction techniques you can go through.6

Swift relief with TIPP techniques: a DBT approach

Exploration of TIPP skills: immediate distress reduction

The TIPP skills are a set of techniques you can employ to decrease emotional overwhelm and calm down by activating the body’s nervous system. TIPP stands for:

  • Temperature change - for example, tipping your face into cold water
  • Intense exercise
  • Paced breathing
  • Paired muscle relaxation1

Strategic application: DBT's rapid coping solutions

Through physical activation of the body’s nervous system, the TIPP skills can help you immediately reduce distress and calm down. 

Temperature change

Tipping your face into cold water induces a cold shock-like response, which stimulates breathing. Exposure to a sudden drop in temperature decreases arousal caused by a distressing situation.1,9

Intense exercise

Exercise helps you to emotionally calm down as well as being good for your physical health. It activates a release of endorphins, the so-called happy hormones that relieve stress and pain. Exercise has been shown to help with depression as well as states of anxiety. Some easy exercises you can do are:

  • Jogging or walking
  • Biking
  • Swimming
  • Hiking6,7

Paced breathing

Paced breathing is a technique that has been shown to reduce stress and improve relaxation states. This is a slow and steady deep breathing technique, also called diaphragmatic breathing. It promotes increased oxygen levels in the blood and massages the abdominal organs. This can be done either sitting or lying down. The steps to practise paced breathing are:

  • Place one hand on your upper chest and one on your stomach, just below the rib cage
  • Slowly inhale through your nose, feeling your stomach expand
  • Then slowly exhale through your mouth
  • You should notice that your stomach goes back to normal as does your hand, while the hand on your chest will remain fairly still8

Paired muscle relaxation

Paired muscle relaxation, or progressive muscle relaxation, is another relaxation technique that pairs tension and subsequent relaxation of the muscles. The cycle of active muscle contraction and progressive muscle relaxation has been proven to provide immediate stress relief, as well as reduce depression and anxiety.8

Personal coping mastery: the art of self-soothing with DBT

Introducing self-soothing concepts

Being in a relaxed state helps you to better deal with your problems in a healthier, calmer manner. As such, it is important to learn ways to soothe yourself to help you relax. Self-soothing techniques involve using your 5 senses of smell, touch, sight, taste, and hearing to help you ground yourself in the present and thus into a relaxed state.6

Using the five senses as self-soothing techniques 


The sense of smell can trigger memories, sentiments, and emotions. This can help you alter your mood. Some activities associated with smell you can do to self-soothe are:

  • Burning scented candles or incense
  • Using scented oils, perfume, or cologne
  • Spending time in nature to smell the grass and flowers
  • Going to places with scents that make you happy like a bakery, cafe, or library6


Touch is a powerful sense given that the skin is the largest organ, carrying many nerves that convey sensations of pleasure or danger. You can seek out tactile activities that are self-soothing such as:

  • Playing with your pet
  • Bringing a soft, velvety item in your pocket or bag
  • Getting a massage
  • Taking a shower or having a bath
  • Wearing comfortable clothes6


The sense of sight is another powerful self-soothing tool. Here are some self-soothing activities you can do that are associated with sight:

  • Getting creative by drawing or painting
  • Flipping through magazines or books at a bookstore or library
  • Exploring a place that is visually relaxing for you such as a park or art museum
  • Enjoying the waves of the ocean
  • Looking at a picture of someone you love or admire6


Hearing certain sounds can spark different emotions in us. For example, listening to music can be energising or relaxing depending on the genre. Some things you can listen to to self-soothe are:

  • Calming music - like classical music
  • Audiobooks or podcasts - listening to someone talk can be soothing, but make sure to stay away from topics that can be distressing like politics
  • Television - listen to a boring or relaxing show, not something upsetting like the news
  • Nature and outside sounds
  • White noise machine
  • The flow of water6


The flavour of certain dishes can trigger memories and emotions. It is important to be mindful of your own perceptions of food and eating. If this is a problem for you, such as having an eating disorder, seek help from a professional first. But if eating food does not cause issues for you, here are some activities you can do:

  • Eat your favourite meal
  • Have candy, gum, or lollipops at the ready
  • Drink soothing liquids like herbal or fruity tea
  • Enjoy fresh fruit or soothing food like ice cream or chocolate6


With its comprehensive programme of treatments, DBT can help you cope through distressing events by developing your ability to tolerate distress. Through the distress tolerance module in DBT, you will learn practical skills and techniques you can easily employ in times of crisis such as the TIPP skills, distraction skills, and self-soothing activities. Identifying techniques that work for you and creating a distress tolerance plan you can easily access will help you better navigate your crises without further harming yourself. Through daily practice and commitment, you will gain the ability to tolerate distress better and deal with your problems in a healthier manner.


  1. Linehan MM, Wilks CR. The Course and Evolution of Dialectical Behavior Therapy. American Journal of Psychotherapy [Internet]. 2018 Apr;69(2):97–110. Available from: https://psychotherapy.psychiatryonline.org/doi/10.1176/appi.psychotherapy.2015.69.2.97
  2. Larrazabal MA, Naragon-Gainey K, Conway CC. Distress tolerance and stress-induced emotion regulation behavior. Journal of Research in Personality. 2022 Aug;99:104243.
  3. ‌Asarnow JR, Berk M, Bedics J, Adrian M, Gallop R, Cohen J, et al. Dialectical Behavior Therapy for Suicidal Self-Harming Youths: Emotion Regulation, Mechanisms, and Mediators. Journal of the American Academy of Child & Adolescent Psychiatry. 2021 Feb;60(9).
  4. Cleveland Clinic. Dialectical Behavior Therapy (DBT) [Internet]. Cleveland Clinic. 2022. Available from: https://my.clevelandclinic.org/health/treatments/22838-dialectical-behavior-therapy-dbt
  5. Fassbinder E, Schweiger U, Martius D, Brand-de Wilde O, Arntz A. Emotion Regulation in Schema Therapy and Dialectical Behavior Therapy. Frontiers in Psychology [Internet]. 2016 Sep 14;7(1373). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5021701/
  6. ‌McKay M, Wood JC, Brantley J. The Dialectical Behavior Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance [Internet]. Google Books. New Harbinger Publications; 2019 [cited 2024 Jan 25]. Available from: https://books.google.co.uk/books?hl=en&lr=&id=CjqvDwAAQBAJ&oi=fnd&pg=PT9&dq=distress+tolerance+dbt&ots=D2FMiO9Sqg&sig=4vLEstGx1DmOYvKce2DJkwr_zj8#v=onepage&q=TIPP&f=false
  7. ‌Tate AK, Petruzzello SJ. Varying the intensity of acute exercise: implications for changes in affect. The Journal of Sports Medicine and Physical Fitness [Internet]. 1995 Dec 1 [cited 2024 Jan 25];35(4):295–302. Available from: https://pubmed.ncbi.nlm.nih.gov/8776078/
  8. ‌Toussaint L, Nguyen QA, Roettger C, Dixon K, Offenbächer M, Kohls N, et al. Effectiveness of Progressive Muscle Relaxation, Deep Breathing, and Guided Imagery in Promoting Psychological and Physiological States of Relaxation. Taylor-Piliae R, editor. Evidence-Based Complementary and Alternative Medicine. 2021 Jul 2;2021(1):1–8.
  9. Jay O, Christensen JPH, White MD. Human face-only immersion in cold water reduces maximal apnoeic times and stimulates ventilation. Experimental Physiology. 2007 Jan 1;92(1):197–206.

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This content is purely informational and isn’t medical guidance. It shouldn’t replace professional medical counsel. Always consult your physician regarding treatment risks and benefits. See our editorial standards for more details.

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Isabel Rivera

Doctor of Philosophy – PhD, University of Manchester, UK

Isabel Rivera, PhD, is an accomplished oncology researcher with a strong acumen for medical communications and creative marketing. With experience in scientific and medical writing, Isabel excels in simplifying intricate scientific concepts. She combines research practice, project management skills, teaching experience, and digital marketing expertise to drive impactful outcomes in roles requiring scientific rigor and effective communication.

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