DBT Distress Tolerance Skills:

Tip Skill, Stop Skill, and More

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• Distress tolerance skills are used for crisis situations

• Distress tolerance skills assist in accepting reality when reality is

difficult to accept and/or strong urges to engage in unskillful behavior
are present

• Popular Distress Tolerance skills include the TIP Skill, STOP Skill, Half-
Smile, Willing Hands, and Radical Acceptance

Stephanie Vaughn, PsyD

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Although most mental health treatments emphasize change, this module pays tribute to the value
which exists in accepting reality just as it is rather than attempting to make things different. The
skills taught in this module will not solve the problem but will assist in not making the problem
worse. These skills should be combined with problem solving and not overuse to the point that
they become an avoidance of engaging in life and creating one’s life worth living. The distress
tolerance skills help with surviving a crisis and in that vein help to determine what is an actual
crisis versus what is something that’s just uncomfortable.

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So a crisis is defined as being something that is very high stress that has the possibility of really
bad outcomes. Crises are short term and there is a strong urge for immediate resolution.

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So there is a whole other set of skills in the distress tolerance module that relates to when the
crisis is addiction but we wouldn’t be going over those in this module. Distress tolerance skills will
also help create short-term relief for painful situations. They help to minimize the risk of
impulsive actions that come as a result of the desire to alleviate the pain that an individual is in
during a crisis. So there are times when the solution to the problem actually makes the problem
worse. And the distress tolerance module is created to provide another variety of skills that could
be utilized instead of the usual go to that the patient have used in the past. Distress tolerance
skills also help with reality acceptance. So when we’re accepting reality, this is not the same thing
as approving of reality. There is a heavy zen influence in this module and the acceptance of reality
is thought to prevent suffering which comes from the non-acceptance of pain. So pain is
inevitable and human beings are subject to pain in a variety of different forms throughout their
lives. However, if non-acceptance is added to the pain, then we have an additional component of
suffering that goes along with it. So the idea in the distress tolerance module is to eliminate
suffering and therefore, we are only left with pain which doesn’t sound fantastic but it’s much
more tolerable than pain plus suffering.

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So distress tolerance skills are supposed to be used when there is intense physical and/or
emotional pain and that pain cannot be alleviated quickly or it cannot be alleviated without
causing additional problems. You can use the distress tolerance skills when there are strong urges
to engage in unskillful behavior. When a person is in emotion mind, there are often very strong
urges to fall back on unskillful behavior that has been successful in alleviating distress in the
short term but has caused long-term pain. This includes self-harm, fantasizing about suicide,
impulsive sexual behavior and substance abuse as well as multiple other problem behaviors. When
the emotional pain is too strong and it feels overwhelming, this is another opportunity to use the
distress tolerance skills. And finally, these skills can be used when there is a need to be able to
be productive or to be able to focus, to be able to center and interact with someone, for example,
but the person feels too emotionally overwhelmed and does not feel like that they can get
themselves together. So this may be a group of skills that an individual uses at work when they
feel emotionally overwhelmed. Go to the restroom and then can walk through a few of these.

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So some of the skills that are taught in this module include several acronyms and for lack of time
we’re not going to go into every one of these but I’m going to pick a few to touch on. So the TIP
skill is one of the fastest and most popular of the distress tolerance skills, fastest in that it
alleviates distress very quickly. And clients are encouraged to use this skill when they are very
emotionally overwhelmed and strong urges to self-harm are present, for example.

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So the TIP acronym stands for tipping, this is the T, tipping the temperature of your face with very
cold water. The idea is to bring on the dive reflex and bring the physiology down to slow it down.
The I stands for intense exercise of approximately 20 minutes. The P stands for paced breathing
as well as paired muscle relaxation. So slowing down and bringing the body’s physiology down to
a more normative level.

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Another acronym is the STOP skill. And STOP stands for – Literally, the S is stop. The T is take a
step back and this is both a figurative and a literal take a step back. So in an interpersonal
situation, taking a step back might mean literally taking a full step back away from the other
person rather than stepping forward and further instigating a conflict. The O is observe and the
observe is the same as the mindfulness skill of observe which is to take in with all of the senses
everything that is happening, not thoughts about what’s happening although those can be
observed but not conclusions about what’s happening. So just observing the data that’s present.
And P is to proceed mindfully. So it involves a pause and then a forward motion into the decision
of what to do.

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Another acronym is the ACCEPTS skill. And this stands for engaging in activities, that’s the A.
Contributing which is doing something for someone else. Comparisons which is juxtaposing a
previous period of your life with your current one, juxtaposing a previous period of your life that
was much worse with the one that you’re in or comparing yourself to someone else whose life is
much worse. E, emotions which is generating different emotions than the ones that you’re feeling.
P is pushing away, sort of like putting the problem on a shelf. T or thoughts, engaging in thinking
about math problems, making a grocery list, making a holiday list, any thoughts that compete with
the thoughts and emotions that are present during the time of the crisis. And sensations which is
using the five senses in order to ground.

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In addition to these acronyms, self-soothing is encouraged and this is doing things that are
comforting and feel good, incorporating positive activities, things that one would enjoy, distracting
which can be self-soothe and distraction at the same time, taking one’s thoughts away from the
problem and putting them on something else. And it’s easy to see how these skills could be
overused or could be an avoidance if practiced at the expense of problem solving. So these skills
should be combined with problem solving. But in the case that the problem cannot be solved and
a time period has to elapse before anything can be done, it’s important to be able to use these
skills to cope with the emotions that arise as you’re waiting on the solution or as you’re waiting
on the opportunity to problem solve.

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So one of the most popular DBT skills is encompassed in the distress tolerance section and this is
radical acceptance. So radical acceptance is beyond just typical acceptance. The term radical
meaning fully, wholly, absolutely, 100% accepting reality as it is. And acceptance again does not
mean approval. It means looking at things in the face. So a radical acceptance of locking your keys
in your car would not be to stare through the window wondering how it happened. It would be to
immediately move to a solution of calling a locksmith. So you cannot move to problem solving
until the problem has been radically accepted. So we have to have acceptance in order to have
change. In order to change the fact that I’ve dropped an egg on the floor and it’s made a mess, I
have to first accept that that has happened rather than staring at it and wishing that it wasn’t
true.

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So the final skills that I’m going to go over are half smile and willing hands. And both of these
capitalize on the feedback loop that exists between the body and mind. When we take a posture
of openness which is willing hands, this is literally opening one’s hands up and showing the wrists,
when we do that when we’re angry or we make a soft smile, we call the Mona Lisa smile, when
stressed, then the mind starts to mimic what the body is saying is happening. And although the
inside may feel very high strung, if the outside suggest relaxation or patience or willingness, then
the inside will start to match.

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The key points for the distress tolerance skills. The distress tolerance skills are used for crisis
situations. Distress tolerance skills assist in accepting reality when reality is difficult to accept
and/or strong urges to engage in unskillful behavior are present. Popular distress tolerance skills
include the TIP skill, STOP skill, half smile, willing hands and radical acceptance.

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