Distress Tolerance Skills for Emotional Regulation

Most people who struggle with intense emotional episodes might think they just need to try harder to get their emotions under control. What they may not realize is that there’s a set of concrete, evidence-based coping skills designed specifically for the times when emotions become unmanageable.

These are called distress tolerance skills, and they come from one of the most well-researched therapeutic approaches in mental health. The positive news is that distress tolerance skills can be learned, no matter how old you are or how far into your journey of understanding your own emotions you currently are.

To help, this page covers:

• What distress tolerance skills are and where they originated.
• How different skills work and their effectiveness.
• What distress tolerance skills look like in real life.
• The relationships between mental health and coping skills.
• What to do if distress tolerance skills aren’t enough on their own.

What Are Distress Tolerance Skills?

Distress tolerance skills can be seen as the emergency toolkit. These are crisis coping skills designed for moments when your emotions have pushed you past the point where you can function in a normal way.^[1]

The only goal is to get you through that particular moment, rather than to resolve a situation or work through what caused the emotion. Distress tolerance skills are like emotional first aid, stabilizing you long enough for the thinking part of your brain to come back “online.” Once the situation has passed, other approaches can look at the underlying causes and help you develop longer-term coping skills.

Where Did Distress Tolerance Skills Originate?

Distress tolerance skills originated in dialectical behavior therapy (DBT). DBT was developed by psychologist Marsha Linehan at the University of Washington.^[2] She had been working with women who were chronically suicidal and found that a change-focused approach in treatment left them feeling invalidated.

Her solution was to balance acceptance with change, which helped with validation, while also teaching skills to manage emotional pain.^[2]

DBT became the first treatment developed specifically for borderline personality disorder and has since been applied across a range of conditions that involve emotional dysregulation.

DBT is built around four skill modules, with each of them targeting different areas of regulation.^[3]

1. Mindfulness skills teach you to observe the present moment without judgment.
2. Emotional regulation helps you understand your emotions and then learn how to change your response to them over time.
3. Interpersonal effectiveness builds your ability to communicate your needs.
4. DBT distress tolerance gives you the tools to survive a crisis.

The skills learned during this aspect of DBT are the focus of this article.

Different Types of Distress Tolerance Skills

Because a crisis looks different for everyone, you can learn several different distress tolerance skills.

TIPP

TIPP stands for:

• Temperature.
• Intense exercise.
• Paced breathing.
• Progressive muscle relaxation.

The aim here is to target your physiology directly, which makes it the fastest option when you’re emotionally flooded.

Within this skill, you can learn several techniques to practice. For example, research on the diving reflex shows that cold water on the face activates the parasympathetic nervous system.^[4] This then slows the heart rate rapidly, making it an option for the “temperature” part of TIPP.

For ‘I’, the idea behind intense exercise is that it burns off the surge of stress-driven energy. A few minutes of jumping jacks or running on the spot may be enough to bring the intensity down.

Paced breathing, with a longer exhale than inhale, has been shown to increase vagal tone and reduce anxiety, even within a single session.^[5]

Progressive muscle relaxation involves tensing and releasing muscle groups to reduce any physical tension. A common way to practice it is to start at your feet and work upward, holding each group tense for a few seconds before you let go.

STOP

STOP stands for:

• Stop.
• Take a step back.
• Observe.
• Proceed mindfully.

It creates a deliberate pause that can help to interrupt the impulse to act.

In any situation that’s causing you distress, you stop what you’re doing, step back from the situation, observe what you’re feeling, and then decide how to proceed once the initial surge has passed. That short pause helps because your first response to a spike in distress isn’t always your most reliable one, and a few seconds is often enough to let it settle.

Pros and Cons

This is used specifically for crisis situations, rather than everyday decision-making. When a destructive urge spikes, you train your mind to weigh the consequences of acting on it against the ability to tolerate distress in that moment.

Self-Soothing With the Five Senses

This distress tolerance skill involves comforting yourself through the five senses:

1. Sight.
2. Sound.
3. Smell.
4. Taste.
5. Touch.

For example, listening to calming music can help calm you through sound, and holding a soft blanket through touch. You can light a scented candle, keep a piece of candy on hand for taste, and look at a photo that makes you feel calm for sight.

The sensory engagement brings your awareness back into the present moment and gives you something safe to focus on.

ACCEPTS

ACCEPTS stands for:

• Activities.
• Contributing.
• Comparisons.
• Emotions (opposite).
• Pushing away.
• Thoughts.
• Sensations.

These are essentially distraction-based strategies that are designed to occupy your mind temporarily until the intensity of the crisis fades away.

The idea here is that you avoid the emotion just enough to give yourself distance from the peak. That way, you’re less likely to act on it, and you can reevaluate once the perceived threat has passed.

Evidence Behind Distress Tolerance Skills

If you’ve been through emotional crises in the past, the idea that managing these in-the-moment emotions is to breathe or to simply take a step back can be hard to believe. But if practiced well, they can make a huge difference, and the research backs this up.

One study tested the individual components of DBT by comparing skills training plus case management, individual therapy plus an activities group, and standard comprehensive DBT.^[6]

The conditions that included skills training produced greater improvements in self-injury and depression than individual therapy without skills.^[6]

Research on skills use followed 108 women with BPD through treatment and found that those in DBT reported using three times more skills by the end of treatment than those in a control condition.^[7] Skills use fully mediated the reduction in suicide attempts and depression, meaning people appeared to get better because they used the skills.^[7]

Standalone DBT skills groups have also shown benefits. A study testing skills training as a standalone treatment for emotion dysregulation found it reduced dysregulation compared to a support-group control, with skills use again mediating the effect.^[8]

It’s worth noting that most of the evidence available supports DBT skills as a package, rather than, for example, TIPP or ACCEPTS being used on their own. This suggests that while distress tolerance skills are an important component of DBT, the whole therapy model needs to be followed for the best result.

How Distress Tolerance Skills Work in Real-Life Situations

When you know how overwhelming a crisis can be, it can be difficult to picture a certain technique working in a specific situation. Here are a few examples of how distress tolerance skills can be applied:

Using TIPP After an Argument

Say you’ve had a heated argument with your partner and you feel the physiological symptoms starting, like a pounding heartbeat.

Fueled by emotion, you feel the urge to say something that makes sense at the time, but deep down, you know you’ll later regret it. Instead, you go to the bathroom and run cold water on your face. That causes the diving reflex to kick in and your heart rate drops.

You step outside, walk around the block, and by the time you come back, you’re back to your emotional baseline and thinking about what you actually want to say.

Using STOP When Triggered by a Message

Your ex-partner sends a text that immediately sets off an emotional reaction. You want to send something back, but instead, you put the phone down and physically step away from it.

You now have the chance to notice the emotions you’re feeling without doing anything about it yet. 20 minutes later, you’re in a much better headspace to work out whether to ignore or respond to the message.

Using Pros and Cons in Stressful Work Situations

You’ve been overwhelmed at work for months, and the urge to walk out and never come back has hit hard. Before acting, you pull out the pros and cons list you prepared with your therapist.

Yes, acting on the urge to leave would feel good for an hour or so, but the problems it would create could last for months afterwards. Tolerating that bit of distress feels difficult in the moment, but it keeps your options open and creates enough distance from the urge to get through the day.

Of course, not all of these situations may apply to you and your life, but the aim is for you to see how these skills help you reassess situations that would usually cause you the most distress.

Professional Treatment for Distress Tolerance

If you’ve been practicing these skills and they’re helping in the moment but the crises keep coming, or if the emotional dysregulation is tied to a mental health condition, the next step is to seek professional help.

Learning and practicing distress tolerance skills with a therapist is key here, as a trained professional can help you identify which skills match your situation.

Therapists can also help you recognize the aspects of your life that trigger crises in the first place, something these skills alone aren’t designed to do.

For most, DBT and other types of therapy happen in an outpatient setting. This means you can attend treatment sessions while you continue to manage your daily life. This is actually an advantage for distress tolerance work because the skills learned within the sessions build emotional resilience that can be practiced in your day-to-day life.

If medication is part of the picture, outpatient treatment also provides a setting where it can be monitored and adjusted regularly alongside the skills work.

If you’re unsure whether or not your situation requires professional mental health treatment intervention, it’s worth speaking things through with trained therapists who can advise you on your next steps.

Build Your Distress Tolerance Skills With Mission Connection

If emotional crises have been affecting your daily life and the skills you’ve tried on your own aren’t producing enough change, Mission Connection can help you take the next step.

We provide outpatient mental health treatment for adults dealing with conditions where emotional dysregulation is a core feature, including:

• Borderline personality disorder.
• PTSD and trauma.
• Depression.
• Anxiety.
• ADHD.

Our outpatient programs include DBT skills training alongside individual therapy. This means that you’re learning distress tolerance and emotional regulation skills within a clinician-led environment while continuing to manage your daily responsibilities.

In addition to standard outpatient care at our locations in California, Virginia, and Washington, we also offer more intensive levels of care, such as a partial hospitalization program (PHP) or an intensive outpatient program (IOP). We are in-network with most major insurance providers.

To find out more about our in-person, virtual telehealth, or hybrid program that combines in-person and virtual care, call us at 866-833-1822. You can also get started online.