Distress Tolerance Skills :TIPP skills
Linehan, N (2015). DBT Skills Training Manual [2nd Edition], New York, The Guilford Press, 9876543(2)
This lesson teaches four skills that can be very effective in managing emotions in a crisis. They are highly effective at reducing emotional arousal, and are simple to do. We aim to learn and practice them, so they are available when we need them.
When we get upset our body chemistry changes. Our temperature may increase, our heart rate may go up. The reverse is also true. If we change our body chemistry we can re-regulate our emotions. For example relaxation techniques can lower our heart rate. This in turn can help relieve our distress. This can be of great help in a crisis, as often it is very difficult to use other DBT skills effectively while our body is experiencing extreme distress.
Caution: These skills are designed to change our body chemistry, including lowering the heart rate. So, please, if you have any medical conditions seek advice before trying these, for example any heart conditions, pregnancy, allergy to cold, breathing difficulties or brain injuries.
These skills create a short lived effect. So they are great for re-regulating the body, but be mindful of then using other skills to maintain your mood.
The skills are
T – Temperature
I – Intense exercise
P – Paced breathing
P – paired muscle relaxation (an extended version of progressive muscle relaxation)
Why it works We can induce the dive reflex by putting our face in very cold water whole holding our breath, it starts to work after around 30-60 secs. This reflex lowers our heart rate to below its normal resting rate. Caution: Never try this if you have any heart problems without your doctors permission (see also caution above).
How to do it. Have a bowl large enough to put your face in. Also a way of lowering the water temperature, maybe an ice pack. And a towel. Hold your breath while putting your face under the water, as far as your temples. Try and stay in the water for 30secs. This should be long enough to trigger the dive reflex, where your heart will return to below its normal resting rate.
Alternatively you can try holding an ice pack on your eyes and cheek area for 30 sec while holding your breath. The effect is increased if you stand and bend your head over while doing this skill.
This is a very unusual sensation, and also highly effective. You are encouraged to give it a try to feel how it works before a crisis. A good suggestion is to keep ice packs in the freezer ready.
Why it works Research shows that anxiety decreases when our heart rate gets up to 70 % of its maximum. Also, positive emotions are increased after 20 to 30 mins intense exercise. Those two facts explain why using exercise is an effective way to regulate our bodies when emotions have affected us so our hearts are racing, we are angry etc.
How to do it Do intense aerobic activity for 20 mins. Examples include running, jumping jacks, walking, cycling. We are all different.
Why it works Our bodies naturally relax when we breathe out, so if we can slow our breathing down, and breathe out for longer than we breathe in then we start to relax. This is a useful skill that can be used at anytime, as it’s very discreet.
How to do it Face a clock which has a second hand. Breathe in deeply, using your diaphragm (abdomen). Count the number of seconds for each breath in and each breath out. Aim to breathe out for a longer count than you breathe in. Count your breath, so if your are counting 4 for the in breath, then count 5 or 6 when breathing out. There are many guided relaxation recordings and apps available which you may find helpful in doing this exercise.
Paired muscle relaxation
Why it works When we create tension in a muscle and then release the tension the muscle has no option, it has to relax.
How to do it
FIRST EXAMPLE The pairing comes from relaxing the muscles at the same time as breathing out . Tense an area of the body, notice the tension and hold the tension for 5 – 10 seconds. Then release the tension and relax for 5 -10 seconds. When relaxing the muscle, breathe out and say the word “Relax”. Continue with different areas of the body. Notice how the body feels when it is tense, and when it is relaxed. It takes practice to be able to do all these things at the same time, there is a worksheet to help you at the bottom, worksheet 4A, Paired Muscle Relaxation.
SECOND EXAMPLE Paired muscle relaxation can also be used to cope ahead for stressful situations. There is a worksheet to help you with this skill, worksheet 4B.
Firstly think of a situation that causes you emotional distress. For example, you have job interview.
Ask yourself what you are telling yourself that is causing the distress. For example, you are telling yourself “If I don’t get this job it shows how useless I am.”
Think of an effective way to rethink this. “I have an interview, which shows others think I am worth considering.”
Write down as many effective coping thoughts as you can.
Now do the exercise. As you breathe in, tensing your muscles, say aloud the effective coping thought. And then as you breathe out say Relax. While you are doing this imagine you are in the stressful situation. Practice, practice, practice. When you are in the distressing situation you can use this skill you have practised to reduce emotionally distress.
Both of these are surprisingly hard to do. You may have to practice many times to be able to do the muscle, breathing and talking bits together. There is a worksheet to help you with this skill, worksheet 4B, Effective Rethinking and Paired Muscle Relaxation.