DBT Distress Tolerance Skills: A Clinician’s Guide to Managing Crisis Situations

Emotions are a natural, and sometimes challenging, part of being human. There is a strong chance that you have encountered clients who experience intense or uncomfortable emotions within your clinical work. Emotions that feel unmanageable can stem from a variety of things, such as limited coping skills, support, or mental health disorders. In these moments, DBT distress tolerance skills offer a structured, evidence-based framework for helping clients safely navigate emotional crises without making the situation worse.

Dialectical Behavior Therapy (DBT) has distress tolerance as one of its four core skill modules. Distress tolerance skills differ from emotion regulation skills in that they focus on helping clients get through challenging moments when emotions feel overwhelming.

Clients who benefit from distress tolerance skills may be struggling with Borderline Personality Disorder (BPD), PTSD, anxiety disorders, depression, substance use disorders, or self-harm behaviors. It can also be helpful for those who are at risk of a crisis. You may choose to incorporate distress tolerance into a comprehensive treatment plan or incorporate other DBT skill modules, depending on your clients’ symptoms and goals.

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Why Distress Tolerance Matters

When clients feel overwhelmed by their emotions, they may make impulsive decisions or engage in avoidance behaviors to cope. While they may feel this provides relief, it often just masks their emotions. Over time, suppressed emotions can intensify or even lead to a crisis.

Clients who are unable to cope with their emotions may struggle with substance abuse, self-harm behaviors, aggression, or interpersonal conflict. Some clients experience numbness or an emotional shutdown.

Distress tolerance skills are crucial for clients experiencing these difficulties and can improve their quality of life. These skills can help clients learn to tolerate the emotional pain they experience, rather than trying to avoid or numb it. This allows them to properly address their emotions and find a path forward that can help reduce their overall distress. These skills are customizable, allowing you to tailor them to your clients based on their age, development, and other characteristics.

Some of the benefits associated with distress tolerance skills include:

• Emotional stability
• Decreased impulsivity
• Improved decision making
• Building confidence regarding challenging emotions
• Promoting treatment engagement

Helping Clients Understand Their Emotions and Distress

Similar to other therapeutic techniques, it can be helpful to provide your client with an overview of emotions, distress tolerance skills, and their effects. Emotions are a natural part of life, so pain and discomfort are unavoidable at times. It is important for clients to understand that distress tolerance skills will not stop them from experiencing challenging emotions, but they can help them manage them more effectively.

For clients who engage in avoidance behaviors, they may have the perception that they are coping with their distress. This is where you can help your client gain insight into how avoidance behaviors push their challenges aside rather than processing or resolving them. Acceptance is often the first step in managing emotions, which can be a challenge in its own for some clients.

You may find it helpful to introduce acceptance as acknowledging their experience, noting that this does not mean that they approve of it. This can be an important differentiation for clients who struggle with unresolved trauma, intense moods, and intrusive thoughts. Help your client learn to differentiate between what they can and cannot control in situations. Distress tolerance skills can help clients develop a game plan for when they experience overwhelming emotions, reducing their risk of a crisis. With regular practice, clients can build their confidence in using their knowledge in tough moments. Having experience with multiple distress tolerance skills is ideal for effectiveness.

Goals of Distress Tolerance Skills

Before teaching specific distress tolerance skills, it is important to discuss the overall purpose of these interventions with clients. This helps establish realistic expectations and addresses common misconceptions about distress tolerance. Many clients initially believe these skills are intended to eliminate emotional pain or make them feel calm immediately. In reality, distress tolerance skills are designed to help clients survive moments of intense emotional distress without engaging in behaviors that worsen the situation. Once the emotional crisis has passed, clients are often better prepared to use other DBT skills, such as emotion regulation, problem-solving, and interpersonal effectiveness.

Survive Crisis Without Making It Worse

The primary goal of distress tolerance skills is to help clients navigate crisis situations safely. During periods of overwhelming distress, individuals may feel strong urges to engage in self-harm, substance use, aggressive behaviors, reckless spending, binge eating, or other impulsive actions that provide temporary relief but create additional problems over time. Distress tolerance skills provide practical alternatives that help clients remain emotionally and physically safe until the intensity of the crisis begins to decrease.

Accept Reality as It Is

Another core goal of distress tolerance is helping clients practice acceptance when situations cannot immediately be changed. Acceptance does not mean approving of, liking, or giving up in response to painful circumstances. Rather, it involves acknowledging reality as it exists in the present moment instead of expending energy fighting against it. DBT emphasizes that resisting reality often increases emotional suffering, while acceptance creates the foundation for more effective decision-making and intentional action.

Tolerate Emotional Pain

Emotions naturally rise, peak, and fall over time, much like waves. Distress tolerance skills help clients move through these periods of heightened emotional intensity without attempting to suppress, avoid, or immediately escape uncomfortable feelings. By learning to tolerate distress rather than react impulsively, clients often discover that even intense emotions are temporary and manageable.

Create Space for Effective Behavior

When emotional arousal decreases, clients are better able to think clearly, evaluate their options, and respond intentionally instead of reacting automatically. Distress tolerance skills create the psychological space needed to access other DBT skills, including emotion regulation, mindfulness, and interpersonal effectiveness. Over time, practicing these skills helps clients build confidence in their ability to cope with future crises while continuing to make progress toward their treatment goals.

Distress Tolerance Skills to Teach Clients

There are a variety of distress tolerance skills that you can incorporate into your sessions. We are going to focus on skills for which clinical worksheets are available on TherapyByPro. In addition to singular options, we have a Distress Tolerance Worksheet Bundle that includes access to 23 customizable templates. Continue reading for an introduction to specific distress tolerance skills.

• Radical Acceptance is a distress tolerance skill that helps clients fully accept their reality without judging, fighting, or denying it. Acceptance can reduce the distress clients experience from trying to resist painful situations. This can be helpful for those struggling with grief, chronic illness, trauma, unexpected loss or change, and life transitions. You can begin by helping clients identify a situation they are struggling with that they cannot change, and by helping them differentiate between pain and suffering. This can help clients see that resisting or avoiding these situations may increase their overall distress. Mindfulness skills can help clients learn to observe their thoughts and emotions without judging them. Acceptance can take time, so this topic may need to be revisited.
• The DBT TIPP Skill uses an acronym related to behaviors that can be used to address intense emotional experiences. These methods focus on altering the body’s physiology through temperature changes, intense exercise, paced breathing, and paired muscle relaxation. This can be helpful for clients who feel overwhelmed with emotions like anxiety, anger, or self-harm urges. The TIPP skill is most effective when used before a client feels their emotions are unmanageable. Many find it easier to practice this skill when they are calm than in moments of stress. You can use the DBT TIPP Skill Worksheet offered by TherapyByPro to guide your client through this technique.
• The DBT ACCEPTS Skill can help clients step back from an intense emotional experience so they can cope more effectively. This acronym stands for activities, contributing (or helping others), comparisons, emotions (creating different ones), pushing away (temporarily- not to be confused with avoidance), thoughts, and sensations. Clients who are struggling with a problem without an immediate solution can benefit from this skill. Clients find it helpful to use resources, like TherapyByPro’s worksheet, to outline their ACCEPTS list ahead of time, making implementation easier. Help your client choose behaviors that they can fully engage in for this technique.
• The DBT Improve the Moment Skill can help clients feel that difficult situations are more manageable by shifting how they experience the present moment. Common components of this technique include imagery, meaning, personal reflection or prayer, relaxation, one thing at a time, vacation, and encouragement. Improving the moment can be helpful with clients who are unable to change their stressors, such as grief, chronic stress, illness, conflict, or uncertainty. This skill can help make current experiences feel tolerable and, therefore, more meaningful. You can use this technique to help your client build a comfort toolkit they can turn to when they need it.

Common Challenges When Teaching Distress Tolerance

As you introduce your client to new distress tolerance skills, you may experience challenges along the way. Clients may find themselves uncomfortable sitting with their discomfort in the initial stages, especially if they have been using maladaptive or avoidant coping strategies for extended periods. This is an understandable experience that you can help your client normalize. Having open discussions about possible challenges and treatment outcomes can help create realistic expectations.

Without realistic expectations, clients may feel that distress tolerance skills don’t work for them. If you encounter this, you can help your client explore how and when they are using these skills. Troubleshooting barriers that they’re experiencing and reinforcing their continued efforts to implement distress tolerance skills can help build confidence and treatment engagement.

After learning distress tolerance skills, some clients find they forget how to use them when facing a challenge or crisis. Because of this, it can be helpful to guide your client in creating a crisis plan with specific directions they can follow in tough moments. Clients can save this plan to their email, phone, or create a card to keep in their wallet for easy access. Encouraging your client to use their skills throughout the day can help boost their confidence in applying them during challenging moments.

You may find that your client continues to use maladaptive or harmful coping skills if they’re struggling to implement or find a benefit from their distress tolerance skills. In these cases, it is important to validate your client’s experience and note the function of their behavior. This can help you understand their unmet needs so that you can introduce healthier replacement skills. Reinforcing their continued efforts to try new skills can promote treatment engagement.

Closing Thoughts About Distress Tolerance Skills

Distress tolerance skills can help your client navigate emotional storms head-on. With regular use, they can gain confidence riding the ups and downs associated with their emotions, normalizing this pattern. They can recognize that their discomfort is temporary and find ways to address it once the intensity has subsided.

Discomfort and pain are inevitable experiences in life, regardless of the precautions we take. We can do our best to help our clients plan for expected challenges, but distress tolerance skills can provide them with in-the-moment support to avoid resorting to avoidance or impulsive coping behaviors.

We hope this post gave you some ideas for incorporating distress tolerance skills into your clinical work. This was intended as an educational introduction to DBT distress tolerance skills and should not be used as an alternative to proper training, supervision, certification, or consultations. Working within the scope of your niche allows you to provide effective and ethical care that supports your clients as they make meaningful changes in their lives.

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Sources

• Pederson, L., & Pederson, C. (2025). The expanded dialectical behavior therapy skills training manual: DBT for self-help, individual, and group treatment settings (3rd ed.). PESI Publishing