Distress Tolerance and DBT: When You Reach Your Tipping Point, Try TIP

As a therapist, I often meet people when they’re not feeling optimal. People come to me angry, ashamed, embarrassed, and so much more. Many of the people I see in therapy feel so uncomfortable with themselves that they have a hard time sitting through a full therapy session, especially when we start hitting the “tough points.” These are the parts of ourselves that we’d like to ignore and avoid because they are super painful when they come to the surface. They’re also often the reasons we seek therapy in the first place.

Being able to tolerate extreme discomfort while going through the nitty-gritty parts of therapy is key to its success. I warn everyone I work with in the beginning that therapy doesn’t always feel great while you’re going through it. However, when complete, it can be one of the most powerful and fulfilling experiences of your life.

It is my job to push you through your comfort zones so you can grow and transform your life. Sometimes that means asking you to sit with painful emotions, thoughts, and experiences. It is also my job to help you develop the tools to be functional in between sessions. After all, there are many more hours spent outside the therapy room than in it.

It can feel a whole lot easier to sit with pain when there is a trained mental health professional around to help contain the overwhelm, someone to help you practice healthy coping skills so you can regroup and ground yourself. However, your brain keeps working and processing after you leave the therapy room, which means it is likely you will experience reminders, or actual discomfort, in between sessions.

I warn everyone I work with in the beginning that therapy doesn’t always feel great while you’re going through it. However, when complete, it can be one of the most powerful and fulfilling experiences of your life.

This is one of the reasons I focus on coping skills when I start working with people. I need to know you know what to do during and in between sessions when things start getting uncomfortable.

Dialectical behavior therapy (DBT) consists of several different skills modules. One of these is called distress tolerance, which focuses on identifying and using healthy coping skills and problem-solving techniques when things feel out of control. While most of the coping skills described in this module take some planning or time to complete, one skill set in particular is handy in the moment. These skills are referred to by the acronym TIP:

• Temperature: Changing the temperature of your body briefly can help refocus and ground yourself when you’re feeling out of control. You can achieve this by running cool or warm water on your forearm or the back of your neck—areas that are sensitive to temperature changes. Chewing on ice, sitting by a fan or heating vent, or even walking outside for a few moments can all create this effect as well.
• Intense exercise: Short, quick bursts of exercise can be beneficial in grounding yourself. It is important to check with your physician and make sure you are using good form so you don’t end up with injuries or complications. Intense exercise may include jumping jacks, wall push-ups, or sit-ups, to name a few. Pacing or walking can also help.
• Paced breathing: Many people are familiar with the concept of deep breathing (inhaling deeply through the nose, holding for a moment, then exhaling slowly through the mouth, then repeating the cycle). I’m a huge fan of deep breathing because it is something we can actually control when we become distressed. You can also do the opposite type of breathing, sometimes referred to as “fire breathing.” This consists of quick, short bursts of inhaling and exhaling through your nose. Use this type of breathing for no more than 10 to 30 seconds, as it may leave you feeling lightheaded or dizzy if you go longer.
• Progressive/paired muscle relaxation: The basic idea behind progressive muscle relaxation is focusing on squeezing or tightening one muscle, then relaxing that muscle and noticing the difference. You can do this throughout your body, focusing on one muscle at a time, or you can focus on one or two muscles and achieve similar results. You can then make six to eight “passes” before moving to the next muscle in the sequence. I often teach the kids I work with to imagine they are squeezing lemons or oranges in their hands, then loosening their grip. If you’re worried about people noticing you squeezing your hands or other muscles, a less visible option is what I call “toe crunches”—squeezing your toes within your shoes.

None of these skills will necessarily change the fact you are feeling distressed, or even the circumstances that led to feeling overwhelmed and out of control. They can, however, help you hang in there through the intensity of the experience until you feel better and calmer. Once the intensity has passed, you can engage with what DBT refers to as your “wise mind thinking” and begin to problem-solve.

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