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Distress Tolerance Skills

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ALPIMS • DBT SKILLS

Distress Tolerance

Get through a difficult moment.
Reduce extra harm. Find support that fits.

You do not have to solve everything now. Choose one skill, a smaller version or practical care.

Start here Back to ALPIMS – DBT

You deserve support while you are distressed.
These skills do not require you to tolerate harmful behaviour, untreated symptoms or overwhelming sensory input.

What is needed first?

Too much to think? Reduce questions and demands. Use familiar support or your care plan.

A strong urge to act? Try a pause with STOP.

A painful reality? Try a small acceptance statement, when you have capacity.

Immediate danger or urgent medical needs require practical help first. Skills can support you alongside that help.

Getting through an intense moment

Open one box. Read the short version first.

STOP

Pause before acting on an urge.

ACCEPTS

Shift attention for a short while.

TIP / TIPP

Body-based skills for intense emotion.

Self-Soothe

Offer comfort through tolerable senses.

IMPROVE

Make this moment more manageable.

Pros & Cons

Compare an urge with a safer response.

Responding to the situation

When you have room to consider what comes next.

Problem Solving

Change what can be changed.

Radical Acceptance

Acknowledge what is true right now.

Pain, acceptance and suffering

DBT uses the idea that fighting an unchangeable fact can add distress to pain. Acceptance may reduce that extra struggle.

The “pain + acceptance” equations are teaching metaphors, not literal rules. Pain, grief and trauma-related distress may remain despite acceptance. Difficulty accepting is not a moral failure.

You can acknowledge reality and still seek treatment, protection, justice or change.

Practise gently • no perfection needed

When you have capacity, try one suitable skill in a manageable situation. Notice what helps and what makes things worse.

Save a short phrase or prepare one support ahead of time. Familiarity can make access easier during distress.

You do not have to practise daily, build tolerance to harmful input or increase effort. Practising beforehand is helpful, not a condition for receiving care.

Neurodivergence and sensory overload

Reduce sensory load and demands first. Use predictable choices, concrete language and processing time.

Writing, communication aids, a familiar interest or a tolerable fidget may help. Eye contact, stillness and imagery are optional.

During shutdown or meltdown, questions and worksheets may add load. Use the person’s agreed support plan. Sensory protection is part of care.

PEM, brain fog and low energy

Reading, thinking, emotional work and social interaction can use energy and contribute to delayed worsening with PEM.

Skip intense exercise. Use less effort, reduce stimulation and ask someone to arrange practical comfort or care.

A smaller distraction may still be too much. Rest without a task is allowed. Follow individual energy limits, including delayed effects; no fixed increases.

Trauma, panic or dissociation

Preserve choice. Skip inward focus, closed eyes or breathing exercises if they are unsettling.

If helpful, orient to a neutral object, your current surroundings or a familiar person’s voice. Stop if distress or disconnection increases.

Acceptance does not require recounting trauma, forgiving someone or remaining in an unsafe situation.

Optional • Across ALPIMS

These adaptations may support coping and access to care. They are not treatments for the underlying conditions.

A • Anxiety & Autonomic

Use a pause or tolerable comfort alongside appropriate bodily care. Dizziness, palpitations or breathlessness are not automatically anxiety. TIP techniques need individual consideration.

L • Laxity / Connective Tissue

Use supported positioning, joint protection and accessible activities. Skip painful movement or muscle tensing. Practical assistance can reduce distress.

P • Pain / Bodily Sensitivity

Reduce light, sound or other demands when helpful. Use prescribed care plans and ask for support. Distress tolerance does not mean enduring untreated pain.

I • Immune / Inflammatory

Respect known allergies and relevant triggers. Skip fragrance, problematic foods or cold exposure where unsuitable. Necessary treatment and environmental protection come first.

M • Mood / Mental Health

A pause, temporary distraction or pros and cons may help with strong urges. Use suitable mental health support. Persistent or escalating distress needs more than a coping worksheet.

S • Sensory / Neurodevelopmental

Adapt communication and reduce sensory input. Offer one option and time to respond. Do not use skills to demand masking or endurance of painful sensations.

For families and supporters

Ask what help is welcome. Offer one simple option: “Would quiet or help with care be useful?” Accept “neither”, “later” or no answer.

Provide practical support and respect consent. Do not demand calm before care or use acceptance to avoid accountability.

Reflect later only if wanted and within capacity.

Sources and scope

Distress tolerance skills come from DBT developed by Marsha Linehan. The ALPIMS, neurodivergence and energy-sensitive examples here are educational adaptations, not a separately validated programme.

Educational information, not individual treatment advice. Choose methods suitable for your health and circumstances. New, severe or changing bodily symptoms need appropriate assessment. Stop a method that increases distress or symptoms.

Back to ALPIMS – DBT

STOP

Small option: pause before sending a message or making a decision. If safe, give yourself some space.

How it may help & what it means

STOP means stop, take a step back, observe and proceed mindfully. A step back can be a pause rather than a physical movement.

ALPIMS adaptations • open if relevant

Use a saved message: “I need a pause.” During overload, fewer words and practical support may help more than reflection.

STOP • ALPIMS page coming soon

ACCEPTS

Small option: look at a familiar photo or listen to something tolerable.

How it may help & what it means

The letters stand for Activities, Contributing, Comparisons, Emotions, Pushing away, Thoughts and Sensations. Choose one useful option; you do not need all seven.

This is a temporary break from distress. Return to necessary care or the problem when you have capacity.

ALPIMS adaptations • open if relevant

Use a low-demand familiar activity. Helping others is optional. Comparisons are optional if they bring shame. Avoid intense sensations, painful input or known triggers.

With PEM, distraction can still use energy. Quiet rest may be more suitable.

ACCEPTS • ALPIMS page coming soon General DBT resource →

TIP / TIPP

Start with suitability. Standard TIP/TIPP includes temperature, intense exercise, paced breathing and paired muscle relaxation.

How it may help & what it means

These methods aim to change physiological arousal. They need individual medical consideration where health conditions or medication affect their suitability.

ALPIMS adaptations • open if relevant

PEM: skip intense exercise as a crisis strategy. Even brief exertion can have delayed costs.

Cold sensitivity, Raynaud’s, heart or circulation concerns: do not assume strong cooling or cold-face techniques are suitable. Seek individual advice before using them.

Breathing or muscle work: stop if dizzy, breathless, painful or more distressed. Do not force deep breaths, breath holding or muscle tensing.

Gentler alternatives: reduce stimulation, use a supported position or let breathing stay natural. These are supportive alternatives, not equivalent versions of standard TIPP.

TIP / TIPP • ALPIMS page coming soon

The general TIP link includes strong cold and exercise suggestions. Read the adaptations above before considering them.

General DBT resource →

Self-Soothe

Small option: a comfortable blanket, a familiar image or a quiet space.

How it may help & what it means

Choose a comforting sensory experience. Comfort is personal; what soothes one person may overwhelm another.

ALPIMS adaptations • open if relevant

You do not need all five senses. Skip scents, music, food, touch or visual input that causes symptoms. Fragrance-free and low-stimulation options may fit better.

With PEM, let someone arrange comfort for you. Self-soothing does not require an activity.

Self-Soothe • ALPIMS page coming soon General DBT resource →

IMPROVE

Small option: use a supportive phrase: “One thing at a time. Help is allowed.”

How it may help & what it means

The letters stand for Imagery, Meaning, Prayer, Relaxation, One thing in the moment, Vacation and Encouragement. Prayer can be spiritual or replaced with personal reflection. Vacation means a brief break from demands.

ALPIMS adaptations • open if relevant

If visualisation is difficult, use a real picture or written words. If relaxation or inner focus increases distress, use external focus or familiar support.

No need to find a positive meaning in harm. A brief break must not delay urgent care; with PEM, actual rest can come first.

IMPROVE • ALPIMS page coming soon General DBT resource →

Pros & Cons

Small option: “What might happen if I act now? What might help if I wait?”

How it may help & what it means

Consider short-term and longer-term effects of acting on an urge, and of using a safer response. Preparing this when settled can make it easier to use later.

ALPIMS adaptations • open if relevant

Use two short points rather than a full worksheet. A supporter can write while you choose.

Include health costs, delayed PEM, safety and your values. Do not weigh up whether you deserve care.

Pros & Cons • ALPIMS page coming soon General DBT resource →

Problem Solving

Small option: name one problem and one practical next step.

How it may help & what it means

Problem solving is usually taught with emotion regulation. It belongs here as a next step when something can be changed and you have enough capacity to plan.

ALPIMS adaptations • open if relevant

Change an environmental demand, arrange help or ask for clarification. Others can handle practical tasks with consent.

During intense overload, settle immediate needs first. Do not turn a flare or shutdown into a planning exercise.

Problem Solving • ALPIMS page coming soon General DBT resource →

Radical Acceptance

Small option: “This is happening. It hurts. What support do I need?”

How it may help & what it means

Acceptance acknowledges a present or past fact, even when it is painful. It does not require approval, forgiveness or giving up change.

ALPIMS adaptations • open if relevant

Use concrete facts: “My capacity is lower today.” Do not treat uncertain diagnoses, someone else’s interpretation or predictions about your future as established reality.

Accepting that harm occurred can go alongside boundaries, accountability and seeking safety. Grief and anger can remain.

Radical Acceptance • ALPIMS page coming soon General DBT resource →

DBT emphasizes learning to bear pain skillfully because pain and distress are part of life and cannot be entirely avoided. Tolerance is necessary during any behavior change because impulsive behavior would interfere. Distress tolerance is the ability to perceive the environment as it is, without demanding that it be different.

pain + non-acceptance = suffering

pain + acceptance = ordinary pain

Practice Makes Perfect

Distress Tolerance Skills are meant to help us survive crisis, but they need to be practiced before a crisis occurs. These skills are helpful when we cannot sort out our emotions. These skills are to be used when a crisis cannot be avoided. An important concept is acceptance of reality. Read more about each of these skills by selecting one from below:

ACCEPTSTIPSelf-SootheImprovePros/ConsProblem SolvingRadical Acceptance