TIPP Skills Therapist Guide: DBT Distress Tolerance With Medical Screening and Age Adaptations

DBT · DBT · Manualised

A clinician protocol for TIPP, the dialectical behaviour therapy distress tolerance skill for moments when arousal is too high for any cognitive intervention to land. It sets out the physiological pathway behind each component (the diving response for Temperature, spent arousal for Intense exercise, a longer out-breath for Paced breathing and a tense and release paired with the exhale for Paired muscle relaxation), gives a dose and a troubleshooting line for each, and adds the medical screening and age-specific defaults that most free TIPP handouts leave out.

Underlying mechanism: Dialectical Behaviour Therapy Distress Tolerance: TIPP Crisis Survival Skills

What it helps with

  • Explaining TIPP to clients as a fire extinguisher for the next few minutes, not a fix for the problem that caused the crisis.
  • Troubleshooting a client who says a skill "is not working" by checking the pathway, the dose and the trial length.
  • Screening for the heart, medication, blood pressure, fainting, cold allergy and eating disorder flags that change which components are safe to teach.
  • Adapting delivery for ADHD clients (fewer real-time choices, countable steps) and autistic clients (sensory response established in advance, literal wording).
  • Setting a more conservative temperature default for adolescents and a different skill mix for younger children.

How clinicians use it

  • Read the guide in full, then complete the screening record with the client before teaching the temperature or exercise skills.
  • Teach and rehearse each component in a calm session, then agree one or two go-to skills and a trial length in advance.
  • Always pair TIPP with a planned next step, so lowering arousal does not become its own avoidance loop.
  • For under-18s, screen with a parent or guardian, default to a cold pack with normal breathing and coordinate with the wider care team where self-harm is part of the presentation.

Clinical Implementation Guide

  1. Complete the screening record before teaching the temperature or exercise skills.
  2. Rehearse every component in session and agree the go-to skills in advance.
  3. Review the practice log to find each client's fastest-acting component.

What the worksheet looks like

Therapist Guide: TIPP Skills — worked example
ComponentHow It WorksSuggested Dose
TemperatureCold on the face with the breath held triggers the diving responseAbout 30 seconds in water above 10°C, or with a cold pack on eyes and cheeks
Intense exerciseSpends the physical arousal the emotion has mobilisedAt least 60 to 90 seconds of vigorous movement
Paced breathingA longer out-breath increases vagal activityIn for 4, out for 6, six rounds a minute
Paired muscle relaxationTense on the in-breath, release on the out-breathWork around the body, saying "relax" silently on each release

Clinical cautions

Very cold water slows the heart quickly and intense exercise speeds it up. Screen before teaching either skill for a heart condition or arrhythmia, uncontrolled high blood pressure, a history of fainting, a lowered resting heart rate from medication (including beta-blockers), an allergy to cold or a current or past eating disorder, and involve the client's doctor where any flag is present. Do not swap in a cold shower for a flagged client, since sudden cold on the body triggers the cold shock response. Face immersion is not the default for anyone under 18 and is not appropriate for younger children. This tool does not diagnose any condition and is not a substitute for individual face-to-face therapy or for emergency crisis support. Anyone in immediate distress should contact their local emergency service or crisis line.

References

  1. Bernstein, E. E., & McNally, R. J. (2017). Acute aerobic exercise helps overcome emotion regulation deficits. Cognition and Emotion, 31(4), 834-843.
  2. Cornelius, J. F., Sadr-Eshkevari, P., Arasho, B. D., Sandu, N., Spiriev, T., Lemaitre, F., & Schaller, B. (2010). The trigemino-cardiac reflex in adults: Own experience. Expert Review of Cardiovascular Therapy, 8(7), 895-898.
  3. DuBois, D., Ameis, S. H., Lai, M. C., Casanova, M. F., & Desarkar, P. (2016). Interoception in autism spectrum disorder: A review. International Journal of Developmental Neuroscience, 52, 104-111.
  4. Fiene, L., & Brownlow, C. (2015). Investigating interoception and body awareness in adults with and without autism spectrum disorder. Autism Research, 8(6), 709-716.
  5. Foster, G. E., & Sheel, A. W. (2005). The human diving response, its function, and its control. Scandinavian Journal of Medicine & Science in Sports, 15(1), 3-12.
  6. Gooden, B. A. (1994). Mechanism of the human diving response. Integrative Physiological and Behavioral Science, 29(1), 6-16.
  7. Jacobson, E. (1938). Progressive relaxation (2nd ed.). University of Chicago Press.
  8. Lehrer, P. M., Vaschillo, E., & Vaschillo, B. (2000). Resonant frequency biofeedback training to increase cardiac variability: Rationale and manual for training. Applied Psychophysiology and Biofeedback, 25(3), 177-191.
  9. Linehan, M. M. (2014). DBT skills training manual (2nd ed.). Guilford Press.
  10. Linehan, M. M. (2015). DBT skills training handouts and worksheets (2nd ed.). Guilford Press.
  11. Lundström, A., Karlsson, M., Rydberg, A., & Wiklund, U. (2025). Assessment of arrhythmias and heart rate response in healthy adolescents performing face immersion and body submersion in ice-cold water. Physiological Reports, 13(13), e70430.
  12. Manzoni, G. M., Pagnini, F., Castelnuovo, G., & Molinari, E. (2008). Relaxation training for anxiety: A ten-years systematic review with meta-analysis. BMC Psychiatry, 8, 41.
  13. Rathus, J. H., & Miller, A. L. (2015). DBT skills manual for adolescents. Guilford Press.
  14. Shattock, M. J., & Tipton, M. J. (2012). 'Autonomic conflict': A different way to die during cold water immersion? The Journal of Physiology, 590(14), 3219-3230.
  15. Shaw, P., Stringaris, A., Nigg, J., & Leibenluft, E. (2014). Emotion dysregulation in attention deficit hyperactivity disorder. American Journal of Psychiatry, 171(3), 276-293.
  16. Zaccaro, A., Piarulli, A., Laurino, M., Garbella, E., Menicucci, D., Neri, B., & Gemignani, A. (2018). How breath-control can change your life: A systematic review on psycho-physiological correlates of slow breathing. Frontiers in Human Neuroscience, 12, 353.

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