TIPP Skills Worksheet: A Crisis Survival Tool for Rapid Physiological Down-Regulation
DBT · DBT · Manualised
A client worksheet for the four TIPP skills, written so it still works when the client cannot think clearly. Every instruction is a literal, countable step: cold water or a cold pack on the face for 30 seconds, at least 60 seconds of vigorous movement, six rounds of breathing in for 4 and out for 6, and squeezing muscles on the in-breath then letting go on the out-breath. A single circled 0 to 10 rating confirms the feeling is at crisis level before the skill is used, and a planned next step makes clear that TIPP is the first move in a sequence, not the whole plan.
Underlying mechanism: DBT Distress Tolerance: TIPP Skills for Extreme Emotional Arousal
What it helps with
- Bringing physiological arousal down fast enough that the client can get through the next few minutes without acting on an urge.
- Removing real-time choice at the worst moment, through a pre-agreed go-to skill field completed in session.
- Giving clients who find "breathe slowly" or "calm your body" too vague a set of exact counts to follow.
- Finding which of the four components works fastest for this client, through a practice log used across a real crisis period.
How clinicians use it
- Complete the worksheet with the client in session, after the medical screening in the therapist guide, before they ever need it in a crisis.
- Rehearse each skill in the room and have the client tick one or two go-to skills.
- Agree the next step together and keep it written on the sheet.
- Review the practice log at the following sessions and update the go-to skills if the answer changes.
Clinical Implementation Guide
- Screen for medical flags before teaching the temperature or exercise skills.
- Complete the go-to skill and next step fields in session.
- Use at genuine crisis intensity, around 7 or more out of 10, not for everyday stress.
What the worksheet looks like
| Skill | What the Client Does |
|---|---|
| Temperature | Face in cold water, or a cold pack on eyes and cheeks, for 30 seconds |
| Intense exercise | At least 60 seconds of fast movement, for example 60 jumping jacks |
| Paced breathing | In for 4, out for 6, six times, then six more if possible |
| Paired muscle relaxation | Squeeze on the in-breath, say "relax" and let go on the out-breath |
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. Water should be cold but not icy (above 10°C). Use the teen worksheet for clients under 18. 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
- Linehan, M. M. (2015). DBT skills training handouts and worksheets (2nd ed.). Guilford Press.
- 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.
- 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.
- 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.
Part of
TIPP Skills
Related worksheets
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