TIPP Skills for Teens: A DBT Distress Tolerance Worksheet With a Safer Temperature Default
DBT · DBT · Manualised
A teen version of the TIPP worksheet for young people aged around 13 to 17. It keeps the same countable steps, crisis check, go-to skill field, next step and practice log as the adult sheet, but changes the temperature skill: a cold pack held on the eyes and cheeks with normal breathing is the default, and face immersion is used only where a therapist, doctor and parent or carer have all agreed. The safety and crisis boxes name a trusted adult rather than assuming the young person manages a crisis alone.
Underlying mechanism: DBT for Adolescents: TIPP Distress Tolerance Skills
What it helps with
- Teaching a body-based crisis skill to adolescents with self-harm urges or acute overwhelm, alongside a wider safety plan.
- Applying a more conservative temperature default in line with evidence of arrhythmias during face immersion in healthy adolescents.
- Keeping a parent, carer or other trusted adult involved in when and how the skill is used.
- Giving young people exact counts rather than vague instructions, which suits ADHD and autistic teenagers in particular.
How clinicians use it
- Complete medical screening with a parent or guardian, not from the young person's self-report alone.
- Confirm whether school counselling staff, a paediatrician or another member of the care team needs to be involved, particularly where self-harm is part of the presentation.
- Rehearse each skill in session and agree the go-to skills and next step before the sheet goes home.
- Review the practice log together at the following sessions.
Clinical Implementation Guide
- Screen with a parent or guardian before teaching the temperature or exercise skills.
- Default to the cold pack with normal breathing, never a held breath.
- Name a trusted adult on the sheet and agree the next step in session.
What the worksheet looks like
| Skill | What the Young Person Does |
|---|---|
| Temperature | Cold pack on eyes and cheeks for 30 seconds, breathing normally |
| Intense exercise | At least 60 seconds of fast movement |
| Paced breathing | In for 4, out for 6, six times |
| Paired muscle relaxation | Squeeze on the in-breath, 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. Face immersion is not the default for anyone under 18: face cold combined with breath-holding activates the diving and cold shock responses together, and should only follow medical clearance and close supervision. 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.
- Rathus, J. H., & Miller, A. L. (2015). DBT skills manual for adolescents. Guilford Press.
- 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.
Part of
TIPP Skills
Related worksheets
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