Distress Tolerance Worksheets
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Looking for distress tolerance worksheets? This article includes an overview of distress tolerance skills to manage stress and provide emotional regulation, along with free downloadable distress tolerance worksheets.
One of the key roles of a mental health therapist is to empower clients to enhance their coping strategies.
Dialectical behavioral therapy (DBT) is a modality often used to strengthen distress tolerance skills and improve emotional regulation.
Visual aids, such as distress tolerance worksheets, can be helpful tools to provide psychoeducation about stress, illustrate DBT skills, and empower clients to implement these new skills in stressful situations.
In this guide, you’ll find an overview of DBT distress tolerance skills and a bundle of free downloadable distress tolerance worksheets that you can save to your electronic health record (EHR) for future use.
The worksheets include descriptions of self-soothing tools, crisis survival techniques, DBT distress tolerance handouts, and more.
What are distress tolerance skills?
Dialectical behavioral therapy (DBT) is an evidence-based modality used by mental health clinicians.
There are four main components to DBT:
- Distress tolerance
- Emotional regulation skills
- Mindfulness
- Interpersonal skills
DBT distress tolerance skills help clients navigate challenging situations and emotions through building resilience to tolerate them—without the need to escape or turn to unhelpful coping strategies, like avoidance, drinking, taking drugs, ruminating, or worrying.
Some examples of distress tolerance skills include:
- Self-soothing strategies that use the senses
- DBT distraction skills, like engaging in pleasurable activities, leaving a situation, counting, distracting your thoughts, or engaging in something more consuming
- Crisis survival techniques, like the ACCEPTS skill, TIP skill, or IMPROVE skill
- Sensory body awareness practices, like mindfulness
We’ve provided a summary of each of these skills below, as well as accompanying worksheets that you can download and save to your EHR for repeated use.
Radical acceptance worksheet
The dialectic aspect of DBT means to balance and compare two things. When practicing radical acceptance, it means balancing change with acceptance.
For example, you might need to change some behaviors while simultaneously accepting yourself exactly as you are. It may also mean acceptance of a situation or circumstance you cannot change, without judgment or resistance. However, radical acceptance doesn’t mean accepting terrible and unjust things that happen, like violence, assault, etc.
The steps of radical acceptance include:
- Note what happened in the distressing situation
- Consider if any historic events led up to the situation
- Reflect on any role(s) you may have played in the situation
- Note any role(s) others had in the event
- Consider what you have control over in this situation and what you do not have control over
- What was your response to the situation and how did it impact your thoughts and feelings, and those of others?
- Consider if you could have responded in a way that led to less suffering for yourself and others
- Note how practicing radical acceptance might have affected your state of mind and others’ responses to your actions
When practicing radical acceptance, it’s important to remember that life is full of challenges and painful experiences, and it is still worth living.
Self-soothing worksheet
Self-soothing can involve using the five senses to relieve stress.
For example, using your senses in the following ways:
- Vision: Look at a calming or inspiring picture, or pleasant object
- Listen: Observe the sounds of nature, like trees rustling in the wind, the crashing of waves, birds chirping, or maybe the sound of your dog sleeping
- Smell: Find a scent you find pleasant, like a flower, aromatherapy oil, the smell of a person, freshly cut grass, or your favorite meal
- Taste: Make your favorite warm drink, like a cup of tea, or enjoy one of your favorite dishes
- Touch: Find a tactile sensation that provides comfort, like taking a bath or shower, getting in a hot tub, going for a walk, feeling the sun on your face, or getting a massage
DBT distraction skills
There are several techniques to create a distraction from distressing thoughts and feelings that you can share with clients, including:
Distractions from self-destructive behaviors
For example, make a warm cup of tea instead of drinking alcohol, or go for a run instead of ruminating about a stressful incident.
Instead of self-harm behaviors, hold an ice cube tightly in your hand and secure it, or put a rubber band around your wrist and snap it when you feel like harming yourself.
Distractions with pleasurable activities
There are many pleasurable hobbies and activities you can use to distract yourself from engaging in maladaptive coping mechanisms.
For example, go for a walk, call a friend, listen to your favorite music or a new podcast, take photographs, garden, do a puzzle with lots of pieces, or play a challenging game online.
Work outside or in a coffee shop if you can, learn a new hobby or skill, or visit your elderly relatives and offer to help. Go on an adventure, like visiting a new art gallery or take a trip to the coast.
Pay attention to someone else
Shifting your attention from your stressors to come to someone else's aid can be a great way to divert stress and avoid unhealthy coping mechanisms.
For example, ask a friend or family member if you can run an errand for them.
Pay less attention to yourself and do something that requires focus, like driving, going to the mall, playing a sport, or going for coffee with a friend. Think of someone you care about and journal about them, noting your favorite qualities, how you met, and what you’d tell them if you saw them.
Leave the situation
If you’re in a difficult and emotionally activating situation, sometimes it's best to distract yourself by simply leaving the situation.
Think about something else
Create a distraction from distressing thoughts by switching to a work task or challenging problem you want to solve.
De-escalate by counting
For example, count the number of tiles in the bathroom, count your breaths, practice the times table, or count how many times you see a bird outside your window.
Other crisis survival techniques and DBT worksheets
There are several crisis survival techniques in DBT, including:
ACCEPTS skill
The DBT ACCEPTS tool is one of several practical techniques to manage stress and difficult emotions. It works to help clients accept present conditions as they are.
ACCEPTS stands for: Activities, Contributing, Comparisons, Emotions, Pushing away, Thoughts, and Sensations.
You’ll find an ACCEPTS worksheet included in the distress tolerance worksheets bundle that you can download above.
TIP skill
This is a tool to quickly calm an overwhelmed body by using temperature, exercise, and breathing techniques.
TIP stands for: Temperature, Intense exercise, and Paced breathing/Paired muscle relaxation.
IMPROVE skill
Using the IMPROVE skill can replace a distressing environment with a more positive one.
IMPROVE stands for Imagery, Meaning, Prayer, Relaxation, focusing on One thing, Vacation, and Encouragement.
REST skill
The REST skill helps clients cope with overwhelming emotions by providing a structure to tolerate stressful situations and emotions.
REST stands for Relax, Evaluate, Set an intention, and Take action.
We’ve also included a REST worksheet in the distress tolerance worksheets bundle that you can download for free.
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