DBT · Distress Tolerance

TIPP

DBT crisis survival skill for changing body chemistry fast

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For moments when emotion is at a 9 or 10 and thinking won't reach. TIPP changes body chemistry in seconds — buy yourself the 20 minutes you need to choose what's next.

Temperature

Cold water on the face for 30–60 seconds, or hold an ice pack against the cheeks. Triggers the mammalian dive reflex — heart rate drops within seconds.

How → Bend over a sink. Cold water above the eyes, below the cheekbones. Hold breath. 30s.

Intense Exercise

Spend the body's stress chemistry. Match the intensity of your emotion with the intensity of movement.

How → Jumping jacks, sprints, stairs — 10 to 15 minutes at high effort.

Paced Breathing

Slow the exhale longer than the inhale. Activates the parasympathetic system — the brake pedal of the nervous system.

How → Inhale 4 · Hold 2 · Exhale 6. Five rounds, then reassess.

Paired Muscle Relaxation

Tense each muscle group as you inhale; release fully as you exhale. The body cannot stay activated and relaxed at once.

How → Hands → arms → shoulders → face → chest → belly → legs → feet. 5s tense, 10s release.

“First the body settles. Then the mind can speak.”

About this worksheet

TIPP is Marsha Linehan's crisis survival skill for moments when emotion intensity is over a 7/10 and cognitive coping isn't going to work. It uses the body to change body chemistry fast — cold temperature to trigger the mammalian dive reflex, intense exercise to burn excess physiological activation, paced breathing to lengthen the exhale, and paired muscle relaxation to drop residual tension. The whole protocol takes 5–15 minutes and reliably moves someone out of the red zone enough to think again. This worksheet puts all four on a single sheet a client can keep in their wallet or on their phone, with the dose for each (water temperature, breath ratios, exercise duration). It is a crisis tool. It does not solve the problem that caused the crisis — it buys the client the regulation they need to use other skills.

When to use it

Emotion intensity over 7/10, where talking through it won't work.
Urge crises — self-harm, substance, dissociation urges in the moment.
Panic attacks, post-trigger flooding, the 3am crisis text.
Avoid the Temperature component in eating disorders (cold-water restriction can be reinforced) or cardiac conditions without medical clearance.

How to use it

1
Temperature
Cold water on the face (above the cheekbones, below the eyes) for 15–30 seconds, or hold an ice pack against the upper face. Triggers the dive reflex, drops heart rate.
2
Intense exercise
10–15 minutes of full-body movement — jumping jacks, running stairs, sprinting in place. Hard enough to be breathless. Burns the adrenaline.
3
Paced breathing
Inhale 4, exhale 6–8. Longer exhale than inhale. Five to ten minutes. Activates the parasympathetic.
4
Paired muscle relaxation
Tense each muscle group hard for 5 seconds, release, breathe out. Move from feet to head. Five minutes.
5
Reassess, then use a different skill
After TIPP, rate distress again. Now the client can actually use a thought record, distress diary, or talk to someone. TIPP is the door, not the room.

Frequently asked questions

What does TIPP stand for in DBT?+

Temperature, Intense exercise, Paced breathing, Paired muscle relaxation. It's one of the distress tolerance skills in DBT's crisis survival module.

When should you use TIPP?+

When emotion or urge intensity is high enough that cognitive skills won't land — typically over 7/10. TIPP changes body chemistry first so the client can then use other coping skills.

Is TIPP safe for everyone?+

The Temperature component should be avoided in eating disorders (restriction-reinforcing), cardiac conditions, or known cold-induced fainting. Intense exercise should be modified for physical limitations. Paced breathing and PMR are universally safe.

How quickly does TIPP work?+

Temperature works in 30–60 seconds via the dive reflex. Full protocol usually drops distress 2–4 points on a 0–10 scale within 15 minutes.

Related worksheets

Worksheet — TIPP — provided by TherapistAssist for clinical use. Not a substitute for assessment or treatment.