DBT Group Therapy | Distress Tolerance | TIPP Skill
DBT DISTRESS TOLERANCE
TIPP Skill — Full Psychoeducative Session Script
Group Therapy Format | Approx. 50–60 minutes
Session overview
Module: Distress Tolerance
Skill: TIPP (Temperature, Intense Exercise, Paced Breathing, Progressive Relaxation)
Format: Group therapy (6–12 participants)
Duration: 50–60 minutes
Materials: Whiteboard or flip chart, printed TIPP worksheet (optional), ice cubes or cold water
Prerequisites: Group members should have had a brief introduction to DBT and emotion regulation
basics
Purpose of this session
TIPP is one of the most powerful skills in DBT for moments of extreme distress. It works by changing
the body's biology directly — lowering physiological arousal without requiring the person to first
change their thoughts or beliefs. This session teaches all four components in detail, provides real-
world examples, practises them live in the group, and equips each member with a personalised crisis
plan.
SECTION 1 — OPENING & ORIENTATION | 5 MINUTES
1.1 Opening check-in
Begin the session by settling the group. Allow people to sit comfortably, feet on the floor. Speak
in a calm, unhurried tone. Do not rush this opening — it models the regulation the session is
about.
"Welcome everyone. Before we begin, let's just take a breath together. Notice you're
here, in this room, in this moment. Whatever is happening outside — you can set it
down for now."
Facilitator note: Give the group 10–15 seconds of genuine quiet. Do not fill the silence
immediately. Breathe visibly yourself.
Page 1
DBT Group Therapy | Distress Tolerance | TIPP Skill
"I want to start with a question. Has anyone ever been so distressed — so
overwhelmed, so activated — that they knew they needed to calm down, but nothing
was working? Your mind was racing, your heart was pounding, and every strategy
felt out of reach?"
Facilitator note: Wait for responses. Validate each one warmly and briefly. Do not go deep
into any individual story at this stage — keep it a check-in, not a processing session. A
response like 'Yes, that makes complete sense' or 'Absolutely — that's exactly the state
we're talking about today' is enough.
"That experience — that moment when your nervous system has taken over and
thinking your way out just isn't possible — that is exactly what today's skill is
designed for. It's called TIPP, and it works in a completely different way to most
coping skills. Instead of asking your mind to do something, it asks your body. And
your body always responds."
SECTION 2 — PSYCHOEDUCATION: WHAT IS TIPP & WHY DOES IT WORK? | 15 MINUTES
2.1 The biology of crisis — why we need TIPP
Before introducing the skill itself, help the group understand what is happening in their bodies
during extreme distress. This framing makes TIPP feel logical, not just like a trick.
"When we experience intense emotion — real fear, rage, shame, overwhelm — our
brain activates the fight-or-flight response. The amygdala, the part of the brain that
processes threat, fires up. Stress hormones like adrenaline and cortisol flood the
body. Heart rate spikes. Muscles tense. Breathing becomes shallow and fast."
"Here is the key thing: in that state, the prefrontal cortex — the part of the brain
responsible for thinking clearly, making decisions, accessing skills — goes partially
offline. It does not stop working completely, but its influence is significantly reduced.
This is why, in a crisis, you can know exactly what you're supposed to do and still be
completely unable to do it. It is not weakness. It is biology."
Facilitator note: Pause here. Ask the group: 'Does that resonate with anyone? Have you
ever had the experience of knowing the right thing to do but feeling completely unable to
access it?' Let 2–3 people briefly respond.
"TIPP works by directly intervening in that physiological state. Not by changing your
thoughts. Not by talking yourself down. It acts directly on your nervous system —
like a biological override switch. Once your body comes down from that peak
activation, your mind becomes accessible again. And then all the other skills
become possible."
Page 2
DBT Group Therapy | Distress Tolerance | TIPP Skill
2.2 Introducing the four letters
Write TIPP on the board or flipchart. Unpack each letter slowly. Pause after each one to check
for questions or reactions. Do not rush.
T — Temperature
"The T in TIPP stands for Temperature — specifically, cold temperature. When you
expose your face or wrists to cold water, or hold ice, something remarkable happens
in your body. There is a reflex called the mammalian dive reflex — it is the same
reflex that slows a diving mammal's heart rate underwater. Cold water on the face
triggers a rapid decrease in heart rate. In studies, this can reduce heart rate by 10 to
25 percent within 30 seconds."
"Practically, this means: hold your face in a bowl of cold water, hold ice cubes in
your hands, splash cold water on your wrists and face, or hold a cold pack to your
forehead and cheeks. Even 30 seconds of cold exposure can bring your body's
arousal level down noticeably."
Facilitator note: Important clinical note: In groups where members have self-harm history,
address this carefully. Say clearly: 'Using cold water or ice is not about causing pain. The
goal is a strong sensory signal, not discomfort. If the cold stops being a sensation and starts
feeling like pain, stop immediately.' Never frame ice as a substitute for self-harm — the
mechanism is different and the framing matters.
Practical examples of T — Temperature:
• Splash cold water on your face at the sink
• Run cold water over your wrists for 30 seconds
• Hold a bag of frozen peas or ice cubes
• Put your face into a bowl of cold water and hold for 15–30 seconds
• Step outside in cold weather and breathe the cold air deliberately
I — Intense Exercise
"The I stands for Intense Exercise. When we are in crisis, our body is flooded with
adrenaline — it is preparing us to fight or run. That adrenaline has to go somewhere.
If we do not use it, it stays in our system and keeps us activated. Intense physical
movement metabolises the adrenaline. It burns off the fuel that is keeping the crisis
going."
"This does not need to be a workout. We are talking about two to five minutes of
intense movement — running in place, jumping jacks, push-ups, burpees, running
up and down a flight of stairs. The point is to make your body work hard enough that
the adrenaline has somewhere to go."
Page 3
DBT Group Therapy | Distress Tolerance | TIPP Skill
Facilitator note: Invite group members to consider what is realistic for them. Some may
have physical limitations. Validate this: 'If high-intensity movement is not possible for you,
even vigorous arm movements or fast walking can help. Adapt it to what your body can do.'
Practical examples of I — Intense Exercise:
• Run up and down the stairs three times
• Do 20 jumping jacks
• Run on the spot as fast as you can for 2 minutes
• Do push-ups until you physically cannot continue
• Go for a very fast walk around the block
• Dance hard to a fast song
P — Paced Breathing
"The first P stands for Paced Breathing. You have probably been told to breathe
before. But what matters with paced breathing is not simply breathing slowly — it is
making the exhale longer than the inhale. This activates the parasympathetic
nervous system, often called the rest-and-digest system, which is the direct counter
to the fight-or-flight response."
"Breathing in activates a mild sympathetic response. Breathing out activates the
parasympathetic. So when your exhale is longer than your inhale, you are spending
more time in the calming half of the breath cycle. A common ratio is: breathe in for
four counts, breathe out for six to eight counts. Do this for two to three minutes —
not just a few breaths."
Facilitator note: Common mistake to address: people often try paced breathing for three or
four breaths, feel no change, and give up. Explain that the effect builds over time. Ask the
group to commit to at least two full minutes before judging whether it is working.
Paced breathing guide:
• In through the nose for 4 counts
• Out through the mouth for 6–8 counts
• Let the belly rise first, then the chest
• Do not hold the breath between in and out
• Set a timer for 2–3 minutes
• If the mind wanders, gently return to the count
P — Progressive Muscle Relaxation
"The second P is Progressive Muscle Relaxation, sometimes shortened to PMR.
When we are in crisis, we unconsciously tense our muscles — particularly around
the jaw, neck, shoulders, hands, and abdomen. This physical tension feeds back
into the emotional experience and intensifies it. PMR works by deliberately tensing
and then fully releasing muscle groups one by one."
Page 4
DBT Group Therapy | Distress Tolerance | TIPP Skill
"The sequence is: tense a muscle group hard for about five seconds — squeeze as
tightly as you can — then release completely and notice the contrast between
tension and relaxation. The release is where the benefit is. Move through the body
from feet to head, or from head to feet. People often find jaw and shoulder releases
particularly powerful."
Facilitator note: PMR takes longer than T or I, making it more suited for situations where
the person has a few minutes — such as before bed, in a safe space at home, or at the start
of a session to ground the group. It is less suited to acute public situations. Acknowledge this
to the group.
Basic PMR sequence:
• Feet and calves — curl toes, tense calves, hold 5 sec, release
• Thighs — squeeze hard, hold 5 sec, release
• Abdomen — tighten core, hold 5 sec, release
• Hands — make tight fists, hold 5 sec, release and open fingers
• Shoulders — raise to ears, hold 5 sec, drop completely
• Face — scrunch all facial muscles, hold 5 sec, release
• After each release: pause and notice the difference
SECTION 3 — WHEN TO USE TIPP: THE SUDS SCALE | 10 MINUTES
3.1 Introducing the SUDS scale
Before presenting the clinical examples, introduce the concept of rating distress. This gives
group members a shared language and helps them identify when TIPP is actually the right tool.
"In DBT we use something called a SUDS scale — Subjective Units of Distress. It
goes from zero to ten. Zero means you are completely calm, at rest, no distress at
all. Ten is the highest distress you have ever experienced — full crisis, feeling
completely out of control. Most of us move up and down this scale throughout every
day without realising it."
"TIPP is designed for the high end of this scale. When you are at a seven, eight,
nine, or ten, your nervous system is so activated that most cognitive coping
strategies — trying to think differently, problem-solving, even mindfulness as we
normally practise it — become very hard to access. TIPP does not require your
thinking brain. That is why it works when everything else fails."
"Below a seven, other skills often work better — checking the facts, opposite action,
self-soothe, mindfulness. But when you are in the red zone, reach for TIPP first.
Bring the body down. Then the mind becomes available again."
Page 5
DBT Group Therapy | Distress Tolerance | TIPP Skill
Facilitator note: Ask the group: 'What number on the SUDS scale do you think is where you
personally start to lose access to your skills?' Write some answers on the board. Most people
find it is somewhere between 6 and 8. Normalise that this is individual — there is no wrong
answer.
3.2 Real-world examples — read these aloud to the group
Read each scenario slowly and clearly. After each one, pause and ask the group: Which TIPP
tool would be most useful here, and why?
Scenario 1
You have just had a devastating argument with your partner. They said something that cut very deep.
You are shaking. Your chest is tight. You can feel the urge to send a long, angry message — one
that you know, somewhere underneath the rage, could seriously damage the relationship. You need
to bring your body down before you do anything.
Suggested TIPP response: T (cold water on face or wrists) followed by P (paced breathing). The cold
quickly reduces physical arousal. The breathing prevents it climbing back up. Once calm enough, the
person can assess whether and how to respond.
Scenario 2
You are sitting alone at home. You have received news that has destabilised you. You feel numb but
also frantic at the same time. You are having urges to self-harm or to use substances — not because
you want to, but because the internal experience feels unbearable and you need it to stop.
Suggested TIPP response: T first (cold water or ice — a strong physical sensation can interrupt the
urge cycle and signal to the nervous system that something has changed). Then I (physical
movement to metabolise the physiological arousal). This combination is particularly effective for urge
interruption.
Scenario 3
It is late at night. You cannot sleep. Anxious thoughts are looping. Your heart is beating too fast. Your
body is tense and you cannot find a comfortable position. The more you try to sleep, the more awake
you feel.
Suggested TIPP response: P (paced breathing — the 4-in, 8-out ratio is particularly effective for
sleep onset) followed by PR (progressive muscle relaxation, starting from the feet upward). This
combination activates the parasympathetic nervous system and releases the physical tension that is
keeping the person awake.
Scenario 4
Page 6
DBT Group Therapy | Distress Tolerance | TIPP Skill
You are at work and you have just been given news that is extremely triggering — a conflict with a
colleague, feedback that felt humiliating, or something that activated an old wound. You cannot
leave. You need to continue functioning. You feel yourself starting to dissociate or shut down.
Suggested TIPP response: T (cold water on wrists and face in the bathroom — quick, private, and
effective). Or I (step outside for two minutes and walk very fast around the building). Both options are
discreet and do not require explanation to colleagues.
SECTION 4 — LIVE IN-SESSION PRACTICE | 10 MINUTES
4.1 Group paced breathing practice
Do not skip this section. Practising paced breathing together in the group is one of the most
important parts of the session. It proves to each member that the skill works, gives them a lived
experience to draw on, and builds group cohesion.
"We are going to practise paced breathing together right now. I want you to notice
your SUDS score before we begin — just check in with yourself, without judgment. A
number between zero and ten. Remember it."
Facilitator note: Give the group 20 seconds to check in. You do not need to collect scores
out loud unless the group is comfortable with this.
"Let's begin. Sit with both feet flat on the floor. Hands resting in your lap. Eyes
closed if that feels comfortable — if not, a soft gaze downward is fine. We will
breathe in through the nose for four counts, and out through the mouth for eight
counts. I will guide you through it."
"In... two... three... four. And out... two... three... four... five... six... seven... eight.
Good. Again. In... two... three... four. And out... two... three... four... five... six...
seven... eight."
Facilitator note: Continue this for approximately 2 full minutes — about 8 to 10 breath
cycles. Keep your voice calm and slow. Do not rush the count. Let the exhale trail off
naturally at the end. After 2 minutes, bring the group back gently.
"Slowly, at your own pace, let your breathing return to normal. When you are ready,
open your eyes. Notice how your body feels right now. Check your SUDS score
again. What is it now?"
Facilitator note: Invite the group to share their before and after SUDS scores. Even a drop
of 1 or 2 points is meaningful — validate this. Common responses include 'I went from a 6 to
a 4' or 'My shoulders dropped' or 'My heart feels slower.' Celebrate these responses. Some
Page 7
DBT Group Therapy | Distress Tolerance | TIPP Skill
people may notice no change — validate this too and explore whether thoughts were
interfering ('I kept thinking about whether it was working').
"What you just experienced is real. That shift in your body — that is what TIPP does.
And you proved to yourself in this room, today, that it is possible. Your body knows
how to do this. The skill is reminding it."
SECTION 5 — GROUP ACTIVITY: MY PERSONAL TIPP PLAN | 15 MINUTES
5.1 Activity instructions
Distribute worksheets if using printed materials, or ask members to write in their DBT
binders/journals. Give the group approximately 8–10 minutes to complete the individual writing,
then 5 minutes to share with a partner or in the group. Participation in sharing is always
voluntary.
"Now we're going to make this personal. TIPP only works in a crisis if you have
already thought through exactly how you will use it — because in the moment, when
your prefrontal cortex is partly offline, you cannot plan. So we plan now, when we
are calm enough to think clearly."
Step 1: Identify your distress signals
Ask members to write down how their body signals that they are approaching a 7 or above.
Prompt:
"Think about the last time you were in real distress. Not everyday stress — real
overwhelming emotion. What was happening in your body? What were the early
warning signs that things were escalating?"
Common signals to prompt if the group is stuck:
• Heart rate increasing noticeably
• Chest tightness or pressure
• Jaw clenching or teeth grinding
• Hands shaking
• Tunnel vision or difficulty focusing
• Dissociation or feeling 'floaty'
• Urge to flee, freeze, or lash out
• Feeling of heat spreading up through the body
Step 2: Write your personalised TIPP plan
Page 8
DBT Group Therapy | Distress Tolerance | TIPP Skill
For each letter, members write what is realistic and accessible for them specifically. Walk them
through each question:
"T — Temperature. What cold source do you have access to at home? At work?
When you are out? Write down at least two options."
"I — Intense exercise. What physical movement can you do in your most common
crisis locations? At home, that might be running up the stairs. At work, it might be
walking very fast around the car park. Think about what is actually possible."
"First P — Paced breathing. What will you say to yourself to remember the ratio?
Some people write '4 in, 8 out' on their phone wallpaper or on a small card in their
wallet. What will work for you?"
"Second P — Progressive relaxation. Where do you hold tension most? Shoulders?
Jaw? Stomach? Your PMR practice does not have to follow a full sequence. If you
know you carry tension in your shoulders, you can start there."
Step 3: Your TIPP trigger point
"Finally, decide now — when will you reach for TIPP? Not after you've already tried
everything else and failed. What SUDS score is your personal trigger point to use
TIPP? Write it down. When I am at a _____, I use TIPP."
Facilitator note: Having a pre-committed trigger point dramatically increases the chance of
skill use in crisis. People who decide in advance at what level to use a skill are far more likely
to actually use it. Encourage specificity — a number, not a vague 'when things get bad.'
SECTION 6 — CLOSING & TAKE-HOME PRACTICE | 5 MINUTES
6.1 Recap
Keep this brief and clear. Do not introduce new material.
"Let's bring together what we covered today. TIPP is a distress tolerance skill for
high-intensity crisis moments — when you are at a 7 or above and your thinking
brain is struggling to come online. The four tools are Temperature, Intense Exercise,
Paced Breathing, and Progressive Relaxation. You do not need all four — pick the
one or two that are most accessible to you in the moment."
"TIPP does not solve the problem. It lowers your distress enough that you can
access your other skills — your problem-solving, your emotion regulation, your
Page 9
DBT Group Therapy | Distress Tolerance | TIPP Skill
interpersonal effectiveness. It clears the way. That is its job. And today you proved
to yourselves that it works."
6.2 Take-home practice
Assign a specific, concrete task — not just 'use TIPP this week.' Vague homework does not get
done. Make it specific.
"This week, I want you to practise paced breathing once a day — not in a crisis, just
as a regular practice. Two minutes, four counts in, six to eight counts out. Morning,
evening, or whenever you can build it in. The reason we practise when we are calm
is so the skill is automatic when we need it most. It is like a fire drill — you practise
before the fire."
"If you do experience a moment of high distress this week — a 7 or above — I want
you to try at least one TIPP tool and note: what was my SUDS before, which tool did
I use, and what was my SUDS after? Bring those observations back to our next
session. There are no wrong answers. We are building data about what works for
you specifically."
Facilitator note: Remind the group that they can also bring observations about what did not
work — those are equally valuable. If TIPP did not help in a particular situation,
understanding why gives important clinical information.
6.3 Closing script
"I want to close with something important. The fact that you are here — that you are
learning these skills and working this hard — matters. Crisis moments can feel like
proof that something is deeply wrong with you. They are not. They are moments of
intense human pain, and you now have tools to move through them. TIPP does not
ask you to change who you are. It just asks your body to do something. And your
body is always with you — even when everything else feels impossible."
"Thank you for today. I will see you next week."
Facilitator note: Allow a moment of quiet after the closing. Do not rush to end the session. If
group members want to share briefly after the close, allow a few minutes. Check in with
anyone who appeared distressed during the session before they leave.
QUICK REFERENCE — TIPP AT A GLANCE
Letter What it is Why it works Best for
T Temperature — cold Triggers dive reflex — rapid Immediate acute crisis,
Page 10
DBT Group Therapy | Distress Tolerance | TIPP Skill
water, ice on face/wrists heart rate reduction urge interruption
I Intense exercise — 2–5 Metabolises stress Rage, agitation, emotional
min vigorous movement hormones (adrenaline, flooding
cortisol)
P Paced breathing — in 4, Activates parasympathetic Anxiety, panic, sleep
out 6–8, for 2+ min system via extended exhale problems
P Progressive relaxation Releases stored physical Tension, insomnia,
— tense & release tension, reduces baseline general physical stress
muscle groups arousal
Clinical reminders for facilitators
1. TIPP reduces distress enough to access other skills — it does not solve the underlying problem.
2. Always clarify the distinction between cold exposure as sensory input vs. pain-based coping for
clients with self-harm history.
3. Adapt intense exercise for members with physical limitations — pacing, chair-based movement, or
vigorous arm movement are valid alternatives.
4. Between-session practice during calm states dramatically improves crisis-time skill access.
5. Validate SUDS reductions of even 1–2 points as meaningful and significant.
6. If a member reports that TIPP did not work in a real crisis, explore collaboratively: Was the distress
too high? Was the technique used for long enough? Were thoughts interfering?
Page 11