Dialectical Behavior Therapy (DBT) was developed by Marsha Linehan to help people regulate emotions, tolerate distress, and improve relationships. Among its four skills modules, Distress Tolerance is often the most immediately useful when clients are facing emotional crises or urges to engage in harmful behaviors.
As a therapist, knowing how to introduce, practice, and review Distress Tolerance worksheets in session is one of the most practical ways to help clients gain confidence with these skills. Below you’ll find a detailed guide you can adapt directly into your clinical work.
Why Distress Tolerance Worksheets Work in Session
-Structure during chaos: Clients in high-distress moments often struggle to think clearly. Worksheets provide a simple, step-by-step process they can follow.
-Concrete practice: DBT is skills-based, not just insight-based. Worksheets transform abstract coping strategies into actionable exercises.
-Between-session carryover: Clients leave with something tangible they can use outside the therapy room, which strengthens skill generalization.
-Tracking growth: Worksheets can be reviewed session-to-session, helping therapists and clients see patterns, progress, and ongoing challenges.
Step 1: Introduce the Concept of Distress Tolerance
Before handing out a worksheet, set the stage:
-Explain that distress tolerance doesn’t mean avoiding or suppressing emotions — it means surviving the storm without making it worse.
-Highlight situations where these skills are most useful: intense urges, interpersonal conflicts, trauma triggers, or when clients feel “out of control.”
-Normalize the struggle: “No one regulates perfectly. These are tools to help you get through the hard moment until it passes.”
Step 2: Choose the Right Worksheet for the Client
DBT Distress Tolerance worksheets often fall into categories. Selecting the right one depends on your client’s needs:
-Crisis Survival Skills Worksheets
- ACCEPTS (Activities, Contributing, Comparisons, Emotions, Pushing away, Thoughts, Sensations)
- TIPP (Temperature, Intense Exercise, Paced Breathing, Progressive Relaxation)
- Pros & Cons of Acting on Urges
-Self-Soothe & Grounding Worksheets
- Focus on using the five senses (sight, sound, touch, taste, smell) to regulate in the moment.
- Helpful for trauma triggers, anxiety spikes, or panic symptoms.
-Radical Acceptance Worksheets
- Guide clients through acknowledging painful realities without judgment.
- Useful for grief, chronic illness, or situations outside the client’s control.
Step 3: Practice the Worksheet in Session
-Walk through an example together.
Invite the client to recall a recent distressing event (mild to moderate intensity for practice).
- Fill out the worksheet collaboratively. For example:
- Trigger/Event: “Argument with my partner.”
- Automatic Urge: “I wanted to scream or leave the house.”
- Worksheet Prompt (ACCEPTS): Brainstorm one or two actions in each category.
Pause often to reflect: “What skill feels doable in the moment?” or “Which of these worked for you in the past?”
This modeling shows clients how to actually use the tool instead of just reading about it.
Step 4: Assign as Homework and Review
-Encourage clients to use the worksheet at least once between sessions.
-Emphasize “real-time” practice: “The next time you feel urges rising, grab this worksheet instead of acting right away.”
-Begin the following session by reviewing what they wrote:
- Where did the worksheet help?
- What was difficult?
- Did the urge decrease after using the skill?
This cycle of practice → review → refine builds mastery.
Therapist Tips for Success
-Match intent to worksheet: Don’t use safety tips or psychoeducation sheets when the client really needs a crisis survival plan.
-Simplify for overwhelmed clients: Highlight just one or two skills per session to prevent cognitive overload.
-Model use yourself: Show clients that even therapists use grounding or breathing exercises.
-Praise effort, not perfection: Even partial completion of a worksheet can be progress.
DBT Distress Tolerance ⬇️
Download Printable DBT Distress Tolerance Worksheets
Looking for More DBT Resources?
- DBT vs. CBT Worksheets – understanding which therapy tool to use.
- Complete DBT Skills Workbook for Therapists – 100+ pages of done-for-you worksheets.