TIPP Skills in DBT: A Therapist's Guide

Key Takeaways

• TIPP skills are fast-acting DBT distress tolerance skills that use the physical body to bring down extreme emotional arousal.
• TIPP stands for Temperature, Intense exercise, Paced breathing, and Paired muscle relaxation.
• Marsha Linehan's handouts title them the "TIP" skills and include paired muscle relaxation as a fourth skill, which is why many clinicians say "TIPP."
• Linehan's handouts advise checking with a health care provider before using the temperature or exercise skills if a client has a heart or medical condition, a lowered heart rate from medication, takes a beta-blocker, is allergic to cold (urticaria), or has an eating disorder.
• TIPP works best when clients practice while calm, so the skills are ready when a crisis hits.
• TIPP is a short-term crisis skill. It doesn't replace risk assessment or safety planning.

Your client is pacing. Fists clenched, voice shaking, words tumbling out faster than they can finish a thought.

You could ask them to challenge that thought. You could ask what wise mind would say. But right now? They can barely hear you.

When emotions hit that level, the body has to come down before any talking can land.

That's exactly what TIPP skills are for. Below, we'll cover what each skill involves, the safety cautions to screen for first, how to teach TIPP in session, and where it fits with the rest of DBT (Dialectical Behavior Therapy).

What Are TIPP Skills in DBT?

TIPP skills are a set of four body-based techniques from dialectical behavior therapy (DBT) that help people quickly reduce intense emotional arousal.

They come from Marsha Linehan, who developed DBT, and they're part of the distress tolerance module in her DBT Skills Training Manual. Distress tolerance skills help clients get through a crisis without making things worse.

Linehan's handout is titled "TIP Skills: Changing Your Body Chemistry," and it states the goal plainly: "To reduce extreme emotion mind fast."

The idea is simple. When emotions are sky-high, the body is revved up too. Change the body's chemistry, and the emotion often follows.

TIP or TIPP?

You'll see both. Linehan's handouts are titled "TIP skills," but they cover four skills, including paired muscle relaxation as the second P. Many clinicians and websites call the full set "TIPP."

You'll also see that last P written as progressive muscle relaxation. The two are close relatives, and we'll break down the difference below.

The TIPP Acronym, Explained

Here's what each letter stands for, based on Linehan's handouts.

T Is for Temperature

The temperature skill uses cold water to calm the body fast.

According to Linehan's handout, clients hold their breath and put their face in a bowl of cold water, or hold a cold pack (or a zip-lock bag of cold water) on their eyes and cheeks. They hold it for 30 seconds, and the water should stay above 50°F.

The handout notes that the effect may take 15 to 30 seconds to kick in, and that it works best when sitting quietly.

How the mammalian dive reflex works. The temperature skill taps into what's often called the mammalian dive reflex (Linehan calls it the "dive response"). According to StatPearls, when the dive reflex is triggered with cold water on the face, "the primary result is a reflex bradycardia response," meaning the client’s heart rate will slow down. A slower heart rate signals more calm to the emotional mind, which can help bring down some of the emotional intensity the client is experiencing.

That heart rate drop is also why the safety screening matters so much.

I Is for Intense Exercise

Strong emotions prepare the body for action. Intense exercise gives all that stored-up energy somewhere to go.

Intense exercise shifts brain chemistry, lowers stress hormones, and strengthens the brain's emotional regulation centers. Exercise increases endorphins, which act as natural mood elevators, and can help clear excess adrenaline and cortisol (the primary stress hormones). In addition, bursts of intense exercise can strengthen the connection between the prefrontal cortex and the amygdala, making it easier to calm down the overactive emotional mind.

Linehan's handout suggests engaging in intense exercise, "if only for a short while." Activities like a fast walk around the block, a few minutes of jumping jacks, or running up and down the stairs can all work.

P Is for Paced Breathing

Paced breathing means slowing the breath way down. Linehan's handout recommends breathing deeply into the belly and slowing to about five to six breaths per minute, if possible. By focusing on expanding your stomach during breaths in, your diaphragm moves down, providing more space for the bottom of your lungs to expand.

The key detail: try to breathe out more slowly than you breathe in. The handout gives the example of 5 seconds in and 7 seconds out.

Paced breathing is usually the easiest TIPP skill to use anywhere, since nobody can tell you're doing it, and you always have your breath with you.

P Is for Paired Muscle Relaxation

In paired muscle relaxation, clients pair tensing and relaxing their muscles with their breath. Here's how Linehan's handout lays it out:

1. While breathing deeply into the belly, tense the body's muscles (not enough to cause a cramp).
2. Notice the tension.
3. While breathing out, say the word "Relax" in your mind.
4. Let go of the tension.
5. Notice the difference in your body.

Paired vs. progressive muscle relaxation. Progressive muscle relaxation (PMR) works through muscle groups one at a time. Paired muscle relaxation adds a twist: it links the release of tension to the breath and the cue word "relax." Over time, that pairing can make "relax" a helpful cue in itself. If you already use PMR, our guide to writing a progressive relaxation script is a great companion.

TIPP Safety Considerations to Screen For First

The temperature and intense exercise skills affect heart rate in a big way, so make sure you review the safety considerations with your clients before recommending either skill. Linehan's handout puts it plainly: "Very cold water decreases your heart rate rapidly. Intense exercise will increase heart rate."

Encourage your clients to check in with a health care provider before using these skills if they:

• Have a heart or medical condition
• Have a lowered base heart rate due to medications
• Take a beta-blocker
• Are allergic to cold (urticaria)
• Have an eating disorder

A few more clinical considerations to keep in mind:

• Ask before you teach. Add a few medical screening questions before introducing temperature or exercise. When in doubt, coordinate with the client's medical provider.
• Follow the specs. Stick to Linehan's guidance (water above 50°F, about 30 seconds). Colder can be dangerous, and longer isn't necessarily better.
• Watch for exercise patterns. For clients with eating disorders or compulsive exercise, intense exercise may not be a good fit, even if for just a few minutes.
• Respect physical limits. Injuries, chronic pain, and mobility limits may call for gentler options, like paced breathing.
• Notice reactions to breath focus. Some clients, including some with panic or trauma histories, find breath-holding or breath focus uncomfortable. If so, start with a different skill and go slowly.
• Offer choices. Clients don't need to use all four skills. Many end up with one or two favorites.

When to Use TIPP Skills

TIPP skills are most effective when a client is having a very strong, distressing emotion, or they are experiencing strong urges to engage in dangerous, risky, or reckless behaviors.

In practice, TIPP tends to fit best when a client:

• Is so flooded they can't think clearly or use other skills
• Feels an urge to act in a way that could make things worse
• Needs to calm their body quickly before a hard conversation or decision

If you use the window of tolerance framework (the zone where a client can feel stress and still think clearly and stay present), TIPP is a handy tool for clients pushed into hyperarousal, above their window. Once arousal comes down, they're more likely to reach wise mind and use their other skills.

How to Teach TIPP Skills in Session

TIPP skills are much easier to use in a crisis when clients have practiced them on a calmer day. Here's a teaching sequence that works well for a lot of clients:

1. Screen first. Run through the safety questions above before teaching temperature or exercise.
2. Explain the "why." Clients buy in more when they understand that TIPP changes body chemistry to bring emotion down fast.
3. Practice together. Walk through paced breathing and paired muscle relaxation in session. Demonstrate the temperature skill with a cold pack if it's appropriate for the client.
4. Rate distress before and after. A simple 0 to 10 rating helps clients see the effect for themselves.
5. Pick favorites. Ask which skills felt most helpful and doable.
6. Make a plan. Where will they keep a cold pack? Where could they move their body if they're at work? Practical details make the skill usable.
7. Practice between sessions. Short, regular practice builds the habit.

Here's an illustrative example (not a real session):

Therapist: "Before we try anything, where's your distress right now, from 0 to 10?"

Client: "Maybe a 6. My chest feels tight."

Therapist: "Okay. Let's try paced breathing together. Breathe in for about five seconds... and out for about seven. We'll keep going for a couple of minutes."

Client: (after a few minutes) "Okay. That actually helped a little."

Therapist: "Where would you put your distress now?"

Client: "Maybe a 4? I still feel anxious, but I can think."

Therapist: "That's exactly what TIPP is for. It takes the edge off so your other skills can kick in."

Notice the before and after ratings. They turn "I guess that helped?" into something concrete the client can remember next time.

TIPP Skill Examples

Wondering what TIPP looks like in real life? A few quick examples:

• Panic before a presentation: Paced breathing in a quiet hallway before getting on stage, 5 seconds in and 7 seconds out.
• Rage after an argument: A fast walk around the block before responding to that frustrating text.
• Overwhelming emotion late at night: A cold pack on the eyes and cheeks for 30 seconds while holding the breath (for a client who's been screened and cleared).
• Racing body at bedtime: A few rounds of paired muscle relaxation to help calm the body and ready it for sleep.

Adapting TIPP for Real Life

Crises don't wait for a bowl of cold water and a quiet room. Helping clients adapt TIPP to their actual day makes the skills far more likely to get used.

• At work or school: Paced breathing works anywhere. A short burst of fast stair climbing in a stairwell can stand in for intense exercise.
• On the go: A reusable cold pack in a lunch bag or car makes the temperature skill portable (for clients who've been screened and cleared). Single-use cold packs are often available at pharmacies and can be used on the go as needed without a cooler.
• With teens: Keep the explanation simple and concrete, and involve parents or caregivers in the medical screening.
• With limited mobility: Lean on paced breathing and paired muscle relaxation, which can be done sitting or lying down.

Common Mistakes to Avoid

A few TIPP missteps come up a lot:

• Teaching it for the first time mid-crisis. A flooded client is unlikely to absorb new instructions. Practice on calmer days first.
• Skipping the screening. Temperature and exercise affect heart rate, so screen before teaching them.
• Going colder or longer. More intense isn't more effective. Stick to the handout's guidance.
• Expecting all four to click. Most clients find one or two that work for them, and that's plenty.
• Stopping at TIPP. TIPP lowers the temperature, literally and figuratively. Follow up with other coping skills once the client can think again.

How TIPP Fits With Other DBT Skills

TIPP rarely works alone. It's usually the first move that makes the next move possible.

• STOP. The STOP skill helps clients pause before reacting. TIPP can come next to bring arousal down.
• Other distress tolerance skills. TIPP sits alongside other crisis survival skills covered in our guide to DBT distress tolerance skills.
• Wise mind. Once the body settles, clients have a much better shot at checking in with wise mind.
• Opposite action. Opposite action can help clients act differently once they're calm enough to choose.
• Somatic work. If you use body-based approaches, TIPP pairs nicely with the tools in our guide to somatic exercises in psychotherapy.

When TIPP Isn't Enough

TIPP is a great short-term tool. It's designed to get clients through an intense moment, and it works best as part of a bigger treatment plan.

A few things to keep in mind:

• TIPP doesn't replace risk assessment. If a client reports thoughts of suicide or self-harm, follow your usual risk assessment and safety planning process. Tools like the C-SSRS can help. If a client is in crisis between sessions, they can call or text 988 to reach the 988 Suicide & Crisis Lifeline, which is free, confidential, and available 24/7.
• Frequent crises are a signal. If a client is reaching for TIPP every day, it may be time to revisit the treatment plan, add support, or consider a higher level of care.
• Medical concerns come first. If a client has any health questions about these skills, loop in their medical provider.
• TIPP manages the moment. Longer-term work on emotion regulation, triggers, and life circumstances still matters.

Documenting TIPP Skills in Your Notes

Clear notes make it easier to track which skills are actually helping. A few things worth capturing:

• The skill taught or practiced
• Any medical screening or provider coordination
• Distress ratings before and after
• The client's response and preferences
• Practice assigned between sessions

For example:

"Reviewed TIPP skills. Completed medical screening; client denies cardiac conditions, beta-blocker use, or eating disorder history. Practiced paced breathing and paired muscle relaxation in session. Client rated distress 6/10 before and 4/10 after. Client identified paced breathing as preferred skill. Assigned daily 5-minute paced breathing practice."

This kind of note fits nicely into DAP notes and makes it easy to see progress over time.

Tracking skills, ratings, and progress across sessions adds up. Blueprint's AI-powered EHR helps therapists write session notes faster and track progress over time, so you can spend less time documenting and more time with clients. See how Blueprint works.

TIPP Skills FAQ

What is an example of a TIPP skill?

Paced breathing is a common example. A client slows their breathing to about five or six breaths per minute, breathing out longer than they breathe in, such as 5 seconds in and 7 seconds out.

Is TIPP CBT or DBT?

TIPP is a DBT skill. It's part of the distress tolerance module in Marsha Linehan's DBT skills training. DBT itself is often described as a type of cognitive behavioral therapy, so you'll sometimes see TIPP mentioned in CBT settings too.

What does TIPP stand for?

TIPP stands for Temperature, Intense exercise, Paced breathing, and Paired muscle relaxation. Some sources write the last P as progressive muscle relaxation, but Linehan's handouts use paired muscle relaxation.

Is it TIP or TIPP?

Both are used. Linehan's handouts are titled "TIP skills" and include paired muscle relaxation as a fourth skill. Many clinicians call the full set "TIPP."

How quickly do TIPP skills work?

They're designed to work fast. Linehan's handout notes that the dive response from the temperature skill may take 15 to 30 seconds to start.

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