Step 6. When a stressful situation occurs, practice effective rethinking and paired relaxation.
Note.  Adapted from Smith, R. E. (1980). Development of an integrated coping response through cognitive–  a ffective stress management train -
ing. In I. G. Sarason & C. D. Spielberger (Eds.), Stress and anxiety (Vol. 7, pp.

265–280). Washington, DC: Hemisphere. Copyright 1980 by
Hemisphere Publishing Corporation. Adapted by permission.Emotional arousalStressful
prompting eventWhat I tell myself
Effective self-statement . . . “ . . . So . . .
 . . . relax.”
(breathing in . . . )( . . . breathing out)
Examples:
“It’s not that important . . . so . . . relax. “I may not like this, but I can definitely stand it . . . so . . . relax.”“I need to concentrate and not make myself  uptight . . . so . . . relax.”“I’m in control . . . so . . . relax.”


333
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission
to photocopy this handout is granted to purchasers of this book for personal use only (see copyright page for details).distress tolerance Handout 7   (Distress Tolerance Worksheets 5–5b)
Distracting
A way to remember these skills is the phrase “Wise m ind accep TS.”
With activities:
Focus attention on a task you need to get
done.
Rent movies; watch TV.
Clean a room in your house.
Find an event to go to.
Play computer games.
Go walking. Exercise.
Surf the Internet. Write e-mails.
Play sports.Go out for a meal or eat a favorite food.
Call or go out with a friend.
Listen to your iPod; download music.
Build something.
Spend time with your children.
Play cards.
Read magazines, books, comics.
Do crossword puzzles or Sudoku.
Other:
With contributing:
Find volunteer work to do.
Help a friend or family member.
Surprise someone with something nice (a
card, a favor, a hug).
Give away things you don’t need.Call or send an instant message encouraging
someone or just saying hi.
Make something nice for someone else.


someone or just saying hi.
Make something nice for someone else.
Do something thoughtful.
Other:
With comparisons:
Compare how you are feeling now to a time when you felt different.
Think about people coping the same as you or
less well than you.Compare yourself to those less fortunate.
Watch reality shows about others’ troubles;
read about disasters, others’ suffering.
Other:
With different e motions:
Read emotional books or stories, old letters.
Watch emotional TV shows; go to emotional movies.
Listen to emotional music.
(Be sure the event creates different emotions.)Ideas : Scary movies, joke books, comedies,
funny records, religious music, soothing music
or music that fires you up, going to a store and reading funny greeting cards.
Other:
With pushing away:
Push the situation away by leaving it for a
while.
Leave the situation mentally.
Build an imaginary wall between yourself and the situation.
Block thoughts and images from your mind.Notice ruminating: Yell “No!”
Refuse to think about the painful situations.
Put the pain on a shelf. Box it up and put it
away for a while.
Deny the problem for the moment.
Other:
With other T houghts:
Count to 10; count colors in a painting or
poster or out the window; count anything.


poster or out the window; count anything.
Repeat words to a song in your mind.Work puzzles.
Watch TV or read.
Other:
With other S ensations:
Squeeze a rubber ball very hard.
Listen to very loud music.
Hold ice in your hand or mouth.Go out in the rain or snow.
Take a hot or cold shower.
Other:


334
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission
to photocopy this handout is granted to purchasers of this book for personal use only (see copyright page for details).distress tolerance Handout 8   (Distress Tolerance Worksheet 6–6b)
Self-  Soothing
A way to remember these skills is to think of soothing each of your five S enSeS.
With vision:
Look at the stars at night.
Look at pictures you like in a book.
Buy one beautiful flower.
Make one space in a room pleasing to look at.
Light a candle and watch the flame.
Set a pretty place at the table using your best
things.
Go people- watching or window-  shopping.
Go to a museum or poster shop with beautiful
art.Sit in the lobby of a beautiful old hotel.
Look at nature around you.
Walk in a pretty part of town.
Watch a sunrise or a sunset.
Go to a dance performance, or watch it on TV.
Be mindful of each sight that passes in front of you.
Take a walk in a park or a scenic hike.
Browse through stores looking at things.
Other:
With hearing:
Listen to soothing or invigorating music.
Pay attention to sounds of nature (waves, birds, rainfall, leaves rustling).


Pay attention to the sounds of the city (traffic, horns, city music).
Sing to your favorite songs.
Hum a soothing tune.
Learn to play an instrument.Burn a CD or make an iPod mix with music that will get you through tough times. Turn it on.
Be mindful of any sounds that come your way, letting them go in one ear and out the other.
Turn on the radio.
Other:
With Smell:
Use your favorite soap, shampoo, aftershave, cologne, or lotions, or try them on in the store.
Burn incense or light a scented candle.
Open a package of coffee and inhale the aroma.
Put lemon oil on your furniture.
Put potpourri or eucalyptus oil in a bowl in your room.Sit in a new car and breathe the aroma.
Boil cinnamon. Make cookies, bread, or popcorn.
Smell the roses.
Walk in a wooded area and mindfully breathe in the fresh smells of nature.
Open the window and smell the air.
Other:
With Taste:
Eat some of your favorite foods.
Drink your favorite soothing drink, such as herbal tea, hot chocolate, a latté, or a
smoothie.
Treat yourself to a dessert.
Eat macaroni and cheese or another favorite
childhood food.


Eat macaroni and cheese or another favorite
childhood food.
Sample flavors in an ice cream store.Suck on a piece of peppermint candy.
Chew your favorite gum.
Get a little bit of a special food you don’t
usually spend the money on, such as fresh-
squeezed orange juice or your favorite candy.
Really taste the food you eat. Eat one thing
mindfully.
Other:
With Touch:
Take a long hot bath or shower.
Pet your dog or cat.
Have a massage. Soak your feet.
Put creamy lotion on your whole body.
Put a cold compress on your forehead.
Sink into a comfortable chair in your home.
Put on a blouse or shirt that has a pleasant feel.Take a drive with the car windows rolled down.
Run your hand along smooth wood or leather.
Hug someone.
Put clean sheets on the bed.
Wrap up in a blanket.
Notice touch that is soothing.
Other:


335
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission
to photocopy this handout is granted to purchasers of this book for personal use only (see copyright page for details).distress tolerance Handout 8a   (Distress Tolerance Worksheet 6c)
Body Scan m editation Step by Step
Sit on a chair, or lie on your back on the floor with legs uncrossed. Put your arms in a comfortable
position by your side, on your abdomen, or (if sitting) put them on your thighs palms up. Open your eyes partially to let light in. If you are lying on the floor, put a cushion under your knees if need
be. Imagine your breath flowing to each part of your body as your attention gently moves up your
body. Adopt a mind of curiosity and interest as you focus on each part of your body.
Focus on your breathing. Notice how the air moves in and out of your body.
••Take several deep breaths until you begin to feel comfortable and relaxed.
••Direct your attention to the toes  of your left foot.
••Notice the sensations in that part of your body while remaining aware of your breathing.
••Imagine each breath flowing to your toes .
••Looking with curiosity, ask, “What am I feeling in this part of my body?”
••Focus on your left toes  for several minutes.
••Then move your focus to the arch  and heel of your left foot, and hold it there for a minute or
two while continuing to pay attention to your breathing.
••Notice the sensations on your skin of warmth or coldness; notice the weight of your foot on
the floor.


the floor.
••Imagine your breath flowing to the arch  and heel of your left foot.
••Ask, “What are the feelings in the arch  and heel of my left foot?”
••Follow the same procedure as you move to your left ankle , calf, knee , upper legs,  and thigh .
••Repeat with the right leg, starting with your toes.
••Then move through your pelvis , and lower  back , and around to your stomach .
••Focus on the rising and falling of your belly as your breath goes in and out.
••Then go on to your chest ; left hand , arm, and shoulder ; right hand , arm, and shoulder ; neck ,
chin, tongue , mouth , lips, and lower face ; and nose .
••Notice your breath as it comes in and out of your nostrils.
••Then focus on your upper cheeks, eyes, forehead, and scalp.
••Finally, focus on the very top of your hair.
••Then let go of your body altogether.
Don’t worry if you notice that thoughts, sounds, or other sensations come into your awareness. Just notice them and then gently refocus your mind. Don’t worry if your mind has been drawn away from the object of your attention and you find yourself thinking about something else (it nearly always happens). Just calmly, gently, but with resolution, turn your mind back to the part of the body you’ve reached. You may need to bring your attention back over and over. You are not alone in this.
It is this bringing of your attention back over and over and over, without judgment or harshness, that
is the essential element of the meditation.


336
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission
to photocopy this handout is granted to purchasers of this book for personal use only (see copyright page for details). distress tolerance Handout 9   (Distress Tolerance Worksheets 7–7b)
improving the m oment
A way to remember these skills is the word improve .
With imagery:
Imagine very relaxing scenes.
Imagine a secret room within yourself. Furnish
it the way you like. Close and lock the door on
anything that can hurt you.
Imagine everything going well.
Make up a calming fantasy world.Imagine hurtful emotions draining out of you
like water out of a pipe.
Remember a happy time and imagine yourself
in it again; play out the time in your mind
again.
Other:
With meaning:
Find purpose or meaning in a painful situation.
Focus on whatever positive aspects of a painful situation you can find.
Repeat these positive aspects in your mind.Remember, listen to, or read about spiritual values.
Other:
With prayer:
Open your heart to a supreme being, God, or your own Wise Mind.
Ask for strength to bear the pain.Turn things over to God or a higher being.
Other:
With relaxing  actions :
Take a hot bath or sit in a hot tub.
Drink hot milk.


Drink hot milk.
Massage your neck and scalp.
Practice yoga or other stretching.Breathe deeply.
Change your facial expression.
Other:
With one thing in the moment:
Focus your entire attention on just what you are doing.
Keep yourself in the moment.
Put your mind in the present.Focus your entire attention on the physical
Listen to a sensory awareness recording (or use Distress Tolerance Handout 9a)
Other:
With a brief v acation:
Give yourself a brief vacation.
Get in bed; pull the covers up over your head.
Go to the beach or the woods for the day.
Get a magazine and read it with chocolates.
Turn off your phone for a day.Take a blanket to the park and sit on it for a whole afternoon.
Take a 1-hour breather from hard work.
Take a brief vacation from responsibility.
Other:
With self- encouragement and rethinking the situation:
Cheerlead yourself: “You go, girl!” “You da man!”
“I will make it out of this.”
“I’m doing the best I can.”
Repeat over and over: “I can stand it.”“This too shall pass.”
“I will be OK.”
“It won’t last forever.”
Other:


“It won’t last forever.”
Other:
List (and then practice) rethoughts that are particularly important in your crisis situations (e.g., “The fact that he did
not pick me up doesn’t mean he doesn’t love me”):


337
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission
to photocopy this handout is granted to purchasers of this book for personal use only (see copyright page for details).distress tolerance Handout 9a
Sensory a wareness, Step by Step
Find a comfortable position. Staying in this position, listen to the questions below, listening for your
response after each question. If you do not have a recording of these questions, you can make one for yourself (or ask a friend to make one), recording each question with about 5 seconds
between each question.
 1. Can you feel your hair touching your head?
 2. Can you feel your belly rising and falling as you breathe?
 3. Can you feel the space between your eyes?
 4. Can you feel the distance between your ears?
 5. Can you feel your breath touching the back of your eyes while you inhale?
 6. Can you picture something far away?
 7. Can you notice your arms touching your body?
 8. Can you feel the bottoms of your feet?
 9. Can you imagine a beautiful day at the beach?
10. Can you notice the space within your mouth?
11. Can you notice the position of your tongue in your mouth?
12. Can you feel a breeze against your cheek?
13. Can you feel how one arm is heavier than the other?
14. Can you feel a tingling or numbness in one hand?
15. Can you feel how one arm is more relaxed than the other?
16. Can you feel a change in the temperature in the air around you?
17. Can you feel how your left arm is warmer than the right?


17. Can you feel how your left arm is warmer than the right?
18. Can you imagine how it would feel to be a rag doll?
19. Can you notice any tightness in your left forearm?
20. Can you imagine something very pleasant?
21. Can you imagine what it would feel like to float on a cloud?
22. Can you imagine what it would feel like to be stuck in molasses?
23. Can you picture something far away?
24. Can you feel a heaviness in your legs?
25. Can you imagine floating in warm water?
26. Can you notice your body hanging on your bones?
27. Can you allow yourself to drift lazily?
28. Can you feel your face getting soft?
29. Can you imagine a beautiful flower?
30. Can you feel how one arm and leg are heavier than the other?
Note.  Items 29 and 30 are adapted from Goldfried, M. R., & Davison, G. C. (1976). Clinical behavior therapy. New York: Holt, Rinehart & Win -
ston. Copyright 1976 by Marvin R. Goldfried and Gerald C. Davison. Adapted by permission of the authors.


341
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission
to photocopy this handout is granted to purchasers of this book for personal use only (see copyright page for details). distress tolerance Handout 10   (Distress Tolerance Worksheets 8–15a)
overview:
reality a cceptance Skills
These are skills for how to live a life that is not the life you want.
raDical a ccep Tance
Turnin G The m inD
Willin Gne SS
half-  Smilin G anD Willin G han DS
alloWinG The m inD:
minDfulne SS of c urren T Thou GhTS


342
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission
to photocopy this handout is granted to purchasers of this book for personal use only (see copyright page for details). distress tolerance Handout 11   (Distress Tolerance Worksheets 8–9a)
radical a cceptance
(When you cannot keep painful events and emotions from coming your way.)
Wha T iS r aDical a ccep Tance?
1. Radical means all the way , complete and total.
2. It is accepting in your mind, your heart, and your body.
3. It’s when you stop fighting reality, stop throwing tantrums because reality is not
the way you want it, and let go of bitterness.
Wha T haS To Be a ccep TeD?
1. Reality is as it is (the facts about the past and the present are the facts, even if you don’t like them).
2. There are limitations on the future for everyone (but only realistic limitations need to be accepted).
3. Everything has a cause (including events and situations that cause you pain and suffering).
4. Life can be worth living even with painful events in it.
Why a ccep T reali Ty?
1. Rejecting reality does not change reality.
2. Changing reality requires first accepting reality.
3. Pain can’t be avoided; it is nature’s way of signaling that something is wrong.
4. Rejecting reality turns pain into suffering.
5. Refusing to accept reality can keep you stuck in unhappiness, bitterness, anger,
sadness, shame, or other painful emotions.
6. Acceptance may lead to sadness, but deep calmness usually follows.


6. Acceptance may lead to sadness, but deep calmness usually follows.
7. The path out of hell is through misery. By refusing to accept the misery that is
part of climbing out of hell, you fall back into hell.


343
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission
to photocopy this handout is granted to purchasers of this book for personal use only (see copyright page for details).distress tolerance Handout 11a
radical a cceptance: f actors That interfere
raDical a ccep Tance iS n oT:
Approval, compassion, love, passivity, or against change.
facTorS Tha T inTerfere W iTh accep Tance
1. You don’t have the skills for acceptance; you do not know
how to accept really painful events and facts.
2. You believe that if you accept a painful event, you are making light of it or are approving of the facts, and that nothing will be done to change or prevent future painful
events.
3. Emotions get in the way (unbearable sadness; anger at
the person or group that caused the painful event; rage at the injustice of the world; overwhelming shame about who you are; guilt about your own behavior).
Other:


344
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission
to photocopy this handout is granted to purchasers of this book for personal use only (see copyright page for details).distress tolerance Handout 11b   (Distress Tolerance Worksheets 9, 9a)
practicing r adical a cceptance Step by Step
Observe that you are questioning or fighting reality (“It shouldn’t be this way”).
Remind yourself that the unpleasant reality is just as it is and cannot be changed (“This is what
happened”).
Remind yourself that there are causes for the reality. Acknowledge that some sort of history led up to this very moment. Consider how people’s lives have been shaped by a series of factors. Notice that given these causal factors and how history led up to this moment, this reality had to occur just this way (“This is how things happened”).
Practice accepting with the whole self (mind, body, and spirit). Be creative in finding ways to involve your whole self. Use accepting self-talk—but also consider using relaxation; mindfulness of your breath; half-  smiling and willing hands while thinking about what feels
unacceptable; prayer; going to a place that helps bring you to acceptance; or imagery.
Practice opposite action. List all the behaviors you would do if you did accept the facts. Then
act as if you have already accepted the facts. Engage in the behaviors that you would do if you
really had accepted.


really had accepted.
Cope ahead with events that seem unacceptable. Imagine (in your mind’s eye) believing what you don’t want to accept. Rehearse in your mind what you would do if you accepted what seems unacceptable.
Attend to body sensations as you think about what you need to accept.
Allow disappointment, sadness, or grief to arise within you.
Acknowledge that life can be worth living even when there is pain.
Do pros and cons if you find yourself resisting practicing acceptance.


345
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission
to photocopy this handout is granted to purchasers of this book for personal use only (see copyright page for details). distress tolerance Handout 12   (Distress Tolerance Worksheets 8, 8a, 10)
Turning the m ind
TURNING  THE  MIND  is like facing a fork in the road. You
have to turn your mind toward the acceptance road, and
away from the road of rejecting reality.
TURNING  THE  MIND  is choosing to accept.
The CHOICE  to accept does not itself equal acceptance.
It just puts you on the path.
Turnin G The m inD, STep B y STep
1. oBS erve  that you are not accepting.
(Look for anger, bitterness, annoyance;
avoiding emotions; saying “Why me?”,
“Why is this happening?”, “I can’t stand this,” “It shouldn’t be this way.”)
2. Go within yourself and make an inner commiTmenT  to accept reality
as it is.
3. Do iT aGain, over and over. Keep
turning your mind to acceptance each time you come to the fork in the road where you can reject reality or accept it.
4. Develop a plan for catching yourself in the future when you drift out of acceptance.If you are here . . .Rejection Acceptance


346
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission
to photocopy this handout is granted to purchasers of this book for personal use only (see copyright page for details). distress tolerance Handout 13   (Distress Tolerance Worksheets 8, 8a, 10)
Willingness
Willingness is readiness to enter and participate fully in life and living.
find a W illin G reSpon Se to each situation.
Willingness is DOING JUST WHAT IS NEEDED :
••In each situation.
••Wholeheartedly, without dragging your feet.
Willingness is listening very carefully to your WISE  MIND, and then
acting from your WISE  MIND.
Willingness is ACTING WITH AWARENESS that you are connected
to the universe (to the stars, people you like and don’t like, the floor, etc.).
replace Willfulne SS with W illinG neSS.
••Willfulness is refu SinG To Tolera Te the moment.
••Willfulness is refusing to make changes that are needed.
••Willfulness is G ivinG up.
••Willfulness is the oppo SiTe of “ DoinG WhaT Work S.”
••Willfulness is trying to fix every S iTuaTion.
••Willfulness is insisting on Bein G in con Trol.
••Willfulness is a TTachmenT  To “me, me, me”  and “what I want
right now!”
Willin GneSS, STep B y STep
1. oBS erve  the willfulness. Label it. Experience it.


1. oBS erve  the willfulness. Label it. Experience it.
2. raDically accep T that at this moment you feel (and may be
acting) willful. You cannot fight willfulness with willfulness.
3. Turn your min D toward acceptance and willingness.
4. Try half-  Smilin G and a W illin G poSTure.
5. When willfulness is immovable, a Sk, “Wha T’S The T hrea T?”
Situations where i notice my own:
Willfulness:
Willingness:


347
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission
to photocopy this handout is granted to purchasers of this book for personal use only (see copyright page for details). distress tolerance Handout 14   (Distress Tolerance Worksheets 8, 8a, 11)
half- Smiling and Willing h ands
accepting reality with your body.
half-  Smilin G
1st. Relax  your face from the top of your head down to your chin and jaw.
Let go of each facial muscle (forehead, eyes, and brows; cheeks,
mouth, and tongue; teeth slightly apart). If you have difficulty, try tensing your facial muscles and then letting go.
A tense smile is a grin (and might tell your brain you are hiding or
masking your real feelings).
2nd. Let both corners of your lips go slightly up, just so you can feel them.
It is not necessary for others to see it. A half-smile is slightly upturned lips with a relaxed face.
3rd. Try to adopt a serene facial expression.
Remember, your face communicates to your brain; your body connects to your mind.
WillinG  hanDS
Standing: Drop your arms down from your shoulders; keep them
straight or bent slightly at the elbows. With hands
unclenched, turn your hands outward, with thumbs out to your sides, palms up, and fingers relaxed.
Sitting: Place your hands on your lap or your thighs. With hands unclenched, turn your hands outward, with palms up and fingers relaxed.
lying down: Arms by your side, hands unclenched, turn your palms up with fingers relaxed.


Remember, your hands communicate to your brain; your body connects to
your mind.


348
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission
to photocopy this handout is granted to purchasers of this book for personal use only (see copyright page for details).distress tolerance Handout 14a   (Distress Tolerance Worksheet 10) (p. 1 of 2)
practicing h alf- Smiling and Willing h ands
1. half- Smile W hen you fir ST W ake up in T he mornin G.
Hang a branch, any other sign, or even the word “smile” on the ceiling or wall, so that you see it
right away when you open your eyes. This sign will serve as your reminder. Use these seconds before you get out of bed to take hold of your breath. Inhale and exhale three breaths gently while maintaining a half-smile. Follow your breaths. Add willing hands to your half-smile, or
practice willing hands alone.
2. half- Smile D urinG  your free momenTS .
Anywhere you find yourself sitting or standing, half-smile. Look at a child, a leaf, a painting on a
wall, or anything that is relatively still, and smile. Inhale and exhale quietly three times.
3. half- Smile W iTh Willin G han DS W hile you are li STenin G To mu Sic.
Listen to a piece of music for 2 or 3 minutes. Pay attention to the words, music, rhythm, and sentiments of the music you are listening to (not your daydreams of other times). Half-smile
while watching your inhalations and exhalations. Adopt a willing-hands posture.


while watching your inhalations and exhalations. Adopt a willing-hands posture.
4. half- Smile W iTh Willin G han DS W hen you are irri TaTeD.
When you realize “I’m irritated,” half-smile or adopt a willing-hands posture at once. Inhale and
exhale quietly, maintaining a half-smile or willing hands for three breaths.
5. half- Smile in a lyinG -DoWn po SiTion.
Lie on your back on a flat surface, without the support of mattress or pillow. Keep your two arms
loosely by your sides, and keep your two legs slightly apart, stretched out before you. Maintain
willing hands and a half-smile. Breathe in and out gently, keeping your attention focused on your breath. Let go of every muscle in your body. Relax each muscle as though it were sinking down through the floor, or as though it were as soft and yielding as a piece of silk hanging in the breeze to dry. Let go entirely, keeping your attention only on your breath and half-smile. Think of yourself as a cat, completely relaxed before a warm fire, whose muscles yield without
resistance to anyone’s touch. Continue for 15 breaths.
6. half- Smile in a S iTTinG po SiTion.
Sit on the floor with your back straight, or on a chair with your two feet touching the floor. Half-
smile. Inhale and exhale while maintaining the half-smile. Let go.
(continued on next page )
Note. Exercises 1 and 3–7 are adapted from The Miracle of Mindfulness (pp. 77–81, 93) by Thich Nhat Hanh. Copyright 1975, 1976 by Thich


Nhat Hanh. Preface and English translation copyright 1975, 1976, 1987 by Mobi Ho. Adapted by permission of Beacon Press, Boston.


349distress tolerance Handout 14a   (p. 2 of 2)
7. half- Smile W iTh Willin G han DS W hile you are con Templa TinG a per Son
you D iSlike or are an Gry W iTh.
••Sit quietly. Breathe and smile a half-smile. Hold your hands open with palms up.
••Imagine the image of the person who has caused you suffering.
••Regard the features you dislike the most or find the most repulsive.
••Try to examine what makes this person happy and what causes suffering in his or her
daily life.
••Imagine the person’s perceptions; try to see what patterns of thought and reason this person follows.
••Examine what motivates this person’s hopes and actions.
••Finally, consider the person’s consciousness. See whether the person’s views and insights are open and free or not, and whether or not the person has been influenced by any prejudices, narrow-  mindedness, hatred, or anger.
••See whether or not the person is master of him- or herself.
••Continue until you feel compassion rise in your heart like a well filling with fresh water,
and your anger and resentment disappear. Practice this exercise many times on the same person.
notes/ other times to half-smile and/or form willing hands:


350
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission
to photocopy this handout is granted to purchasers of this book for personal use only (see copyright page for details). distress tolerance Handout 15   (Distress Tolerance Worksheets 8, 8a, 12)
mindfulness of c urrent Thoughts
1. oBS erve your T hou GhTS.
••As waves, coming and going.
••Not suppressing thoughts.
••Not judging thoughts.
••Acknowledging their presence.
••Not keeping thoughts around.••Not analyzing thoughts.
••Practicing willingness.
••Stepping back and observing
thoughts as they run in and out of your mind.
2. aD opT a curiou S min D.
••Ask, “Where do my thoughts come from?” Watch and see.
••Notice that every thought that comes also goes out of your mind.
••Observe but do not evaluate your thoughts. Let go of judgments.
3. remem Ber: y ou are no T your T hou GhTS.
••Do not necessarily act on thoughts.
••Remember times when you have had very different thoughts.
••Remind yourself that catastrophic thinking is “emotion mind.”
••Remember how you think when you are not feeling such intense suffering and pain.
4. Don’ T Block or S uppre SS T hou GhTS.
••Ask, “What sensations are these thoughts trying to avoid?” Turn your mind to the sensation. Then come back to the thought. Repeat several times.
••Step back; allow your thoughts to come and go as you observe your breath.


••Step back; allow your thoughts to come and go as you observe your breath.
••Play with your thoughts: Repeat them out loud over and over as fast as
you can. Sing them. Imagine the thoughts as the words of a clown, as
recordings getting all tangled up; as cute animals you can cuddle up to; as bright colors running through your mind; as only sounds.
••Try loving your thoughts.


351
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission
to photocopy this handout is granted to purchasers of this book for personal use only (see copyright page for details).distress tolerance Handout 15a   (Distress Tolerance Worksheets 8, 8a, 12) (p. 1 of 2)
practicing m indfulness of Thoughts
prac Tice m inDfulne SS of Thou GhTS B y oBS ervin G Them
 1. Notice thoughts as they come into your mind. As a thought comes into your mind, say
“a thought has entered my mind.” Label the thought as a thought, saying, “The thought
[describe thought] arose in my mind.” Use a gentle voice tone.
 2. As you notice thoughts in your mind, ask, “Where did the thought come from?” Then watch
your mind to see if you can see where it came from.
 3. Step back from your mind, as if you are on top of a mountain and your mind is just a boulder down below. Gaze at your mind, watching what thoughts come up when you are watching it. Come back into your mind before you stop.
 4. Close your eyes and scan your body for the first physical sensation that you notice. Then scan your mind for the first thought you notice. Shuttle back and forth between scanning for physical sensations and scanning for thoughts. Another time, replace scanning your body for physical sensations to scanning yourself for any emotional feelings. Then shuttle back
and forth between an emotional feeling and a thought.


and forth between an emotional feeling and a thought.
prac Tice m inDfulne SS of Thou GhTS B y uS inG Wor DS an D voice Tone
 5. Verbalize thoughts or beliefs out loud, using a nonjudgmental voice tone, over and over and
over:
As fast as you can until the thoughts make no sense.
Very, very slowly (one syllable or word per breath).
In a different voice from yours (high- or low-  pitched, like a cartoon character or celebrity).
As a dialogue on a TV comedy show (“You’ll never believe what thought went through
my mind. I was thinking, ‘I’m a jerk.’ Can you believe that?”).
As songs, sung wholeheartedly and dramatically, in a tune that fits the thoughts.
prac Tice m inDfulne SS of Thou GhTS W iTh oppoSiTe acTion
 6. Relax your face and body while imagining accepting your thoughts as only thoughts—
sensations of the brain.
 7. Imagine things you would do if you stopped believing everything you think.
 8. Rehearse in your mind the things that you would do if you did not view your thoughts as
facts.
 9. Practice loving your thoughts as they go through your mind.
(continued on next page )


352distress tolerance Handout 15a   (p. 2 of 2)
prac Tice m inDfulne SS of Thou GhTS B y imaGininG Tha T your m inD iS:
10. A conveyor belt, and that thoughts and feelings are coming down the belt. Put each thought
or feeling in a box labeled with the type of thought that it is (e.g., worry thoughts, thoughts
about my past, thoughts about my mother, planning what to do thoughts). Just keep
observing and sorting thoughts into the labeled boxes.
11. A river, and that thoughts and feelings are boats going down the river. Imagine sitting on the grass, watching the boats go by. Try not to jump on the boat.
12. A railroad track, and that thoughts and feelings are train cars going by. Try not to jump on
the train.
13. A leaf that has dropped off a tree into a beautiful creek flowing by you as you sit on the grass. Each time a thought or image comes into your mind, imagine that it is written or
pictured on the leaf floating by. Let each leaf go by, watching as it goes out of sight.
14. The sky, and thoughts have wings and can fly through the sky. Watch as each flies out of
sight.
15. The sky, and thoughts are clouds. Notice each thought-cloud as it drifts by, letting it drift out of your mind.
16. A white room with two doors. Through one door, thoughts come in; through the other,
thoughts go out. Watch each thought with attention and curiosity until it leaves. Let go of


judgments. Let go of analyzing thoughts and of figuring out if they fit the facts. As a thought
comes into your mind, say, “A thought has entered my mind.”
Other:
Other:
Other:
Other:
Other:


Handouts for Skills When the Crisis
Is Addiction


355
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission
to photocopy this handout is granted to purchasers of this book for personal use only (see copyright page for details).distress tolerance Handout 16   (Distress Tolerance Worksheets 13–18)
overview:
When the c risis i s addiction
Skills for backing down from addiction.
you can remember them as D, c , B, a .
DDialecTical aBSTinence
Cclear m inD
communiT y reinforcemenT
BBurnin G BriDGe S
anD  Buil DinG neW one S
AalTerna Te reB ellion
aDapTive Denial


356
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission
to photocopy this handout is granted to purchasers of this book for personal use only (see copyright page for details).distress tolerance Handout 16a
common a ddictions
in case you thought you had no addictions, here is a list.
you are  addicted  when you are unable to stop a behavior pattern or use of
substances, despite negative consequences and despite your best efforts to stop.
Alcohol
Attention seeking
Avoiding:
Auto racing
Betting
Bulimia (purging/vomiting)
Cheating
Coffee
Colas
Collecting:
Art
Coins
Junk
Clothes
Shoes
Music
Other:
Other:
Computers
Criminal activities
Dieting
Drugs (illicit and prescribed)
Diuretics
E-mail
Food/eating
Carbohydrates
Chocolate
Specific food:
Gambling
Games/puzzles
Gossiping
Imagining/fantasizing
InternetInternet games


InternetInternet games
Kleptomania/stealing/shoplifting
Lying
Pornography
Reckless driving
Risky behaviors
Self- inflicted injury/self-  mutilation
Sex
Shopping
Sleeping
Smartphone apps
Smoking/tobacco
Social networking
Speed
Spiritual practices
Sports activities:
Biking
Body building
Hiking/rock climbing
Running
Weight lifting
Other:
Other:
Television
Texting
Vandalism
Videos
Video games
Working
Other:
Other:
Other:


357
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission
to photocopy this handout is granted to purchasers of this book for personal use only (see copyright page for details).distress tolerance Handout 17   (Distress Tolerance Worksheet 14)
Dialectical a bstinence
SYNTHESIS  = Dialec Tical aBST inence
The goal is not to engage in addictive behavior again—
in other words, to achieve complete abstinence.
However, if there is a slip, the goal is to minimize harm
and get back to abstinence as soon as possible.
pros:  It works!
cons:  It’s work. You don’t get a vacation.
(You’re always either abstinent or working to get back to abstinence.)
An example of expecting the best and planning for the trouble spots:
Olympic athletes must believe and behave as though they can win
every race, even though they have lost before and will lose again.

  HARM REDUCTION
(Acknowledging there will be
slips; minimizing the damage,
but not demanding perfection)ABSTINENCE
(Swearing off
addictive behavior)vs.
Pro: People who commit to
abstinence stay off longer.
Con: It takes longer for people
to get back “on the wagon” once they fall off.Pro: When a slip does happen,
people can get back “on the
wagon” faster.
Con: People who commit to
harm reduction relapse quicker.


358
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission
to photocopy this handout is granted to purchasers of this book for personal use only (see copyright page for details).distress tolerance Handout 17a   (Distress Tolerance Worksheet 14)
planning for Dialectical a bstinence
plan for abstinence
 1. Enjoy your success, but with a clear mind; plan for temptations to relapse.
 2. Spend time or touch base with people who will reinforce you for abstinence.
 3. Plan reinforcing activities to do instead of addictive behaviors.
 4. Burn bridges: Avoid cues and high-risk situations for addictive behaviors.
 5. Build new bridges: Develop images, smells, and mental activities (such as,
urge surfing) to compete with information associated with craving.
 6. Find alternative ways to rebel.
 7. Publicly announce abstinence; deny any idea of lapsing to addiction.
plan for h arm r eduction
 1. Call your therapist, sponsor, or mentor for skills coaching.
 2. Get in contact with other effective people who can help.
 3. Get rid of temptations; surround yourself with cues for effective behaviors.
 4. Review skills and handouts from DBT.
 5. Opposite action (Emotion Regulation Handout 10) can be rehearsed to fight guilt and shame. If no other option works, go to an anonymous
meeting of any sort and publicly report your lapse.


meeting of any sort and publicly report your lapse.
 6. Building mastery and coping ahead for emotional situations (Emotion
Regulation Handout 19), and checking the facts (Emotion Regulation Handout 8), can be used to fight feelings of being out of control.
 7. Interpersonal skills (Interpersonal Effectiveness Handouts 5–7), such as asking for help from family, friends, sponsors, ministers, or counselors, can also be helpful. If you are isolated, help can often be found via online support groups.
 8. Conduct a chain analysis to analyze what prompted the lapse (General Handouts 7, 7a).
 9. Problem-solve right away to find a way to “get back on the wagon” and repair any damage you have done (Emotion Regulation Handout 12).
10. Distract yourself, self-  soothe, and improve the moment.
11. Cheerlead yourself.
12. Do pros and cons of stopping addictive behaviors (Distress Tolerance
Handout 5).
13. Stay away from extreme thinking. Don’t let one slip turn into a disaster.
14. Recommit to 100% total abstinence.


359
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission
to photocopy this handout is granted to purchasers of this book for personal use only (see copyright page for details).distress tolerance Handout 18   (Distress Tolerance Worksheet 15)
clear m ind
addict mind is:
impulsive
one-  minded
Willing to do anything for a “fix”
When in addict mind,  you are ruled
by the addiction. The urges for habitual
problem behaviors determine your
thoughts, emotions, and behaviors.clean mind is:
naive
risk- taking
oblivious to dangers
When in clean mind,  you are clean
but oblivious to dangers that might
cue habitual problem behaviors. You
believe you are invincible and immune
to future temptation.
Both extremes are DanGerou S!
clear min D: The safest place to be.
You are clean, but you remember addict mind.
You radically accept that relapse is not impossible .
You enjoy your success , while still expecting urges and cues
and planning for when you’re tempted.ADDICT
MIND
FOGGY MINDCLEAR
MINDCLEAN
MIND



360
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission
to photocopy this handout is granted to purchasers of this book for personal use only (see copyright page for details).Distress tolerance Han Do ut 18a   (Distress Tolerance Worksheet 16)
Behavior Patterns Characteristic of Addict Mind
and of Clean Mind
Addi Ct M ind
 Engaging in addictive behavior.
 Thinking, “I don’t really have a problem with
addiction.”
 Thinking, “I can do a little.”
 Thinking, “I can indulge my habit, if only on weekends.”
 Thinking, “I can’t stand this!”
 Glamorizing addiction.
 Surfing the Internet for ways to engage in addictive behaviors.
 Buying paraphernalia (food, drugs, videos, etc.) for addictive behavior.
 Selling or exchanging items related to addictive behaviors.
 Stealing to pay for addiction.
 Prostituting for money or for paraphernalia.
 Lying.
 Hiding.
 Isolating.
 Acting always busy; “Got to go!”
 Breaking promises.
 Committing crimes.
 Acting like a corpse.
 Having “no life.”
 Acting desperate/obsessed.
 Not looking people in the eyes.
 Having poor hygiene.
 Avoiding doctors.


 Having poor hygiene.
 Avoiding doctors.
 Other:

 O
ther:
 O
ther:  CleAn  Mind
 Engaging in apparently irrelevant behaviors
that in the past inevitably led to addictive behavior.
 Thinking, “I’ve learned my lesson.”
 Thinking, “I can control the habit.”
 Thinking, “I don’t really have an addiction problem any more.”
 Stopping or cutting back medication that helps with addiction.
 Being in environments where others engage in addictive behaviors.
 Seeing friends who are still addicted.
 Living with people who are addicted.
 Keeping addiction paraphernalia.
 Carrying around extra money.
 Being irresponsible with bills.
 Dressing like an addict.
 Not going to meetings.
 Not confronting the problems that fuel my addictive behaviors.
 Acting as if only willpower is needed.
 Isolating.
 Believing, “I can do this alone.”
 Thinking, “I can take pain medicine/diet/engage in addictive behavior if prescribed or advised; I don’t need to say anything about my past addiction.”
 Thinking, “I can’t stand this!”
 Other:

 O
ther:
 O
ther:


361
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission
to photocopy this handout is granted to purchasers of this book for personal use only (see copyright page for details).distress tolerance Handout 19   (Distress Tolerance Worksheet 16)
community r einforcement
community reinforcement means replacing addiction reinforcers
with abstinence reinforcers.
reinforcin G aBST inence iS c riTical
Reinforcers in your environment play a powerful role in encouraging or discouraging addictive
behaviors.
To stop addictive behavior, you have to figure out how to make a lifestyle without  your
addictive behaviors more rewarding than a lifestyle with  your addictive behaviors.
You have to find a way to get behaviors incompatible with addictions to pay off and be
rewarded by those around you.
Willpower is not  sufficient. If it were, we would all be perfect!
replace aDD icTion reinforcer S WiTh aBST inence reinforcer S
Begin a series of action steps that will increase your chances of accumulating positive events
to replace addictive behavior.
Search for people to spend time with who aren’t addicted.
Increase the number of enjoyable activities you engage in that do not involve your addiction.
If you cannot decide what people or activities you like, sample a lot of different groups of people and a lot of different activities.
aBST inence Samplin G
Commit to    days off your addiction, and observe the benefits that naturally occur.
Temporarily avoid high-risk addiction triggers, and replace these with competing behaviors to get you through the sampling period.


Observe all the extra positive events occurring when you are not engaging in addictive behaviors.
Note.  Adapted from Meyers, R. J., & Squires, D. D. (2001, September). The community reinforcement approach. Retrieved from www.bhrm.org/
guidelines/CRAmanual.pdf. Adapted by permission of the authors.


362
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission
to photocopy this handout is granted to purchasers of this book for personal use only (see copyright page for details).distress tolerance Handout 20   (Distress Tolerance Worksheet 17)
Burning Bridges and Building n ew o nes
BurninG  BriDG eS
accept at the most radical level that you are not going to engage in addictive behavior
again, and then move actively to cut off all addictive behavior options.
1. Make an absolute commitment to abstinence from the addictive behavior, which is
           (describe addictive behavior). Then walk into the garage of
abstinence and slam the garage door shut. (Remember that the tiniest slit of space can let an entire elephant in.)
2. List everything in your life that makes addiction possible.
3. Get rid of these things:
Throw out contact information of people who collude with you.
Get rid of all possible cues and temptations.
4. List and do everything you can that will make it hard or impossible to continue your
addictive behavior.
Ruthlessly and at every moment, tell the truth about your behavior.
Tell all your friends and family that you have quit.
Buil DinG neW BriDG eS
create visual images and smells that will compete with the information loaded into
your visual and olfactory brain systems when cravings occur.
Cravings and urges are strongly related to vivid images and smells of what is craved. The stron -
ger the imagery or smell, the stronger the craving.


ger the imagery or smell, the stronger the craving.
Build different images or smells to think about. Try to keep these images or smells
in memory when you have an unwanted craving. For example, whenever you crave a cigarette, imagine being on the beach; see and smell it in your mind to reduce the
craving.
When you have unwanted cravings, look at moving images or surround yourself with smells unrelated to the addiction. Moving images and new smells will compete with your
cravings.
“Urge-surf” by imagining yourself on a surfboard riding the waves of your urges. Notice them coming and going, rising high, going low, and finally going away.


363
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission
to photocopy this handout is granted to purchasers of this book for personal use only (see copyright page for details).distress tolerance Handout 21   (Distress Tolerance Worksheet 18)
alternate r ebellion and a daptive Denial
alTerna Te reB ellion
When addictive behaviors are a way to rebel against authority, conventions, and the boredom
of not breaking rules or laws, try alternate rebellion. Alternate rebellion replaces destructive rebellion and keeps you on a path to your goals.
Examples:
Shave your head.
Wear crazy underwear.
Wear unmatched shoes.
Have secret thoughts.
Express unpopular views.
Do random acts of kindness.
Vacation with your family at a nudist colony.
Write a letter saying exactly what you want to.Dye your hair a wild color.
Get a tattoo or body piercing.
Wear clothes inside out.
Don’t bathe for a week.
Print a slogan on a t-shirt.
Paint your face.
Dress up or dress down where
doing so is unexpected.
aDapTive Denial
When your mind can’t tolerate craving for addictive behaviors, try adaptive denial.
Give logic a break when you are doing this. Don’t argue with yourself.


When urges hit, deny that you want the problem behavior or substance. Convince yourself you want something other than the problem behavior. For example, reframe an urge to have a cigarette as an urge to have a flavored toothpick; an urge to have alcohol as an urge to have something sweet; or an urge to gamble as an urge to alternate rebellion (see above).
Other:
Other:
Be adamant with yourself in your denial, and engage in the alternative behavior.
Put off addictive behavior. Put it off for 5 minutes, then put it off for another 5 minutes, and
so on and on, each time saying, “I only have to stand this for 5 minutes.” By telling yourself each day you will be abstinent for today (or each hour for just this hour, and so on), you are saying, “This is not forever. I can stand this right now.”


369
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permis -
sion to photocopy this worksheet is granted to purchasers of this book for personal use only (see copyright page for details). Purchasers may
download a larger version of this worksheet from www.guilford.com/dbt-
worksheets .distress tolerance WorksHeet 1   (Distress Tolerance Handouts 2–9a)
crisis Survival Skills
Due Date:       Name:                   Week Starting:
Practice your crisis survival skills at least twice. Describe the crisis event; check off which skills you
used for that event; and then describe how you used the skill and what happened.
criSiS even T 1: Rate level of distress (0–100) Before:     After:
prompting event  for my distress (who, what, when, where): What triggered the state of crisis?
STop
pros and cons
Tip
Distract with accep TS
Self-  soothe
improve the momentAt left, check the skills you used, and describe here:
Describe the outcome of using skills:
Circle a number to indicate how effective the skills were in helping you tolerate the distress and
cope with the situation (keeping you from doing something to make the situation worse). Use the following scale:
I still couldn’t stand
the situation, even
for one more minute.I was able to cope somewhat,
at least for a little while.
It helped somewhat.I could use skills,
tolerated distress, and
resisted problem urges.
1 2 3 4 5


resisted problem urges.
1 2 3 4 5
criSiS even T 2: Rate level of distress (0–100) Before:     After:
prompting event  for my distress (who, what, when, where): What triggered the state of crisis?
STop
pros and cons
Tip
Distract with accep TS
Self-  soothe
improve the momentAt left, check the skills you used, and describe here:
Describe the outcome of using skills:
Circle effectiveness of skills:
I still couldn’t stand
the situation, even
for one more minute.I was able to cope somewhat,
at least for a little while.
It helped somewhat.I could use skills,
tolerated distress, and
resisted problem urges.
1 2 3 4 5


370
distress tolerance WorksHeet 1a   (Distress Tolerance Handouts 2–9a)
crisis Survival Skills
Name:                         Week Starting:
Practice each crisis survival skill twice, and describe your experience as follows:
When did you practice this skill, and
what did you do to practice?What was the crisis (what
prompted needing the skill)?Amount
of time
practicing
skill?rate before/after skill use
Conclusions or questions
about this skills practiceYour level of
distress tolerance
(0 = I can’t stand
it; 5 = I can
definitely survive)Emotion
Negative
emotion
intensity
(0–100)Positive
emotion
intensity
(0–100)
Stop: / / /
/ / /
Pros and cons: / / /
/ / /
TIP: / / /
/ / /
Distract with ACCEPTS: / / /
/ / /
Self- soothe: / / /
/ / /
IMPROVE the moment: / / /
/ / /
Adapted from an unpublished worksheet by Seth Axelrod, with his permission.
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission to photocopy this worksheet is granted to purchasers of
this book for personal use only (see copyright page for details). Purchasers may download a larger version of this worksheet from www.guilford.com/dbt-  worksheets .


371
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permis -
sion to photocopy this worksheet is granted to purchasers of this book for personal use only (see copyright page for details). Purchasers may
download a larger version of this worksheet from www.guilford.com/dbt-
worksheets .distress tolerance WorksHeet 1b   (Distress Tolerance Handouts 2–9a)
crisis Survival Skills
Due Date:       Name:                   Week Starting:
For each survival skill, write down what you did during the week, and then give a number to
indicate how effective the skill was in helping you tolerate the distress and cope with the situation (keeping you from doing something to make the situation worse). Use the following scale:
I still couldn’t stand
the situation, even
for one more minute.I was able to cope somewhat,
at least for a little while.
It helped somewhat.I could use skills,
tolerated distress, and
resisted problem urges.
1 2 3 4 5
Day: STop
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: pros and cons
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: Tip
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: Distract with accep TS
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: Self-  soothe
    /                                 Effectiveness:


Day: Self-  soothe
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: improve the moment
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Adapted from an unpublished worksheet by Seth Axelrod, with his permission.


372
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permis -
sion to photocopy this worksheet is granted to purchasers of this book for personal use only (see copyright page for details). Purchasers may
download a larger version of this worksheet from www.guilford.com/dbt-
worksheets .di stress t olerance Works H eet 2   (Distress Tolerance Handout 4)
pr acticing the ST o p  Skill
Due Date:       Name:                   Week Starting:
Des
cribe two crisis situations that happened to you. Then describe your use of the STOP skill.
c
riSiS
even T 1
: Rate level of distress (0–100) Before:
 After:
promp ting event  for my distress (who, what, when, where): What triggered the state of crisis?
Behavior you are trying to stop:
 Stop
 Take a step back
 ob
serve
 pr
oceed mindfullyAt left, check the steps you used, and describe what you did
here:
Describe the outcome of using skills:
Circle a number to indicate how effective the skill was in helping you tolerate the distress and cope with the situation (keeping you from doing something to make the situation worse). Use the following scale:
I still couldn’t stand
the situation, even
for one more minute.I was able to cope somewhat,
at least for a little while.
It helped somewhat.I could use skills,
tolerated distress, and
resisted problem urges.
1 2 3 4 5


resisted problem urges.
1 2 3 4 5
criSiS even T 2 : Rate level of distress (0–100) Before:  After:
promp ting event  for my distress (who, what, when, where): What triggered the state of crisis?
Behavior you are trying to stop:
 Stop
 Take a step back
 ob
serve
 pr
oceed mindfullyAt left, check the steps you used, and describe what you did here:
Describe the outcome of using the skills:
Circle effectiveness of the skill:
I still couldn’t stand
the situation, even
for one more minute.I was able to cope somewhat,
at least for a little while.
It helped somewhat.I could use skills,
tolerated distress, and
resisted problem urges.
1 2 3 4 5


373Distress tolerance Worksheet 2a   (Distress Tolerance Handout 4)
Practicing the STOP Skill
Due Date:       Name:                   Week Starting:
Des
cribe situations that happened to you where you used the STOP skill. Then describe how you used the STOP skill. Try to find a situation
each day where you can practice your STOP skill.
Day Crisis situationHow did you practice
this skill?Behavior
stopped?Rate before/after skill use
Conclusions or questions
about this skills practiceYour level of
distress tolerance
(0 = I can’t stand
it; 5 = I can
definitely survive)Emotion
Negative
emotion
intensity
(0–100)Positive
emotion
intensity
(0–100)
/ / /
/ / /
/ / /
/ / /
/ / /
/ / /
/ / /
Adapted from an unpublished worksheet by Seth Axelrod, with his permission.
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission to photocopy this worksheet is granted to purchasers of
this book for personal use only (see copyright page for details). Purchasers may download a larger version of this worksheet from www.guilford.com/dbt-
worksheets .


374
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permis -
sion to photocopy this worksheet is granted to purchasers of this book for personal use only (see copyright page for details). Purchasers may
download a larger version of this worksheet from www.guilford.com/dbt-
worksheets .distress tolerance WorksHeet 3   (Distress Tolerance Handout 5)
pros and c ons of a cting on c risis u rges
Due Date:       Name:                   Week Starting:
1. Describe the problem behavior  you are trying to stop:
2. List pros and cons for acting on crisis urges (including urges to act and urges to quit), and
create a separate list for resisting crisis behavior by tolerating distress and using skills. Use the back of this sheet if you need more room.
3. Read the pros and cons when an urge toward the problem behavior occurs.
problem behavior pro S con S
acting on crisis
urges1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
resisting crisis
urges1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
Identify which pros and cons are short-term (just for today) or long-term (beyond today). Then ask your Wise Mind: Would you rather have a good day or a good life? Make a mindful choice about
your behavior.
If this worksheet helps you choose skillful behavior over crisis behavior, be sure to keep it where
you can find it and review it again when you are in crisis.


you can find it and review it again when you are in crisis.
Adapted from an unpublished worksheet by Seth Axelrod, with his permission.


375
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permis -
sion to photocopy this worksheet is granted to purchasers of this book for personal use only (see copyright page for details). Purchasers may
download a larger version of this worksheet from www.guilford.com/dbt-
worksheets .distress tolerance WorksHeet 3a   (Distress Tolerance Handout 5)
pros and c ons of a cting on c risis u rges
Due Date:       Name:                   Week Starting:
1. Describe the problem behavior  you are trying to stop:
2. List pros and cons for acting on crisis urges (including urges to act and urges to quit), and
create a separate list for resisting crisis behavior by tolerating distress and using skills. Use the back of this sheet if you need more room.
3. Read the pros and cons when an urge toward the problem behavior occurs.
problem behavior acting on crisis urges resisting crisis urges
pro S 1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
con S1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
Identify which pros and cons are short-term (just for today) or long-term (beyond today). Then ask your Wise Mind: Would you rather have a good day or a good life? Make a mindful choice about
your behavior.
If this worksheet helps you choose skillful behavior over crisis behavior, be sure to keep it where
you can find it and review it again when you are in crisis.


376
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permis -
sion to photocopy this worksheet is granted to purchasers of this book for personal use only (see copyright page for details). Purchasers may
download a larger version of this worksheet from www.guilford.com/dbt-
worksheets .Distress tolerance Worksheet 4   (Distress Tolerance Handouts 6–6b)
Changing Body Chemistry with TIP Skills
Due Date:       Name:                   Week Starting:
Des
cribe the situation you were in when you chose to practice each skill. Rate both your emotional
arousal and distress tolerance before and after using the TIP skill. Describe what you actually did.
Use the back of this sheet if necessary.
T
Chang In g My Fa C Ial TeM Per aTu re
Used cold water to change emotions
Situation:

A
rousal (0–100) Before:

 After:
D
istress tolerance (0 = I can’t stand it; 100 = I can definitely survive) Before:

 After:
W
hat I did (describe):

IInTenSe  exe rC ISe
S
ituation:

A
rousal (0–100) Before:

 After:
D


rousal (0–100) Before:

 After:
D
istress tolerance (0 = I can’t stand it; 100 = I can definitely survive) Before:

 After:
W
hat I did (describe):

PPaCed Brea ThIn g
Situation:

A
rousal (0–100) Before:

 After:
D
istress tolerance (0 = I can’t stand it; 100 = I can definitely survive) Before:

 After:
W
hat I did (describe):

PaIred  Mu SC le r elaxa T Io n
Situation:

A
rousal (0–100) Before:

 After:
D
istress tolerance (0 = I can’t stand it; 100 = I can definitely survive) Before:

 After:
W
hat I did (describe):


377
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permis -
sion to photocopy this worksheet is granted to purchasers of this book for personal use only (see copyright page for details). Purchasers may
download a larger version of this worksheet from www.guilford.com/dbt-
worksheets .distress tolerance WorksHeet 4a   (Distress Tolerance Handout 6b)
paired m uscle r elaxation
Due Date:       Name:                   Week Starting:
Practice paired m uscle r elaxation (tensing your body muscles and then letting go of tension
completely as you breathe out). Practice as many times a day as you can at first until you notice that
when you exhale, our body automatically relaxes on its own. At this point, you have paired breathing
out with relaxation. Once that happens, continue practicing but not as often.
Practice paired muscle relaxation as many times a day as you can, and describe your experience
below. Check the type of practice you did: individual muscles, muscle groups, or all of your muscles at once.
DayNumber
of times
practiced
paired
muscle
relaxationAverage
level of
relaxation
before/after
(0–100)Number of
times used
skill when
tense or
overwhelmedAverage level
of relaxation
before/after
(0–100)Check which muscles
you tensed and
relaxed (check more
than one if necessary)
/ /Individual muscles
Groups
All at once


Groups
All at once
/ /Individual muscles
Groups
All at once
/ /Individual muscles
Groups
All at once
/ /Individual muscles
Groups
All at once
/ /Individual muscles
Groups
All at once
/ /Individual muscles
Groups
All at once
Describe your experience:
Conclusions about practice and/or questions about this skills practice:


378
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permis -
sion to photocopy this worksheet is granted to purchasers of this book for personal use only (see copyright page for details). Purchasers may
download a larger version of this worksheet from www.guilford.com/dbt-
worksheets .distress tolerance WorksHeet 4b   (Distress Tolerance Handout 6c)
effective r ethinking and p aired r elaxation
Due Date:       Name:                   Week Starting:
Step 1. Describe one typical prompting event  for distress in your life: What led up to what? What
is it about this event that is a problem for you? Be very specific in your answers. Use describing
skills. Check the facts.
Step 2. a sk: “What must I be telling myself (or what are my interpretations and thoughts )
about this event that contributes to my stress?” Write them down.
Step 3. r ethink the thoughts that lead to distress. Rethinking involves reevaluating the situation
and its meaning in ways that counteract stress-  producing thoughts and thereby reduce stress
responses. Write down as many effective thoughts as you can to replace the stressful thoughts.
Step 4. Did you practice in your imagination effective rethinking of a stressful situation this
week? Yes    No
If you engaged in rethinking, did it reduce fear of the situation happening again? (0–5,
0 = not at all; 5 = very much):
What effective thoughts did you use to replace stress-  causing thoughts?
Rate average level of relaxation (0–100): Before    After


Rate average level of relaxation (0–100): Before    After
Step 5. Did you practice rethinking plus paired relaxation ? Yes    No
If you engaged in rethinking plus paired relaxation, did it help you reduce your stress? (0–5,
0 = not at all; 5 = very much):
What effective thoughts did you use to replace stress-  causing thoughts?
Comments:


379
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permis -
sion to photocopy this worksheet is granted to purchasers of this book for personal use only (see copyright page for details). Purchasers may
download a larger version of this worksheet from www.guilford.com/dbt-
worksheets .distress tolerance WorksHeet 5   (Distress Tolerance Handout 7)
Distracting with Wise m ind accep TS
Due Date:       Name:                   Week Starting:
Describe two crisis situations that happened to you. Then describe your use of the ACCEPTS
skills.
criSiS even T 1: Rate level of distress (0–100) Before:     After:
prompting event  for my distress (who, what, when, where): What triggered the state of crisis?
activities
contributions
comparisons
emotions
pushing away
Thoughts
SensationsAt left, check the skills you used, and describe here:
Describe the outcome of using skills:
Circle a number to indicate how effective the skills were in helping you tolerate the distress and
cope with the situation (keeping you from doing something to make the situation worse). Use the
following scale:
I still couldn’t stand
the situation, even
for one more minute.I was able to cope somewhat,
at least for a little while.
It helped somewhat.I could use skills,
tolerated distress, and
resisted problem urges.
1 2 3 4 5


resisted problem urges.
1 2 3 4 5
criSiS even T 2: Rate level of distress (0–100) Before:     After:
prompting event  for my distress (who, what, when, where): What triggered the state of crisis?
activities
contributions
comparisons
emotions
pushing away
Thoughts
SensationsAt left, check the skills you used, and describe here:
Describe the outcome of using skills:
Circle effectiveness of skills:
I still couldn’t stand
the situation, even
for one more minute.I was able to cope somewhat,
at least for a little while.
It helped somewhat.I could use skills,
tolerated distress, and
resisted problem urges.
1 2 3 4 5


380
distress tolerance WorksHeet 5a   (Distress Tolerance Handout 7)
Distracting with Wise m ind accep TS
Due Date:       Name:                   Week Starting:
Practice each distraction skill twice, and describe your experience as follows:
When did you practice this skill, and
what did you do to practice?What was the crisis (what
prompted needing the skill)?How
much time
passed in
doing this
skill?rate before/after skill use
Conclusions or questions
about this skills practiceDistress tolerance
(0 = I can’t stand it;
5 = I can definitely
survive)Emotion
Negative
emotion
intensity
(0–100)Positive
emotion
intensity
(0–100)
Activities: / / /
/ / /
Contributions: / / /
/ / /
Comparisons: / / /
/ / /
Emotions: / / /
/ / /
Pushing away: / / /
/ / /
Thoughts: / / /
/ / /
Sensations: / / /
/ / /
Adapted from an unpublished worksheet by Seth Axelrod, with his permission.
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission to photocopy this worksheet is granted to purchasers of
this book for personal use only (see copyright page for details). Purchasers may download a larger version of this worksheet from www.guilford.com/dbt-  worksheets .


381
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permis -
sion to photocopy this worksheet is granted to purchasers of this book for personal use only (see copyright page for details). Purchasers may
download a larger version of this worksheet from www.guilford.com/dbt-
worksheets .distress tolerance WorksHeet 5b   (Distress Tolerance Handout 7)
Distracting with Wise m ind accep TS
Due Date:       Name:                   Week Starting:
For each ACCEPTS skill, write down what you did during the week, and write down a number to
indicate how effective the skill was in helping you tolerate the distress and cope with the situation (keeping you from doing something to make the situation worse). Use the following scale:
I still couldn’t stand
the situation, even
for one more minute.I was able to cope somewhat,
at least for a little while.
It helped somewhat.I could use skills,
tolerated distress, and
resisted problem urges.
1 2 3 4 5
Day: acTivi TieS
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: conT riBuTionS
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: compari SonS
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: emoTionS
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: puShinG aWay


/                                 Effectiveness:
Day: puShinG aWay
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: Thou GhTS
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: SenSaTionS
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:


382
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permis -
sion to photocopy this worksheet is granted to purchasers of this book for personal use only (see copyright page for details). Purchasers may
download a larger version of this worksheet from www.guilford.com/dbt-
worksheets .distress tolerance WorksHeet 6   (Distress Tolerance Handout 8)
Self-  Soothing
Due Date:       Name:                   Week Starting:
Describe two crisis situations that happened to you. Then describe your use of the self-  soothing
skills.
criSiS even T 1: Rate level of distress (0–100) Before:     After:
prompting event  for my distress (who, what, when, where): What triggered the state of crisis?
vision
hearing
Smell
Taste
TouchAt left, check the skills you used, and describe here:
Describe the outcome of using skills:
Circle a number to indicate how effective the skills were in helping you tolerate the distress and
cope with the situation (keeping you from doing something to make the situation worse). Use the
following scale:
I still couldn’t stand
the situation, even
for one more minute.I was able to cope somewhat,
at least for a little while.
It helped somewhat.I could use skills,
tolerated distress, and
resisted problem urges.
1 2 3 4 5
criSiS even T 2: Rate level of distress (0–100) Before:     After:


prompting event  for my distress (who, what, when, where): What triggered the state of crisis?
vision
hearing
Smell
Taste
TouchAt left, check the skills you used, and describe here:
Describe the outcome of using skills:
Circle effectiveness of skills:
I still couldn’t stand
the situation, even
for one more minute.I was able to cope somewhat,
at least for a little while.
It helped somewhat.I could use skills,
tolerated distress, and
resisted problem urges.
1 2 3 4 5


383distress tolerance WorksHeet 6a   (Distress Tolerance Handout 8)
Self-  Soothing
Due Date:       Name:                   Week Starting:
Practice each self-  soothing skill twice, and describe your experience as follows:
When did you practice this skill, and
what did you do to practice?What was going on that
was painful or stressful (if
anything)?How
much
time
passed in
doing this
skill?rate before/after skill use
Conclusions or questions
about this skills practiceDistress tolerance
(0 = I can’t stand it;
5 = I can definitely
survive)Emotion
Negative
emotion
intensity
(0–100)Positive
emotion
intensity
(0–100)
Vision: / / /
/ / /
Hearing: / / /
/ / /
Smell: / / /
/ / /
Taste: / / /
/ / /
Touch: / / /
/ / /
Adapted from an unpublished worksheet by Seth Axelrod, with his permission.
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission to photocopy this worksheet is granted to purchasers of
this book for personal use only (see copyright page for details). Purchasers may download a larger version of this worksheet from www.guilford.com/dbt-  worksheets .


384
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permis -
sion to photocopy this worksheet is granted to purchasers of this book for personal use only (see copyright page for details). Purchasers may
download a larger version of this worksheet from www.guilford.com/dbt-
worksheets .distress tolerance WorksHeet 6b   (Distress Tolerance Handout 8)
Self-  Soothing
Due Date:       Name:                   Week Starting:
For each self-  soothing skill, write down what you did during the week, and write down a number to
indicate how effective the skill was in helping you tolerate the distress and cope with the situation
(keeping you from doing something to make the situation worse). Use the following scale:
I still couldn’t stand
the situation, even
for one more minute.I was able to cope somewhat,
at least for a little while.
It helped somewhat.I could use skills,
tolerated distress, and
resisted problem urges.
1 2 3 4 5
Day: viSion
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: hearin G
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: Smell
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: TaSTe
    /                                 Effectiveness:
    /                                 Effectiveness:


/                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: Touch
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:


385
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permis -
sion to photocopy this worksheet is granted to purchasers of this book for personal use only (see copyright page for details). Purchasers may
download a larger version of this worksheet from www.guilford.com/dbt-
worksheets .distress tolerance WorksHeet 6c   (Distress Tolerance Handout 8a)
Body Scan m editation, Step by Step
Due Date:       Name:                   Week Starting:
Practice as many times as you can. Check whether you practiced alone, listening to a recording,
watching YouTube, or being guided by a person.
Day Describe your experienceHow much time
passed doing
this skiill?Rate before and after body scan
Distress tolerance
(0 = I can’t stand
it; 5 = I can
definitely survive)Emotion
Negative
emotion
intensity
(0–100)Positive
emotion
intensity
(0–100)
1Alone       Recording
Person guiding   YouTube/ / /
2Alone       Recording
Person guiding   YouTube/ / /
3Alone       Recording
Person guiding   YouTube/ / /
4Alone       Recording
Person guiding   YouTube/ / /
5Alone       Recording
Person guiding   YouTube/ / /
Conclusions or questions about this skills practice:


Conclusions or questions about this skills practice:
Adapted from an unpublished worksheet by Seth Axelrod, with his permission.


386
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permis -
sion to photocopy this worksheet is granted to purchasers of this book for personal use only (see copyright page for details). Purchasers may
download a larger version of this worksheet from www.guilford.com/dbt-
worksheets .distress tolerance WorksHeet 7   (Distress Tolerance Handout 9)
improve the m oment
Due Date:       Name:                   Week Starting:
Describe two crisis situations that happened to you. Then describe your use of the IMPROVE
skills.
criSiS even T 1: Rate level of distress (0–100) Before:     After:
prompting event  for my distress (who, what, when, where): What triggered the state of crisis?
imagery
meaning
prayer
relaxation
one thing
vacation
encouragementAt left, check the skills you used, and describe here:
Describe the outcome of using skills:
Circle a number to indicate how effective the skills were in helping you tolerate the distress and
cope with the situation (keeping you from doing something to make the situation worse). Use the
following scale:
I still couldn’t stand
the situation, even
for one more minute.I was able to cope somewhat,
at least for a little while.
It helped somewhat.I could use skills,
tolerated distress, and
resisted problem urges.
1 2 3 4 5


resisted problem urges.
1 2 3 4 5
criSiS even T 2: Rate level of distress (0–100) Before:     After:
prompting event  for my distress (who, what, when, where): What triggered the state of crisis?
imagery
meaning
prayer
relaxation
one thing
vacation
encouragementAt left, check the skills you used, and describe here:
Describe the outcome of using skills:
Circle effectiveness of skills:
I still couldn’t stand
the situation, even
for one more minute.I was able to cope somewhat,
at least for a little while.
It helped somewhat.I could use skills,
tolerated distress, and
resisted problem urges.
1 2 3 4 5


387distress tolerance WorksHeet 7a   (Distress Tolerance Handout 9)
improve the m oment
Due Date:       Name:                   Week Starting:
Practice each IMPROVE skill twice, and describe your experience as follows:
When did you practice this skill, and
what did you do to practice?What was going on that
was painful or stressful (if
anything)?How
much
time
passed in
doing this
skill?rate before/after skill use
Conclusions or questions
about this skills practiceDistress tolerance
(0 = I can’t stand it;
5 = I can definitely
survive)Emotion
Negative
emotion
intensity
(0–100)Positive
emotion
intensity
(0–100)
Imagery: / / /
/ / /
Meaning: / / /
/ / /
Prayer: / / /
/ / /
Relaxation: / / /
/ / /
One thing: / / /
/ / /
Vacation: / / /
/ / /
Encouragement: / / /
/ / /
Adapted from an unpublished worksheet by Seth Axelrod, with his permission.
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission to photocopy this worksheet is granted to purchasers of
this book for personal use only (see copyright page for details). Purchasers may download a larger version of this worksheet from www.guilford.com/dbt-  worksheets .


388
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permis -
sion to photocopy this worksheet is granted to purchasers of this book for personal use only (see copyright page for details). Purchasers may
download a larger version of this worksheet from www.guilford.com/dbt-
worksheets .distress tolerance WorksHeet 7b   (Distress Tolerance Handout 9)
improve the m oment
Due Date:       Name:                   Week Starting:
For each IMPROVE skill, write down what you did during the week, and write down a number to
indicate how effective the skill was in helping you tolerate the distress and cope with the situation (keeping you from doing something to make the situation worse). Use the following scale:
I still couldn’t stand
the situation, even
for one more minute.I was able to cope somewhat,
at least for a little while.
It helped somewhat.I could use skills,
tolerated distress, and
resisted problem urges.
1 2 3 4 5
Day: imaG ery
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: meanin G
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: prayer
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: relaxa Tion
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: one T hinG  in T he momenT
    /                                 Effectiveness:


/                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: vacaT ion
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: encoura Gemen T
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:


Worksheets for Reality
Acceptance Skills


391
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permis -
sion to photocopy this worksheet is granted to purchasers of this book for personal use only (see copyright page for details). Purchasers may
download a larger version of this worksheet from www.guilford.com/dbt-
worksheets .distress tolerance WorksHeet 8   (Distress Tolerance Handouts 10–15a)
reality a cceptance Skills
Due Date:       Name:                   Week Starting:
Check off two reality acceptance skills to practice this week during a stressful situation:
Radical acceptance
Turning the mind
WillingnessHalf- smiling
Willing hands
Mindfulness of current thoughts
Skill 1. Describe the situation and how you practiced the skill:

How effective was the skill in helping you cope with the situation (keeping you from doing
something to make the situation worse)? Circle a number below.
I still couldn’t stand
the situation, even
for one more minute.I was able to cope somewhat,
at least for a little while.
It helped somewhat.I could use skills,
tolerated distress, and
resisted problem urges.
1 2 3 4 5
Did this skill help you cope with uncomfortable emotions or urges, or  avoid conflict of any
kind? Circle YES or NO.
Describe how the skill helped or did not help:

Skill 2. Describe the situation and how you practiced the skill:

How effective was the skill in helping you cope with the situation (keeping you from doing


How effective was the skill in helping you cope with the situation (keeping you from doing
something to make the situation worse)? Circle a number below.
I still couldn’t stand
the situation, even
for one more minute.I was able to cope somewhat,
at least for a little while.
It helped somewhat.I could use skills,
tolerated distress, and
resisted problem urges.
1 2 3 4 5
Did this skill help you cope with uncomfortable emotions or urges, or  avoid conflict of any
kind? Circle YES or NO.
Describe how the skill helped or did not help:


392
distress tolerance WorksHeet 8a   (Distress Tolerance Handouts 10–15a)
reality a cceptance Skills
Due Date:       Name:                   Week Starting:
Practice each reality acceptance skill twice, and describe your experience as follows:
When did you practice this skill, and
what did you do to practice?What was going on that you
had trouble accepting (if
anything)?How long
did you
practice
accepting?rate before/after skill use
Conclusions or questions
about this skills practiceAcceptance
(0 = none at
all; 5 = I am
at peace with
this)Emotion
Negative
emotion
intensity
(0–100)Positive
emotion
intensity
(0–100)
Radical acceptance: / / /
/ / /
Turning the mind: / / /
/ / /
Willingness: / / /
/ / /
Half- smiling: / / /
/ / /
Willing hands: / / /
/ / /
Mindfulness of current thoughts: / / /
/ / /
Adapted from an unpublished worksheet by Seth Axelrod, with his permission.
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission to photocopy this worksheet is granted to purchasers of
this book for personal use only (see copyright page for details). Purchasers may download a larger version of this worksheet from www.guilford.com/dbt-  worksheets .


393
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permis -
sion to photocopy this worksheet is granted to purchasers of this book for personal use only (see copyright page for details). Purchasers may
download a larger version of this worksheet from www.guilford.com/dbt-
worksheets .distress tolerance WorksHeet 8b   (Distress Tolerance Handouts 10–15a)
reality a cceptance Skills
Due Date:       Name:                   Week Starting:
For each reality acceptance skill, describe the skill you used during the week, and circle a number
(0–5) indicating your own experience of acceptance of yourself, your life, or events outside yourself. Use the following scale:
No acceptance; I am
in complete denial
and/or rebellionI was able to
accept somewhat or
for a little while.Complete
acceptance; I am at
peace with this.
1 2 3 4 5
Day: raDical accep Tance (describe what and how often you practiced)
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: Turnin G The min D (describe the cross-road you were at, and what you chose)
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: WillinG neSS (describe the situation, what you were willful about, and how
you practiced)
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: half-  Smilin G (describe the situation and how you practiced)


Day: half-  Smilin G (describe the situation and how you practiced)
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: WillinG  hanDS  (describe the situation and how you practiced)
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:
Day: minDfulne SS of curren T Thou GhTS (describe what thoughts were
going through your mind and how  you observed your thoughts)
    /                                 Effectiveness:
    /                                 Effectiveness:
    /                                 Effectiveness:


394
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permis -
sion to photocopy this worksheet is granted to purchasers of this book for personal use only (see copyright page for details). Purchasers may
download a larger version of this worksheet from www.guilford.com/dbt-
worksheets .distress tolerance WorksHeet 9   (Distress Tolerance Handouts 11–11b)
radical a cceptance
Due Date:       Name:                   Week Starting:
fiGure o uT Wha T you n eeD To raDically a ccep T
1. Make a list of two very important  things in your life right now that you need to radically accept.
Then give each one a number indicating how much you accept this part of yourself or your life:
from 0 (no acceptance, I am in complete denial and/or rebellion) to 5 (complete acceptance, I
am at peace with this). Note:  if you have already completed this section, you don’t need to do it
again unless things have changed.
What I need to accept  (Acceptance, 0–5)
1.                                      (    )
2.                                      (    )
2. Make a list of two less important  things in your life you are having trouble accepting this week.
Then rate your acceptance just as you did above.What I need to accept  (Acceptance, 0–5)
1.                                      (    )
2.                                      (    )
refine y our li ST
3. Review your two lists above. c heck the facts. Check for interpretations and opinions. Make


sure that what you are trying to accept is in fact the case. check for judgments.  Avoid “good,”
“bad,” and judgmental language. Rewrite any items above if needed so that they are factual
and nonjudgmental.
prac Tice r aDical a ccep Tance
4. Choose one item from the very important list and one item from the less important list to
practice on.
1.
2.
5. Focus your mind on each of these facts or events separately, allowing your Wise Mind to
radically accept that these are  facts of your life. Check off  any of the following exercises that
you did.
Observed that I was questioning or fighting
reality.
Reminded myself that reality is what it is.
Considered the causes of the reality, and nonjudgmentally accepted that causes exist.
Practiced accepting all the way with my whole being (mind, body, spirit).
Practiced opposite action.
Coped ahead with events that seemed unacceptable.Attended to my body sensations as I thought about what I need to accept.
Allowed myself to experience disappointment, sadness, or grief.
Acknowledged that life can be worth living even when there is pain.
Did pros and cons of accepting versus denial and rejection.
Other:

6. Rate your degree of acceptance after practicing radical acceptance (0–5):


395distress tolerance WorksHeet 9a   (Distress Tolerance Handouts 11–11b)
practicing r adical a cceptance
Due Date:       Name:                   Week Starting:
Practice each skill twice, and describe and rate your experience below.
When did you practice this skill, and
what did you do to practice?What was going on that you
had trouble accepting (if
anything)?How long
did you
practice
accepting?rate before/after skill use
Conclusions or questions
about this skills practiceAcceptance
(0 = none at
all; 5 = I am
at peace with
this)Emotion
Negative
emotion
intensity
(0–100)Positive
emotion
intensity
(0–100)
Considered causes of the reality: / / /
/ / /
Practiced with my whole self: / / /
/ / /
Practiced opposite action: / / /
/ / /
Practiced coping ahead: / / /
/ / /
Attended to body sensations: / / /
/ / /
Allowed disappointment/grieving: / / /
/ / /
Acknowledged life as worth living: / / /
/ / /
Did pros and cons: / / /
/ / /
Adapted from an unpublished worksheet by Seth Axelrod, with his permission.
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission to photocopy this worksheet is granted to purchasers of
this book for personal use only (see copyright page for details). Purchasers may download a larger version of this worksheet from www.guilford.com/dbt-  worksheets .


396
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permis -
sion to photocopy this worksheet is granted to purchasers of this book for personal use only (see copyright page for details). Purchasers may
download a larger version of this worksheet from www.guilford.com/dbt-
worksheets .distress tolerance WorksHeet 10   (Distress Tolerance Handouts 12, 13)
Turning the m ind, Willingness, Willfulness
Due Date:       Name:                   Week Starting:
Practice each skill, and rate your level of acceptance of reality as it is before and after: from 0 (no
acceptance at all) to 5 (I’m at peace with this). List what you tried specifically under the rating.
Turning the m ind: Acceptance   Before:     After:
oBS erve  not accepting. What did you observe? What were you having trouble accepting?
make an inner commiTmenT  to accept what feels unacceptable. How did you do this?
Describe your plan for ca Tchin G your Self the next time you drift from acceptance.
WillinG neSS (rate 0–5): Acceptance  Before:     After:
Willfulness   Before:     After:
Describe effec Tive Behavior you did to move forward toward a goal.
noTice Willfulne SS. Describe how you are not participating effectively in the world as it
is, or how you are not doing something you know needs to be done to move toward a goal.
Describe how you prac TiceD raD ically accep TinG your W illfulne SS.
make an inner commiTmenT  to accept what feels unacceptable. How did you do this?


Describe what you did that was W illinG .


397
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permis -
sion to photocopy this worksheet is granted to purchasers of this book for personal use only (see copyright page for details). Purchasers may
download a larger version of this worksheet from www.guilford.com/dbt-
worksheets .distress tolerance WorksHeet 11   (Distress Tolerance Handout 14, 14a)
half- Smiling and Willing h ands
Due Date:       Name:                   Week Starting:
Describe your practice with half-  smiling and willing hands this past week. Practice each day at least
once. Practice both when you are not emotionally distressed and when you are distressed.
Check off  any of the following exercises that you did.
 1. Half- smiled when I first woke up in the
morning.
 2. Half- smiled during my free moments.
 3. Half- smiled with willing hands while I
was listening to music.
 4. Half- smiled with willing hands when I
was irritated.
 5. Half- smiled in a lying-down position.
 6. Half- smiled in a sitting position.
 7. Half- smiled when I was walking down
the street. 8. Half- smiled with willing hands when my
feelings were hurt.
 9. Half- smiled with willing hands when I did
not want to accept something.
10. Half- smiled with willing hands when I
started getting really angry.


started getting really angry.
11. Half- smiled when I had negative
thoughts.
12. Half- smiled when I couldn’t sleep.
13. Half- smiled with another person.
14. Other:

Describe practicing half-  smiling and willing hands.
1. Situation:
Describe strategies you used or give numbers from above:
Circle how effective this was at helping you be more mindful and less reactive:
1 2 3 4 5
Not effective Somewhat effective Very effective
2. Situation:
Describe strategies you used or give numbers from above:
Circle how effective this was at helping you be more mindful and less reactive:
1 2 3 4 5
Not effective Somewhat effective Very effective
3. Situation:
Describe strategies you used or give numbers from above:
Circle how effective this was at helping you be more mindful and less reactive:
1 2 3 4 5
Not effective Somewhat effective Very effective


398
distress tolerance WorksHeet 11a   (Distress Tolerance Handouts 14, 14a)
practicing h alf- Smiling and Willing h ands
Due Date:       Name:                   Week Starting:
Practice half-  smiling/willing hands twice each day. Describe what you did to practice, and what you were trying to accept. (See Distress
Tolerance Worksheet 11 for ideas.)
What did you do to practice allowing
your thoughts?What were you having trouble
accepting (if any)?How
much time
passed in
doing this
skill?rate before/after skill use
Conclusions or questions
about this skills practiceAcceptance
(0 = none at
all; 5 = I am
at peace with
this)Emotion
Negative
emotion
intensity
(0–100)Positive
emotion
intensity
(0–100)
Mon / / /
/ / /
Tues / / /
/ / /
Wed / / /
/ / /
Thurs / / /
/ / /
Fri / / /
/ / /
Sat / / /
/ / /
Sun / / /
/ / /
Adapted from an unpublished worksheet by Seth Axelrod, with his permission.
From DBT Skills Training Handouts and Worksheets, Second Edition  by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission to photocopy this worksheet is granted to purchasers of
this book for personal use only (see copyright page for details). Purchasers may download a larger version of this worksheet from www.guilford.com/dbt-  worksheets .