1. Feelings Rating scale
5 – Overwhelming Feeling: I am out of control. Body reactions, thoughts and action urges are impossible to ignore. I have engaged in actions that hurt myself, hurt others or hurt property.
4 – Strong Feeling: My body reactions are stronger. My urges for action are very strong. My thoughts are off track. I find it very difficult to focus on anything else.
3 – Medium Feeling: My body reactions may become stronger and more uncomfortable or I may start to experience more body reactions. I may notice off track thoughts and urges for action. It becomes more difficult to focus my attention away from body reactions, thoughts and urges for action.
2 – Small Feeling: I may begin to notice my body reacting. I can still think clearly, even if it is a little difficult and I can control my actions.
1 – Tiny Feeling: I am mindful that a feeling is present. I can still think clearly, even if it is s little difficult, and I can control my actions.
0 – No Feeling: You do not observe this feeling at all.

2. Interpersonal Effectiveness
Skill Use graph 5
Distress Tolerance
Mindfulness 4 3
Emotion Regulation 2 1
Interpersonal Effectiveness

3. Interpersonal Effectiveness
How they work together
5 - Overwhelming
4 - Strong
3 - Medium
2 - Small
1 - Tiny
0 - None 5
Distress Tolerance
Mindfulness 4 3
Emotion Regulation 2 1
Interpersonal Effectiveness

4. Crisis Survival Skills
Distress tolerance
Crisis Survival Skills

5. Goals of distress tolerance
Survive Crisis Situations
Without Making Them Worse
Accept Reality
Replace Suffering and Being “Stuck” with Ordinary Pain and the Possibility of Moving Forward
Become Free
Of Having to Satisfy the Demands of Your Own Desires, Urges and Intense Emotions

6. Overview: crisis survival skills
STOP
Pros and Cons
TIP
Distract with Wise Mind Accepts
Self-Soothe
IMPROVE

7. When to use crisis survival skills
You are in a CRISIS when the situation is:
Highly stressful
Short-term (it won’t last a long time)
Creates intense pressure to resolve the crisis now
Use Crisis Survival Skills when:
You have intense pain that cannot be helped quickly
You want to act on your emotions, but doing so will only make things worse
Emotion mind threatens to overwhelm you and you need to stay skillful
You are overwhelmed, yet demands must be met
Arousal is extreme, but problems can’t be solved immediately
Don’t use Crisis Survival Skills for:
Everyday problems
Solving all your life problems
Making your life worth living

9. stop S: Stop T: Take a step back O: Observe P: Proceed Mindfully
Do not just react. Stop! Freeze! Do not move a muscle! Your emotions may try to make you act without thinking. Stay in control!
T: Take a step back
Take a break from the situation. Let go. Take a deep breath. Do not let your feelings make you act impulsively.
O: Observe
Notice what is going on inside and outside you. What is the situation? What are your thoughts and feelings? What are others saying and doing?
P: Proceed Mindfully
Act with awareness. In deciding what to do, consider your thoughts and feelings, the situation, and other people’s thoughts and feelings. Think about your goals. Which actions will make it better? Which actions will make it worse?

11. Pros and cons
Use Pros and Cons any time you have to decide between 2 courses of action.
An urge is a crisis when it is very strong and when acting on the urge will make things worse in the long term.
Make a list of the pros and cons of action in your crisis urges. These might be to engage in dangerous, addictive or harmful behavior or they might be to give in, give up or avoid doing what is necessary to build a life you want to live.
Make another list of the pros and cons of resisting the crisis urges – that is, tolerating the distress and not giving in to the urges.

12. When do I use pros and cons?
Before an overwhelming crisis urge hits:
Write out your pros and cons and carry them with you.
Rehearse your pros and cons over and over.
When an overwhelming crisis urge hits:
Review your pros and cons. Get out your list and read it over again.
Imagine the positive outcomes of resisting the urge.
Think of the negative outcomes of giving in to crisis behaviors.
Remember past consequences when you have acted on crisis urges.

13. Use this grid to evaluate pros and cons
Acting on crisis urges
Pros of acting on impulsive urges, giving in, giving up or avoiding what needs to be done
Cons of acting on impulsive urges, giving in, giving up or avoiding what needs to be done
Resisting crisis urges
Pros of resisting impulsive urges, giving in, giving up or avoiding what needs to be done
Cons of resisting impulsive urges, giving in, giving up or avoiding what needs to be done

14. TIP

15. Tip: changing your body chemistry
T: TIP THE TEMPERATURE of your face with COLD WATER (to calm down fast)
Holding your breath, put your face in a bowl of cold water or hold a cold pack on your eyes and cheeks. Hold for 30 seconds. Keep water above 50 degrees F.
I: INTENSE EXERCISE (to calm dfown your body when it is reved up by emotion)
Engage in intense exercise, if only for a short while. Expend your body’s stored up physical energy by running, walking fast, jumping, playing basketball, etc.
P: PACED BREATHING (pace your breathing by slowing it down)
Breathe deeply into your belly. Slow your pace of inhaling and exhaling way down. Breathe out more slowly than you breathe in. (5 seconds in, 7 seconds out)
P: PAIRED MUSCLE RELAXATION (to calm down by pairing muscle relaxation with breathing out)
While breathing into your belly, deeply tense your body muscles. Notice the tension in your body. While breathing out, say the word “Relax” in your mind. Let go of the tension. Notice the difference in your body.

16. Cold water can work wonders!
When you put your face into cold water or you put a zip-lock bag with cold water on your eyes and upper cheeks and hold your breath, it tells your brain you are diving underwater. This causes the “dive response” to occur. Your heart slows down, blood flow to nonessential organs is reduced and blood flow is redirected to the brain and heart. This response can actually help regulate your emotions. This will be useful as a distress tolerance strategy when you are having a very strong, distressing emotion, or when you are having very strong urges to engage in dangerous behaviors.

17. Dive response in action

19. Distracting with accepts
A: Activities
Go for a walk, call a friend, play a video game, watch a movie, etc.
C: Contributing
Volunteer somewhere, make something nice for someone, help a friend, etc.
C: Comparisons
Compare how you feel now to a time when you felt different, compare yourself to those less fortunate, etc.
E: Emotions
Listen to emotional music, Watch emotional videos, Read emotional stories, etc.
P: Pushing Away
Leave the situation mentally, Block thoughts and images from your mind, Refuse to talk about painful situations, etc.
T: Thoughts
Count to 10, count colors on a painting, repeat words to a song, A-Z list of foods, imagine what you would do if you won the lottery, etc.
S: Sensations
Squeeze a rubber ball, listen to loud music, hold ice in your hand, go out in the rain, take a hot or cold shower, etc.

23. Improve the moment I: Imagery M: Meaning P: Prayer R: Relaxing
Imagine very relaxing scenes, Imagine everything going well, Imagine emotions draining out of you like water out of a pipe.
M: Meaning
Find purpose or meaning in a painful situation, focus on positive aspects of the situation.
P: Prayer
Open your heart to a supreme being, ask for strength to bear the pain, turn things over to a higher power.
R: Relaxing
Take a hot bath, drink hot milk, massage your head and scalp, practice yoga.
O: One thing in the moment
Focus your attention on what you are doing, keep yourself in the moment, focus your entire attention on the physical.
V: Vacation
Get in bed, take a drive, turn off your phone for a day, take a brief vacation from responsibility.
E: Encouragement and rethinking
Cheerlead yourself: “This too shall pass” “It won’t last forever” “Don’t believe everything you think”