20 Distress Tolerance Activities for Your Clients in Therapy Sessions

Distress tolerance skills are most commonly known for their role within Dialectical Behavioral Therapy (DBT), an approach originally developed to help clients living with borderline personality disorder.  Research has been exploring the benefits of focusing on developing distress tolerance skills for various mental health conditions and concerns and other forms of psychological discomfort. When we look at the term distress tolerance, there are different components to be mindful of. This includes a person’s perceived ability and the behavioral act of managing negative emotions and other adverse situations. Keep reading to learn 20 Distress Tolerance activities you can do with your clients in counseling sessions.

If someone does not believe that they are capable of managing their distress, they may be less likely to try using skills and other coping skills. This can increase their overall level of distress causing noticeable functional impairment.  Additionally, it takes time to practice implementing distress tolerance skills. For some, there is a period of trial and error to find which approaches are effective and to determine which ones are easy to incorporate into everyday life. This is an important concept to remind clients we work with, as learning new skills is not often a quick fix for symptoms. 

Distress tolerance skills can help those who struggle with uncertainty, ambiguity, frustration, physical discomfort, and what they determine as negative emotions. These skills can be a helpful topic for a range of mental health conditions, including borderline personality disorder, post-traumatic stress disorder, depression, substance use disorders, anxiety disorders, eating disorders, obsessive-compulsive disorder, adjustment disorders, and self-harming behaviors.

Distress tolerance skills are  an example of an everyday life skill that can be helpful for those who do not have a formal mental health diagnosis but find themselves struggling with stress, emotion regulation, and disappointment. This can include individuals of all ages, including children, adolescents, adults, and older adults. 

How Distress Tolerance Activities Can Help Your Clients

Distress tolerance activities can be incorporated into individual, group, and family therapy sessions. They may be used in inpatient and outpatient care settings, allowing for personalization for each client. They are a practical tool that can help your clients learn to manage their emotions healthily, rather than letting it snowball and create higher levels of distress. These skills can be used during emotional crises, which can help clients cope until they can utilize problem-solving skills.

Some of the benefits that can come from using distress tolerance skills include decreasing the occurrence of impulsive or harmful behaviors. This can include learning to resist urges to engage in self-harm, like self-injurious behaviors or substance abuse. Clients often find that using distress tolerance skills helps improve their emotion regulation skills. With continued use over time, they can learn to sit with the discomfort they experience without feeling as though they need to “fix” or respond to the situation immediately.

Being confident in their ability to manage distress can also help clients reduce avoidance behaviors tied to difficult or uncomfortable topics. This could be related to mental health challenges like trauma or grief, or relationship dynamics with family or friends. Your client may find themselves feeling a sense of control over their ability to verbalize their thoughts while sitting with their discomfort.

Overall, strengthening distress tolerance skills can help your clients improve their overall emotional well-being. They may see noticeable improvements at work, school, social settings, and within their relationships. Over time, the use of these skills can become more natural and automatic, demonstrating their resiliency and growth. 

Distress Tolerance Activities

As mentioned above, distress tolerance is an important life skill that can be beneficial for individuals of all ages. Because of this, we will review distress tolerance activities for adults as well as for kids. Depending on your clinical setting and the client’s needs, you may choose to introduce these skills in a fluid or structured manner. Those who prefer structure to their sessions are encouraged to review related worksheet options with TherapyByPro. This is a trusted resource for mental health professionals that offers personalized and printable worksheet options for a range of mental health conditions and challenges. Examples of worksheets that could be helpful with adults and children include:

Distress Tolerance Activities for Kids

Here are some distress tolerance activities for kids, perfect for your younger clients:

1. Glitter Jar

Kids can make their own glitter jar using water, glue, and glitter. Shaking the jar represents their emotions in chaos, while watching the glitter settle models emotional calming and regulation.

2. Draw Your Safe Place

Invite children to draw or paint a real or imaginary place where they feel safe and calm. This visualization can become a mental refuge during moments of emotional stress.

3. Feelings Wheel Game

Use a spinner or emotion wheel to help children identify and talk about different emotions. This can build emotional vocabulary and improve their ability to recognize and name their feelings.

4. Emotion Animal Game

Ask children to match emotions with animals (e.g., “Anger feels like a lion”). This playful activity encourages emotional expression and helps externalize difficult feelings.

5. Stuffed Animal Breathing Buddy

Have the child lie down with a stuffed animal on their stomach. As they breathe, the movement of the stuffed animal provides a visual cue to promote deep belly breathing and calmness.

6. Coloring Mandalas or Patterns

Coloring intricate patterns helps children focus attention, reduce anxiety, and enter a relaxed, meditative state. Encourage them to choose colors based on their mood and reflect on how they feel afterward.

7. Emotion Thermometer

Create an emotion thermometer with colors ranging from calm to overwhelmed. Help children identify where they are on the scale and talk about what helps them move down toward calm.

8. Create a “Calm Down” Box

Work with children to build a calm down kit filled with sensory and soothing tools like stress balls, fidget toys, calming scents, or affirmations. Having this on hand teaches kids to self-regulate.

9. Movement Breaks or Freeze Dance

Short bursts of movement—such as dancing, jumping, or yoga—can help kids release pent-up energy and stress. Games like Freeze Dance add fun and help transition from high arousal back to calm.

10. Bubble Breathing

Give children a bubble wand and encourage them to blow slowly and gently to make big bubbles. This reinforces slow, controlled breathing and provides a visual cue to manage emotional arousal.

Distress Tolerance Activities for Adults

Below are some distress tolerance activities for adults, perfect for your older clients:

11. TIPP Skill

The TIPP skill—Temperature, Intense Exercise, Paced Breathing, and Progressive Relaxation—uses body-based strategies to rapidly regulate intense emotions. Clients may splash cold water on their face, engage in jumping jacks, or slow their breathing to signal safety to the nervous system. After introducing this technique, provide your client with a TIPP Worksheet to personalize and revisit outside of sessions.

12. 5-4-3-2-1 Grounding Technique

This sensory grounding exercise encourages clients to focus on their immediate surroundings by identifying five things they see, four they feel, three they hear, two they smell, and one they taste. It’s especially helpful for clients who struggle with anxiety, dissociation, or rumination.

13. Journaling

Encourage clients to journal freely or in response to specific prompts. Writing can provide emotional release and help them process overwhelming thoughts. Reviewing journal entries in session can help highlight growth, recognize patterns, and reinforce self-awareness.

14. ACCEPTS Distraction Skill

ACCEPTS stands for Activities, Contributing, Comparisons, Emotions, Pushing away, Thoughts, and Sensations. This DBT-based tool offers multiple ways to redirect focus during high emotional intensity. It allows clients to choose the most relevant distraction method depending on their environment and current distress.

15. Self-Soothe Box

Have clients create a personalized self-soothe box containing sensory items such as a scented lotion, a calming playlist, a small textured object, or meaningful photos. The goal is to engage the five senses during emotional distress to promote grounding and comfort.

16. Mindful Walking

Mindful walking combines physical movement with intentional focus. Encourage clients to walk slowly while noticing their steps, breathing, and surroundings. This can be a helpful outdoor practice that allows for movement and mindfulness simultaneously.

17. Radical Acceptance Practice

Teach clients to practice radical acceptance of situations they cannot change. Use worksheets or visual metaphors (like “dropping the rope in a tug-of-war”) to help them explore the benefits of releasing resistance and accepting reality as it is.

18. Visualization Exercises

Guide clients through calming mental imagery, such as picturing a peaceful forest, beach, or a safe space. This can be especially effective for clients who are highly imaginative and benefit from internal focus to reduce external overwhelm.

19. Emotion Regulation Cards

Create or use emotion regulation cards that contain brief, calming statements or instructions (e.g., “Pause and Breathe,” “This Will Pass,” “Notice Without Judgment”). Clients can carry them and refer to them during distressing moments.

20. Progressive Muscle Relaxation (PMR)

PMR teaches clients to tense and release muscle groups to reduce physical tension. Practicing PMR helps increase awareness of body sensations and teaches clients how to calm their body during emotional escalation.

Final Thoughts On Choosing The Right Distress Tolerance Activities for your Clients

Teaching distress tolerance skills for those living with and without mental health conditions can help them learn to manage emotional crises and other overwhelming emotions. These skills can help develop resilience, improve coping, and build emotional intelligence. Distress tolerance skills can be used to enhance the effects of other therapy approaches.

To learn more about how distress tolerance skills can be beneficial for your clients, we encourage you to explore available continuing education and other training opportunities within your professional niche. 

Resources:

• Zvolensky MJ, Vujanovic AA, Bernstein A, Leyro T. Distress Tolerance: Theory, Measurement, and Relations to Psychopathology. Curr Dir Psychol Sci. 2010 Dec 1;19(6):406-410. doi: 10.1177/0963721410388642. Epub 2010 Dec 14. PMID: 33746374; PMCID: PMC7978414.