TIP comes from dialectical behavior therapy (DBT), the treatment created by psychologist Marsha M. Linehan, and the steps on this page follow the TIP handout in the 2015 second edition of her DBT Skills Training Handouts and Worksheets. HabitatZero made this worksheet on its own. Dr. Linehan, Behavioral Tech (the training organization she founded) and the wider DBT community had no hand in it, and none of them has reviewed or endorsed it.

A skill for the top of the scale

Most coping skills ask you to think. TIP is for the moments when thinking has stopped working because the feeling is too big. Linehan's handout describes it as a way "to reduce extreme emotion mind fast," and it works through the body instead. You change the temperature of your face, spend the energy a surge of emotion builds up, slow your breathing, or tense and then release your muscles. None of this solves whatever set the feeling off. The point is to bring your body down far enough that you choose your next step, instead of the urge choosing it for you.

The four skills

• Temperature. Hold your breath and put your face in a bowl of cold water, or press a cold pack or a sealed bag of cold water over your eyes and upper cheeks, for about thirty seconds. The handout says to keep the water above 50°F, and its companion page notes that the effect can take fifteen to thirty seconds to start and works best while you sit quietly.
• Intense exercise. Run, walk fast, jump or lift weights, as the handout puts it, "if only for a short while." A minute of real effort still counts.
• Paced breathing. Breathe deep into your belly and slow down to about five or six breaths a minute, with the out-breath longer than the in-breath. Five seconds in and seven out is the handout's own example.
• Paired muscle relaxation. Tense your muscles as you breathe in, firmly but short of a cramp, then breathe out, let go, and say the word relax in your mind. The step-by-step version holds the tension for five or six seconds, spends ten to fifteen seconds noticing the difference, and works from small muscle groups up to the whole body at once.

Cold water drops your heart rate fast and a hard burst of exercise raises it, which is why the handout asks you to check with a health care provider before trying either one if you have a heart condition or another medical condition, a heart rate lowered by medication, an eating disorder or an allergy to cold, or if you take a beta-blocker.

How the level works

The page is a carpenter's spirit level, because TIP is a word about tipping. Tap the scale under it to say how strong the feeling is, from zero, level, to ten, all the way over, and the painted level tips to match. Pick one of the four and its steps come one at a time; cold water and exercise open on their caution. The cold-water hold gets a silent thirty-second count, exercise gets a quiet timer, and paired relaxation runs a tense-and-release round. For paced breathing the level itself becomes the pacer, tipping up as you breathe in and settling back, more slowly, as you breathe out. Nothing on the page makes a sound.

When you finish, read the level again; a dashed ring keeps the bubble's old spot on the glass. Keep the reading, and after a couple of tries at each skill the page names the one that brings your number down furthest and marks its card for the next hard moment.

What the evidence does and does not say

When you hold your breath with your face wet, the diving reflex slows the heart. A systematic review of slow-breathing research linked breathing at under ten breaths a minute with higher heart rate variability and with people reporting less arousal, anxiety and anger, though only fifteen studies made the cut, all of them in healthy people.

Research on TIP as a set mostly looks at it inside full DBT programs, alongside many other skills, so it is hard to say how much any single skill adds. In interviews with twenty-four people in eighteen months of DBT, every one of them said distress tolerance skills eased their tension right away, thirteen used TIP skills, and most said the skills that suited them had to be found by trying and then practiced. That is the case for keeping a record: the skill that works fastest for someone else may not be yours.

This page is practice, not treatment. DBT is best learned with a therapist, and if feelings this strong arrive often, that is worth bringing to one. If you are in crisis or thinking about hurting yourself, call or text 988 (US) right now, or reach your local emergency number.

When to use it

Try each skill once on an ordinary day, so the steps feel familiar before you need them. Reach for the level when a feeling sits at eight or above and you can feel the pull to act on it. Once your body has come down, Urge Surfing helps you ride out an urge that is still hanging around, The Window of Tolerance maps the zone you are working your way back into, and The Skills Compass points to the slower DBT skills for whatever caused the storm.