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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 6a   (Distress Tolerance Worksheet 4)
Using Cold Water, Step by Step
Cold Wa ter Can  Wor k Wo nder S*
When you put your full face into cold water .  . . or y ou 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. (It may take 15–30 seconds to 
start.)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 .
(This strategy works best when you are sitting quietly—
 a
ctivity and 
distraction may make it less effective.)
tr y it o U t!
*Caution:  Very cold water decreases your heart rate. If you have any heart or medical condition, have a lowered base heart rate due to medica -
tions, or are on a beta-  b
locker, consult your health care provider before using these skills. Avoid ice water if you are allergic to the cold.