I told my patient to hold an ice cube until it melted. She looked at me like I'd lost my mind.

But it worked better than three different medications.When we—as therapists, clinicians, or just as humans living day to day—have had a little too much of the demands of work, family, bills, we don't talk about distress tolerance skills. We talk about needing to chill out, go for a walk, play a game on our phone.

Our patients are the same.

I think about Sarah. Twenty-eight years old. She'd been rejected by her housing program and her support person. That night, she found herself holding a kitchen knife, staring at her reflection.

By the time she got to our unit, three med changes hadn't touched the real problem.

She didn't need different chemistry. She needed different strategies.

The thing about distress tolerance skills? They're not therapy jargon. They're survival tools dressed up in clinical language.

When Sarah's world felt unbearable, we didn't start with mindfulness meditation. We started with ice cubes.

"Hold this until it melts," I told her. "Feel the cold. Notice how it changes.

"Then we moved through the basics:

→ Cold water on her face when the rage hit

→ Loud music when the thoughts got too quiet 

→ Calling her sister—not to fix anything, just to hear a voice 

→ Pulling weeds in the hospital garden

We overcomplicate coping because we're trained to pathologize survival.

But distress tolerance isn't about eliminating pain. It's about learning to surf the wave instead of drowning in it.

The next time a patient says they're "losing it," maybe the answer isn't another prescription. Maybe it's permission to feel overwhelmed—and practical tools to ride it out.

Based on techniques from dialectical behavior therapy and explored by Dr. Greg Sazima in the July 2020 issue of The Carlat Psychiatry Report on borderline personality disorder. 

What's one distress tolerance skill that actually works in your practice?

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