Art Therapy and DBT: Distress Tolerance

Dialectical Behavior Therapy (DBT) is a structured, evidence-based treatment designed to help people manage overwhelming emotions and difficult behaviors. Developed by Dr. Marsha Linehan, DBT is widely used for conditions like borderline personality disorder, but its skills—mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness—are valuable for anyone seeking better emotional regulation. The heart of DBT is helping clients accept their experiences while learning practical ways to create positive change.

Art therapy offers a creative and nonverbal way to help clients explore and process emotions, which can complement DBT’s cognitive and behavioral tools. By integrating art therapy with DBT, therapists encourage self-expression, mindfulness, and emotional regulation through activities like drawing, painting, collage, and sculpture. These hands-on approaches can make DBT concepts more accessible and engaging, especially when it comes to distress tolerance—the focus of this week’s article.

Distress tolerance is the ability to accept and withstand emotional discomfort without turning to unhelpful or impulsive behaviors. In DBT, these skills are taught to help clients manage crises and ride out intense feelings. Art therapy can make these lessons tangible by using creative tasks that gently challenge clients and encourage them to stay present with discomfort. These activities provide a safe space to experiment with frustration, uncertainty, and imperfection—mirroring the emotional hurdles of daily life.

Understanding Distress Tolerance in Art Therapy

When distress tolerance is applied in art therapy, therapists select or design projects that naturally involve minor setbacks, mistakes, or the need for patience. For example, an art task might require clients to use unfamiliar materials, follow specific steps, or accept unpredictable results. The focus is not on artistic skill, but on how clients handle the process—how they cope with frustration, adjust expectations, and practice self-compassion. This experiential learning builds resilience that can be carried into other parts of life.

Clinical Application

For both groups and individuals, applying distress tolerance in art therapy calls for clear structure, professional boundaries, and a commitment to safety. Therapists must work within their scope of practice and thoughtfully prepare sessions—starting with orientation and preparation, moving through the art-making process, and concluding with a debrief. In groups, rules around confidentiality and respect are essential; for individuals, therapists can tailor the pace and challenges to the client’s needs. Throughout, it is critical to monitor for signs of overwhelm and adapt as needed. A clear beginning and ending help clients feel contained and supported, while post-art discussion reinforces coping skills and integrates learning.

Art Directives

Origami

Origami, the art of paper folding, is a powerful directive for distress tolerance. While it appears simple, even basic models require patience and focus. Mistakes are common, leading to mild frustration—making origami an ideal task for practicing staying with discomfort and trying again. Therapists can adjust the difficulty to fit all ages and abilities, and the low-stakes nature of paper folding encourages creative risk-taking.

Controlled Challenge: The steps are clear, but the process demands patience and the willingness to tolerate errors or imperfections.

Nonverbal Engagement: Origami offers a break from verbal processing, allowing clients to engage their hands and minds in a meditative and mindful activity.

Sense of Accomplishment: Completing a model, even if imperfect, boosts confidence and demonstrates the rewards of persistence.

Safe Failure: Mistakes in origami are low-stakes and reversible, encouraging experimentation without fear of harsh consequences.

By guiding clients through origami, therapists help them practice distress tolerance, self-soothing, and creative problem-solving. Learning a new shape together can also strengthen the therapeutic relationship and model healthy coping.

Other Mildly Challenging Art Tasks for Distress Tolerance

Other art tasks can also nurture distress tolerance. The key is to choose activities that are engaging but not overwhelming and that naturally involve minor setbacks or require sustained attention.

1. Blind Contour Drawing

- Blind Contour Drawing: Draw an object or hand without looking at the paper. The result is often distorted, teaching acceptance of imperfection and helping clients observe their emotional responses to unexpected outcomes.

2. Embroidery or Simple Sewing

- Embroidery or Simple Sewing: Using needle and thread requires patience and problem-solving when mistakes arise. The tactile process is calming and encourages clients to slow down and persist.

3. Puzzle Collage

- Puzzle Collage: Clients cut images into pieces and reassemble them into a new composition, fostering flexibility and adaptation when things don’t fit as expected.

4. Clay Pinch Pots

- Clay Pinch Pots: Working with clay is grounding but can be frustrating when pots crack or collapse. The process encourages persistence and shows that setbacks can be reshaped.

5. Watercolor Washes with Masking

- Watercolor Washes with Masking: Using tape or masking fluid leads to unpredictable results, helping clients let go of control and embrace surprises.

6. Anything new or modified

Trying new materials, switching dominant hands, or using unconventional tools can all create mild, manageable challenges that support distress tolerance.

Implementing These Directives in Therapy

When introducing these art tasks, therapists should:

- Set the Stage: Explain the activity’s purpose and normalize frustration as part of growth.

- Encourage Mindfulness: Prompt clients to notice their thoughts and feelings as they work.

- Model Self-Compassion: Accept mistakes and show self-kindness.

- Facilitate Reflection: Afterward, discuss emotions that arose and coping strategies used.

Conclusion

In summary, blending DBT’s distress tolerance skills with art therapy gives clients a unique, hands-on way to practice managing discomfort. With thoughtful structure, clear boundaries, and attention to safety, therapists can help individuals and groups build resilience, emotional regulation, and real-world coping skills. This creative, evidence-based approach supports lasting growth for anyone seeking better ways to handle life’s challenges.

Resources

Clark, S. M. (2017). DBT-Informed Art Therapy: mindfulness, cognitive behavior therapy, and the creative process. Jessica Kingsley Publishers. 

Linehan, M. M. (2015). DBT skills training handouts and worksheets (2nd ed.). New York: Guilford Press. 

Linehan, M. M. (2015). DBT skills training manual (2nd ed.). New York: Guilford Press. 

Bernier, M. (2023). Process and Materials of Art Psychotherapy II: Crafts  in Art Therapy [Class handout]. Eastern Virginia Medical School, ATC 524.