Holding Ice is one of my go-to distress tolerance skills.  It is a modification of the DBT TIP skills, which aim to change your emotional state through changing your body’s physiology.  This blog is for clinicians and those seeking healing alike.  You’ll notice some comments are directed more towards clinicians to know what to consider when recommending this technique.  However, the overall tone is written based on how I talk when teaching Holding Ice in individual and group psychotherapy.  I use the general “we” to normalize and validate the commonality of the patterns I describe.

Distress Tolerance

The goal of distress tolerance skills is to quickly and effectively get out of high intensity, or numb/dissociated, emotional states in a safe way.  These states are referred to as Emotion Mind. For many, the coping we apply when in Emotion Mind can include planning for or communicating suicide, engaging in self-harm, dissociating, using substances, engaging in risky sexual behaviors, gambling, etc.  Anything that can give us something else to think about, something else to feel, and something to do to help us feel better as quickly as possible.

When in this sort of high acuity, high intensity distress, we aren’t able to think about long term consequences.  We aren’t able to evaluate how we might feel after cutting ourselves or losing money at the slots.  Often the outcome of those behaviors triggers feelings of shame.  Shame can then trigger the desire to withdraw or engage in further reactive behaviors.  This can create a difficult cycle to break.

The purpose of distress tolerance skills is to buy time and get out of Emotion Mind tunnel vision (or off the hamster wheel, I like to use both images) to support effective problem-solving.  The key is to do this in a safe way. 

The Diving Reflex

In the original version of the Holding Ice skill, you are instructed to dunk your head in a bucket of ice water.  This is intended to both jar you into a different psychological state (it’s hard to think about your distress when hit with that extreme of physical sensations – thus why cutting is so effective) and to trigger the diving reflex.  The diving reflex is that when we are underwater, our body recognizes that we will not be able to immediately access oxygen if we need it.  To compensate, our heart and breath rate slows.  From a distress tolerance perspective, the idea is that if we can cue our body to slow, our thoughts and the intensity of our emotions will follow. 

Feasibility

While I’ve had clients use the dunking approach, I find it is not the most readily accessible or practical tool.  When adding tools to our mental health toolbox, it is essential that those tools are feasible, accessible, and something we are willing and able to do.  This is additively more important when we are talking about crisis survival skills or the things that we would put on a safety plan (more on safety plans in my Understanding Suicide series).  Thus, the modification of this tool to simply Holding Ice.  I like talking about this skill on three levels: distress tolerance, mindfulness, and as a metaphor.

Holding Ice

Holding Ice is exactly as it sounds. It involves holding ice cubes in your hands and staying connected with and tolerating the sensations involved.   As described above, the goal is to have a jarring physiological experience that will not cause physical harm; to jump start you out of your tunnel vision.  Holding Ice for thirty seconds to a minute is usually sufficient.

Making it Accessible

Just like you might not have a bucket of ice water around, you might not have ice cubes always prepped and ready.   So, what are the options? First is to get in the habit of making sure you do have ice to use this tool at home or work.  Ice packs of different shapes and sizes are also an option (though they do not work as well with the metaphor I’ll describe below).  If you prefer to use an ice pack on the back of your neck or your forehead – go for it! 

Know Your Triggers

When are you most likely to benefit from Holding Ice? Prepare accordingly.  I’ve worked with a lot of folks where driving is triggering; we problem-solved to have them go to Circle K, get a large cup of ice (which is basically a dollar and change for the cup) and at red lights, stick their hand in the cup of ice as needed.

I’ve also worked with folks who struggle with skin-picking.  For them, moving a single ice cube across the areas they would want to pick was effective for giving them a safer alternative behavior and soothing the irritated skin.

Figuring out how to make this work for you, or your clients, is what’s most important, so be flexible and get creative.

Practice Makes Progress

I always, always, always recommend practicing skills when you don’t need them. Holding Ice is no exception.  When our Emotion Mind is in full swing, it will be too hard to remember a new skill. It will also feel too effortful to take the steps to use the skill, even if that just means getting off the couch and going to the freezer. That’s the power of Emotion Mind. 

Like I talked about in my blog on mindfulness, (refresh yourself here) using skills are muscles we must develop.  I normalize and reinforce this by reminding clients that no one wants a firefighter learning how to put out fires when there is a family trapped inside a burning building.  We want them practicing when there are no stakes involved.  The same is true for our mental health skills.  We will not maximally benefit the first time out. We have to our skills practice when we don’t need them.

Caveats

Holding Ice is a generally safe approach, with a few caveats.  First, Holding Ice might not be a good fit for those with Raynaud’s given their high sensitivity to cold.   Second, if someone has a relationship with physical pain such that it is their go-to for coping, clarifying what Holding Ice may reinforce is important.  It may be an effective harm reduction approach.  For example, the pain of Holding Ice is preferred to the pain of cutting. It will not cause actual physical harm or long-term consequences like needing medical attention or causing scars.  Alternatively though, the pain may reinforce beliefs that they are deserving of pain. Rather than functioning as a distress tolerance skill, Holding Ice may then function as self-punishment.  If this is the case, Holding Ice is not recommended.

Your Turn

Hopefully by now I’ve sold you that Holding Ice is a worthwhile distress tolerance skill.  But have you tried it yet? If not, pause your reading and go get some ice!  As clinicians, it’s important to practice what we preach and know what we are teaching.

Welcome back.  What did you notice? Did you maintain your focus on the ice? Did you use distraction to try and white knuckle your way through the exercise? After a few seconds did you say, “to hell with this” and drop the ice? Did you even notice your action urges, thoughts, and feelings? Here we can apply mindfulness to enhance the benefits of this tool. This might be too much to include the first time introducing this skill to a client or using it yourself.  That’s fine! Focus on the distress tolerance aspect first.  When you are ready, revisit this section to enhance your practice.

Mindfulness

Mindfulness is the intentional awareness of the here and now, without judgment. We practice mindfulness by choosing what we are focusing our attention on, committing to bringing our attention back to that focus when our mind wanders, and by observing and describing the facts of what is happening in this moment. 

When Holding Ice, this means that when our thoughts wander from the sensations of the ice, we gently bring it back.  We choose to focus on the ice rather than trying to distract ourselves as a way of coping with the discomfort.  This reinforces the fact that we can tolerate discomfort.  With the incorporation of other skills, we can then also differentiate discomfort that should be tolerated versus when we need to seek change. Holding Ice can be tolerated. It is not causing us harm and is goal-oriented to using effective coping strategies.

To support keeping our focus on the ice, we observe and describe all that we are experiencing without judgment. Just labeling what is happening in this moment.  This can include, the sensations of the ice in our hands, what the rest of our body is doing (tensing up the shoulders is common, if that happens to you, see if you can breathe into it and relax your shoulders),  our action urges to distract or drop the ice, our judgements of the sensations and the exercise itself and more.

Metaphor

Last but not least, I use this tool as a metaphor.  One of the key principles of DBT is that change is inevitable.  In the heat of Emotion Mind this is hard to believe.   Our Emotion Mind tells us our pain, at this level of intensity, is here to stay.  We cannot see a light at the end of the tunnel, and it is all too much to bear.  Holding Ice gives us a physical representation of the principle of change.  No matter how miserable Holding Ice starts off, it will inevitably change.  Why? Because the ice will melt.  And just like the ice will change, so too will our emotions. 

Keep In Mind

Holding Ice, like the other distress tolerance skills, will not fix your problems.  It will not take your pain and turn it into joy.  It can help decrease your suffering enough to at a minimum while not make things worse and ideally, buy you time.  With this added time, and the quieting of Emotion Mind, there is more opportunity to call on your other skills or seek support and work towards dealing with the situations that caused your initial distress in effective, and value-driven ways.

For Clinicians: I hope this gave you a new tool to incorporate into your clinical toolbox, new ideas and language for how to teach distress tolerance, and more.

For Those Seeking Healing: If you think Holding Ice may serve you, give it a go.  Please remember, this blog is not giving personalized advice or therapy. And if you can still benefit, then I call that a win!