Mental Health: Where to Start
So many people struggle with mental health. To seek help, people generally read self-help books, read inspirational articles, follow common advice such as “follow your passion,” or go to therapy.
As a therapist, I am certainly pro-therapy. But, going to therapy can be intimidating and for some, expensive.
If you need some practical, no-nonsense direction and skills for improving your mental health, learning the framework for cognitive behavioral therapy is absolutely the place to start.
This post is long but THE most helpful, impactful help you will find. Learning this technique is the best way to learn to manage painful and overwhelming emotions, and is an important skill for overcoming depression and anxiety.
Let’s get started:
People usually do one of two things with emotions: they avoid them or they “circle the drain” with them. To escape painful or unpleasant emotions, people use evading behaviors that consist of either numbing behaviors or avoiding behaviors. Examples of these behaviors include alcohol or drug use, shopping, watching television, playing on cell phones, being promiscuous or distracting themselves with a romantic relationship, completely avoiding anxiety producing situations, or an assortment of addictive behaviors.
Circling the drain involves allowing the emotion to overwhelm you, resulting in behaviors such as staying in bed all day, not showering, not getting help for mental health issues, remaining in abusive relationships (not an easy task to leave abusive situations), or just becoming one with it.
Fortunately, there is a third option that does not involve merely coping, which, in essence, is an avoidance tactic. Managing or resolving the emotion is a much healthier solution. This lesson will teach you the cognitive process which leads to management or resolution using a method called ABC worksheets.
ABC worksheets are a powerful tool used in Cognitive Behavioral Therapy (“CBT”). Most psychotherapy performed today uses CBT techniques. When you go to a therapist for a session and talk, this technique is most likely what they are using while you are talking; they are identifying where your thought processes are distorted or negative. It is incredibly transformative when you begin using it in your own life.
How many times have you said or heard someone say, “I can’t help how I feel” or “she made me angry/mad/sad.” We actually can help how we feel; we have more control over our emotions than we think we do. Once you have the process down, you will carry a very powerful tool in your mind at all times! We will review two examples, then you can use the blank worksheet for your own situations. Make copies of the blank worksheet before you fill it in so that you have extras.
Read the instructions first in order to understand the various sections, then read “Putting It All Together” to fully understand the process.
HOW THE WORKSHEET IS SET UP:
Notice that “Situation” goes straight across the top. Situations are events that occur. Events that happen to us cannot be changed. I cannot change that someone was abused as a child and I cannot change the event of a car accident. A situation can also be a behavior, such as someone saying something to us or something that someone does.
The next section below Situation is “Thoughts.” Thoughts are how we interpret the situation, what we think about the situation in terms of what we say to ourselves about ourselves. Thoughts are often automatic and we may not be aware of what they really are.
But there is a trick to discovering our thoughts that you will learn!
After Thoughts is “Emotions or Feelings.” Our thoughts drive the way that we feel. Adjust our thoughts, and our feelings change. This mechanism is how we control our emotions. If I tell myself that I’m ugly, no one will ever love me, I’m going to die alone, how will I feel? Pretty depressed, right?
If I tell myself that I am beautiful, I am worthy of love, I have a very important purpose in my life right now, the right person will come along when the time is right, I will feel much differently, won’t I? Now I feel grateful and empowered!
The goal of managing emotions is not necessarily to create a positive emotion. There are situations where you obviously would not feel happy. The goal is to either eliminate or weaken negative emotions. It is important to learn to tolerate feeling negative emotions and know that emotions are temporary. The purpose of learning this skill is to lessen the intensity and duration of negative emotions and train the brain to think more positively. We are more productive and we engage the world more frequently and more effectively when we feel positive.
After Emotions is “Physical.” Physical responses may not occur subsequent to the emotional response, but occur simultaneously with the situation and the emotion. The purpose of the physical section is to identify what is physiologically going on in the body. What does my body physically feel like? This step is very helpful for anxiety and anger because those emotions are often accompanied by physical manifestations. Once you become more in touch with your physiological responses, your mind and body connection will strengthen and you can engage the cognitive process before your physiological responses become too intense.
The “Action/Behavior” step refers to the resulting action. What did I do in response to the situation? As you learn the sequence of situation-thought-emotion and begin to master your emotional responses, your physiological responses will reduce in intensity and possibly subside, as will your reactive behaviors. You will become less reactive and more responsive as you master this skill and feel more in control of yourself.
The goal of the worksheet is to identify negative and distorted thoughts, challenge them, and replace them with more helpful thoughts. You will start in the unhelpful column, complete the unhelpful column, then shift to the helpful column. For example, if my partner ends a romantic relationship with me (situation), an unhelpful way of thinking about the situation would be to tell myself that I’m unlovable, I’m going to be alone forever, no one will ever want me again. How am I going to feel? Depressed and sad! If I tell myself that the relationship ran its course, I will learn something important from the experience, he/she is missing out because I’m awesome, I will find the right person for me some day, I will have a much more positive emotional response.
Putting It All Together
When completing the worksheet, first identify the situation you wish to analyze. NOTE: when you choose a situation, do not choose the death of a loved one that is related to the normal grieving process. It is normal to be sad over the loss of my elderly grandmother.
Choose a situation and identify the behavior involved. A behavior is something that happens. Be specific. If it involves another person, identify what the person did or didn’t do, said or didn’t say. For example, “my husband didn’t respond to my text message.” “My husband is selfish” is not a situation, it is a criticism. Thus, identify the act, the behavior, or the statement which generated a strong reaction from you.
Next, skip Thoughts for now. Go to Emotions. Use the word list to identify every single emotion associated with the Situation. Don’t just pick the most intense 3 or 4 words. There is tremendous power and healing in putting words to what you feel. Often, a single situation can generate thirty emotions.
In situations, we can generally identify the emotions we feel, but we may not know what we are thinking or how we are interpreting the situation.
After you identify all of your emotions regarding the situation, go back to the Thoughts section.
A Word About Thoughts
Our goal for Thoughts is to identify what we say to ourselves about ourselves. You are going to use a technique called “drilling down.” Your initial interpretation about a situation may be about someone else, such as “He doesn’t care about me.” Drill down on the thought. In other words, ask yourself why you interpret the situation that way and specifically what does your interpretations say about you?
Get down to the “I am….” statement from the he/she statement.
For example, “He doesn’t care about me” drills down to “I am not worth caring about.”
The Trick to Identifying Thoughts
Here’s the trick: look at the emotions you listed. Those words are the clue to what you are thinking. Use the emotions listed to discover what you are saying to yourself. For example, if I write down an emotion of ‘worthless,’ that means I am telling myself (my thought) that I have no value or worth. If I feel inadequate, I am telling myself (my thought) I am worthy of being thrown away or I am not good enough.
Again, it is important to be specific and thorough when listing your emotions because the emotions hold a lot of information about ourselves.
The emotions we feel hold the key to our thoughts.
Completing the Worksheet
So, the actual order of our cognitive process is:
Situation – Thoughts – Feelings
but we complete the worksheet in the order of:
Situation – Feelings – Thoughts
The Physical section is used to identify what my body feels like. Some examples of physiological responses include stomach pains, physical tension, headache, clenched jaw, hands balled into fists, or low energy.
The Action/Behavior section is used to identify my resulting behavior. What am I doing in response to the situation? Examples include arguing, shutting down, walking away, drug or alcohol use, or using sarcasm.
A Word about Helpful Thoughts
After you have identified your unhelpful thoughts, the next step is to challenge them and create a new, more helpful interpretation of the situation. Day 6 will be a more detailed way of challenging thoughts and beliefs that will further your mastery of this skill.
As you begin changing unhelpful thoughts, it is common to struggle with identifying a helpful thought. Look at the unhelpful thought. Your thought is most likely something negative about yourself that you believe to be true. Often, we believe our thoughts and beliefs to be true because there is a strong emotion associated with it. Often, we accept our automatic thoughts as accurate without challenging them. In fact, we may not accept the helpful version of a negative belief to be true.
Write it down anyway.
New thoughts and beliefs may feel weird at first. This feeling is normal. As you make your way through this Boot Camp, those new thoughts will begin to feel less awkward and, hopefully, will eventually begin to feel normal!
Let’s look at some examples to demonstrate the cognitive process:
In the first example, the event that has occurred (Situation) is I am shopping at the big box store and someone I know walks by and does not acknowledge me.
My immediate thought is that they ignored me.
That may be true! However, we need to “drill down” to the “I am” statement.
Why would someone ignore me?
They might ignore me if they don’t like me.
That may be true! Why wouldn’t someone like me?
Because I am not a likeable person. I am not a likeable person is one of my deep-down, core beliefs that came from somewhere else in my life, but I carry it around like luggage!
Because of that belief, I feel low, sad, rejected.
The rejection comes from thinking that I am not a likeable person, not from the situation. We simply used the situation to confirm what we already believed to be true.
I have a physiological response of stomach cramps, low energy, feeling sick.
My resulting behavior is to go home and avoid the person.
Now we need to reframe the thought. There is no room in my life for beliefs that I am not a likeable person.
Not everyone in life will like you. That does not mean that you are not a likeable person. Do you like everyone that crosses your path? No!
I like to use artwork as an example to demonstrate this concept. When you go to an art gallery, you have your opinions about which artwork is good and which artwork you don’t care for. Maybe the person you are with likes a piece of art that you do not like. Liking artwork is based on your own opinion. Opinions are like bellybuttons – everyone has one. But the artwork does not change based on my opinion, or my like or dislike of it. Think of yourself as a piece of art! It does not change based on the opinions of others.
Let’s reframe our belief and identify something more realistic.
Here is an example of a healthier way of thinking: The person I saw at the store seemed a bit wrapped up in themselves. I wonder if there is something wrong? It’s not personal. I am ok as a person. My value and worth does not depend on how others treat me or what others think of me.
Nothing in this world is personal. Nothing. We all act from our own needs ALL OF THE TIME.
An amazing amount of freedom comes with the understanding that NOTHING IN THIS WORLD IS PERSONAL. The behaviors of others may affect us personally, but others do not do things to us because it is US. Their behavior is driven by who they are and what they need.
Now how do you feel about the situation? Maybe now I feel concerned about the person since I am no longer taking the situation personally.
I no longer have a physiological response. I no longer feel a kick in the gut of rejection.
I no longer need to avoid, but maybe instead I call the person to make sure they are ok. Observe how we tend to engage the world more frequently and more effectively when we frame our experiences more neutrally or positively.
Suppose I call the person and they say they didn’t see me and they apologize. Relationship saved!
Suppose when I contact the person they tell me they actually saw me and they were, in fact, avoiding me because I talk too much. While this may seem hurtful, I don’t need to take it personally. Maybe I do talk too much for that person, or maybe they are busy and don’t have time to chat. Either way, it is not personal if someone does not want to chat. Remember, they are busy filling needs they have which have nothing to do with you.
Let’s look at another example that involves anger.
As you review this example, keep in mind “anger management” courses that teach people to breathe deeply, count to 10, and think about the consequences of their anger.
In this situation, I’m at the big box store and the cashier is rude, she is throwing my purchases in the plastic bags, throws the receipt at me, and won’t make eye contact with me.
My immediate interpretation of her behavior is that she is rude and I should not be treated this way.
Those thoughts may be true. But if I have a “should” in my thoughts, then I am setting myself up for disappointment because I am creating an expectation about how someone else should behave.
What does it mean about me that I “shouldn’t” be treated this way? My core interpretation is that if I was important, like a VIP or a celebrity, the cashier would have treated me differently, which means that I am telling myself that I am not important and I don’t matter.
These beliefs are open wounds that I carry around just below the surface. They are luggage and baggage that I am carrying around from the past and every time I experience a situation like a rude cashier, it touches on those wounds which generates my emotional response of anger.
I feel anger! Often, in these situations, the anger bubbles to the surface very quickly. It is so quick, we don’t realize there is a thought wedged in between the event and the emotion and it appears that the cashier made me angry.
Someone or something cannot make you angry.
Anger comes from within.
Anger is what is called a secondary emotion, which means that it is the reflection of another primary emotion, which is either hurt, fear, or frustration.
In the rude cashier example, the anger may be a reflection of all three primary emotions.
The hurt comes from the belief that I am not important and I don’t matter.
The fear comes from what can happen if I am not considered important in this world. Important people get what they need in this world and I am at risk in some way by not being important.
The frustration comes from having my purchases squashed on top of each other and possibly damaged, as well as the frustration of not being able to control someone else’s behavior.
The emotional response is accompanied by a physiological response of an increased heart rate, becoming tense, hot face. In this instance, my body is involuntarily preparing for the fight/flight response. The anger (fear) emotion is signaling my brain to prepare for the physical or psychological threat that my brain perceives in my environment.
The problem with anger is that the accompanying physiological response serves as a circular reinforcer of the emotion. The strong physical response reinforces the emotion and the emotion and interpretation of the situation generates the physical response.
My resulting behavior is to yell at the cashier. We have all seen (or maybe been) the person yelling at a cashier in anger. Now you know the chain of events that occur when you witness someone upset with a cashier.
Time to reframe that unhelpful thought again!
First, we obviously cannot control the cashier’s behavior. We are going to encounter people in life who are rude. We are going to encounter people who do not treat us the way we “should” be treated, or treat us with respect. We can seek to influence the behavior of others, but we cannot control it.
What we can control is the way we think. Let’s reframe the core belief we identified, “I am not important. I don’t matter.”
Remember, that belief is not true. If we think it is true, it is because we FEEL like it is true. But now you are learning that the way that we think determines how we feel.
A more helpful way to think about the situation of a rude cashier is I wonder if she is having a bad day. She is treating everyone badly. It’s not personal. I’m ok as a person. My value and worth does not depend on how others treat me.
It doesn’t even make sense that my value and worth would be dependent upon a cashier at a store who is a stranger to me. But if I get angry at a cashier, that belief is exactly what is being triggered in that situation. How can my value and worth be dependent upon how a stranger treats me? No wonder people walk around with anxiety!
Now what do I feel? Concern, sympathy, and perhaps empathy. I can genuinely empathize with the cashier because I am no longer taking the situation personally.
Notice now that I have no physiological response. There is no breathing deeply, counting to 10 or walking away. No anger management techniques needed!
My resulting behavior is to tell her to have a good day and smile at her. There is no sarcasm, no gritting my words between my teeth, no snarky looks.
While the two examples provided may not apply to you, the concepts are the same. Many people do not struggle with anger or feelings of rejection but the cognitive process is the same.
For the blank worksheets, remember to identify the situation first, then identify your emotions using the word list provided, identify every word that applies, identify your thoughts with the help of the emotions listed, then identify physical responses and finally, actions.
More about “Thoughts”
On average, 80% of our self-talk is negative. There are two main reasons for this phenomenon. First, negative cognitions (thoughts) and beliefs are created in childhood when there is little ability to challenge these thoughts and to understand the context and complexity of situations. Children have an inability to understand cause and effect. For example, if mom comes home and makes a comment about her bad day at work, then subsequently yells at the child out of frustration and exhaustion, the child will not make the connection between the cause (bad day at work) and the effect (yelling). Instead, what happens is a thought process of, “mom is yelling because I did a bad thing. I am bad,” is created. Extensive research exists that demonstrates the connection between verbal and emotional abuse in childhood and depression and anxiety in adulthood.
Second, retaining negative information is necessary for survival (our brain needs to be aware of potential or actual threats), while positive information is useless for survival purposes and is therefore discarded. The survival mechanisms in our brains are very powerful and generally work faster and take over the thinking part of the brain. Negative information and experiences are stored in the neural pathways of the brain. So, if someone insults me and someone compliments me, who is more of a potential threat to me? Exactly – the one who insulted me. This mechanism is the reason the negative stays and the positive leaves. As we learn to be more aware of the positive, it becomes part of the neural structure rather than passing through.
“Just think positively!” has become a bit of a joke in our society but positive affirmations do play an effective role in transforming lives. Positive thoughts create positive emotions which can actually affect our physiology. A concept called neuroplasticity, which is the brain’s capacity to reorganize its structure and function, is a powerful tool that explains why positive affirmations work. The brain is malleable and we have the power and ability to generate positive change. However, because initial changes are temporary, it takes repetition and consistency to make changes permanent. Therefore, as we practice positive affirmations and gratitude, our brains strengthen those neural connections.
Each time our brain strengthens a connection, it simultaneously weakens a connection of neurons that weren’t used in that moment. The brain can erase and override information that wasn’t used, as it becomes irrelevant. Think about riding a mountain bike on a dirt trail. Imagine there are ruts on the trail into which the tire slips. With conscious effort, you can maneuver the bike to a different part of the trail. As you avoid the old rut and follow the new path, the old rut eventually fills in and disappears, while the new path will get deeper and the bike will begin to follow the new rut. The new rut becomes the automatic “go to.” With practice, new thoughts can become our automatic “go to.” New, positive thoughts can feel awkward and clunky at first but will eventually begin to feel normal.
For more information on mental health skills, check out my new book, 30 Day Mental Health Boot Camp. The book is a compilation of 30 topics learned over the course of 30 days. It’s available on Amazon as a paperback or a Kindle. Check it out!
|Situation:||I’m at the big box store, walking down the aisle and someone I know walks by and does not acknowledge me.|
|He/she ignored me.
They don’t like me.
I am not likeable.
|He/she looks a bit wrapped up in themselves.
I wonder if there is something wrong?
It’s not personal. I’m ok.
My value and worth does not depend on how others treat me or what others think of me.
|Emotions/ Feelings||Low, sad, rejected||Concern|
|Physical:||Stomach cramps, low energy, feel sick||None, feel comfortable|
|Action/Behavior:||Go home and avoid them.||Get in touch and make sure they are ok.|
|Situation:||The cashier at the big box store is rude, rolls her eyes, throws my purchases in a bag, throws the receipt at me, won’t make eye contact.|
|She is rude.
I should not be treated this way.
If I was important, I would not be treated this way.
I’m not important. I don’t matter.
|I wonder if she is having a bad day.
She is treating everyone badly.
It’s not personal. I’m ok.
My value and worth does not depend on how others treat me.
|Emotions/ Feelings||Angry||Concern, sympathy, empathy|
|Physical:||Increased heart rate, tense, hot face.||None, feel comfortable.|
|Action/Behavior:||Yell at her.||Tell her to have a good day and smile.|