Table of Contents

Cognitive Behavioural Therapy (CBT) 3

ABCs 5
Cognitions 9
Behavioural Interventions 19
CBT for Insomnia 25
Acceptance and Commitment Therapy 26
Present Moment Awareness 27
Acceptance vs. Avoidance 29
Defusion From Thoughts 34
Compassion 37
Self-Criticism: Changing Your Self-Talk 39
Values and Committed Action 42
Dialectical Behaviour Therapy 49
Mindfulness 53
Distress Tolerance 60
Emotion Regulation 65
Interpersonal Effectiveness 68
DBT Skills Summary 71
Resources 74

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 Cognitive Behavioural Therapy (CBT)
CBT is considered an evidence-based therapy for a variety of mental health conditions. There’s
been a lot of research done on CBT, and it’s very effective. It’s considered the “gold standard”
psychological treatment for a number of different mental health conditions.

That’s not to say that it’s useful for everyone. It’s very present-focused, so it’s not going to help
you work through things like early attachment issues. It’s also quite structured and focused on
the key problems identified, so there’s not a lot of room for talking about anything and
everything that might be going on in your life. Still, even for people that don’t think CBT is the
right fit for them overall, there are likely to be some CBT tools that can be useful.

CBT identifies three levels of thought. The deepest is core beliefs, which are absolute beliefs we
hold about ourselves, others, and the future (these three elements are sometimes referred to as the
cognitive triad).

Layered on top of those are underlying assumptions, which are beliefs that take the form of
if… then…
On top of those are automatic thoughts. These pop up in response to a situation, and they have
an immediate impact on both our mood and behaviour.

Core beliefs tend to be ideas that we’ve held onto for a long time, and when we’re faced with
new information that is discrepant from our core beliefs, cognitive distortions may develop in
order to shield the core beliefs and maintain them as being true. Since core beliefs are highly
resistant to change, they can be hard to work on without guidance and objective feedback from a
therapist.

Core beliefs may be used as the basis for developing rigid, maladaptive rules/schemas of what
we must/should do. These schemas in turn feed into negative automatic thoughts. In a later
section, we’ll take a closer look at these rules.

Uncovering core beliefs involves peeling apart the layers of things that we experience to identify
what is underpinning them. This can be done by asking questions such as:
• What does that mean?
• What is bad about that?
• If that were true/false, what would that say about me?

The Centre for Clinical Interventions has a core beliefs module that you can work through here:
https://www.cci.health.wa.gov.au/~/media/CCI/Consumer%20Modules/
Back%20from%20The%20Bluez/Back%20from%20the%20Bluez%20-%2008%20-
%20Core%20Beliefs.pdf

The diagram below of Beck’s cognitive triad (beliefs about self-world-future) shows how
negative beliefs can feed into one another, keeping someone trapped in negativity.
Recognizing these patterns isn’t going to magically bring about change. CBT requires practice,
and in particular, real-world practice, which is why therapists will typically give homework at
the end of each session to be completed before the next session.

I like to conceptualize familiar thought patterns as well-worn neural pathways through the forest
of the brain. Our brains like shortcuts, so that well-worn pathway is going to look pretty
appealing, even if it’s not actually producing a good outcome.

CBT is about building new neural pathways, and then practicing those pathways often enough
that they become the new easy, automatic route. If you don’t put in the practice, you’re just
trying to bushwhack your way through overgrown forest each time you try a new way of
thinking.

ABCs
The ABCs are the basic building blocks of CBT.

• A = Activating event (antecedents): What event(s) occurred that triggered a response for
you? Were there certain aspects of the event that made it more triggering? Are there certain
specifics that are showing up over and over across multiple events?

• B = Belief(s): What automatic thought(s) arose in response to the activating event?

• C = Consequences: How did this make you feel, both emotionally and in your body? How
did it affect your behaviour? Did it produce any changes in the way you view yourself, others,
or the world around you?

When we react to triggers, those reactions can involve four components: thoughts, emotions,
bodily sensations, and behaviours.

Prompting events, thoughts, feelings, and behaviour often become so tightly intertwined that
there seems to be an inevitability to each of those pieces. V happened, so I will think X, so I will
feel Y, and I will react by doing Z. When you work on teasing the pieces apart and consider them
individual, suddenly there’s a lot less inevitability and more potential targets for change.

When using the ABCs to evaluate our responses to events, we often fail to notice the B and
directly link A and C. This feels quite disempowering, as there is a sense that we can’t change A,
 so we are forced to put up with C. If we can recognize that B is often distorted, particularly by
mental illness, that gives us a target to work on that’s a lot more malleable than the event A that
we have no control over.

For example, another person can’t directly make you feel something. Their action is a prompting
event, but your emotional response is not a foregone conclusion. That’s not to say that it’s easy to
change your response, but separating prompting event and feeling response opens up a window,
however tiny, for change to occur.

Re ection questions
Can you think of a time in the last few days when you felt triggered, and identify the ABCs?

When you were thinking of the B and C in your ABCs, how did you find it trying to separate
out thoughts, emotions, physiological sensations, and behaviours?

Identifying Emotions
In order to understand how our emotions are fitting into the overall picture of our responses, we
need to first be able to recognize those emotions. There may be one emotion that’s most
prominent, with others bubbling away In the background. Using an emotion wheel or an emotion
list can be really helpful in starting to identify those behind-the-scenes emotions.
fl
Emotions themselves are neither bad nor good. They’re a product of what your mind and body
are reacting to, and can serve as clues to understand what’s driving your reactions. Let’s say
you’re feeling anger towards someone, but you scratch beneath the emotional surface and
discover there’s hurt, which is linked to various beliefs. That might be a crucial piece in linking
your A-B-C’s for that situation.

While emotions can be good clues to internal responses, they’re not a reliable way of evaluating
others’ motives. If a friend was supposed to call to set up a coffee date for the two of you, and
they didn’t, you might feel disappointed, hurt, or even worthless. Those emotions are completely
valid, but what was going on in your “C” doesn’t mean that there was something inherent in “A”
to produce that.
 Cognitions
Cognitive Distortions
Cognitive distortions are skewed thought patterns that are not realistic (although not in the sense
of being delusional). They are not necessarily symptoms of mental illness, although they can
become much easier to get caught up in when dealing with a mental illness.

Most people fall into these thinking traps at least some of the time. Some relate to cognitive
biases, which are natural shortcuts and assumptions that our brains make to decrease the
cognitive effort required to evaluate common situations. Others may be used to make the world
seem more consistent with core beliefs.

Cognitive distortions can be hard to recognize, since we’re often pretty convinced that our
assessment of a situation is bang on. When you practice identifying your own cognitive
distortions, it gives you a good starting point to challenge those automatic patterns that don’t
accurately reflect the reality of a given situation.

All-or-nothing
This is also known as black & white thinking, polarized thinking, dichotomous thinking, and
splitting. It involves viewing things as all one way (e.g. good) or all the opposite way (e.g. bad),
with no shades of grey in between. One way to challenge this type of thinking is to use a shades-
of-grey ruler of sorts. One end of the ruler is black and the other is white, but take those extremes
off the table entirely, and look for concrete examples to support the shade of grey that you decide
to go with.

Always being right

This cognitive distortion involves being convinced that one's thoughts/actions are correct
regardless of the situation. If you have a loud inner critic, chances are it’s often telling you that
you’re doing things wrong. However, there may also be thoughts about the external world that
you’re clutching onto tightly that you’re not prepared to let go of even if they’re not realistic.

Blaming
This involves blaming another person for causing one's own emotions or experiences when there
is no such direct connection. We may blame others for making us feel hurt or angry, when in fact
that hurt or anger was our emotional reaction to others’ behaviour. The difference may seem
subtle, but blaming is a very powerless stance, while acknowledging that the reaction is your
own gives you something to work with.
Catastrophizing
As the name suggests, this cognitive distortion involves expecting that the worst possible
outcome will happen - think Chicken Little the sky is falling! And while sometimes the worst
possible outcome happens, most often it doesn’t. It can be useful to go back and do an inventory
of similar situations in the past and consider how often catastrophic results ensued.

Disqualifying the positive

This involves dismissing anything positive as unimportant or meaningless. Even when there’s a
whole fat pile of negative, there’s some positive floating around, and it still counts.

Emotional reasoning
Emotional reasoning is “I feel it, therefore it must be so" (kind of a distorted twist on "I think,
therefore I am”). This isn’t a matter of your feelings being valid or invalid, but rather something
along the lines of “I feel neglected, so he must have been intentionally neglecting me.” Our
emotions are valid reactions to precipitating events, but the emotion doesn’t define that event.

Fallacy of change
This is about expecting that others will change to suit our needs if we just push them hard
enough and long enough. They’re not going to change unless they’re motivated to do it
themselves, and even then, it can be a crapshoot.

Fallacy of control
The locus of control may be seen as fully external (i.e. I don't have any control over what
happens to me) or fully internal (i.e. I am responsible for everything that’s happening to me as
well as to others around me).

Fallacy of fairness
The belief that the world is a just place can seem like a good one to hold onto. However, as nice
as it may seem, it’s just not true, and it sets up unrealistic expectations.

Filtering
While disqualifying the positive minimizes the good thing, filtering (also known as selective
abstraction) shuts out the positive entirely and only sees the negative. This is something that’s
deeply ingrained as a survival mechanism, so it’s a very easy thought trap to fall into.
Fortune-telling
This is a type of arbitrary inference that involves predicting how something will turn out using
your non-existent crystal ball. While most of us would accept that the crystal ball type of fortune-
telling is a bit ridiculous, it’s easy to fall into the trap of thinking that the past predicts the future.

Heaven's reward fallacy

This is the belief that if you have sacrificed/suffered then something good/ rewarding must come
of it eventually. Like the fallacy of fairness, it sounds nice, but it’s just not true.

Mind-reading
Like fortune-telling, mind-reading is a type of arbitrary inference. It involves the belief that you
can know another person's thoughts based on their behaviour. This is a very easy trap to fall into,
and it’s certainly one that I struggle with. It can seem so obvious that a person’s reaction means
that they’re thinking/feeling a certain thing, but the only way to actually know is if they tell us.

Labelling
This cognitive distortion is about labelling a person as a whole based on a specific behaviour. If
someone snaps at you once, you might label them as a mean person, but what you might not
know is that they hadn’t slept for days because of a sick toddler. Labelling can also serve as a
basis for stigma.

Overgeneralization
This involves extrapolating what happened in one situation to apply to many other situations that
really aren’t related.

Personalization
This involves blaming oneself for external events when there’s no logical way that there could be
that type of cause and effect relationship.

Shoulds
Shoulds often encompass a few different things. Some things you truly need to do, and other
things (like following the law) are essentially needs because the cost of not doing them is too
high to be acceptable. Then there are things we like to do, but maybe have to do some
rearranging to fit in. There are also things that may not be enjoyable at the time, but they serve a
useful purpose or are consistent with our goals and values.
 The shoulds that are cognitive distortions revolve around expectations and unrealistic or arbitrary
standards. These shoulds are often used as an excuse for self-criticism. Some people hold one
very tightly to their shoulds, out of concern that they wouldn’t do things properly without them.
Acceptance and commitment therapy, which incorporates concepts from CBT, would say that
values are a more useful guide than shoulds.

Re ection question
Which cognitive distortions do you use most often, and in what types of situations do you tend to
use them typically?

Ongoing practice
When distressing thoughts arise, go through this list and see if any of these cognitive distortions
might apply. Consider how likely it is that the thought is distorted, and see if you can defuse
some of the emotion attached to it in light of the thought that it could possibly be distorted. A
thought record (coming up in the next section) can help with this.

Thought Records
Thought records are used to test automatic thoughts, and they’re a key tool in CBT. The idea is to
practice these over and over so it starts to become automatic to critically evaluate your thoughts
– so automatic that your mind goes through the process even if you don’t actually have a thought
record form in front of you.

The thought record starts with the activating event, the A from your ABCs. Be specific about
this, including details like who, what, when, and where.

The next step is to identify the “hot thought” or thoughts. These stand out as the thoughts that
generate the strongest reaction and the most distress, and they tend to exemplify the meaning you
attribute to the triggering incident.

Next, you identify the strongest emotion that the hot thought stirs up. Use a single word (this
helps make sure you’re identifying an emotion rather than another thought), and rate the intensity
from 0-100%.

Finding Evidence for & Against Thoughts

Often, we support our beliefs using our thoughts and feelings, and we don’t go beyond our own
heads to look for more objective evidence. Objective evidence is anything that would be
fl
apparent to anyone looking at the situation; what’s going on inside your head doesn’t count as
objective evidence, no matter how real or strong it is to you.

As an example, let’s say you made a mistake doing something. As a result, you might conclude
that you’re stupid/incompetent/useless, which leads to you feeling generally lousy about yourself
as a person. To an objective bystander, however, your mistake proves no such thing; it simply
proves that you made a mistake. The fact that you think you’re stupid is not objective evidence
of your stupidity; rather, it’s your subjective reaction and appraisal.

Evidence for and against can also be used to evaluate expectations. What is the worst that could
happen? What is the likelihood of that happening? How would you manage even if the worst did
happen? What is a more likely outcome? What unhelpful behaviours do you have related to these
expectations?

Identifying a More Balanced Thought

Based on the evidence you identified for and against the hot thought, develop a more balanced
alternative thought. Rate the strength of your belief in that thought on a scale of 0-100%.

Once you’ve identified the balanced thought, rate the intensity of the hot emotion that you
identified at the beginning of the thought record. The “expected” drop in intensity is 20-30%.

Sometimes it will turn out that the hot thought is true in a literal sense. In this case, getting
distressed about it is a significant drain on your mental resources, and it may be better to shift
focus onto developing an action plan to address the reality of the situation as it is.

Situation “Hot thought” Associated Identify evidence Identify more Re-rate

– the thought emotion for and against balanced emotional
that causes and the thought alternative intensity
the most intensity thought(s) and
distress rating rate the strength
of belief in it
 Trouble-Shooting
If you’re having trouble identifying evidence for and against a thought, or coming up with a
balanced alternative thought, there are a couple of things you could try. One is to remove
yourself from the situation and imagine a close friend or family member being in your shoes.
What feedback might you give to them? You could also ask someone close to you to help you
work through the thought record with you. They may have some ideas that you hadn’t thought
of.

You can do thought records as often or as seldom as you want, but once a day is a good
frequency to aim for if you want to give it a serious try. It can be done shortly after the trigger
occurred, or you can wait a bit, but you’ll want to do it when you’re still feeling the hot emotion.

Evaluating Rules & Assumptions

We’ve all got them – rules and assumptions that guide how we approach our day-to-day lives.
Mostly we tend to take them for granted. However, often these rules and assumptions aren’t
actually serving us very well. Learning to recognize these is the first step in evaluating how
helpful or unhelpful they are in our lives.

Most of us have a pile of shoulds that we tote around with us. Unless they’re associated with an
“I need to” or “I want to,” they could probably use some re-evaluating. Here are a few questions
to reflect on related to rules and assumptions:

Re ection questions
What are some of the rules and assumptions you commonly use?

Which rule has the greatest impact in your daily life, and how has this affected you?

What does it feel like when you are following that rule?

What is the original source of the rule/assumption?

What could be an alternate explanation for what fed into the rule/assumption/core belief?

What are the pros and cons of adhering to the rule/assumption?

What would be the pros and cons of changing the rule/assumption/core belief?

What is a more balanced, flexible version of the rule/assumption?

fl
 Cognitive Interventions
Like the name suggests, CBT involves a mix of cognitive-focused and behaviour-focused
interventions. In this section, we’ll look at some of the cognitive interventions.

Reframing
To improve a difficult situation, you can either change your reality or lower your expectations.
The closer reality and expectations and reality are to one another, the better you’re likely to feel.

Guided discovery with a therapist will help with this, but it’s also something you can do your
own work on. When you have a mental illness, the reality of that typically isn’t going to budge,
at least in the very short term, so adjusting expectations will probably be the easier side of this
equation to work on. A common trap is expecting the same level of ability/performance as you’d
have when you’re well. Yet most likely that’s completely unreasonable, and evidence of how
people (both yourself and others) function when well is not the right evidence to address the
issue of functioning when ill.

Vertical Descent
This strategy is used to uncover a line of implications leading down to core beliefs, and examine
the probabilities of each successive event given previous events.

It begins with a negative automatic thought about a situation. You then consider the question “If
this were true, so what? What would that mean?” You would then keep going until you reach the
core belief that’s feeding into all the other negative thoughts.

Double Standard Method

This involves testing beliefs by considering what you’d think of another person who was in the
same situation that’s activating for you. Often, we apply very different standards to others than
we do to ourselves. Consider how you would evaluate a person close to you, or even a neutral
acquaintance, in that situation. Would you evaluate and judge them the same way you evaluate
yourself?

Worry Tree
While anxiety encompasses emotional, cognitive, and physical elements, worry is a mostly
cognitive process that’s focused on potential problems in the future. While sometimes people
believe that worrying is necessary in order to prevent a negative outcome, that’s actually not the
case. Worry gets really caught up in the problem without taking that next step to problem-solve
and identify solutions.
The worry tree is a basic tool to help you decide what to do with whatever worry you might be
experiencing. If the worry is hypothetical, you could waste a lot of valuable cognitive energy on
it, or you could let it go. Now, that letting the worry go part isn’t quite as easy as the worry tree
implies, but the basic idea is still a good one.

The steps are:

• Notice that you’re worried and identify what
the worry is about
• Decide if the worry is a hypothetical situation
that may or may not happen, or if it’s a current
problem you can act on
• If it’s hypothetical, there’s nothing you
can actually do about it, so try to let the
worry go and refocus your attention on
something else
• If it’s something that you can act on,
develop an action plan
• Can you do it now? Then go ahead and
do it.
• Otherwise, schedule it for later.

Scheduled Worrying
This involves scheduling a period of time during which you can worry all you want, and then
restricting worrying at other times. You can make notes during the day of things you don’t want
to forget about during your worry time.

This technique isn’t always going to be useful, and the result you get will likely have a lot to do
with what you’re using it for. If you try to schedule your anxiety with the emotion-cognitive-
physical full meal deal, you’re most likely not going to get very far. However, if you’re worrying
about how you’re going to pay for expense X in 6 months, scheduled worrying is going to offer
more potential benefit.

A variation of this can help if worries are coming up at bedtime. Keep a notepad next to your bed
and write down exactly what you want to worry about in the morning, and that may ease the
sense that you need to attend to the problem, and help slow your mind down a little.
Thinking in Shades of Grey
This is used to challenge all-or-nothing, black-and-white type cognitive distortions. It involves
evaluating beliefs and appraisals on a scale from 0 to 100, but not allowing yourself to assign
values from the extreme ends of the scale. Then consider what other shades of grey might
contribute to the whole picture.

As an example, consider a task you’d set for yourself to clean the kitchen. Let’s say that while
doing so you dropped a plate and it shattered. An all-or-nothing way of looking at this situation
would be that because you broke the plate you were not 100% successful at your task, and that
would mean you were 0% successful at your task of cleaning the kitchen. Approaching this in
shades of grey, you couldn’t rate yourself as 0% successful. If you were even 10% successful,
where might that 10% of success have come from?

Structured Problem-Solving
This clear, step-by-step approach can be useful when illness is causing difficulties with problem-
solving and decision-making.
• Select a problem
• Open your mind to all solutions
• List pros and cons of each potential solution
• Verify the solution
• Enact a plan
• Decide if the plan worked

Prediction Logs
Keep a log of your predictions about how situations would turn out, and how they actually turned
out. This way, you can start to accumulate evidence regarding the thoughts underlying the
predictions.

Semantic Method
The semantic method involves substituting less emotionally charged language. Instead of
slapping a label on yourself, use neutral, nonjudgmental language instead. Instead of using
“shoulds,” drop the word “should” and frame the idea in a different way.
Reattribution
While it’s easy to conclude that you are responsible for everything that’s going on around you,
that’s probably not the case, or at least not entirely. Reattribution is about looking for other
factors that may have contributed to what’s going on.

For example, let’s say you tried to chat with a coworker, and it seemed like they brushed you off.
While that may have had something specifically to do with you, what other factors can you come
up with that may have contributed? Did the boss recently dump a bunch of extra work on them?
Has their child been sick? Might they have a migraine?
 Behavioural Interventions
Rather than targeting thoughts directly, the behavioural side of CBT works on changing
behaviours in order to have a positive impact on thoughts and feelings. Mental illness can often
bring about behaviour changes that in turn feed into and reinforce the illness, and this is a major
target for CBT. A good example of this is compulsive behaviours in OCD.

The most appropriate behavioural interventions will depend a lot on the specific illness and
illness-related behaviours. However, this section gives an overview of some of the behavioural
strategies that are used in CBT.

Observation and Self-Monitoring

In order to tease apart what’s happening with thoughts, feelings, physiological reactions, and
behaviours, we have to be aware of what’s actually happening so that we can start to figure out
what our patterns are. A bullet journal or mood tracking app can be a great way of keeping track
of all of these pieces.

When you’re doing the self-monitoring, try to separate out thoughts and feelings. We often use
the words “I feel” when we’re actually referring to thoughts. As an example, “I feel like
something bad is going to happen to me today” is a thought, which is likely accompanied by a
feeling like anxiety or foreboding. A quick way to differentiate thoughts and feelings is how
many words are required to describe them. Feelings are described by single words (e.g. happy,
angry, anxious), while thoughts require a string of several words to express. Being able to
distinguish between thoughts and emotions is important for you to be able to work on unlinking
the two.

Behavioural Activation
Behavioural activation is a major part of CBT for depression. This activation refers both to
increasing physical activity and increasing other daily activities, and it can be done within the
home or outside of the home. Before and after participating activities, you’re supposed to rate
your mood and how you perceive your ability to do the activity (mastery).

Physical activity should be done at a level that’s appropriate for how you’re currently feeling,
which may be a far lesser level of exertion than you would normally aim for.

It’s also important to fit in activities that are pleasurable (or at least they would be pleasurable if
you were feeling better). This includes acts of kindness towards both yourself and others. If these
activities just aren’t happening on their own, try scheduling them in your calendar for specific
days and times.

Another recommendation is setting goals and identifying activities that can help you in the
direction of achieving your goal(s). When goals for certain tasks seem overwhelming, it’s useful
to break it down into individual steps. This functions as a staircase to help you make your way
up toward your goal.

The basic premise of behavioural activation in CBT is that it’s easier to focus on changing
behaviour compared to changing thinking, and motivation follows activation.

Personally, I’ve got mixed feelings about the whole idea of behavioural activation. For some
people, behavioural activation works really well; for others, not so much. I’m one of those not so
much people.

If I’ve lost all interest in doing something, doing it over and over again anyway is just going to
leave me annoyed. I’ve tried pushing physical exercise for months because I knew that’s what
you’re “supposed” to do, and it just remained consistently unpleasant, even though it was a form
of exercise I used to enjoy.

At the same time, giving in to the depressive urges not to get out of bed isn’t helpful either. I try
to focus on basic functional activities and self-care activities and not worry as much about trying
to push myself in other areas.

I also believe that with behavioural activation it’s better to aim low and feel like you’ve
accomplished something than it is to aim high, not be able to do it, and beat yourself up. Keep in
mind that the targets you set for yourself should be calibrated to your current level of functional
ability, not the way you function when you’re at your best. If you’re really low, taking a shower
is a huge behavioural activation gold star.

Relaxation Techniques
Relaxation techniques commonly used in CBT include progressive muscle relaxation, deep
breathing exercises, and the use of imagery.

Progressive muscle relaxation goes through different muscle groups in your body, consciously
tightening and then releasing them. Notice the difference between how it feels when the muscles
are tense and when they’re relaxed. You can start at your feet and move one area at a time up to
your head, tensing and relaxing each muscle group.
Anxiety has a progressive muscle relaxation audio exercise here: https://
www.anxietycanada.com/articles/how-to-do-progressive-muscle-relaxation/

Deep breathing exercises are important as they signal to your brain to activate the
parasympathetic nervous system (which handles activities like resting and digesting) and tone
down the sympathetic nervous system (which handles the fight or flight response). Breathing
deeply and slowly helps you to achieve this effect.

Addressing Safety Behaviours

CBT differentiates between adaptive coping behaviours and safety behaviours. Adaptive coping
behaviours are things that would reasonably be expected to decrease potential threats, and as a
result, they decrease anxiety. Safety behaviours are things that don’t actually do much of
anything to keep us safe, and while they may temporarily give a reprieve from anxiety, overall
they end up actually perpetuating the anxiety.

Distinguishing between the two isn’t just about the behaviour itself. The context, rationale,
outcome, and attributed meaning also matter.

Locking the door to your home is something that’s done by most people to reduce the risk of
theft or other threats. You may lock the door behind you when you get home, which sets your
mind at ease so you can carry on with your day. Perhaps you were a bit preoccupied when you
got home, so you can’t remember if you locked the door when you got home. You check it and
see that it is in fact locked, so you feel reassured, and that’s the end of that. This is an example of
adaptive coping behaviours.

Let’s say, though, you have a high level of anxiety, or perhaps obsessions, related to your home
not being secure. Maybe you compulsively check the door every 10 minutes to make sure it’s
locked. While your mind is telling you that this makes you safer, it doesn’t, and it ends up
reinforcing the anxiety.

In CBT, it’s important to identify safety behaviours and work on finding more adaptive ways of
coping that don’t fuel anxiety.

Behavioural Experiments
Behaviour experiments are a way to play psychology researcher and test out predictions/
hypotheses in real-life settings. They can be used to test if… then… underlying assumptions, or
you can do surveys to check if other people actually are thinking (or noticing) what you expect
them to think.

The first step in devising a behavioural experiment is to identify the belief being tested. Then you
come up with an experiment that could test that belief. The next step is to make specific
predictions about the absolute worst thing that could happen, the best thing that could happen,
and the most likely outcome you expect. Rate the percentage certainty of your belief in the
outcome you expect.

These are the steps in doing a behavioural experiment:

1. Select a belief that makes predictions about the world to test
2. Rate the strength of the belief
3. Decide on a setting/context to test the belief
4. Decide on a method for the experiment
5. Conduct the experiment
6. Evaluate the results, assessing what happened and how much of your initial prediction turned
out to be true
7. Review any changes in the belief and re-rate the strength of it

The experiment should be set up such that people doing nothing is not treated as evidence for
your belief. People are lazy, and doing nothing is usually going to be the default response. People
doing nothing may serve as evidence against certain predictions (e.g. if you predict that people
will comment on a certain behaviour of yours, but they don’t), but if your prediction is that
people will ignore you when you walk into a room, people doing nothing is the default, and it
doesn’t necessarily have anything whatsoever to do with you.

When doing CBT with a therapist, you have someone to help you devise experiments and
evaluate them afterwards. If you’re doing this on your own for the first time and you haven’t
done CBT before, ask someone close to you to get creative and help you devise an experiment.
Having that objective input is important because you don’t want to inadvertently (or
intentionally) set yourself up with an experiment that’s bound to go badly.

If you’re finding that it’s hard to step back and take the role of curious researcher, but you see the
potential value of doing behavioural experiments, working with a therapist will probably help.
This is something that’s fairly conducive to online therapy if that’s more accessible for you.
 Prolonged Exposure
Any major prolonged exposure work is best done with a therapist. However, there are elements
of exposure therapy that can be used on your own for less serious challenges related to anxiety-
provoking stimuli.

Prolonged exposure is a very effective, evidence-based therapeutic intervention that aims to

promote emotional processing by activating the brain’s fear centre (the amygdala) while
simultaneously integrating new information that’s inconsistent with the fear. Exposure can be
imaginal (mentally imagining an anxiety-provoking situation) or in vivo (actually going into the
situation).

What’s key with prolonged exposure is continuing it until the initial physiological fight-or-flight
response naturally starts to ebb. This is usually around 45 minutes. Leaving the situation before
your body starts to calm itself down may just perpetuate the anxiety.

Before beginning exposure work, you’ll develop a hierarchy of anxiety-provoking stimuli, rating
them from lowest to highest intensity of associated anxiety/distress. You’ll also need to identify
any safety behaviours you would normally use in these situations, and then you’d have to avoid
using those during the exposure.

Exposure begins with the least anxiety-provoking situation from the hierarchy, and then you
gradually work your way up. Self-help exposure work might be manageable for issues where
even the highest item on the fear hierarchy isn’t intensely distressing. However, exposure for
more severe problems should definitely be done with the support of a therapist.

There’s more on exposure in this section of a group therapy manual from the University of
Michigan: https://medicine.umich.edu/sites/default/files/content/downloads/Exposure-and-
Desensitization.pdf

Exposure and Response Prevention

A variation on prolonged exposure that’s used in OCD is exposure and response prevention
(ERP). This involves exposure to a triggering stimulus without performing the compulsive
behaviour, and it’s a good idea to have the support of a therapist with this.

OCD involves a vicious cycle of obsessive thoughts => anxiety => compulsion => temporary
relief => reinforces that obsessive thought is actually harmful
ERP disrupts this cycle by breaking the feedback loop of compulsions reinforcing obsessions.
This also teaches the brain that the feared stimuli aren’t actually as dangerous as they’re
perceived to be.

Workbooks are available from:

• CRUfAD: https://crufad.org/wp-content/uploads/2017/01/crufad_OCDmanual.pdf
• NHS inform: https://www.nhsinform.scot/illnesses-and-conditions/mental-health/mental-
health-self-help-guides/obsessive-compulsive-disorder-ocd-self-help-guide
 CBT for Insomnia
CBT for insomnia (CBT-i) targets both behaviours related to sleep and distorted beliefs around
sleep that may be contributing to insomnia.

It involves targeting common problematic beliefs related to sleep, such as:

• I need 8 hours of sleep to survive.
• If I don’t get a good night’s sleep, then ... [something bad will happen].
• If I'm having trouble sleeping, I need to try harder. (Paradoxical intention refers to the way
badly wanting to sleep can paradoxically make it harder to sleep.)
• If I have a bad night of sleep I should try to catch up on sleep later.

Behaviourally, a major focus is limiting the amount of time that you’re spending in bed awake.
This means not going to bed until you’re actually sleepy and getting out of bed if you’re lying
there awake for more than 10-15 minutes. Sleep efficiency is the ratio of the time spent asleep to
the total time spent in bed. To start improving sleep efficiency, you need to start spending less
time in bed.

Rather than having a set bedtime, you’re supposed to have a set wake-up time, and always get up
at that time, regardless of how much/little you’ve slept. You’re also not supposed to nap during
the day. This allows you to boost your sleep drive, which comes from the amount of time you’ve
spent awake, which will make it easier to fall asleep at night.

CBT-i can actually mean sleeping less initially, but it’s got a strong evidence base as one of the
most effective treatments for insomnia.

Here are some self-help resources:

• NHS inform self-help guide: https://www.nhsinform.scot/illnesses-and-conditions/mental-
health/mental-health-self-help-guides/sleep-problems-and-insomnia-self-help-guide
• Sleepwalk CBT-i resources: https://mysleepwell.ca/cbti/
• Veterans Affairs has a CBT-i Coach app: https://mobile.va.gov/app/cbt-i-coach
• Veterans Affairs also has an Improve Your Sleep guide: https://mirecc.va.gov/docs/visn6/
Improve_Your_Sleep_Self-Guided_Approach_for_Veterans_with_Insomnia-March-2017.pdf

The University of Washington has a CBT-i manual that’s meant for therapists rather than clients,
but it can give you an idea of what’s involved in doing CBT-i with a therapist. https://
aims.uw.edu/nyscc/training/sites/default/files/CBTi%20Manual.pdf
 Acceptance and Commitment Therapy
Acceptance and commitment therapy, or ACT, is based on the idea that increasing psychological
flexibility is a key element to achieve wellbeing. As the diagram below from the National
Library of Medicine shows, there are several pieces that contribute to psychological flexibility:
• attention to the present moment (mindfulness)
• values
• committed action (in the direction of values)
• self-as-context (self is where thoughts and emotions occur; they’re not a part of the self)
• defusion (separating oneself from thoughts)
• acceptance
 Present Moment Awareness
Present moment awareness is an important starting point to be able to fully accept things as they
currently are. Being able to anchor in the present helps in recognizing the transience of thoughts
and emotions. It also helps you to recognize when thoughts are dragging you off in the direction
of either the past (as with rumination) or the future (as with worry).

Present moment awareness can involve formal meditation practice, but it certainly doesn’t have
to. It’s equally valid to take an informal approach centred on active awareness of what is
happening inside the mind/body as well as what’s perceived through the senses from outside of it
in the right here, right now.

Questions for re ection

When you’re walking somewhere, how much do you tend to notice things along the way?

How often do you feel like you’re running on autopilot? Do you think you might be missing out
on things because of that?

How often do you try to multitask? How does that work out for you?

Mindfulness Techniques
The situations described in the previous questions all make it hard to practice acceptance because
your mind gets caught up somewhere else. Here are a few strategies that can help to connect
mind and body in the present moment:

• Body scan: This involves moving your awareness in a systematic way over the entire body,
noticing as many sensations as you can. The pattern you follow across the body isn’t
important; what matters is covering the whole body and only focusing on one spot at once. You
might pick up tension, discomfort, ease, or other sensations. Notice them, allow them to be,
release them and keep moving with your awareness.

• Mindful eating: A classic ACT exercise is the raisin meditation, which involves curiously
experiencing holding and then eating a raisin in each of the five senses in turn. You can also
focus mindfulness on the eating process in general. Sit down with some food, with no tv or
devices to distract you. Imagine you are eating this food for the last time ever, and you’re
trying to imprint it in your memory. Notice the different flavours and textures. Have a party in
your mouth.
fl
• Mindful walking: There are a couple of ways to do this. One is to turn the mindfulness
inwards, focusing on the movements of your body, the shifts in weight, the feeling of your feet
hitting the pavement, etc. Your body is a truly amazing machine, and deserves to be noticed for
it! An alternative is to direct your mindful awareness outwards. Home in on little details of
your surroundings, like the way the sun hits your face, the way the breeze ruffles your hair, or
the sound of the breeze rustling tree leaves. Focus on being exactly where you are at that
moment, and be curious about what’s there along with you.

Mindful Crisis Management

• Slow down breathing
• Take note of what’s happening inside of you
• Open up, allowing space for whatever thoughts and feelings are passing through you
• Pursue your values in deciding how to move forward in the situation

You’ve probably heard the saying that the only way out is through. Similarly, Winston Churchill
said, “If you’re going through hell, keep going.” In challenging situations, mindfulness keeps
you grounded and focused so you can see the way through and come out on the other side.

What’s key with the ACT STOP stance is that you’re not trying to suppress your reaction. It’s not
necessarily going to be easy to open up to difficult feelings, but those feelings are going to be
there whether you want them or not. If you let them flow freely through you, you’re better able
to get to a place where you can choose actions that are consistent with your values.
 Acceptance vs. Avoidance
Acceptance isn’t about liking or agreeing with an internal or external experience. Rather,
acceptance is the opposite of avoidance. Often, we try to control or suppress certain thoughts and
feelings that we perceive as negative or unpleasant, but that doesn’t actually work very well, and
can end up just making things worse.

Controlling Thoughts
Intuitively, it probably seems that the ability to control your thoughts is a good thing. Cognitive
behavioural therapy (CBT) focuses on challenging problematic thoughts to create new patterns
of thinking. The angle that ACT focuses on, though, is that trying to suppress your thoughts is
likely to increase your level of distress.

How about you take a minute to think about a white bear; chances are you’re not regularly
coming across either a polar bear or a while spirit bear wherever it is that you happen to live, so
they’re probably not on your mind much. Great, so you’ve got your white bear. Now, for the next
minute, I want you to not think about a white bear at all. All of a sudden those rare white bears
are doing the hokey pokey in your head, right?

The questions below are adapted from the Thought Control Questionnaire. When answering
them, consider a disturbing thought that you’ve been having on a recurring basis. The more of
these strategies that you often use in response to unpleasant/unwanted thoughts, the more control
you’re trying to exercise over your thoughts.

1. Do you focus on the thought?

2. Do you avoid talking to anyone about the thought?
3. Do you get angry or punish yourself for having the thought?
4. Do you try to distract yourself from the thought?
5. Do you challenge the thought’s validity?
6. Do you try to rationally analyze the thought?
7. Do you try to reinterpret the thought?
8. Do you try to find a different way of thinking about the thought?
9. Do you question why you’re having the thought?
10. Do you tell yourself that something bad will happen if you think the thought?
 Avoidance
We naturally want to avoid the things we experience that are unpleasant. Obviously, it makes to
avoid situations that will put us in immediate physical danger; that’s a highly adaptive response.
Avoidant patterns do nothing to actually keep us safe; instead, they serve as a means of running
away from difficulties. That running away just goes in circles and ends up bringing us right back
to the problem we started with.

When something painful happens, it will naturally create a painful reaction. From an ACT
perspective, if you allow yourself to let that pain be, it will start to dissipate in due course. By
avoiding it, though, the pain grows rather than lessens. As counterintuitive as it may seem,
acceptance results in less pain overall than avoidance does.

Common Avoidance Techniques Follow the DOTS

• Distraction
• Opt out (of places, actions)
• Thinking (trying to think your way out of a problem by rehashing it, blaming, self-criticism, etc.)
• Substances, Self-harm, and other harmful strategies

The (S) is obviously a harmful thing, but the DOT sound like they could actually be good things.
However, if you’re using them in an attempt to avoid dealing with a situation and finding a
resolution, then that’s not helping you.

Distraction can be useful when there’s an issue that’s ongoing and comes in bursts. In that case,
you know the difficult feeling will resolve if given a bit of time, and distraction helps that time
go by faster. It’s not a way of avoiding dealing with a problem, so it’s not a DOTS situation.

Opting out can be a healthy, proactive way of sticking to boundaries. Often, though, opting out is
a reactive avoidance response that actually ends up feeding into mental illness symptoms.

Thinking can be useful if it’s solution-focused and forward-oriented. The problematic thinking
styles that are part of DOTS are repetitive, circular, and problem-oriented. They may not feel
avoidant, because the problem is shouting loud and clear in your mind, but where the avoidance
aspect comes in is avoidance of dealing with the problem and coming to a resolution. It’s time to
step off the hamster wheel.
DOTS: Questions for Re ection
Are any of the DOTS go-to’s for you?

Do you feel like thoughts/feelings can harm you? How would that happen?

Do you feel like you need to have control over your thoughts and feelings?

What strategies do you use to push away your feelings?

When you use those strategies, how does it feel?

Costs of Avoidance
The problem with avoiding activities in an attempt to avoid pain is that we end up missing out on
some of the things that actually make life worthwhile. Given that pain is inevitable anyway, is
that avoidance costing you more than you’re getting out of it?

How might avoidance be holding you back from things that are consistent with your values?

What are the costs of avoidance? What are you giving up or missing out on?
• Interpersonal
• Career
• Health
• Mental/emotional costs
• Energy
• Loss of freedom
• Financial costs
• Other areas

Acceptance
Acceptance requires willingness. Both acceptance and willingness also make an appearance as
skills in dialectical behaviour therapy (DBT). Acceptance doesn’t mean liking something, and it
doesn’t mean thinking that something is a good thing. It doesn’t mean that you don’t look for
fl
ways to make things better. Acceptance is also not passive, so it’s not the same as resignation. It’s
a choice and an active stance.

The next time that something comes up that is mildly distressing, see what it feels like to just sit
with the thoughts and feelings, and mindfully consider how those thoughts and feelings are
affecting your mind and body in that moment.

ACT is big on the use of metaphors to promote understanding of concepts. Here are a few that
relate to acceptance.

Quicksand is one useful metaphor for acceptance. If you try to struggle, it will suck you in and
you might drown. However, if you relax and stop fighting, you will float to the surface and
you’ll be okay.

Similarly, consider a riptide. If you try to fight against it and swim to shore, you’ll exhaust
yourself and possibly drown. However, if you swim with the current, eventually it will release
you and you’ll be free to head to shore.

If you’re in a tug of war, while you are pulling the other side
will pull back in resistance. The harder you pull, the harder
they pull in return, and it can seem like neither side will
win. However, if you stop pulling and instead just let go
of the rope, the other side will fall down, and you’ll be
the one left standing.

If you’re fighting on a battleground, trying to win the war might be a lost cause, but what if you
were to just leave the battlefield altogether?

Expansion
Expansion is a way of practicing acceptance that involves figuratively opening up and making
space for thoughts, feelings, and the accompanying bodily sensations so they can flow through
you without getting stuck. It may be useful to tie this into breathing exercises. As you inhale,
imagine your chest opening to let your internal stream flow through.

You may not want to make room for things that are unpleasant, but keeping them compressed in
the back of your head somewhere is not going to let those things be released, and they will keep
knocking on your mental door trying to get your attention.
 Control vs Acceptance Balance Sheet
This type of log helps you to monitor how often you’re using control strategies and keep track of
your practice using acceptance, as well as how well these different strategies are working.

Di cult thoughts/feelings, Control or acceptance Outcome

situation strategies used
ffi
 Defusion From Thoughts
From an ACT perspective, distress arises from getting hooked tightly by our thoughts, so that the
self and the thoughts seem to become fused. Cognitive defusion (as in de-fusion, not diffusion) is
about changing the relationship between your thoughts and yourself, creating a sense of
separation between them.

Before we take a closer look at defusion, consider some of the strategies you may already have
used in an attempt to control your thoughts, emotions, and reactions to the world around you.
Most likely, you’ve used at least some of these strategies, but the question is, have they actually
been working very well for you?
• Worrying about the future
• Ruminating about the past
• Blaming yourself, others, or the world in general
• Engaged in self-criticism
• Tried to “just think positive”

What those strategies have in common is that you’re getting really cozy with those thoughts and
trying to wrestle them in a certain direction. However, that’s not the only way to relate to
thoughts.

It’s very easy to think that because we have a thought, it must be true – true about us, and true
about the world around us. Our thoughts often represent interpretations, evaluations, and
judgments that are entirely subjective, yet we cling to them like gospel and often feel compelled
to act on them. We can even start to use them as weapons to attack ourselves and our worth, and
convince ourselves that we are oh so deserving of those self-inflicted attacks.

Indicators of Fusion
• Rules, such as should, must, right, wrong, always, never
• Judgments
• Focus on the past (rumination) or future (worrying, predicting the worst)
• Self-judgments and self-limiting ideas
• Belief that thoughts represent absolute truth
• Thoughts make it seem like something is happening here and now even though they’re actually
associated with past or future
• Beliefs that are held onto even though they actually make your life worse
• Thoughts that are perceived as imminent threats
Emotions are naturally short-lived and changeable, but if you get hooked on the thoughts
associated with an emotion, that can drag you into the process of ruminating, thus extending the
emotion’s lifespan far longer than it would normally stick around.

What are some of the thoughts that you might be most strongly fused with?

Are there any ways you can think of that this fusion might not be helping you?

Self-as-Context vs. Self-as-Content

What is it that makes you, you? Is it your thoughts and feelings? Or is it something else? Self-as-
content refers to the perception that the content of thoughts, emotions, and other inner
experiences are an inherent part of the self. ACT promotes a self-as-context approach, meaning
that your self provides the context across which inner experiences temporarily pass. Your
thoughts and feelings occur within the context of yourself, but they don’t define who you are.
This serves as the basis for defusing from thoughts. A little later, we’ll talk about values, which
provide a much more useful anchor for the self.

ACT has a number of metaphors to represent self-as-context and cognitive defusion.

One particularly useful one related to self-as-context involves a

chessboard. The self is seen as the chessboard, and thoughts
and emotions are the chess pieces that move across it.

Another metaphor is the classroom. The context of the classroom represents your self. The
students in the class are your thoughts and feelings. The teacher plays the role of your
metacognition (thinking about thinking). It evaluates the students and tries to keep them in line,
but the teacher is not the essence of the classroom. The teacher may judge, but the classroom
itself is not judging; it’s just there, holding the class, and it’s still fundamentally the same room
even if the teacher and students change.

Another metaphor involves leaves on a stream. The self is the stream bed, and the leaves are
thoughts and emotions that float on by without affecting the course of the stream itself. Very
similar to this is the idea of thoughts as clouds transiently moving across the sky, which
represents the self.

The passengers on a bus metaphor treats thoughts and emotions as passengers you pick up
along the road of life. Sometimes the passengers may get a bit rowdy, but rather than letting them
control the bus, you could crank up the tunes and drive the bus where you want to go regardless
of what the rowdies happen to be doing.

Other Defusion Techniques

• Repeat a one-syllable word (try “milk”) rapidly for 30 seconds, and notice that the words
become a series of sounds that are detached from the actual characteristics of milk itself.

• Language matters. Often, the language we use (e.g. “I am angry”) describes our thoughts and
feelings as being who we are. Try to use the phrasing (internal, spoken, or written) “I’m having
the thought [or feeling] that …” and then “I’m noticing I’m having the thought…” This helps
with recognizing thoughts as just thoughts and labelling them as such. In this way, “I am
angry” would become “I’m having the feeling of anger” and then “I notice that right now I’m
having the feeling of anger.”

• Recognize and name the distorted patterns and rules in your thoughts, such as should-ing,
which can help you to start to unhook from those thoughts

• The mental rules that we create for ourselves often come with conditions. Try to recognize and
challenge your “buts”, e.g. “I would… but…” Identify how these represent underlying fusion
with thoughts, and consider how you might be able to defuse from whatever is underlying
those rules.

As much as we might feel tied to our thoughts, it is possible to change the relationship with
them.
 Compassion
Researcher Dr. Thupten Jinpa describes compassion as having three elements: perceiving
another’s suffering or need, emotionally connecting with that suffering or need, and wishing to
see that suffering relieved. Strengthening compassion is associated with decreased emotional
suppression and greater resilience and self-acceptance.

Re ection Questions
What does compassion mean to you?

Is it something that you extend to yourself? How do you do so? How often do you do so?

Is there anything that’s holding you back from being compassionate towards yourself?

Do you treat yourself with the same compassion with which you treat others?

The Buddhist loving-kindness, or metta, meditation is focused on expanding circles of

compassion. In the Book of Joy, His Holiness the Dalai Lama uses these words for the
meditation: “May you be free from suffering. May you be healthy. May you be happy. May you
find peace and joy.”

The meditation begins by imagining receiving this compassionate message from someone who
loves you. You then begin to expand outward, sending compassion to someone very close to you.
The next step is to include other people that you love. The compassion then expands outward to
include neutral people, who you don’t have strong feelings about either way. Next is to extend
compassion toward those who you dislike. Finally, the meditation is expanded to all living
beings.

Receiving Compassion from Others

What were some instances when important people in your life have been kind and caring towards
you?

What were some instances when people you barely knew were kind or caring towards you?

What were some situations in which you felt a sense of belonging?

fl
 Evaluating Self-Compassion
The items below are based on compassion researcher Dr. Kristin Neff’s Self-Compassion Scale.
They make a useful place to start in understanding how compassionate we are towards ourselves.

1. I’m judgmental about my own flaws.

2. When I’m feeling down I tend to fixate on all that’s wrong.
3. When things are going badly, I tend to think that most other people don’t go through such
difficulties.
4. When I think about my flaws, I tend to feel isolated from the rest of the world.
5. When I fail at something important I’m consumed by feelings of inadequacy.
6. When things upset me I try to keep my emotions in check.
7. I’m intolerant of the aspects of myself I don’t like.
8. When I’m feeling low, I believe that most other people are feeling happier than I am.
9. When things are difficult for me, I tend to think it must be easier for other people.

Self-Compassion Challenge
Do a daily self-compassion rating for one week. Use a rating scale of 0-10, with 0 being the level
of compassion you would show to someone you dislike, and 10 being the level of compassion
you would show to the person nearest and dearest to you if they were in need.

Each day, try to identify three examples of what you did to show compassion. Try to bring a little
bit more compassion to yourself every day.

Did you find that paying attention to self-compassion made it any easier or harder to practice?

Did you notice any changes in the level of self-compassion the more days you practiced?
 Self-Criticism: Changing Your Self-Talk
We all have one—an inner critic that can easily match and likely exceed anything negative that
anyone else might have to say about us. Think of it as the mental version of a racist person; it’s
absolutely convinced that everything it says is true, but it’s looking through a profoundly
distorted lens that shows a very different picture than what everyone else sees.

Your Inner Critic

How strong is your inner critic? The Compassionate Mind Foundation has a Forms of Self-
Criticising/Attacking & Self-Reassuring Scale that you can try out to get a better idea.

Here are a few questions to help you reflect on your inner critic.

In what way do you believe you are most flawed?

How do you treat yourself with respect to those flaws?

Are there certain contexts in which you are the least likely to tolerate your flaws?

What happens in your mind and body when your inner critic starts getting louder?

Write a job description for your self-critic

• How many hours is it expected to work per week?

• Key responsibilities: 1)
2)
3)

• Job duties: 1)
2)
3)

• What skills is it expected to have?

Questions to challenge your inner critic
How would you feel if someone close to you had the same flaws you identify in yourself? How
would you treat them?

How do you treat your own failure compared to the same failure by someone you are close to?

Is your evaluation of others’ status and successes relative to your own realistic?

Self-Talk About Emotions

We often have ideas we carry around with us about how we should feel and should manage our
emotions. This concept is not unique to ACT; emotion myths are also covered in dialectical
behaviour therapy. Some common thoughts about feelings are:

• Happiness is the natural state for all human beings.

• If you’re not happy, you’re defective.
• To create a better life, you must get rid of negative feelings.
• You should be able to control how you think/feel.
• It’s not okay to remember unpleasant things.
• My emotions can harm me.

What feeling rules are you trying to hold yourself to?

What would it take to create some wiggle room around these feeling rules?

Shame
The inner critic can feed into a sense of shame, which in turn is associated with an array of
negative mental health effects. Shame can involve thoughts, bodily sensations, urges, and
memories. High levels of shame are associated with increased PTSD symptoms, suicidal
thoughts, substance abuse, and self-harm.

What’s the difference between shame and guilt? Guilt is focused on an action or situation that
didn’t go well. Shame is a negative appraisal and devaluation of the self.

In ACT, work on shame includes:

• acceptance of that part of the self that feels broken
• building awareness of negative self-evaluations by being present in the moment
• defusing from the self-critical talk
• approaching self-stories more flexibly, and recognizing the fusion you may have with these
stories you’ve created
• identifying values and make sure those values (e.g. empathy) are being applied to the self
• cultivating self-compassion and a care-taking approach
• taking committed action towards genuine values rather than whatever your self-critic is telling
you that you need to do
 Values and Committed Action
In ACT, values serve as directions that can help to guide our actions. Unlike goals, which have
clear endpoints, values are more like compass directions, and there is no set destination. In order
to act in ways that are consistent with our values, we first need to identify what those values are.

Identifying Your Values

Select the values that are most important to you. You can draw on this list for inspiration, or
come up with your own ideas.

Acceptance Creativity Honesty Persistence

Adventure Curiosity Humour Pleasure

Assertiveness Encouragement Humility Power

Authenticity Equality Industry Reciprocity

Beauty Excitement Independence Respect

Caring Fairness Intimacy Responsibility

Challenge Flexibility Justice Safety

Compassion Freedom Kindness Self-awareness

Connection Friendliness Love Self-care

Contribution Forgiveness Mindfulness Self-development

Conformity Fun Order Self-control

Cooperation Generosity Open-mindedness Spirituality

Courage Gratitude Patience Skilfulness

What are your top five?

1)
2)
3)
4)
5)
 Re ecting on Values
How closely do you stick to your values in different areas of your life?

What has been holding you back from enacting your values?

How well do you enact your values in your important relationships?

What would you want as your epitaph? How does that reflect your key values?

Bullseye Exercise
ACT identifies several different areas of our life where our values come into play. The bullseye
exercise involves setting up a bullseye with seven rings. The bullseye is divided into quarters;
one each for work/school, leisure, personal well-being, and relationships. At the centre of the
bullseye lie your values. You can use Xs or colours to mark how close your behaviour is to your
values.

ACT Life Compass

The ACT life compass is a way of looking at seven different valued domains. For each domain,
identify the core values that you associate with it. Rate the importance that each domain has for
you, and then rate your satisfaction with how you’re doing in that area. In areas where there’s a
large discrepancy between importance and satisfaction, that could be a sign that it’s time to
review your actions and evaluate whether they’re actually consistent with what matters most to
you. Try to identify any barriers that may be getting in the way of enacting your values, and ways
of addressing them.

Compass Domains
• Work
• Intimate relationships
• Parenting
• Personal growth/education/learning
• Social
• Health
• Spirituality
• Family of origin
• Community life/environment/nature
• Recreation/leisure
fl
For each domain, identify the following:
• Core values: 1)
2)
3)

• Importance (rate out of 10)

• Satisfaction (rate out of 10)

• Barriers preventing you from enacting your values and optimizing your satisfaction:
1)
2)
3)

Goals
Goals are waypoints (practical, quantifiable, clear endpoints) that serve as stepping stones to
keep you heading in a valued direction. Setting short-term and long-term goals for each life
domain can help to keep you on the right track.

Have you heard of dead person’s goals? It’s best to avoid setting goals for yourself involving
things a corpse could do better than a living person (corpses will always be better than you at not
doing something). Instead, keep your goals focused on things you can do rather than things you
want to not do.

When setting goals, it’s a good idea to:

1) identify guiding values
2) set a SMART goal: Specific, Meaningful, Adaptive, Realistic, Time-framed
3) identify benefits of accomplishing the goal
4) identify potential obstacles
5) make a public commitment to the goal

What are your short, medium, and long-term goals for each of the areas in your life compass?
Work Goals
• short-term:

• medium-term:

• long-term:

Intimate relationship goals

• short-term:

• medium-term:

• long-term:

Parenting goals
• short-term:

• medium-term:

• long-term:

Personal growth/education/learning goals

• short-term:

• medium-term:

• long-term:
Social goals
• short-term:

• medium-term:

• long-term:

Health goals
• short-term:

• medium-term:

• long-term:

Family of origin goals

• short-term:

• medium-term:

• long-term:

Spirituality goals
• short-term:

• medium-term:

• long-term:
Community life/environment/nature goals
• short-term:

• medium-term:

• long-term:

Recreation/leisure goals
• short-term:

• medium-term:

• long-term:

Barriers to goals: F.E.A.R.

• Fusion with thoughts
• Excessive goals (taking on more than you’re able to)
• Avoidance of discomfort (change isn’t always comfortable, even when it’s a good thing)
• Remoteness from values (getting sidetracked from what really matters to you)

What are some of the FEARS that stand in your way?

D.A.R.E. to counteract F.E.A.R.

• Defusion
• Acceptance of discomfort
• Realistic goal-setting
• Embrace values

The defusion and acceptance part of DARE allows you to stabilize so that you can then move
forward with realistic goals in a values-consistent direction.
 Conclusion

Coming back to the model of psychological flexibility, you can see the interplay between the
different elements of ACT that we’ve covered. Values keep us anchored in who we are, and
attention to the present moment keeps us anchored in the here and now. Self-as-context provides
the backdrop to allow the acceptance and defusion that let us stickhandle our way through the
world.

While none of these are that difficult conceptually, some, particularly acceptance and defusion,
can be very different from our usual patterns that have been keeping us stuck. Like anything else,
though, practice will make it easier.
 Dialectical Behaviour Therapy
Dialectical behaviour therapy (DBT) is an adaptation of cognitive behavioural therapy (CBT)
that was developed by psychologist Dr. Marsha Linehan to treat borderline personality disorder
(BPD). It’s a very skills-based form of therapy, and while its primary use is in BPD, many of the
skills are widely applicable, and there’s research supporting its use in a number of different
conditions.

The DBT full meal deal is an intensive group program, but even if that’s not a good fit for you, it
can still be really helpful to incorporate elements of DBT into either the work you’re doing with
a therapist or as self-help to supplement other strategies you’re using to manage your illness.

The “dialectic” in DBT refers to two opposing poles:

• Accepting that you’re doing the best you can with what you’ve got, and
• Recognizing that there’s a need for change and you can do better through developing new
skills

It sounds simple, but it’s actually quite profound; it’s a perspective that validates the effort
you’ve put into managing your illness and getting to the point where you are now, but also
empowers you to find new ways of coping that may work better.

DBT also takes the stance that even though you didn’t create the problems that you face, it’s still
going to be up to you to fix them. That may sound discouraging at first, but getting trapped in
thinking about the unfairness of things can suck up a lot of mental energy without helping you
move forward. Your biology contributed to your illness, at least to some extent, and there isn’t
much you can do to change that. Instead of pouring energy into resentment that you got sick in
the first place, you can look for areas where you can make changes.

DBT is quite practical in that it focuses on what’s workable. Not what’s the “right” thing to do or
the “best” thing to do, but what works for you, with your illness, in the context that you’re in.

There are four modules covered in DBT:

• mindfulness
• distress tolerance
• emotional regulation
• interpersonal effectiveness
DBT uses a lot of acronyms to make the skills easier to remember. The goal is to build up an
arsenal of skills in which you’ve achieved some degree of mastery so you’ll have multiple
options to choose from to meet the demands of any given situation. No one technique is going to
work every time, which is why it’s important to accumulate a toolbox with multiple options, and
then the best option for a given task can be selected.

Problem-Solving in DBT
The DBT approach to problem-solving involves four simple steps that probably seem pretty
obvious when you’re well, but during times of acute illness, the steps will probably require a bit
more conscious effort to work through. The steps are:
1) writing down the problem in simple terms
2) writing down all possible solutions
3) examining all options, then choosing the preferred
4) executing the decisions

This is a similar process to doing a decisional balance grid, in which you set up four quadrants
and list the pros and cons of doing a potential course of action and not doing it. Problem-solving
matters in terms of overall functioning, and it’s an area in which illness can easily hijack the
machinery if left to its own devices.

This kind of systematic problem-solving process engages your rational mind to help balance out
the skewed directions that emotion mind can pull you in, helping you to get into wise mind,
which we’ll cover in the next section.

Diary Cards
Diary cards are used to maintain a daily record of emotions, urges to self-harm or suicide, use of
drugs and/or medications, and what skills were practiced. A template and instructions can be
found on the University of Washington website at https://depts.washington.edu/uwbrtc/wp-
content/uploads/NIMH4-S-DBT-Diary-Cards-with-Instructions.pdf.

Even if you don’t find the diary card useful as a whole, it may give you some helpful ideas to
include in your bullet journal, diary, or whatever method you use to keep track of how you’re
doing. It may not be immediately obvious which skills are working for you and which aren’t, and
keeping a record gives you a chance to reflect later on and see what patterns have emerged. Our
memories aren’t great at keeping track of day-to-day changes to begin with, much less when
mental illness symptoms get in the way. Using some form of tracking system can give you a
much clearer picture of how things have been going.
 Behaviour Chain Analysis
This is a way of breaking down problematic behavioural responses to difficult situations. It’s
similar to doing an ABC worksheet in CBT, which looks at an activating event, beliefs/thoughts,
and consequences. Especially when illness is trying to take control of the vehicle, it’s easy to
combine all of these elements into one tight, tangled knot. That knot is very difficult to take on
when it’s all stuck together, but by teasing apart the individual elements, it’s easier to see where
things started to go wrong and what can be done differently in the future.

This sort of process tends to work best if you can start practicing when you’re not feeling too
badly, and then once you’ve practiced, it’ll be more easily available to you when you need it.

There are plenty of behaviour chain analysis worksheets available online A good example is:
https://cls.unc.edu/files/2014/10/Behavior-Chain-Analysis-Information-1.pdf
Behaviour chain analysis includes the following steps:
• prompting event: what happened to get the whole thing started
• vulnerabilities: what factors made you vulnerable to have the kind of reaction that you did;
your illness may be a major factor, but likely not the only one
• chain of events: this is a specific, step-by-step breakdown, including thoughts, emotions,
bodily sensations, and physical reactions that arose
• consequences: what were the consequences that resulted from the problematic behaviour
• identify skillful behaviours: consider how you could have done things differently at any point
in the chain of events in order to potentially improve the outcome

Even in situations where there was very little you could have done differently, it’s still useful to
engage in reflection by working through this process. It can also be enlightening to examine the
different factors that contributed to the way a situation turned out.

Now that we’ve covered some of the basic building blocks of DBT, we’ll move on to specific
skills covered in each of the four modules.
 Mindfulness
There are a number of benefits to mindfulness. In the context of DBT, mindfulness doesn’t refer
to meditation, but rather to increasing self-awareness and paying attention to one’s own
landscape of experiences, both mental and physical. Fighting emotions tends to increase distress,
and an important aim of mindfulness is being able to tolerate uncomfortable emotional states
without turning to avoidance strategies or unhealthy coping behaviours.

Wise Mind
Wise mind is the area where our emotional mind and logical/reasonable mind overlap. During a
mood episode, it’s very, easy to swing too far into emotion mind, whether that be in a manic or
depressive direction. Drawing on reasonable mind to get into a more balanced state of wise mind
promotes more skilled decision-making.

I’ve found this to be a very helpful way of conceptualizing my thinking. It’s also quite validating,
as neither reasonable mind or emotion mind are considered bad/wrong, but there’s a sweet spot
of balance between the two where we can function at our best. Wherever your mind happens to
be is okay, but there’s room to move to a better place.

Another way to conceptualize wise mind is a balance between doing mind, which is goal-
oriented, and being mind, which is present-oriented. Wise mind is a balance between being and
doing, somewhat along the lines of the journey being more important than the destination. For
me, this way of looking at it is less helpful, since when I’m depressed I’m not particularly
interested in being or doing.
There are two types of mindfulness skills to help get you grounded in wise mind: what skills and
how skills. What skills are about relating to the environment around you, and how skills are
about the attitude you bring to a situation.

What Skills
Observe
This involves impartially observing events without trying to label or influence them. We
normally interpret everything we see through all kinds of filters and biases. Observing is about
dropping all of that and seeing what’s in front of you rather than what you think/feel is there.

Some tips for practicing this:

• be curious—consider the situation as if it’s brand new, and you’ve never seen anything like it
before
• pay attention to all of the senses – what do you see, hear, feel, smell, and taste? Are there
sensory details that you didn’t notice at first?
• be like Teflon, so things can’t stick to you – let things happen around you without them
getting attached to you

The idea here is to step back from some of the negative judgments we automatically pass on
situations, such as the cognitive distortions described in CBT. Judgments may initially
masquerade as impartial observations, so consider whether what you “observe” would be
apparent if an alien from outer space was also looking at the same situation.

△ ▽ △

Describe
This skill uses facts rather than interpretations/assumptions, which .helps to distinguish between
the actual event itself and the personal reaction to it. Often we describe things not as they are, but
rather the way we see them through whatever lens we happen to be using at the time. That lens is
often shaded by our mood state, and we’re often not aware of it.

While the observe skill is about taking a step back from your environment, describing takes you
back in towards the environment, but from that same sort of neutral stance.

Some tips for using this skill:

• use neutral language that doesn’t have judgment built into it
 • avoid emotional words
• try to let go of the idea of right or wrong

When using this skill, the description should be as objective as possible. Imagine you were
coming up with a description for a dictionary or an encyclopedia like Wikipedia; what words
would you use in order to be objective? What if you were supporting someone who was blind,
deaf, or had other sensory issues—how would you convey to them what was going on?

△ ▽ △

Participate
Participating is about entering fully into the moment, without being held back by self-
consciousness or fear of failure/judgment. The self-consciousness and fears might still be there,
and that’s okay; this skill means committing to something anyway.
• become so absorbed that you lose sense of time
• try to just be your true, natural self

This skill is all about present moment awareness and engagement. Depression and anxiety tend
to push in the direction of withdrawal from both people and activities. Participate means diving
right in anyway.

Are there certain songs that always help boost your mood, even if it’s just a little? Perhaps fully
participating could involve cranking those tunes and singing along.

△ ▽ △

As practice, try using these what skills in an emotionally neutral environment, and then use them
again in a mildly emotionally charged situation. Initially, they’ll probably be quite difficult to
apply in highly charged or triggering settings, but putting in some practice in easier settings will
help you in developing these skills.

How Skills
One-mindfully
This skill involves focusing your whole attention on whatever the current activity is that you are
doing. It involves:
• do only one thing at a time
 • whenever you get distracted, repeatedly bring yourself back to whatever activity you are
focusing on

Mental illness symptoms can make it difficult to maintain focus, but that’s where the second part
of the skill comes in.

There’s a lot of social pressure to multitask, even though that’s something our brains aren’t very
good at even at the best of times. Releasing that pressure can feel difficult at first, but the more
you’re able to mindfully focus on one thing at a time, the more effective you’ll be at whatever
you’re trying to do.

When things are going too fast, one-mindfully is a way of slowing things down and cutting out
the noise.

△ ▽ △

Non-judgmentally
This skill is about observing without letting internal judgments get in the way.
• recognize ideas related to good or bad, musts, and shoulds or should not, and change them
into more neutral language
• tease out opinion from facts
• accept each moment as it comes
• if you notice you start judging, just step back and observe that

This is similar to what’s described in the what skills, but it has more of an inward focus rather
than being focused on your external environment. Negative judgments aren’t going to go away
just because you try to detach from them, and that’s okay. You can allow them to be there while
evaluating them to determine whether they deserve any attention or not. Chances are, they
deserve a lot less attention than they’ve been getting.

△ ▽ △

Effectively
Being effective means doing what works rather than holding on to preconceived notions of right
and wrong.

Some tips on being effective:

 • let go of what feels right or wrong, fair or unfair
• use the best skills you can for the situation you’re in even if you don’t want to be there
• try to let go of feelings like anger and righteousness that are likely not serving you by
identifying the emotions, identifying rational mind beliefs about the situation, identifying
rational mind options, and then choosing a wise mind response

It’s to get caught up in shoulds—what you “should” do, what you “shouldn’t” do. This skill
involves throwing the shoulds out the window and focusing solely on what works in a practical
sense.

I try to use this skill when someone has done something that affected me negatively. I get a
strong urge to make a stink about the situation, but I try to recognize that when I do that, I only
end up more agitated, so it’s really not a workable solution, even if what the other person did was
wrong.

The one-mindfully and non-judgmentally skills are fairly obvious, but the effectively skill often
requires a bit more thought. It’s a very pragmatic way of looking at difficult situations, and
involves releasing some of the mental baggage that we tend to carry around.

△ ▽ △

Describing emotions
This isn’t quite as easy as it may initially seem. Often there is one dominant emotion that’s not
too difficult to name, although depression can sometimes cause alexithymia, which is difficulty
describing emotions. There may also be a number of other emotions simmering away in the
background that aren’t immediately noticeable. Being able to mindfully observe and describe
emotions can make it easier not to get swept away by them.

Start by identifying any emotions you’re feeling right now. It can be helpful to have a list of
different emotions to give a bit of guidance. Emotions can be expressed in single words; if
multiple words are needed to express something, it’s probably a thought rather than an emotion.
Next, consider how intense the emotions are for you, and where you might be feeling them in
your body.

Some emotions are inherently social, meaning they arise in response to how we relate to others.
For example, envy (I want your…) and jealousy (don’t take my…) are social emotions, and to
understand them, it’s important to consider the social context in which they’ve come up.
Mindfully examining and identifying your emotions can make it easier to figure out what it is
they’re trying to tell you, because, by their very nature, emotions are your mind and body’s way
of telling you something’s going on.

△ ▽ △

Radical acceptance
A stance of radical acceptance comes from the position that resistance to how things are causes
suffering whereas acceptance will relieve suffering. Radical acceptance involves tolerating the
moment exactly as it is, without judging it as good or bad. Practicing radical acceptance is an
active stance that means recommitting your mind in that direction over and over and over again.

That’s what radical acceptance is, and now here’s what it’s not:
• Agreeing, either with another person or with the situation
• Liking the situation and how it impacts you
• Giving up on change
• Allowing people to treat you badly
• Taking a passive approach

Mood episodes aren’t pleasant, in terms of both the symptoms you experience inwardly and the
way it affects the ability to cope with the surrounding environment. That’s reality. Taking a
stance of radical acceptance makes it easier to make the most of what may well be a fairly crappy
situation. After all, no matter how awful a situation, you still have to get through it.

△ ▽ △

Willingness
Learning DBT skills requires a willingness to find and listen to your wise mind in order to
respond effectively to situations. Willingness means not giving up, and being open to making
change where it is needed to be more effective.

Mental illness brain can be pretty persistent in telling you to give up, there’s no point, it’s not
worth it, etc. Willingness means pulling back from where you’ve been pulled deep into emotion
mind, and reaching as best you can towards wise mind. Willingness means fighting to get better
by using whatever techniques are available to you and being open to trying new things that can
support well-being.
 △ ▽ △

Self-validation
Mindfulness and radical acceptance can be directed towards yourself in a way that allows you to
let go of judgment and promotes self-validation. There is a useful series of handouts on this topic
from the Nevada Psychological Association at:
https://www.nvpsychology.org/wp-content/uploads/2015/04/Self-Validation-Skills-2013-
Fruzzetti.pdf.

Your illness may tell you that you’re no good, but it’s lying, and it helps to have regular
reminders of that.

Consider whether you’re harder on yourself than you are on others. Do you demand more of
yourself? Is this fair? No matter how unworthy you may feel, you deserve self-compassion. That
doesn’t mean accepting that where you are right now is a good place and you need to stay there.
It comes back to the basic DBT dialectic, acknowledging that you’re doing the best you can with
the resources you have right now, and at the same time, there’s room for positive change.

△ ▽ △

FLAME: this acronym summarizes some of the key skills for mindfulness
• Focus on the present moment
• Let go of distracting thoughts/judgments
• radical Acceptance
• wise Mind
• do what’s Effective

If you take just two things away from DBT, I would say that wise mind and radical acceptance
are going to be the most powerful.
 Distress Tolerance
Distress tolerance is about recognizing that a crisis is only temporary, and it can be worked
through with the application of skills. These skills revolve primarily around radical acceptance
and distraction.

STOP: These crisis survival skills are aimed at preventing an immediate, automatic reaction and
giving you a bit of space to make a more reasoned decision.

• Stop: Freeze. Do nothing; don’t let your emotions automatically trigger a reaction; allow time
for other, more adaptive reactions to kick in.

• Take a step back: Take a break from the situation, either physically or by taking some deep
breaths.

• Observe: Draw on this “what skill” to mindfully notice what is going on both inside and
outside of you.

• Proceed mindfully: Act with awareness and engage wise mind. Considering your and others’
thoughts and feelings and the workability of different actions before choosing how to
proceed.

There’s nothing fancy about these skills, but STOP provides a structured way to place some
distance between yourself and the difficult situation.

△ ▽ △

TIP: change your body chemistry rapidly

These skills are used to deliver a jolt to your body to interrupt the intense mental reaction. They
may be useful if you’re having intense urges to self-harm or suicide, or if you find yourself
trapped on a mental hamster wheel of distress, as they can be a rapid way to gain some control
back.

• Temperature: Hold your breath and immerse your face in cold water or hold a cold pack to
your face. Once you’ve held it for 15-30 seconds, your body’s natural dive reflex will
automatically occur, keeping blood flow focused on the heart and brain. More oxygen to
your brain puts you in a better position to make decisions.
• Intense exercise: The idea is to drain yourself with a short burst of intense activity, like
burning it up some stairs.

• Paced breathing: This skill involves slow breathing, paired with muscle relaxations on each
exhale.

△ ▽ △

Wise mind ACCEPTS

If the distressing stimulus can’t be stopped, these skills are used to shift your mental state.

• Activities: Keep attention on other things, e.g. chores or counting, that engage your attention
but are emotionally neutral. Knitting or mandala colouring are other ideas you could try.

• Contributing: Take care of others, such as through volunteering or helping out a family
member, to shift the focus away from your problems, at least for a little while.

• Comparisons: Compare the current situation to worse situations; our natural tendency is to
compare to situations in which things have been better, but this skill is about recognizing
that this is not the worst thing you’ve ever been through and handled in the past.

• Emotions: Stimulate opposite emotions to what one is feeling; for example, if you’re feeling
sad, watch your favourite funny movie.

• Pushing away: Decrease contact with negative cues that might be triggering you, which may
involve removing yourself from a physical location.

• Thoughts: Think of other things that are either positive or emotionally neutral.
• Sensations: Use intense sensory stimuli, such as an ice cube against the skin or snapping a
rubber band on the wrist, to ground yourself in the present moment.

△ ▽ △

IMPROVE the moment

These skills are used to make distressing moments feel a little bit better and more manageable.
They involve setting whatever the problem is aside for a little bit and focusing on ways to take a
bit of a mental getaway. They don’t fix the problem, but rather give you a bit of a break.
• Imagery: safe place visualization – establish your safe place at a time when you’re feeling
okay, and practice it so that it will be readily available to you during times of distress

• Meaning: create/find meaning in your life – this may mean religious practice, finding
meaningful volunteer work or employment, or participating in social campaigns/causes

• Prayer: connect to a higher power – not necessarily religious, but perhaps a sense of shared
humanity or mother nature

• Relaxing: counteract the body’s stress response with your favourite relaxation techniques

• One thing in the moment: temporarily commit all of your focus to one activity
• Vacation: take a vacation from stress by retreating into yourself briefly or allowing yourself to
be taken care of by someone else (either a family member or a service like a massage or nail
salon)

• Encouragement: cheerlead for yourself, using self-affirming statements—this doesn’t have to

be rainbows and unicorns over-the-top affirmations; it can be anything that works for you.

△ ▽ △

Turning the mind

Imagine you are standing at a crossroads and you have the choice to decide whether to accept or
reject the present reality. Turning the mind is about choosing to accept, observing that
acceptance, and making an inner commitment to sticking with it.

△ ▽ △

DISTRACT: While distraction may not change the problem in the long term, it can be an
effective temporary intervention. It shouldn’t be used as an excuse for avoiding underlying
problems that need to be addressed. DISTRACT includes a mix of skills that have already been
covered.

• Do something else: This corresponds to Activities in wise mind ACCEPTS. This can be a
routine task, or even better, it could be a pleasurable activity. If you’re depressed and nothing
is pleasurable, try for something that would have been pleasurable when you were feeling
better.
• Imagine something else: Try your favourite movie fantasy – I’m a big fan of Dirty Dancing.
• Sensations to interrupt focus on pain: Intense sensations (such as holding an ice cube) can
ground you in the present moment and distract from what’s bothering you.

• Think about something else: This can involve visualizing your safe place, or thinking about
pleasant things that you have coming up.

• Remember times when things were better: Unlike the ACCEPTS skills where you compare to
a worse situation in the past, this skill is about reminding yourself that things aren’t always
bad, and if they were good before they’ll probably be good again.

• Accept the pain: This is all about radical acceptance and letting what will be, be.
• Create meaning: This appears in the IMPROVE skills.
• Take opposite action: This will be explained below.

△ ▽ △

RESIST the urge: If you’re having destructive behavioural urges, these skills can help to shift
your mindset so you don’t end up following through on the urges.

• Reframe: The urge is what it is, but you can change the direction that you’re looking at it from
• Engage mindfully in an activity
• do something for Someone else

• Intense sensations
• Shut it out: leave the situation physically, using the pushing away skill
• Take a break

△ ▽ △

Self-soothing
Self-soothing involves using pleasurable stimuli for all five senses. It can be helpful to assemble
a self-care box including items to appeal to each sense. Some ideas:
• Smell: your favourite essential oil
• Touch: fuzzy socks
 • Sound: this could be something that makes a nice crinkly sound, or a note reminding you
of a song or guided meditation to listen to
• Taste: individually wrapped chocolates or candies, or some of your favourite tea
• Sight: photos of a happy time in your life, cherished people, or beloved pets

△ ▽ △

Put on a half-smile
This isn’t a fake broad grin, but more of a subtle upturning of the outer corners of your lips that
signals to the brain that maybe things are actually more okay than it thinks they are. It may sound
silly, but your brain actually does respond to the expressions on your face.

△ ▽ △

Body scan
Systematically scan through your entire body, and listen to what it’s telling you – perhaps there’s
some tension that could be addressed using progressive muscle relaxation.

△ ▽ △

Decisional balance grid

Do a cost-benefit analysis before going ahead with an impulsive action. Divide a sheet of paper
into four quadrants. The top two are for pros and cons of going ahead with the action. The
bottom two are pros and cons of not going with it. This helps to engage reasonable mind to help
balance out emotion mind and bring you into wise mind.
 Emotion Regulation
One of the assumptions in DBT is that emotional behaviour is functional in some way, and
identifying those functions can be helpful in managing those emotions. Behaviour chain analysis,
as described earlier, can be useful. Being aware of the types of thoughts that trigger strong
emotions can help to reduce your vulnerability and help to manage your overarching mood.
Mindfulness and distress tolerance skills are also applicable in regulating emotions.

DBT considers emotions this way:

• They aren’t good or bad, right or wrong; they just are.
• Having an emotion doesn’t mean you have to act on it.
• Emotions are temporary.
• Emotions are not facts. They’re how you feel about things, not the way things are.
• Emotions are part of the normal human experience.

Feeling Rules & Myths

It’s easy to get trapped in rules about how we should think, but often these are myths rather than
reality-based. Some examples adapted from Marsha Linehan’s DBT handouts:
• Asking for help makes me a weak person
• I should only ask for something if I know ahead of time that the person will say yes
• If I can't fix this myself, there must be something wrong with me
• If others don't approve of my feelings, then there must be something wrong with them
• Making requests of others is selfish
• Saying no to others is selfish
• Others' needs are more important than my own
• In a given situation, there’s a certain way I should feel
• Negative feelings are harmful
• Some emotions are wrong or stupid
• Painful emotions should be ignored
• My emotions define who I am
• I can always trust my emotions

Are any of these feeling rules and myths keeping you stuck?
Mindfulness of current emotion
Note the presence of an emotion, and experience it as a wave that ebbs and flows. Consider how
it might be serving you, or what need it may be helping (or trying to help) to meet. Where do you
feel it in your body? What thoughts or associations is it stirring up for you?

Try to recognize that the emotion is not who you are, and radically accept the emotion as it is in
the present moment. Emotions don’t have to be comfortable to be accepted, nor do they have to
be embraced. Feelings of hopelessness and despair, for example, aren’t “good” no matter how
you spin it, but those feelings are there whether you want them there or not. By acknowledging
their presence and making space for them to be inside of you, you’re giving those emotions the
chance to ebb into the background (at least in a relative sense).

△ ▽ △

ABC PLEASE: These skills are used to decrease emotional vulnerability, putting you in a
better position to handle strong emotions when they arise. Mental illness is likely to push you to
forget to do some of these things, but maintaining them anyway is an important part of
supporting your overall health.

• Accumulate positive emotions: Doing this involves both increasing pleasant events in the short
term and pursuing your values in the long term. Illness can make this hard, but at least try to
fit in activities that are at least slightly more positive than neutral, and be mindfully present
while you’re doing them.

• Build mastery: Depression often involves feelings of helplessness and hopelessness, and you
can help to combat these by doing things that make you feel competent and effective. If it
doesn’t feel like there’s anything that you’re competent and effective at, ask loved ones for
ideas to help you get started.

• Cope ahead of time: Identify encouraging coping thoughts, plans, and strategies that may be
useful in a difficult situation. Try to imagine the situation vividly as though it’s happening in
the present tense, and practice implementing your coping strategies. This practice can help
you feel more prepared to use those strategies when you’re actually in the situation.

• treat Physical iLlness: Take care of your body, see your health care provider regularly, and
take any prescribed treatments regularly.

• Eating balanced: Keeping the body healthy helps to keep the mind healthy. Your brain needs
fuel to work optimally, and that fuel comes in the form of food.
• Avoid mood-altering substances: this includes drugs and alcohol
• Sleep: Try to get the optimal amount of sleep for you, maintain a consistent sleep schedule,
and practice good sleep hygiene.

• Exercise: Try to get some form of exercise every day. This doesn’t mean you have to go to the
gym every day; getting outside for walks works just as well.

△ ▽ △

Opposite action
This involves considering what your emotion-driven impulse is to do in a given situation, and
then doing the opposite instead. The idea is that if your automatic, emotion-driven responses that
your illness has feeding you haven’t been working out well, you’re better off doing the opposite.

Thinking back, when illness brain and emotion mind have pushed you in a certain direction, how
often has that ended up being helpful? Under 10%, perhaps? If illness brain-driven emotion
mind’s batting average is so low, doing the opposite is almost bound to go better.

• If your depression is telling you to stay in bed all day, doing the opposite would be pushing
yourself to spend as much time out of bed as you can manage.
• If there is something you fear and feel the urge to avoid, then opposite action would be to
approach it.
• If you’re feeling guilt or shame and want to stay silent about it or avoid the source of those
feelings, opposite action might look like apologizing (if your action went against your wise
mind-based values), or continuing to do whatever it is that’s contributing to you feeling guilty
or ashamed (again, as long as it doesn’t go against wise mind values).
• If you are angry with someone and want to direct that anger towards them, opposite action
could mean being nice to them, or feeling sympathy for them.
• If you’re feeling an impulse to quit your job, stay put for the time being until you can
reconnect with wise mind.
 Interpersonal E ectiveness
Myths can get in the way of interpersonal effectiveness, such as believing that you need to be
liked by everyone, that you’re incompetent if you don’t do things right every time, and that you
aren’t good enough to deserve good things. It can be hard to stand up for yourself and ask for
things and say no. It’s easy to fall into the trap of thinking that others should be able to know
what you need without you explicitly saying it. You may think your partner should be able to tell
your mood state from your behaviour, but it may not be as obvious as you think it is. Emotion
mind can start to take over, and it can take some effort to pull yourself back to wise mind.

It’s useful to identify any cognitive distortions that might be getting in the way of effective
communication. Are you mind-reading, assuming you know what the other person is thinking?
Are you filtering out anything positive they might be saying and focusing solely on the negative?

Boundaries
Boundaries act as a sort of mental skin that can help keep others from getting too close into your
mental space. They can also prevent you from giving so much of yourself to others that there’s
nothing left for you to take care of yourself.

Even if you have healthy boundaries when you’re doing well, mental illness can sometimes send
those right out the window. That’d where interpersonal effectiveness skills come in.

△ ▽ △

DEAR MAN: These skills are used for objectives-related effectiveness, i.e. helping you to get
what you want/need. Of course, a good starting point is to make sure that what you want is
reasonable and not based on ideas that are skewed by your illness.

• Describe: Describe the current situation in a factual manner, drawing on your mindful what
skills. Tell the other person what you are reacting to.

• Express: Express your feelings and opinions about the situation. Present these as your own
feelings rather than as facts (“I feel…” rather than “this is…). Don’t assume that the other
person will automatically know where you’re coming from, and give a brief rationale for
your position. Avoid using words that represent absolutes or imperatives, like need, must,
should, can’t, etc.
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• Assert: Assert yourself by clearly asking for what you want and stating what you don’t want.
Don’t expect someone to know what you want unless you directly ask for it.

• Reinforce: Explain the consequences of the other person’s response to your request. Try to
show the person how they might feel good or be rewarded if they respond positively to your
request.

• Mindful: Remain mindful of your purpose in the interaction, and don’t allow yourself to be
distracted away from that purpose.

• Appear confident: This is basically fake it ’til you make it. While fake it ’til you make it is bad
when it involves avoiding what’s actually going on for you, this is about doing what’s
workable so that you can function more effectively in a particular situation.

• Negotiate: Be prepared to negotiate within the limits that are acceptable to you. This may
involve an element of give and take, or a reduction in what you’re asking for. Invite the
other person to propose an alternative solution.

Developing scripts can be useful in helping you to be assertive. This is different from ruminating
and rehearsing potential conversations; it’s focused entirely on what you can say to express your
needs effectively.

△ ▽ △

GIVE: The GIVE skills are used to support relationship effectiveness.

• Gentle: Be courteous, with no attacks, threats, or judging.

• act Interested: This can be done by using active listening (as opposed to passively hearing).

• Validate: Acknowledge the other person’s feelings and wants; even if you don’t agree with
them, it’s okay for them to have their own way of approaching the situation.

• Easy manner: Try to smile and use some humour to lighten the situation.

Validation is probably most important when we’re unwell, but often that’s the time when we’re
least likely to get it. People may not want to “approve” of ideas and behaviours that are coming
from a place of illness, so it may be worth having a conversation when things are going okay to
identify ways that your loved one can validate your distress but at the same time help you steer in
a healthier direction. Those things shouldn’t have to be mutually exclusive.
 △ ▽ △

FAST: The FAST skills are used to effectively demonstrate self-respect in interpersonal
interactions. These can be useful in dealing with people who are trying to take advantage of you
or are not treating you in the way that you deserve.

• Fair: be fair to both yourself and the other person, don’t engage in helplessness

• no Apologies: don’t apologize for who you are, how you feel, etc.

• Stick to your values: it’s very easy to get distracted by the challenges of illness, including
thoughts of unworthiness, but values can help you to stay grounded in your authentic self

• Truthful: you don’t have to disclose everything, but being truthful helps to establish a level
playing field.
 DBT Skills Summary
There’s an excellent graphic showing how to decide which skill to use on the DBT Self Help
website, which is copied from Getselfhelp: http://www.dbtselfhelp.com/Decider_pdf.pdf

Mindfulness
What Observe How One-mindfully FLAME Focus on the present
skills skills moment

Describe Non-judgmentally Let go of distractions

Participate E ectively radical Acceptance

wise Mind

do what’s E ective

Emotion regulation
ABC PLEASE Accumulate positive emotions

Build mastery

Cope ahead of time

treat Physical iLlness

Eating balanced

Avoid mood-altering substances

Sleep

Exercise

Mindful of current emotion

Opposite action
ff
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Distress tolerance
STOP Stop TIP Temperature

Take a step back Intense exercise

Observe Paced breathing

Proceed mindfully RESIST Reframe

Wise Activities the urge Engage mindfully in an activity

mind Contributing do Something for someone else

ACCEPTS
Comparisons Intense sensations

Emotions Shut it out

Pushing away Take a break

Thoughts DISTRACT Do something else

Sensations Imagine something else

IMPROVE the Imagery Sensations to interrupt the pain

moment Meaning Think about something else

Prayer Remember when things were

better

Relaxation Accept the pain

One thing in the Create meanings

moment

Vacation Take opposite action

Encouragement
 Inter-personal e ectiveness
DEAR Describe GIVE Gentle FAST Fair

MAN Express act Interested no Apologies

Assert Validate Stick to your values

Reinforce Easy manner Truthful

Mindful

Appear con dent

Negotiate
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 Resources
These sites have free worksheets and workbooks. There’s a more extensive list on Mental Health
@ Home here: https://mentalhealthathome.org/2018/06/14/mental-health-workbooks/

• ACT Mindfully: https://www.actmindfully.com.au/free-stuff/

• Centre for Clinical Interventions: https://www.cci.health.wa.gov.au/Resources/Looking-After-
Yourself
• Clinical Research Unit for Anxiety and Depression: https://crufad.org/for-clinicians/
• DBT Skills Application: https://dbtselfhelp.weebly.com/work-sheets-index.html
• GetSelfHelp: https://www.get.gg/freedownloads2.htm
• ilovedbt.wordpress.com
• Psychology Tools: https://www.psychologytools.com/
• Therapist Aid: https://www.therapistaid.com/therapy-worksheets