Shades of depression in the cave

Shades of depression in the cave
Contents
Introduction    1
Cave Entry    2
Loss of meaning    2
Treatment    2
Social Element    3
Treatment    4
What then keeps us in the cave?    5
Learned helplessness    5
Punishment    5
Cognitive\Behavioural maintaining factors    5
Social element    5
Finally Time    6
Treatment    7
Summary    8
References    8

Introduction
In evolutionary terms, depressive symptoms can be seen a defensive reaction.  Paul Gilbert sees  depression as a return to the cave when overwhelmed to recuperate before returning back to the fray.  This seems to agree with clients who talk of their depressive symptoms of not wanting to socialise for fear of being judged as boring or uninteresting, or not wanting to do things as they wouldn’t enjoy them or it would go wrong. They seem to be talking about protecting themselves from criticism, displeasure, emptiness and failure by withdrawal.  In short if I don’t do and don’t engage it won’t go anymore wrong, I won’t be criticised and I won’t be hurt even more. 
Therefore there are two aspects of depressive symptoms, what gets you into the cave and what keeps you there.
Cave Entry
Loss of meaning
Dorothy Rowe thought that the entry to the cave is due to a loss of meaning in your life, a gap between how your life is and how it should be and blaming yourself for this .  The possible reasons for this gap seem varied:
1.    How my life is and how it should be, therefore I haven’t achieved
a.    Because how I’ve been treated (anger)
b.    Because I’m not good enough (depression)
2.    I have no knowledge of how my life should be its just not like this as its empty
a.    I did know but then I lost a life defining aspect (specific loss)
b.    Over the years what my life should be has made less and less sense (gradual loss)
3.    I can never have my life as it should be as I am in a social\cultural group that is  mistreated
Treatment
It would seem then these three different aspects might call for different treatment approaches.
How my life is and how it should be, therefore I haven’t achieved
This seems to have two parts.
Firstly understanding the sense of how my life should be, opens up conditions of worth questions and also introjections. For conditions of worth the questions could be asked about the connection of achievement and love. For introjection then there would be the questions of where did this “how my life should be” come from and does it suit me now.
Secondly is the conclusion of why there is a gap, i.e. because I’m not good enough.  This sounds the outcome of blame based criticism which asks the question of where being critical was learnt which may lead back to critical people in the client’s life. Then to how it is perpetuated which may show the internalisation of this original experience, to result in self-criticism.
Whilst there are different treatment approaches to self-criticism. It would seem understanding both the “traumatic” origins of self -criticism followed and a functional analysis of self or other criticism, to notice the effects, would be a good place to start. This could then be followed by a compassionate approach to self when things go wrong or encouragement is needed. If self-criticism pops up then a mindful\attention switching approach to something more valuable, in an ACT related way, would also support the compassionate approach.
I have no knowledge of how my life should be its just not like this as its empty
This is in two parts either due to a specific or cumulative loss of meaning.
Firstly with a specific loss you would be doing bereavement work with a view to integrating and accepting the loss both of the specific thing and the beliefs about how the world should be and then rebuild your life on the basis of this new foundation.
Secondly with the cumulative loss bereavement work would be harder as you have a cumulative bereavement but no obvious thing to grieve for. Here I guess there might be a move to look at all the times when there was a decline, what was the meaningful thing that was lost, to make sense and to grieve for that. 
For both of these there is a need to reconstruct/reconnect with value, although possibly harder with the cumulative decline as there isn’t an obvious loss. There seems a few options here. Firstly to enable access to existing meaning through working with any of the blocks to that meaning, i.e. fear of failure, criticism etc., as people might know what might give them meaning but be blocked from engaging with it. Alternatively there could be a case of reconnecting to what has been important in the past but now lost. Finally you may need to create\discover meaning, which can be done in the same way that we did when we were kids, by trying, by following what others do and by doing what you are told to.
I can never have my life as it should be as I am in a social\cultural group that is mistreated
This seems a tough one in psychotherapy as it enters both the social and political realm, the abused child, and a person in an abused group. Safeguarding would be the first port of call, and risk management. Once the high level work has taken place, and the level of risk has reduced then the work here would be around firstly normalising and depersonalising, facilitating if there are any legal routes to pursue, and then finally noticing if there are treatment opportunities in terms of the reaction to abuse, even if you can’t stop that abuse, you can minimise it. Then in terms of cave entry, the how life should be gets modified to how the context of my life currently is.
Social Element
One aspect that is part of all the above ideas about cave entry is people and it merits talking about separately. There are a cast of people that help get people into caves and this can be due to how they act or how the client perceives them acting, or how they imagine they think.
To get cave entry then people need to be seen as not understanding you, or critical, or higher achievers than you, or more interesting, or treating you badly. You need to see yourself as not popular in the eyes of others, or others as not valuing you or your work. You can’t take the compassion of others or you wouldn’t get into the cave, you certainly don’t want to identify with others as similar to you, your depression needs to be because of your perceived dysfunctional characteristic. You need to suffer it alone although you can make it worse by thinking of how other people have it worse than you and yet they still manage.
There is a highly isolated aspect to depressive symptoms, there is a highly isolating aspect about them. In some ways inside the cave there is something of the social outcast, the hermit, again this is a self-outcast, apart from the person who is abused by group or context.
So to understand entry to the cave, what were the roles and changing roles of the others significant to this entry, they may be known people, film stars or anonymous friends on Facebook. They define the life that should be, that persecute me through what they believe, who taught me self-criticism by criticising me, who bullied me to plant the seeds of I’m useless.
Treatment
As we get to meet this cast, then we get the chance to get to know them better, as this happens so we can open up different thoughts:
Is their life as good as it seems and would it suit you?
What do you make of people that bullied and criticised you, does their behaviour say anything about them?
There is a good chance that the person with depressed symptoms has some of this casts voices and attitudes as their thoughts\beliefs and values. So as we get to know them better, we effectively get to know some of the cognitive mechanisms that takes the person into the cave.
In some ways the “cognitive restructuring” is more about getting to know about the specific people who made for the cave entry and then also other people. In understanding the cast then we enrichen their behaviour, if their behaviour was critical then there were reasons for this, and not all of them were about you. If their life seemed to be envied, then as we understand more about it, we hear more about their suffering.
 
What then keeps us in the cave?
I will mention three main ideas here, learned helplessness, punishment and cognitive/behavioural factors.
Learned helplessness
Seligman tells us of learned helplessness, i.e. pessimism towards our self-efficacy, through interpretation of misfortune in terms of the continuums of personalisation, pervasiveness and permanence . So if you interpret misfortune because it was your fault, you always mess up and always will, then this leads to learned helplessness. So you stay in the cave as you have no belief in your ability to either define or live the life you want so you seek damage limitation. 
This in some ways helps us to understand the difference between the reactions of unhappiness and depressive symptoms to unpleasant events. The former has hope, and will accept comfort and give themselves it where the latter does not.
Punishment
Rowe would also add that if you have learnt to believe yourself as bad,  either as a result of taking the blame as a child, or the outcome of continued criticism\self-criticism, then “You review the stupidities and failures of your life and punish yourself for crimes known and unknown” (Rowe, 2003, p. 6). Again you stay in the cave as both prisoner and gaoler.
Cognitive\Behavioural maintaining factors
The following seem to perpetuate low mood, and keep you in the cave:
1.    Low value activity: creates low mood and continues depressive thoughts about self, world and others.
2.    Self-criticism: telling yourself how you are no good/incapable.
3.    Comparisons telling yourself you’re no good in comparison with others
4.    Rumination: The replaying of all the bad things in your life, both lowers mood and reinforces depressive thoughts about self, world and other
5.    Self-care: reducing self-care leaves you to experiencing yourself as of low value in society and having low abilities.
6.    The inability to accept compassion (this would confirm low status) or give it to one self (kindness would condone your position)
7.    An inability to make meaning out of our depressive symptoms: the future is hopeless as you can’t imagine the ending of this story and the next chapter.

Social element
Again with the elements above there contains a social element.

There is a cast of people that keep people in the cave, be they real or imaginary. These are the people who would criticise, whose lives are better, who don’t understand you and say the right thing.
So in the work to forge an escape there is an aspect of re-engaging with people, to reduce the sense of isolation and that its only you that suffers, to get the validation of your worth as a person because people want to take the time with you, to challenge the ideas of both the levels of unpleasantness that people will be to you and how awful it would be if they are.  Likewise as much as you reconnect with people, repopulate your life so there is a virtuous circle of feeling better about yourself due to the validation, a reduction in isolation, which is a form of torture used throughout history, and a opening to both the meaningful activities you can do with or for others. Again as this happens we get to either challenge the beliefs we have about other people:

The interesting other who I must stay away from as I will bore them.
The critical other who will laugh at me as I struggle to do things I used to excel at.
The other who is better than me, whose life is what my life should be.
No-one understands my suffering
They don’t suffer like I do

There is also a relationship to yourself that keeps you in the cave
I must criticise myself to motivate myself
I must ruminate to learn
I shouldn’t care for myself
I must not be compassionate to myself
The effect of this is there is hostility outside the cave from people, and inside the cave there elf-hostility, an “it’s good for me hostility”, almost boarding school hostility if I can call it that.

Finally Time
One last thing to mention before I say goodbye is to mention time, which is rarely mentioned. In the cave time is heavy, slow and painful. This is sometimes worth noticing both as a depressive symptom and also something that can be engaged with, as non-cave activities, or shall we say escape route have a different cadence, a different way times feel that can help guide the cave dweller back home.


Treatment
In some way the bed rock of coming out of the cave is self-care, self-compassion and making meaning.  I guess without some looking after yourself and care towards yourself everything else becomes much harder. So in some ways this might be the place to start.
The entwined nature of life however would also point out that self-care is reduced because of low self-valuation which is maintained by rumination, self-criticism, comparisons and low value activity. So I guess here is to find an “in”. Somewhere you can make a difference, and in some way as you reduce the low value creating activity or inactivity, then to increase self-care and compassion would seem to be the way to go as this could create more momentum for tackling the next cave staying aspect.
Meaning seems also key: to make sense, to make meaningful how you got into the cave and therefore the meaning of being in and getting out of the cave would also seem important. It places cave dwelling as part of a narrative that shows how the main character, gets his second chance, overcomes his adversities, learns and builds on his prior mistakes to a phoenix return.  As soon as you can make sense of cave dwelling and escaping, it offers you a method to get out, and you can orient yourself with this narrative.
So after we provide some foundations then we need to tackle the different shades of cave dwelling:
If learned helplessness seems powerful a good anti dote to this would be shaped behavioural activation as you want to enhance self-efficacy.
If there are core beliefs around about being bad\useless etc. compassion work would seem a soothing balm.
If self-criticism is high then to understand its purpose, generally to do with learning and motivation and then to see its effects and seemingly then the encouraging aspect of compassion seems helpful.
If rumination is high then to understand its purpose and effects seems critical, again to notice the secondary benefits that the rumination might be an attempt to hold onto a view of the world that I had good parents or it’s a just world etc. Attention switching\mindfulness to more valued activity seems helpful in this space.
If comparisons are high then you can work with them in the same way as self-criticism as they are part of this in that you compare with yourself to result in a critical attitude to yourself.
The social element of staying in the cave seems about using some of the techniques to cave entry back with the client. So as often peoples self-relation is a lot harsher than their other relations, you can use comparison to ask would you say that to a friend.  In the face of self-criticism or rumination learnt from a significant other you can invoke a compassionate other be it as an individual or composite of individuals and ask how they would react to you. You can also bring in the imaginary person, if you had a child and something went wrong, would you encourage them to criticise themselves and ruminate. So in some ways this is a cognitive restructuring but the method is through relations. It uses the same mechanisms, comparisons, imagination and memory but just with different people, people that you love or loved you. In some ways it seems less of a cognitive curiosity rather a meeting old friend and maybe even new ones.

Summary
Entry to the cave happens like this:
1.    Feel distress in life
2.    Consider the reason for this that I’m not living or don’t know the good life
3.    Consider others better than me\punitive and uncaring
4.    Go to the cave to minimise damage, no mistakes, nothing goes wrong, no criticism, no failure as I’m not trying and that’s the reason I’m depressed.
And you stay in the case like this
1.    Through learned helplessness consider I can’t find out how to get\live the good life
2.    Use the depressive cognitive\behavioural maintaining factors mentioned above

Whilst it seems significant to address the cave entry ticket to both ensure early release and prevent relapse, the maintaining factors whilst related to the entry ticket are significant and without treatment of these escape is unlikely. Of course the division isn’t as clean as this and the maintainers will also be seen in the cave entry and vice versa, but logical clarity here seems helpful.

Of course I guess one obvious answer to all of this not mentioned above, it to make a really swish cave, all bear skin, plasma, wine and grapes and wait for everyone else to come to yours, but then that is another story….bye now.

References
Gilbert, Paul. The Compassionate Mind (Compassion Focused Therapy) (p. 40). Little, Brown Book Group. Kindle Edition.
Rowe, Dorothy. Depression: The Way Out of Your Prison (pp. 18-19). Taylor and Francis. Kindle Edition
Seligman, Martin E.P.. Learned Optimism: How to Change Your Mind and Your Life (p. 58). Knopf Doubleday Publishing Group. Kindle Edition

Overdoing presentation to PWPs

Overdoing clinical skills presentation for pwps from Rob Thomson

Overcoming Stress: Brosan and Todd

Overcoming Stress: Brosan and Todd
Contents
Chapter 1 What is stress 3
Defining 4
Demands 4
Internal\External 4
Timescales 4
Goals and expectation 5
Stress Modulators 5
Peoples response to stress 5
Range 5
Optimal level 5
Myths about stress 5
Chapter 2 Stress and your body 6
Physical symptoms 6
Fight\Flight\Freeze 6
Stress hormones 6
Stages of stress response 6
Allostasis 7
Stressful live events and health 7
Stress and immune system. 7
Stress and infectious diseases 7
Autoimmune disease and stress 7
Chapter 3 Stress and Personality 7
Chapter 4 The role of thinking in stress 7
Chapter 5 Is Stress a problem for you 7
Chapter 6 What makes you stressed 8
Uplifts 8
Chapter 7 How do you cope 8
Types of coping 8
Emotional based coping 8
Stress carrying 8
Avoidance based coping 8
Problem based coping 9
Advantages and disadvantages of different ways of coping 9
Chapter 8 Your stress profile and stress management plan 9
Stress management plan 10
Think of area that is causing you the most difficulty 10
Define your goals 10
Choose a technique 10
Stress diary 10
Chapter 9 Changing your stressful thinking 10
Chapter 10 Changing your stress related behaviour 10
Working with avoidance 11
Chapter 11 Stress and Relationships 11
Changing stressful relationships 11
Relationship as system 11
Partner 1 withdraws and seems cold 11
Relationships are affected by the past 12
Expectations play a big part in relationships 12
Chapter 12 Stress at Work 13
Effects of stress at work 13
Problems with communications and stress at work 14
Using the skills: positive or negative challenging 14
Assertiveness, aggression and placatory submission 14
Being assertive in the workplace 14
Day to day coping strategies 15
Unhelpful attitudes 15
Travel stress 15
Chapter 13 organizing yourself and your time 16
Thinking about priorities 16
Planning activities: the value of lists 16
Structure and routine 17
Managing work load 17
Chapter 14 Overcoming barriers and enhancing coping 17
Procrastination 17
Treating procrastination 17
Motivation 18
CBA 18
Action plan 18
Perfectionism and stress 18
Treating it 18
Dealing with worry 18
What keeps worry going? 18
Worry management 18
Worry maintenance cycle 19
Worry metacognitions 19
Task Interfering Cognitions, Task Orientated Cognitions 19
Problem solving 20
Regulating stressful emotions 20
Chapter 15 20
Diet 20
Alcohol 20
Managing alcohol of food for stress management 20
Exercise 21
Sleep 21
Preparing to go to bed 21
Chapter 16 Attending to the positive 21
Build confidence: 21
Chapter 17 Your stress plan revisited 22


Chapter 1 What is stress

Symptoms
1. Emotions
a. Anxiety
b. Depression
c. Anger
2. Physical
a. Tension
b. Illnesses
c. Headaches
3. Behavioural
a. Making mistakes
b. Can’t concentrate
c. Avoid difficult situations
d. Comfort eat\drink
e. Procrastinate
f. Never have time to do things for yourself


Defining
Early ideas about stress were from physics, so how much stress a bridge was under was the indication of load, its pattern, frequency etc.
This then got appropriated in physiology where there was understood a stressful event and a stress response e.g. cortisol.  Of course between the event and the response is the appraisal.
Different kinds of appraisal. Lazarus: primary appraisal: Weigh up what’s going on and establish if it’s a problem for you. Some things everyone would think was a problem, others are there may be specific to the person who appraises.
Secondary appraisal is can I cope with it, by myself with help etc.

Stress is when we are under pressure via demands, and not having enough resources to deal with them.
Stress is the response when the demands that are put on us are more than we can cope with
Understanding that there is a problem that puts you under pressure via a demand
And not being able to cope with it
That leads to a stressed response

Demands
Internal\External
Stress can be thought of too many demands on us to allow us to cope. Demands can be thought of internal and external. External I need to work, internal. External demands are things you have to do as another is asking that of you, internal demands are things you think you have to do.  So I guess you can have internal and external on a continuum.
External is the demand externally
Job needs to be done
Internal demand comes internally
I need to do x
I need to do an external demand to a certain standard.
Timescales
How long does the demand go on for, acute or chronic?

Goals and expectation
When personal goals are threatened we become stressed. Stress can be the outcome of when your goals are threatened and you fear disappointment.
Stress Modulators
Control
If you don’t think you have control after a while you get learned helplessness and you stop trying, this then generalises and when you do have control again you stop trying.
Knowledge about the future
Knowing that a traffic jam will only take an hour makes it easier to bear.
Perceptions of control
If you believe you have no control (even if you have) this increases distress
If you believe you have no control what happens to you, as its external forces, i.e., external focus of control then this increase distress.

Stress= (demands * level of importance) –levels of power
Stress
Demand (how and when) * significance =importance
Minus
Coping abilities (abilities * level of control + people to help)

Peoples response to stress
Range
There’s a continuum between adrenaline junkies to people with chronic fatigues. Can’t get enough stress to can’t manage any.
Optimal level
Under aroused (Bored and under stimulated) =perform badly
Aroused=optimal performance
Over aroused=stressed and anxious

Myths about stress
1. Getting stressed means I’m weak
a. So now you are stressed and you insult yourself
b. (everyone gets stressed)
2. Everyone else can cope it’s just me
a. However we compare people’s outsides to my insides.
b. They might look like they’re coping but how do they feel
3. Life is stressful there’s nothing you can do about it
a. You can change the situation, change how you interpret it, change how you respond to stress
Chapter 2 Stress and your body
Physical symptoms
Muscular=tension
Gastrointestinal=IBS symptoms
Cardiovascular=higher blood pressure
Respiratory=shortness of breath
Sexual=lower of libido
General=more colds, weakened immune system

Fight\Flight\Freeze
Our threat response system is developed for physical threat.  Emptying bowels means you can run faster.  Freeze can be a useful physical response as some animals very good at detecting movement. Muscle tension allows the body to be held still.
Stress hormones
Cortisol and adrenaline
Adrenaline enables fight or flight. To return the body to a resting state then the PNS releases noradrenaline is released.

Cortisol
Acts more slowly than adrenaline. It peaks after 40 mins and then disperses more slowly. Cortisol is used in many day to day maintenance of the body, but PRN then it is used to support the adrenaline changes, e.g.  maintaining elevated blood sugar levels.

Stages of stress response
Hans Seyle=General Adaption System
Stage 1: Alarm stage
Rapid decision to fight or flight
Stage 2 Resistance stage
Energy is being borrowed by the on too much stress system from other systems
Stage 3 Exhaustion stage
Body can’t cope with the demands put on it

To maintain long periods of stress, the stress system hasty borrow energy from other parts of the system, e.g. eating\digestive, menstrual system,

Allostasis
Keeping stable through a constant state of change, i.e. minor adjustments for a homeostatic system.
In a stress over aroused state our bodies are constantly trying to get us back into a less aroused, better coping state.

Stressful live events and health
Whilst stressful life events correlated in bad health, it could be that bad health caused stressful life events. It could also be that when stressed, you remember more your bad health.

Stress and immune system.
Changes in the central nervous system, CNS changes how our immune system works. Stress impacts CNS and impacts the immune system.  No correlation between breast cancer and stress, causally., or keeping it going. However the behaviours that stress people do, smoking and drinking does correlate with cancer.
Stress and infectious diseases
Infectious diseases are caused by bacteria or viruses called pathogens. You don’t always develop the disease even if you have a pathogen. Chronic stress is related to colds, acute isn’t.
Autoimmune disease and stress
Autoimmune disease is where the immune system attacks good cells: MS, Lupus and rheumatoid arthritis.
Small stress does correlate, acute stress doesn’t.

Chapter 3 Stress and Personality
Omitted
Chapter 4 The role of thinking in stress
Omitted
Chapter 5 Is Stress a problem for you
1. Cognitive symptoms
a. Thoughts=I can’t cope
b. Memory and concentration difficulties
c. Worry\Rumination
d. Self-criticism
2. Emotional symptoms
a. Tense wound up
b. Overwhelmed
3. Physical symptoms
a. Head aches
b. Indigestive problems
c. Sore muscles
4. Behavioural
a. Avoiding situations
b. Drinking\eating too much
c. Losing temper
d. More clumsy
e. Always late
f. Procrastinating
Stress monitor against each heading with severity and frequency.

Chapter 6 What makes you stressed
Life events: divorce, lose job
Hassles: lose bank card, get parking ticket, traffic etc.
The severity of these is dependent on the appraisal you make of them.
Uplifts
These are the opposite of stresses, things that make you feel good, give you a sense of achievement, give meaning and pleasure to your life.
Do stressors outweigh uplifts, if they don’t then you’re not going to feel good.

Chapter 7 How do you cope
Coping styles
When you’re faced with an extra stressor, someone making a demand on you what do you do.
Exercise not stress level, coping style and effects on stress level.

Types of coping
Emotional based coping
I.e. manage the emotional effect of stress, meditation, exercise
Stress carrying
Find it hard to manage the emotions stress causes, so they end up taking out their feelings on others, e.g. anger. Their response then creates stress for others.
Avoidance based coping
Pretend everything is ok, avoid emotional pain with drink and drugs
Problem based coping
Concentrate on what is causing stress and try to fix it

Advantages and disadvantages of different ways of coping
Emotion based coping: this can help calm you down to enable you to tolerate the stressful situation
However sometimes focussing on the emotions and the problem can lead to rumination
Avoidant based coping= this can lead to physical problems and things building up to outburst.
Problem based coping=this both reduces the problem, and makes you feel more in control.  However many problems you can’t problem solve, e.g. traffic jams.
Bottom line is some forms of coping are better for different situations, so having the ability to do all of them really helps.
Chapter 8 Your stress profile and stress management plan
Formulation comprised out of
Stress symptoms
Cognitive, behavioural, physiological, emotional
Stressors
Life events
Hassles
Uplifts
Coping strategies
Avoidant, emotional, stress carrier, problem solving

You get a stress trigger, you get stressed, apply a coping strategy which if it doesn’t work makes the stress worse.
So
Event=>
Primary appraisal=>
Secondary appraisal=>
Stress response=>
(Appraisal, means I’m not coping)
Coping strategy

Sometimes the stress response is then appraised, e.g. I’m not coping

Stress management plan
1. Think of area that is causing you the most difficulty
2. Think about what changes can be made in this area and set a specific goal
3. Work out strategies to achieve this goal
4. Review your plan as it is implemented

Think of area that is causing you the most difficulty
Look at the types of stressors that are causing you most difficulty
Define your goals
Get an achievable one that makes an improvement of your current position
Choose a technique
So this can be from around the formulation NATs, SATs, Different coping response, either type or content, Stress appraisal

Stress diary
Columns
1. Stressor
2. Technique
3. Review progress


Chapter 9 Changing your stressful thinking
Chapter on cognitive restructuring
Sociotrphic, most interest around how loveable\likable you think you are. , so social desirability is a major part of identity
Autonomous most interest around achievement, so achievement is a major part of identity

Chapter 10 Changing your stress related behaviour
We believe what we and others do much more than what they say. If someone says I love you or acts in a loving way then you are more likely to believe the latter.  So as much as you challenge thoughts, if you act on them that will really confirm to you their truth even if it feels a bit alien at first.
So ask yourself how you would act if you weren’t stressed and act on that. Ask yourself if you had a twin who didn’t suffer from stress how would they act.
When people are stressed and anxious they avoid stressful situations.
Appraise situation as bad\difficult=>
Feel more stress=>
Avoid=>
Appraisal=>self-criticism=>
More stress

Working with avoidance
Two approaches
1. Shaping :
a. Graded task assignment, take first step, after finishing how do you feel. Take second step
2. Working with the thoughts that make this something to be avoided
a. Test predictions with an experiment
Chapter 11 Stress and Relationships
Factors that correlate with depression for women
1. Mum dies before 12
2. 3 children under 14
3. No occupation outside the home
4. Having no one they feel close to or can talk to
Given relationships can reduce stress, then stress in relationships can be a double whammy.
Assess
Notice the stressful\supportive relationships in your life
How frequently do you see them? Can you reduce the stressful contacts and increase the supportive.
Changing stressful relationships
1. Relationships are systems
2. Current relationships are influenced by previous relationships
3. Problems in relationships are often about hidden expectations each partner has about how the other should behave
4. Problems in relationships can be affected by irrational appraisals
5. Problems in relationships can be cause by not communicating well
6. Problems in relationships by reductions in constructive behaviour
Relationship as system
Partner 1 cold=>
Partner 2 angry
Partner 1 withdraws and seems cold
So the ideas is firstly to see what part you play in the problem, and then change that. Demanding the other change can produce resistance, but changing what you do that they react to is possible
Relationships are affected by the past
Early experience shapes wheat we think of people and how we expect them to react.
This can be conscious or unconscious. You may be annoyed your partner doesn’t know what you are thinking much like mum used to.
We repeat our childhood patterns as it is safer doing what we know, and we also get the feeling maybe I will be able to put it right this time.
How to find this out
1. Have I been in this situation before
2. What is my earliest memory of being in this situation
So when you realise this is a repeated pattern when you notice the pattern in action ask yourself is this how you want to act.
Expectations play a big part in relationships
For example
1. You don’t need to work at a good relationship
2. My partner should now what’s on my mind
3. My partner should always think about me and him
If the expectations are not met then this causes friction, although they may be unreasonable, your partner might not know your expectations.
Identify expectations
When upset, ask yourself what do you think the other ought to have done and therefore what is my expectation of him.  Once identified then question them with are they fair, reasonable, does my partner know about them, are they reciprocal.

Problems in relationships are due to faulty appraisals
You can mind read, or misinterpret behaviour. Then act on the basis of the misinterpretation, which sometimes can start making it true.

Problems in relationships are often affected by faulty communications
Half listening to someone gives them a message about what you think about what they are saying. Interrupting the other again gives messages about what they are saying and its value to you. Do not mind read, you can’t listen, do not listen just to find something to prove a point again you are not listening.
To listen, have the time when you can devote your time and attention to them. Don’t think about yourself, think about what they are saying, Have what you have understood validated by them.
Things to avoid:
Talking too little: Avoiding questions, how do you feel: fine?
Talking too much and not allowing the other person to engage in the conversation.
Talking about the wrong thing, blow up as the milk hasn’t been bought, when actually it’s about paying the mortgage
Talking too much about the same thing: nagging, it’s a veiled criticism in ever more irritated tones.
Don’t let a big gap be between what you say and what you mean, e.g. darling will you with gritted teeth, when you mean look you’re out of order don’t do that.

Things to try
Avoid blaming, criticising or generalising that will mean they become cross or defensive
Timing: Trying new ways of communicating is best done when calm rather than angry or upset.

Being nice to each other
Start of relationship you want to win your partners approval so you say and do nice things and notice their good features. Later you take those good features for granted and become increasingly focussed on the things that irritate you about them.

Chapter 12 Stress at Work
Over working=> Over-tired, reduced pleasurable activities, increase stress
Stress factors at work1
1. Constant change
2. Being used as a political football
3. Threat of job loss
4. Feeling you have no control in your job
5. Feeling you are unsupported by your manager

Just because you’re stressed at work it doesn’t necessarily mean it’s because you can’t manage but rather it can be the nature of the organisation, or you are being given unreasonable demands.
Effects of stress at work
Absenteeism or presenteeism
Either not at work physically or mentally
Health
Work stress affects physical health
Understanding work stress
1. Keep a stress diary and notice the NATs, primary and secondary?  and coping response
2. Notice the common themes both in NATs and responses,

Problems with communications and stress at work
Communication skills can reduce stress.
Improving communications:
1. Listen for 6 minutes to a friend without interrupting, then get them to do the same for you
2. Ask open questions, i.e. question that don’t require a single word response
3. Empathise, stand in their shoes and show them you understand something of their concerns, intellectually, emotionally
4. Summarising: demonstrates that you are listening and have understood
5. Being clear about what you say. If you mind is full of fearful thoughts about what the other might react then it might be difficult to put across your point of view. If you’re not sure of what you think then either ask to think about it. Don’t get personal and don’t ramble.
Using the skills: positive or negative challenging
Positive challenging, you look like you’ve been having difficulty doing x, I wonder what’s going on.
Negative challenging, takes away control, you should do x, you need to, if you don’t bad things will happen.
Respect people’s views it’s unlikely that they will be completely wrong.
Before putting your view, say something positive about theirs, that’s an interesting view
A positive statement followed by a but becomes a criticism, use and instead.

Assertiveness, aggression and placatory submission
Assertiveness is about expressing your needs, feelings and what you would like to happen without leaving yourself or another hurt. Assertiveness doesn’t mean you will get what you want.
Aggression may be active, with people being rude, critical or threatening, or it can be passive, where people block your ideas, make life unpleasant without ever admitting this is what they are doing.  Both active aggression and passive aggression have the same effect where people feel frightened, attacked and bullied.
Being assertive in the workplace
Broken record, if what you said hasn’t been heard say it again
Be direct and clear
Give the bottom line instead of rambling
Don’t mind read?
Avoid sarcasm, labelling and whys.
Ask for feedback
Practise saying no

Being asked to do something unreasonable:
1. Explain that you haven’t the time\skills\resources to do this at the moment
2. If you’re challenged stick to your point
Day to day coping strategies
1. Take a break, move from your desk and stretch your body
2. Do a stress busting activity such as yoga, swimming or running
3. Have reminders of nice things at your desk
4. Use a stress gadget like a ball
5. How messy\stressful is your environment, if you weren’t stressed what would it look like and make it like that
Unhelpful attitudes
For instance
1. I’m always right and the other is always wrong
2. When you have don’t something wrong do you refuse to own up
3. Do you find it hard to own up to your own problems and tend to blame others
4. Do you try to take over and make everything all right for others rescuing the situation and taking full responsibility?

Travel stress
Some research shows that a long commute is one of the most important factors of reducing overall life satisfaction. People who get a promotion and a longer travel get used to the increase of reward, but the longer travel gets increasingly stressful.
Travel strikes at the three main factors of stress, being helpless, out of control and trapped.
Driving
Keep an emergency kit in case of heavy traffic, take another perspective on the queue, you could have been in the accident, or had your car break down. Notice how your beliefs get triggered, the it’s not fair, things going wrong, feeling helpless, people in my way, feeling like a cog in a machine, people are idiots\angry etc.
1. Negotiate hours with employers so you can avoid rush hour. Work from home more often. Be realistic on how long the journey lasts and allow for it being slightly worse.
2. Bring things to make traffic jams endurable, CDS, podcasts etc.
3. Do physical exercise in the car, Pilates,
4. Meditate in the car
5. Sing along to a CD
6. If someone behaves like an idiot, remember there are lots of idiots in the world and you are not one. Their rage\idiocy is directed at you but it is not about you, it could be anyone. Think of what you put into the world as increasing, kindness will elicit more kindness, anger more anger

Train
We are all used to having our own personal space and not used to public space.
1. Choose the least stressful journey, rather than the quickest
2. Network on the train
3. Make friends on the train
4. Work on the train
5. Leave enough time
6. If you are tense, then notice where and release this
7. Try mindfulness
Chapter 13 organizing yourself and your time
Good time management is for spending most time on what is most important to us.
Thinking about priorities
Draw yourself in a spider diagram, draw key areas for you around these, then around those mark down what you would like to achieve in relation to them.  As you do this notice are there things that you spend a lot of time doing that you don’t care that much about. Any areas that you value but you aren’t spending time on?
From looking at the spider diagram, establish your priorities and your goals. Take the goals and split them down into manageable sub goals.
Now log your time for a week and notice where you spend your time and does it fit with your priorities. Then notice the omissions and patterns. Are you avoiding doing things you need to\should. Are you doing too much or too little of one thing?
Use Coveys time management matrix, to understand how to priorities your tasks
1. Important
a. Urgent
i. Fire fighting
b. Not urgent
i. Quality time
2. Not important
a. Urgent
i. Distraction
b. Not urgent
i. Time washing
1. Important\urgent do straight away, not doing them =crisis and stress
2. Important not urgent do them next
3. Reduce where possible distracting tasks
4. Avoid doing time washing
Analyse how you spend your time during the day
1. Did you spend your time doing tasks that were important
2. Did some tasks take longer than they needed? Why
Planning activities: the value of lists
Draw up a to do list for the day ahead.
Efficient lists
1. Write down everything that has been buzzing around your head
2. Prioritise into urgent and important
3. Prioritise into what must be done today and what can wait
4. End of day review the list in terms of whats been done
Structure and routine
When our time management goes out of the window we don’t look after ourselves as our lives get very disrupted, work all night, don’t eat etc. The lack of self care then has an impact increasing the level of stress and haos To counteract this then plan your self care in, create a structure in which to live.
Build in breaks in work for rest and pleasure, you will be less efficient if you don’t.
Managing work load
1. Delegate
2. Say no. Don’t make excuses, say sorry I cant, but I cant.
Chapter 14 Overcoming barriers and enhancing coping

Difficult stress based behaviours:
1. Worrying
2. Procrastination
3. Perfectionism
Procrastination
This increases stress as putting things off leaves their need, and you can worry about them more and intensifies their distress. Procrastination can be motivated by emotional reasoning, I don’t feel like doing it now, or Im not in the right mood to do it properly. Procrsatinationj can also be driven by perfectionistic and punishing working regimes, so you put it off as it will be painful. Procrastination can also be encouratged by a fear or uncertainty, if you start something you are uncertain how it will turn out so best to not start.  Procrastination can also be fuelled by a fear of failing and this can underpin perfectionist tendencies. Procrastination can also be about not wanting to be controlled, so someone else owns the task and you don’t want to od it as you don’t want to be controlled by them.
Summary
Reason for procrastination
1. Waiting for the right mood to come
2. Fear of failure
a. Perfectionist
b. Too low expectations
3. Feeling controlled by others
4. Lack of assertiveness
5. Lack of interest
Consquence short term stress relief at the cost of long term increase.

Treating procrastination
1. Notice procrastination
2. Notice thoughts that support it
3. Challenges the thoughts
4. Notice how its easier to motivate yourself to continue doing something than to motivate yourself to start
5. Do a pros and cons of starting it or putting it off
6. Break task down into small parts
Motivation
Motivattion works in a circular fashion in that in motivates action and action increases motivation. Sometimes its hard to get things started but if you wait to be motivated you may wait a very long time
CBA
So do one on procrastinating and one on starting the task today.
Action plan
Write what the problems are and how to solve them or solutions
Perfectionism and stress
Studies show that perfectionists tend to get more stressed in challenging situations than others. They can fear criticism, they see the non perfect as a failure, they might see if they are not perfect they will be punished, or it will be dreadful.  Perfectionism can also be tied up with the desire to please people, if I do well people will like me, so if I do really well, they will really like me.  So perfectionism can be a way to deal with low self esteem as it can be a away to get yourself to like yourself.
Treating it
1. CBA of being one
2. Noticing should musts etc.: what are their effects, no room for error, bossy, stress, and demotivating you wouldn’t talk to someone else like that
3. Test out your worst fears of not being a perfectionist
4. Noticing striving for perfection means you are less likely to achieve it
Dealing with worry
Is it a hypothetical or real worry? Can you do something about your worry. If your worry is productive it should quite quickly lead to solutions
What keeps worry going?
1. Reassurance seeking
a. Worry builds anxiety up, reassurance brings it down but it doesn’t deal with the process of worrying
2. Checking
a. Worry builds anxiety, checking there isn’t a problem brings it down but doesn’t deal with the act of worrying
3. Struggling with uncertainty
a. People find not knowing what will happen difficult, then they make negative predictions that leads to worry
Worry management
1. Worry diary, noticing triggers
2. Challenging thinking errors in worry
3. Challenging probability that your worry will come true
a. The more you worry the more likely you think it is that it will happen
b. How good are you at predicting

Worry maintenance cycle
Worrying increases your belief in the probability that bad things will happen that makes you worry more
Reduce sense of probability:
1. Will I be worried about this in a week
2. If a friend had this worry, would I say to them
3. What’s the likelihood of this worry coming true, how many have my last ones come true
Worry metacognitions
Worry can be useful or worry can be harmful
-ve beliefs
1. I can’t control worry
2. Worry causes stress and then heart attacks

+ve belies
1. Prevents bad things happening
2. Prepares me for bad things
3. Shows I care
Test this by having a worry\no worry day and see what happens, does worrying help?

If worry is really difficult to stop as you have been doing it for so long, then use a worry diary, with worry time. Your worry time should be 15 mins long and not 2-3 hours before bed.
Task Interfering Cognitions, Task Orientated Cognitions
TIC\TOCs
TICs: I will do it later, I can’t be bothered, I will never get it done
TOCs: The sooner I will start, the sooner I will finish. Doing something makes a start.

TICs what kind of thinking gets in the way of tasks, TOCs what kind of thinking helps you do tasks.
It’s easier to list TOCs in non-stressful situations, then they can be recalled in stressful situations.

Problem solving
1. Define the problem, be as specific as possible
a. Break problem down into small pieces
2. List all possible solutions
3. Choose a solution
a. Put pros and cons
4. Make a specific plan
a. Break the task into manageable steps
5. Do it
a. Review outcome
i. Use feedback to adjust the plan if necessary
Regulating stressful emotions
1. Meditation
2. Activities
a. Exercise
3. Create different emotions
a. Watch an emotionally powerful movie, funny\scary etc.
4. Distract your mind
a. Count backwards from 1001 in 3s
Chapter 15
Diet
No such thing as bad food stuffs, but you need balance. You need fuel for the body, if you get overweight that will add another stress.
Four types of fat
1. Polyunsaturated
2. Monounsaturated
3. Saturated
4. Transfat
Poly\Mono unsaturated fat are found in oils of vegetable origin, these are healthier than those of animal origin, e.g. saturated fats. High saturated fat diets are correlated with CHD. Transfat which is found in processed food, which is vegetable fat is hydrogenised to harden it is associated with heart disease.
Too much\too little salt is associated with high blood pressure.
The sugar high and crash is a myth. Glucose is finely regulated and always you have one teaspoon of glucose in the blood
Alcohol
Reduces symptoms of stress when drunk but reduced coping when hungover. Reduces quality of sleep so reduces recuperating.
Managing alcohol of food for stress management
1. Realise triggers, put in some other options
Exercise
Best stress management tool: creates endorphins, stretches tensed muscles. Improved blood flow: improved concentration.
If you enjoy your exercise you will do it more often: fun exercise can be really helpful.
Sleep
Stress can make you sleep worse, which then adds to stress.
The thought I won’t cope with sleep can be challenged, you can cope with a lot less sleep than you think, junior doctors do it, parents of young children do it. Research shows sleep deprivation affects dull repetitive tasks strongly but not those that require our attention.
Don’t look at the clock, you are reminding yourself how bad the problem is, which is creating distress which gets in the way of sleep.
Problems can seem worse at night, as night time historically was a time of threat, Problems doing the day don’t seem as bad as you can do things about them.  So you can have a rule, anything you think at night doesn’t count, it’s just nocturnal anxiety kicking in.
Distracting yourself can help from your worries, count backwards from 1001 in 3s.
If you can’t sleep, don’t stay there worrying get up and do something boring until you feel tired enough to go to sleep. Don’t associate your bed with not sleeping.
Preparing to go to bed
Alcohol can help you get to sleep, but makes you more likely to pee in the middle of the night. ~Alcohol affects your quality of sleep.
Don’t exercise within 2 hours of bed time.
Don’t watch TV computer within 2 hours of bedtime as the light is very bright and tells your brain that its midday.
Make your bedroom a haven.
Have a bedtime ritual\routine.
~PMR works like a pendulum the further you go one way the further you will go the other.

Chapter 16 Attending to the positive
Self efficacy has two parts:
1. Think of solutions to problems
2. Belief in your ability to carry the solutions out
Build confidence:
1. Keep positive data log
a. Moving from one stressful problem to the next, means you don’t pay attention to what you have achieved
b. Data
i. What you achieve, things going better than expected
ii. Learning new things
iii. Getting praise, gratitude
iv. Recognising good qualities that you act on
v. Recognising when you do things that you value
2. Create a more positive image of yourself
a. Go through and rate yourself against a list of positive qualities
b. Ask someone you know well to do the same
c. Notice how often these qualities appear on your PDL
3. Create a resourceful self
a. Think of a problem you are trying to deal with, notice how it makes you feel, physically and emotionally
b. Now imagine yourself at your best, how would you be feeling, acting and thinking.
c. Bring this imaginal self more into reality, bit by bit.
4. Reward yourself
a. Give yourself rewards for tackling stress.

Chapter 17 Your stress plan revisited
Stress plan
1. Identify stressors
2. Identify goals and sub goals
3. Choose techniques to help
a. Thought challenging
b. Using best coping responses
c. Taking care of yourself
d. Time management
e. Worry management
4. Monitor your plan, its activity and progress
5. Revise the plan in light of the monitoring
Notice any thoughts that give you permission to stop your stress plan.

Driving phobia

Thinking and Doing

There seem two ways to act in the world, via thinking or doing.  In thinking we see problem solving, use of rules, its conscious, thought based, and focuses on one thing at a time, it uses propositional knowledge and logic. In doing we see an engagement with the whole

and  is seen with complex tasks like driving, playing tennis or giving therapy. It’s a knowing how to, its intuitive, instinctive and action happens via feel, via the body. When you drive your focus is light across the environment in front of you, the road, its conditions, the engine and its sound. As something changes in the environment, you then respond to this, not in a conscious problem solving way but rather to continue the act of driving.

Driving phobia

When people become anxious with driving, the difficulty occurs because in the face of the feeling out of controllness of anxiety they use thinking to help them, they look for the danger, the car in front, the kerb etc. They give commands to themselves, you’re driving too fast, too close etc. The thing is trying to perform a complex task with individual rational thoughts is impossible, its how you learn but not how you do. In short they try to control the danger via problem solving, possibly because this is how they originally learnt how to overcome driving difficulties when they were learning how to do it.  The art then of working with driving phobia is to help your client remember how to trust their instincts again and do rather than think.

Thinking about meaning (Presentation to PWPs at an IAPT service by Step 3 CBT clinician)

Thinking aboutmeaningv1 from Rob Thomson

Contents
Theory 1
Mental health essence 1
Meaning’s base medium 2
Language 2
Attention 2
Drivers of attention 3
Attentional effects 3
Thought 3
Thought types 4
Speech Characters 4
Practice 5
Meaning is core to mental health 5
Meaning is held in thoughts\perception 6
Thoughts can be dynamic\passive 6
Thoughts are communication 7
Communication can be between different characters 7
Attentional Focus 7

Theory

Mental health essence

Meaning is key to mental health.  This is not because it defines a mental health disorder in the way that the meaning of a swollen liver defines cirrhosis but rather because meaning creates it.

Mental health disorders are considered to be disorders of cognition, emotion or behaviour, a sense of something not being functional in one of these three areas. However there is no essential aspect of any of them that defines a mental health disorder. Rather it is meaning plus state of cognition\emotion\behaviour that defines a disorder.

If you are sad and have little interest in doing things but have just lost your loved family in a freak accident then this could be understood as grieving.  If you have suffered no recent loss then you could be understood as having the mental disorder of depression.

If you have thoughts of wanting to push people under trains, then you could think of this of as an unpleasant thought. If you think it’s a sign that you want to then it can provoke anxiety and you will be afraid of your thoughts and your behaviour around train stations.  This could lead thinking you have a mental disorder of OCD. 

If you always want to make sure you arrange your room in a certain way then you could understand this as superstitious or if you think there’s something abnormal about it, then you could consider it OCD.

It is how we interpret events that generate emotions and our meaningful desires that drive behaviour that likewise produces emotions. Meaning is the key to emotions and behaviours and consequently mental health.

Meaning’s base medium

The base medium of meaning is language, but it is also held in behaviour and perception. Behaviour carries meaning historically through the things we create or in the present through my gestures and actions.  So we are linguistically taught to push the pedals to move the bicycle, then we do it, then we don’t need language to do this as we understand pushing pedals as that which moves bicycles.

Perception carries meaning as our experiencing of the world with our 5 senses is done meaningfully: there is the squirrel that runs up the tree, next to the river in the park where I walk today.  When we were small we were taught the meaning of things in our perception, that’s a cat in front of you, that’s a mat etc. After having been taught it we no longer use language in perception. So whilst meaning is held in behaviour and perception it is only done so in so far it is describable and made meaningful by language.

Language

Language enables communication through a speaking and a listening. This communication is originally between people and can also be between parts of yourself when used in thought. Language as speech then becomes an act, so you might congratulate, or criticise and therefore has a purpose and an effect from both the speaker and the listener.

Language as a meaning bearer also enables creation\demarcation of the world and can thus enable an understanding and a satisfaction of our desires. As much as I the world is understood in certain ways, therefore it enables me to satisfy my desires.  As I understand woods as scary then I can satisfy my desires to stay safe by staying away from woods.  It can also be said that language can create the world as well and then be used to satisfy our desires. The word happiness points at a certain state of humans (thoughts, emotions, behaviours, physiology). People then strive to achieve it and are distress when they don’t. The word happiness, the label that attempts to define a human state, creates a part of the world that then people have desires for.

Attention

We perceive in so far as we orient ourselves in a certain way to the world. There are also different way in which we can perceive, long focus, short, narrow angle, broad, repeatedly perceiving the same type of thing. This can leave our attention have a certain style.

We can orient ourselves to external or internal events. If internal it can be focussed on a thought about the past, present or future.

When our attention is on something then we may build a sequence of actions on top of it. So I see the kettle and boil it to make tea, or I start thinking about how I am going to spend my time this weekend.  So we can see the initial act of attention, then a volitional building on top of action.

Our experience, our life is constructed out of perception and the attentional style we have.

Drivers of attention

The attention that we give the world can be said to be driven by different forces.

Firstly our general mood or disposition. If angry our attention is on more things that cohere with this emotion. If hungry we would see more things to eat, and get mistake more impression for signs of food.

Secondly our belief system. If we believe that human relationships are generally competitive with winners and losers, then we will see more instances of this, as opposed to different ways of being.

Thirdly our previous experiences as with our beliefs, we will be more sensitive to things that we have experienced before. So if a child has manipulative parents, then when someone acts differently to them, gives them something, then they might not interpret this as a kind gesture as they have had very little experience of this.

Fourthly it can be a deliberate strategy. If I am frightened of being sick then I may be on the lookout anything that could cause this, i.e. out of date food, people being ill etc. In this instance attention is motivated as a safety strategy.

Attentional effects

As you orient yourself to the world, take a perspective and understand it in certain ways. This has certain effects:

1.       Beliefs

a.       If you repeatedly understand the world in certain ways, it confirms this belief. So if you are continually trying to protect yourself from illness, your belief in the probability of being ill increases, the awfulness increases as you are thinking about it so much and experiencing to some small extent the effects of it as you imagine it.

2.       Physiology

a.       If you pay attention to a bump, then the effects of it increase. It feels more painful as the pain is on your mind more. It seems these effects might be because the meaning you give to it is unpleasant, which might make you struggle with it, e.g. tense your muscles, or scratch it.

3.       Emotions

a.       If you pay attention to an unpleasant emotion, then you can enhance unpleasant emotions as you are perceiving the emotion to be unwanted, unfair, something you can’t stand, this meaningful act of perception in turn produces more emotions, which will keep the original emotion going.

Thought

Thought can be described as constructed out of language or image.

The language part of thought can be thought either as speech or desire satisfaction.  Speech is seen between two parts of you and can be an act that has an effect, for instance self-criticism.  Desire satisfaction can run from the initial demarcation\understanding of the world so that you know what is there, and what you want, through problem solving to ensure you get what you want.

Image based thinking, is more emotional and more action based. Perception is the basis for image based thinking and this we do in so far as we aim to get our needs met in the world, we act and react. As I talked about earlier perception is meaningful and its meaning is within language.

Thought types

Thoughts that happen to us, pop into our head without our asking, let’s call them passive thoughts. There are also thoughts that we actively have, let’s call them dynamic, for instance when you plan what to do next weekend. Dynamic thoughts are streams of purposive thought, they are acts we choose.  For instance with meta thoughts, then if you have the first passive thought  “we could have a car accident” the Meta thought would be that thoughts true, then you feel anxious, and have other thoughts about how to keep yourself safe.

If would seem that every set of dynamic thoughts is preceded by a passive thought that just comes to us.

Passive thoughts seem to relate to:

1.       Our current concerns

2.       Our perceptions

3.       Out associations

4.       Fantasy thoughts

Our current concerns. If you are planning your wedding, you may well find many thoughts about weddings popping into your head unbidden.

Our perceptions. If you are in the supermarket and see carrots in someone’s shopping basket you may think about carrots. If you feel your stomach gurgle you may think about food. You generally only have a thought about things that are significant to you, it’s only the things that jump out that seem to merit a thought.

Our associations, you may have an association from the event you have just experienced, be it external perception or an internal event. So a smell might be associated with a family holiday and  you remember it, or the sight of bread you might associate with pack lunches and then the thought of what’s in your child’s packed lunch comes into your head.

Fantasy thoughts have two aspects, one the horrifying for instance, what if I stabbed my partner, the other the jubilant, what if I won the lottery.

Speech Characters

The dynamic act of speech that happens in thought is dialogic, that is there is a speaker and there is a listener. Thus as you think in speech, one part of you is talking to another part of you. As with any conversation the speaker has motives in speaking, and aimed for outcomes, the listener has outcomes and will respond back to the speaker. The learning theory of CBT shows us that our beliefs and behaviours are learnt from experience.  So as we see a type of speech in thought then we might ask where this was learnt. This can lead to some significant people in the person’s life who have influenced this way of thinking. As much as there can be key influence in a type of speech, we can also characterise the type of speech, so you might get the doubter, the show off, the policeman etc. Characterising the internal speech in this way, can also allow you to see the behaviours and values that go with this character, so that when they are activated which parts they are responsible for.

Practice

1. Meaning is core to mental health
2. Meaning is held in thoughts\perception
3. Thoughts can be dynamic\passive
4. Thoughts are communication
5. Communication can be between different characters
6. Attentional focus

Meaning is core to mental health

1.       It’s not what happens to us that causes mental health problems but how we understand it.

2.       Thoughts aren’t facts but beliefs.

3.       There are many different ways to look at the same event.

It’s not what happens to us that causes mental health problems but how we understand it.

The beginning of treatment seems to be to get a relationship between how I think and the emotions that I have.  This means that events don’t cause emotions and therefore I have more control over my emotions that I thought I had.

A powerful way to show this is if you can find an event that has happened to your client and other people they know and then you can notice the same event and different reaction. For instance a significant event bad or good that happens to a group (family, friends, school, sports team etc.). If this isn’t available, then you can do it with imagination. Ask your client to imagine you are in a different emotional/cognitive/behavioural state, how would you understand the event and then how what emotion would that provoke. This then provides a range of emotional response, which relate to how people think about the situation and demonstrates its not the situation that caused the emotion.

Thoughts aren’t facts but beliefs.

To look at thoughts as not being facts, you can generally ask someone if they have ever been wrong about anything. I have had someone who has said no, in that case, you can ask them one of the following:

1.       Have your beliefs changed over time?

2.       Have you thought someone thought something but found out later this was wrong?

3.       How do you understand what ideas to adopt as your own, as there are a lot that get offered from the media for what’s good and bad. This will lead to them saying evidence is the criteria used, which then gives us the position that I believe what I have evidence for, so for anything I believe I should have good evidence for it, which shows that the best we have is a belief we have good evidence for and we should change that when we have contradictory evidence.

There are many different ways to look at the same event.

There are many different ways to look at the same event. Take an everyday event like its raining. What are the different types of thought and emotions you might have about it? What happens if you have strong emotions, how does that change it. How do you think about it if you’ve been working hard, or going out a lot, how does that change what you think?  So if you change the context for the client, they interpret differently, if you make them older\younger they interpret differently. If you ask what about different people again you get a different interpretation.

If the only thing a client takes away from your work is an understanding the relationship between thoughts and emotions and that thoughts aren’t facts and there are different ways to look at things, I’d say you’ve done a good job

Meaning is held in thoughts\perception

Clients can when asked to say what they were thinking to help us understand a strong emotion, say they don’t know. It can be helpful here to know that meaning is perceptual so that you aim to elucidate the meaning of the scenario, which can then explain the emotion.  So as you’re feeling angry what is the situation like (describe perception). Of this what is it that made you angry (link meaning to emotion). If the client reports no current meaningful link between the perception and the emotion, for instance, my anger is related to there being so many people about, but I don’t understand why being jostled would make me angry, then the emotion may be created by association or memory. In this case then you would need to be asking what was the first time you remember being angry because of a lot of people, or if that doesn’t yield a meaningful answer then to ask what was the time when you got angriest when there were a lot of people about.

Thoughts can be dynamic\passive

A lot of mental distress can be caused by confusing these two categories. Some thoughts we receive as events, some cognitive activity we choose for a reason. People with OCD think the intrusive thoughts they receive as events means they have chosen them, so it means something bad about them, this then cause’s anxiety which they then try to manage.  People who worry a lot or ruminate don’t think they can control it, they consider either what they do because who they are, or that you can’t stop these things.

You can demonstrate that thoughts can be mental events with a client by asking them not to think of anything for 30 seconds and every time they do think of something to put their hand up.

Dynamic thoughts you can ask the client to think of an elephant, or to think about what they will do over the weekend.

It can be helpful in terms of psychoeducation for clients to realise the two different types of thought, some we choose, some we receive.

The treatment with passive thoughts is to learn how we react to them:

1.       What is our Meta thought? Do we believe the received thought? Monitoring the thought and noticing what the meta thought is can help

2.       Do we attach to the thought, i.e. pay attention to it and build thoughts and behaviours on top of it. Again firstly monitor it, then secondly practise detaching from thoughts with the skills learn from a breathing meditation or informal mindfulness practice.

If people have troubling passive thoughts, then the psychoeducation of what can increase these can help

1.       Giving thoughts attention increases them

2.       My current concerns increase these thoughts.

So

1.       Cognitively

a.       Thought suppression will increase thoughts

2.       Behaviourally

a.       Safety behaviours will increase the feared thoughts

Thoughts are communication

Clinically it can be useful for clients to notice that a thought communicates from one part of themselves to the other. Speech communicates between people, as you think then you get communication from parts of you. So as you criticise yourself, there is the critic and the criticised.

The first movement with clients can be to pull out the two sides of the communication to understand what each side is trying to do and how they feel. So the critic might be trying to improve performance, or to keep safe. The criticised might feel sad and that they can’t do anything right.  Opening this up allows the client to understand more about why they act and its effects so they can evaluate it.

Once the two sides have been highlighted, then you can ask about origins. Have there been any relationships where you have learnt to behave like this? This then allows another level of evaluation by the client. Whilst their current behaviour might be integrated and justified, when it first started it wouldn’t have been. So what was it like, how did it make you feel, how would you prefer to have been acted towards?

Again in a similar tack you can ask if you would behave like you do to yourself to another.

Communication can be between different characters

As much as you have identified the type of communication, sometimes it can help clients name this part of themselves, as it may relate to a collection of ways of thinking and acting.  So to name one part of them, the policeman, can collect all the times when they make themselves or others obey the law, and punish them if they don’t.   This can be helpful in terms of firstly distancing themselves from their thoughts and behaviours by noticing when they do something, which allows them to take different choices.  Secondly it provides a way to understand themselves, a framework. Thirdly if they start monitoring when they see the policemen, they can start to see how dominating it is. If they identify other characters, they can also then start seeing how marginalised some of the quieter voices are.

Again through creating a character can allow clients to then start relating it to all the people, or significant persons who have contributed to its formation. They can then ask at point of origin what they thought of these people\person, how it made them feel when they acted to them in this way.

Attentional Focus

Psychoeducation

Physiological effects of attentional focus: get client to say how their hand feels, then get them to pay attention to it for 2 mins

Cognitive effects of attentional focus: Ask them how many pigeons they saw on the way in. Then ask them how many they think they would see if they believed there was a deadly strain of pigeon flu

Emotional effects of attentional focus: Decide on a type of emotion to work with, take the current temperature of that emotion, get them to remember in vivid detail an event that had provoked that emotion in the past

Treatment

Mindfulness: breathing meditation, pay attention to the breath, and whenever you notice your attention has wandered then gently move it back to your breath. Rationale strengthens the attentional switching muscle. 

Cognitive: When you have a strong emotion notice what thought helps explain it. Then write what are the strong influences on why you think like this at the moment. Rationale look for cognitive bias.

Wells Attentional training from Overcoming Health anxiety:

The aim here is to only pay attention to what is asked, treat all other as noise and if you are distracted return to what you have been asked. Collect three different sounds in three different locations. You should do this daily for 4 weeks.

1.       Focus your gaze on one spot on the wall and keep it there

2.       Slow switch

a.       For 5 minutes pay attention to one sound for 30 seconds then move to another different sound work around your list

3.       Fast Switch

a.       For 5 minutes pay attention to one sound for 30 seconds then move to another different sound work around your list

4.       All zones

a.       For 2 minutes hold your awareness on all nine sounds and see how many you can hear at the same time