Self-Help Course Cognitive Behaviour Therapy: An Introductory
Self-Help Course Cognitive Behaviour Therapy: An Introductory
Self-Help Course Cognitive Behaviour Therapy: An Introductory
Self-Help Course
in
www.get.gg
www.getselfhelp.co.uk
Carol Vivyan
2009-2015
1
This mini 7-step self-help course includes an introduction to techniques which could
be useful for all, but professional help should be sought for complex or long-standing
problems. The course is, with many other additional resources, also available online
at www.getselfhelp.co.uk
Contents
Step Title Page
Introduction to Cognitive Behaviour Therapy 2
1 Identifying Thoughts, Feelings & Behaviours 5
Vicious Cycle 8
2 Understanding the links between Thoughts, 9
Feelings & Behaviours Depression, Anxiety, Anger
Vicious Cogs 15
Emotions and their associated thoughts, body 17
reactions and behaviours
Dealing with Negative Emotions 18
3 Making Changes Behaviours 19
Weekly Planner 23
ACE Log 24
Treatment Plan 26
Problem Solving Worksheet 27
Communication Styles 28
4 Making Changes Thoughts 29
About Automatic Thoughts 31
Unhelpful Thinking Habits 32
Finding Alternative Thoughts 33
Fact or Opinion? 34
Different Perspectives 35
5 Challenging our Thoughts 39
The Court Case 40
Thought Record Sheet 41
Positive Affirmations 42
The Worry Tree 43
STOPP Worksheet 44
6 Defusing from our Thoughts 45
Mindfulness 47
ACT Worksheet 53
STOPP 54
Defusion Techniques 55
7 Imagery for Self-Help 56
Sleeping Well 60
What now? 62
Positive Steps to Wellbeing 64
Further copies of this guide, and of additional worksheets and leaflets in italics above, can be
downloaded freely (in Adobe document format) from www.getselfhelp.co.uk/freedownloads.htm
How you think about yourself, the world and other people
How what you do affects your thoughts and feelings
CBT can help you to change how you think ("Cognitive") and what you do
("Behaviour)". These changes can help you to feel better. Unlike some of the
other talking treatments, it focuses on the "here and now" problems and
difficulties. Whilst it is often useful to discuss the past and understand how our
pasts have influenced our lives and how problems have arisen, CBT mostly
focuses on looking for ways to improve your mental wellbeing now.
CBT says that it's not the event which causes our emotions, but how we
interpret that event - what we think or what meaning we give that event or
situation.
For instance, if someone you know passes you in the street without
acknowledging you, you can interpret it several ways. You might think they
don't want to know you because no-one likes you (which may lead you to feel
depressed), your thought may be that you hope they don't stop to talk to you,
because you won't know what to say and they'll think you're boring and stupid
(anxiety), you may think theyre being deliberately snotty (leading to anger).
A healthier response might be that they just didn't see you.
mess up again", or "What's the point of anything?", which will make them feel
even more depressed (feelings), and may prompt them to pull the covers over
their head and stay in bed (behaviours). It's very likely that this will increase
their negative thoughts, which in turn will increase the feelings of depression,
and make them even less likely to get out of bed. A vicious cycle is the result
- continuing to think and act the same way will help maintain our depression
(diagram below).
CBT can help you to break these vicious cycles of negative thinking, feelings
and behaviour. When you see the parts of the vicious cycle clearly, you can
change them - and therefore change the way you feel. It can also be useful to
look at the way our thoughts and feelings affect our bodies, and the physical
sensations we can experience
CBT aims to get you to a point where you can "do it yourself", and work out
your own ways of tackling problems. CBT has often been described as guided
self-help, and this self-help course will help you learn how CBT can help you.
The following self-help steps will enable you, with or without the help of a
therapist or mental health professional, to gain some useful insights and begin
to address and work through your problems.
www.get.gg H
www.getselfhelp.co.uk
Step 1
Now we can start to look at what's helping to keep your problems going.
Let's use a recent example, when you've been distressed - perhaps something
has happened in the past week or so when you've felt particularly anxious,
angry, or depressed.
What was the situation? What happened? When did it happen? What else
was going on? Was it a situation that you often find yourself
in? Who were you with?
E.g. In anxiety and anger (and excitement) the body's adrenaline can
result in us feeling physical sensations which can include: heart
pounding or racing, palpitations, rapid breathing, difficulty breathing,
light-headed, dizzy, shaky, sweaty, hot, red, pins & needles, tense or
sore muscles, urge to go to the toilet, butterflies in the tummy, warm
uncomfortable feeling in the abdomen or chest, difficulty concentrating, lump
in throat. This is the fight & flight response - the body's survival mechanism
which helps us escape or to stand up to the threat at times of real danger.
The body is unable to differentiate between a real or imagined danger, so the
alarm signal is pressed and activated regardless.
What did you do? What didn't you do? How did you cope?
Examples include:
(Anxiety): Stayed home, left wherever you were or felt the urge
to leave, didnt talk to anyone, avoided eye contact, fiddled with
a pen, sat in a corner, didnt go out, chose to shop at less busy
times, went to local corner shop instead of the big supermarket,
distracted yourself (TV, radio, kept busy etc), urge to go (or
went) to toilet, looked for reassurance, drank more, smoked more, ate more
(or less), disturbed sleep.
(Depression): Stayed in bed, pulled covers over your head, didn't go out, sat
and stared, watched television, didn't answer the phone, turned down an invite
from a friend, didn't go to work, ate more (or less), slept more (or less), paced
around , kept starting to do things but couldn't finish, no interest in others, no
interest in sex, no interest in anything.
This Vicious cycle form will help you practise. Photocopy the form (or
download more copies from the website) and write down at least one
situation every day for the next few days.
Vicious Cycle
BEHAVIOURS FEELINGS
What did I do at that time? What did I avoid doing? What Emotions / Moods
was my automatic response? What would a fly on the wall What emotion did I feel at the time? How intense was that
have seen me do? feeling? (0-100%)
So far, we have looked at vicious cycles and learned how thoughts, feelings
and behaviours are linked and each one affects the others.
If we use the depression example from that page, we see that on waking in the
morning, 'Dave' had thoughts that included "There's no point", and "I'll only
mess up again". If we think those thoughts and believe them, there is every
chance that we are going to feel depressed. If we think those thoughts and
feel depressed, then it's likely that we would be sorely tempted to pull the
covers over our head and stay in bed.
How does doing that affect the way Dave feels and thinks? Hmm. Staying in
bed might mean that his thoughts get carried away and he continues to think
that way, making him feel even worse, and even more likely to stay in bed. A
vicious cycle. This is a typical vicious cycle of depression:
DEPRESSION
People who are depressed tend to think very negatively about themselves, the
future and the world around them. It can be like seeing life through
"gloomy specs".
Because of the tiredness, difficulty sleeping and eating, and negative style of
thinking, we tend to do less and less. We stop doing the things we used to do
and enjoy. It could get so bad that we can't even go to work, or do things at
home. We want to stay in bed, or stay at home doing very little. We might
isolate ourselves from friends and family.
ANXIETY
When there is real, or we believe there is a real, threat or danger, our bodies'
automatic survival mechanism kicks in very quickly. This helps energise us to
fight or run away ('fight or flight response'). We will notice lots of physical
sensations, which might include:
Heart racing - This helps to take the blood to where it is most needed
his legs so that he can run faster (flight); his arms so that he can hit out
(FIGHT); his lungs to increase his stamina. At the same time blood is
taken from the places it is not needed for example fingers, toes and
skin. These changes cause tingling coldness and numbness.
Breathing gets faster - This helps the bloodstream to carry oxygen to
the arms, legs and lungs. This will give him more power. The side
effects may include chest pain, breathlessness and a choking feeling. As
there is a slight drop in the blood and oxygen being sent to the brain he
may feel dizzy or light headed, he may experience blurred vision.
Muscles tense and prepare - The large skeletal muscles tense and
create power, this may cause pain, aching and shaking.
Sweating - Sweating helps to cool the muscles and the body. It helps to
stop them from overheating. Sweating can also make us more slippery
to our enemies!
Pupils dilate - This lets more light into his eyes so his overall vision
improves. Side effects may include sensitivity to light or spots before his
eyes.
Digestive system slows down - These are not important while in
danger and so are slowed down then the saved energy goes to where it
is most needed. Side effects may include nausea, butterflies and a dry
mouth.
More alert - He will be concentrating on looking for danger, much less
able to concentrate on anything else. He will be waiting for something to
happen. This is the basis of the way we worry.
Whilst avoiding people or situations might help you feel better at that time, it
doesn't make your anxiety any better over a longer period. If you're
frightened that your anxiety will make you pass out or vomit in the
supermarket aisle, you won't find out that won't actually happen, because you
don't go. So the belief that it will happen remains, along with the anxiety.
What is Anger?
We all feel angry some times. Some people tend to become angry easily (a
"short fuse"), and some have problems controlling their anger. Anger has
consequences, and they often involve hurting other people - more usually their
feelings, but sometimes physically. Anger can cause problems in our personal
lives, and affect work and study. After an angry outburst, we can think very
critically of ourselves and our actions, leading us to feel guilty, ashamed and
lower our mood, which might result in our withdrawing from others, not
wanting to do anything (see depression cycle).
Summary
In CBT, we aim to break those cycles by changing something - what we think
or what we do. We might start by looking at what might be easiest to change.
Perhaps in this case, it might be easiest to change what we do.
How would Dave have felt if he had got up anyway, in spite of how he was
feeling. Maybe ate some breakfast, had a shower, got dressed, and perhaps
went out for a walk. How would that affect his depression? What would that
do to the way he was thinking?
It's very likely that his mood would have improved, and that he would have
started to think a little more realistically. He might have even enjoyed his day,
or got a sense of achievement from having done something.
Have a look at what you've written down on your sheets of several examples of
distressing situations (Step 1 practice). What links can you see between what
you think and what you do, and how they affect the way you feel.
In the next step, you'll be starting to make some changes that will work for
you.
If you have a problem other than depression, anxiety or anger, please see the note on page 63
In order to reduce and deal with the anxiety, we need to target and make positive
helpful changes in each of those smaller cogs.
EXAMPLE COGS
Write the name of your problem (e.g. anxiety, depression, OCD etc) in the
large middle cog. You can also substitute an unhelpful belief (e.g. Im a
failure) in the large middle cog.
Write all the factors (unhelpful things you do or unhelpful ways of thinking) in
the smaller surrounding cogs.
Take each smaller cog, and identify ways of making positive changes. You can
work up to these changes gradually, so it may help to write down the steps on
the way to achieving your goal for each cog.
Is this threat a real one or is it really bound How will doing this affect me Imagine yourself coping in a
Anxiety Adrenaline to happen? Am I exaggerating the threat? in the long term? Dont situation that you feel anxious
Something bad is response Am I misreading things? avoid situations go anyway. about. See the situation
going to happen. Bodys alarm I feel bad, but that doesnt mean things Problem solve or make plans through to a successful
I wont be able to system. really are so bad. if necessary. Take things completion.
cope Energised for I can cope with these feelings, Ive got slowly or gradually.
fight or flight through it before. Focus attention outside of me Visualise blue for calm.
What would someone else say about this? external rather than Breathe in blue and breathe out
What would be a more helpful way of internal focus. red.
looking at things?
What am I reacting to? Whats pressing my Take a breath. Do the best Visualise yourself handling this
Anger Adrenaline buttons? Am I over-reacting? Is my thing best for me, for situation in a calm, non-
Its not response reaction in proportion to the actual event? others and for the situation. aggressive but assertive way,
fair. Bodys alarm How important is this? Walk away? respecting the rights and
Others are bad. system. I feel like Im being unfairly treated, but When feeling calm, if still opinions of everyone involved.
I wont stand for it. Energised for maybe they didnt mean it that way. Am I appropriate, do something Visualise blue for calm, or
fight or flight misreading things? about it in a calm, non- green for balance. Breathe in
Whats the best thing to do here? aggressive but assertive way. green/blue & breathe out red.
Carol Vivyan 2009-2015 www.get.gg
19
Step 3
When you look at your 'Vicious Cycle' form/s where you wrote
down your thoughts, feelings (emotions and physical sensations)
and behaviours, notice particularly what you wrote for
'behaviours'. Very often we react automatically, without
considering our actions or the consequences of them.
What would someone else have done in that situation? (it might help to
think about particular people that you know, and what they might have
done differently)
Have there been times in the past when I would have done something
else?
If I had paused, and taken a breath, what would I have done?
Write down several options that you might have done differently if it had
occurred to you, then ask yourself:
If I had tried that, how would the situation have been different?
How would it have affected what I felt?
How would it have affected what I thought?
Would it have been more helpful or effective for me, another person or
for the situation?
What would the consequences have been of doing something differently?
(www.getselfhelp.co.uk/relax.htm)
Put on some music - sing and dance along, or just listen
H H
Meditation or Prayer
H H
( www.getselfhelp.co.uk/meditation.htm )
H H
Help others
Be with others - contact a friend, visit family
Talk to someone
Grounding techniques - look around you, what do you see, hear, smell,
sense? Hold a comforting object.
Physical exercise - walk, swim, go to the gym
Engage in a hobby or other interest - if you don't have one, find one!
What have you enjoyed in the past? What have you sometimes thought
about doing but not got around to?
Write down your thoughts and feelings - get them out of your
head
Just take one step at a time - don't plan too far ahead
Pamper yourself - do something you really enjoy, or something
relaxing
Positive self-talk - encourage yourself, tell yourself: I can do this, I am
strong and capable - find an affirmation that works for you (even if you
don't believe it at first!). Write it down and memorise it for when you
need it. See Affirmations on page 41
Do something creative
Use Safe Place Imagery (page 54)
Tell yourself: "This will pass, it's only temporary". "I've got
through this before, I can do it now". When we're going
through a tunnel and become fearful of being trapped, there's
no point in stopping - we just have to carry on in order to reach the end
of the tunnel. That light is there, and waiting!
Achievement
Closeness to others
Enjoyment
Use either or both of these sheets to record what you do and how it
affects your mood.
Weekly Planner
ACE Log
Treatment Plan
More information at www.getselfhelp.co.uk/links3.htm
H
Try different relaxation techniques - some will work better for you than others.
Weekly Planner
Plan activities each day, keeping a balance of activities which include Work, Rest and Play (or Achieve, Enjoy and Connect with
others). Pace yourself!
Day
Morning
Afternoon
Evening
ACE Log
(Achievement, Closeness, Enjoyment)
Our mood can be greatly affected by what we do, when, and with whom. Keep track of what you
do each day which gives you a sense of Achievement, Closeness to others, and Enjoyment. Write
down the day, date and time, the activity, and rate the sense of Achievement, Closeness and
Enjoyment on a scale of 0 (none) 10 (maximum), or simply tick the relevant ACE columns.
Achievement
Day
Enjoyment
Closeness
Date Activity what you did, who you were with
Time
A C E
Monday Example: Played computer games after tea
10th 1 1 7
7pm
Tuesday Example: Telephoned Miriam and invited her
11th around for coffee 4 9 8
10am
Achievement
Day
Enjoyment
Closeness
Date Activity what you did, who you were with
Time
A C E
Step Brainstorm and write down as many ideas as you can that might help solve the problem,
2 no matter how silly they seem dont dismiss any possible solutions.
Step Consider the pros and cons of each possible solution, using a separate piece of paper.
3
Step Choose one of the possible solutions that looks likely to work, based on the advantages and
4 disadvantages
Step Plan out step-by-step what you need to do to carry out this solution. What? When? How?
5 With whom or what? What could cause problems? How can you get around those
problems? Is this realistic and achievable?
Step If you achieved your goal consider tackling the next step of your original problem.
8
If you didnt fully achieve your goal make adjustments to your chosen solution, or return
to steps 3 and 4 and choose another possible solution.
Communication Styles
Passive Assertive Aggressive
Consequences Give in to others, dont Good relationships with Make enemies, upset
get what we others, happy with others and self, feel
want/need, self-critical outcome and to angry and resentful
thoughts, miserable compromise
Step 4
When we look at your completed "Vicious Cycle" sheet/s from Step 1, how did
your thoughts (or images or memories) affect what you felt and what you did?
It's easy to think that we can't change the way we think - that thoughts just
happen and that we have no control over them. That last bit is certainly true.
We cannot stop our thoughts, and we can't control them. Whatever we do, the
thoughts are going to happen anyway. But we can choose how we react to
them.
Thoughts are generated randomly, automatically, messages from our brain. They
are not necessarily true, and not necessarily helpful. We can learn to react to
thoughts differently.
The bully laughs and shouts, pointing and humiliating each victim in turn, "You're
so stupid" and the like. Maybe much worse. Consider these three victims:
1. Victim number 1 hears the abuse, becomes upset and runs away
crying. How does the bully react? Right - it's great entertainment,
what a laugh! It's likely the bully will carry on targeting this young victim.
It can be like that with our thoughts. If we imagine our thoughts as our own
internal bully, then maybe we have similar options that we can use to respond to
our bully.
At the moment, we believe the thoughts (the bully). We're being upset by the
thoughts, and reacting to them automatically. The thoughts keep on coming, and
we continue to believe and be upset by them. Just like victim number 1.
Victim number 2 challenged the bully - the bully got his facts wrong. Victim
number 2 isn't stupid at all; he did better than the bully in the spelling test! We
can learn to challenge our thoughts. We can ask ourselves whether the thought
is accurate or not - and we can look for hard evidence to check that out, like the
spelling test. We'll be learning to challenge thoughts in Step 5 - the next step.
Victim 3 didn't react to the bully at all. He acknowledged him, then walked away,
and moved his focus of attention elsewhere. We can learn to do that with our
thoughts. Learn to just notice and acknowledge them Oh there's that thought
again!, realise that it is just a thought, choose not to believe it, dismiss it and
move our attention onto something else. We'll be looking at that in Step 6.
Print out the handout, and tick the Unhelpful Thinking Habits
that you recognise that you do most often. Use the Finding
Alternative Thoughts handout, to help you learn to think
differently.
Our thoughts are constantly helping us to interpret the world around us,
describing whats happening, and trying to make sense of it by helping us
interpret events, sights, sounds, smells, feelings.
Without even realising it, we are interpreting and giving our own
meanings to everything happening around us. We might decide that
something is pleasant or nasty, good or bad, dangerous or safe.
Because of our previous experiences, our upbringing, our culture, religious beliefs
and family values, we may well make very different interpretations and
evaluations of situations than someone else. These interpretations and meanings
we give events and situations, result in physical and emotional feelings.
Automatic thoughts
Can be words, an image, a memory, a physical sensation, an imagined
sound, or based on intuition a sense of just knowing
Believable we tend automatically to believe our thoughts, usually not
stopping to question their validity. When another driver cuts me up, I
might judge that hes a selfish thoughtless toad, but in fact, he might be
taking his wife to hospital as shes about to give birth. Thoughts are not
necessarily true, accurate or helpful.
Are automatic. They just happen, popping into your head and you often
wont even notice them.
Our thoughts are ours they can be quite specific to us, perhaps because
of our present or past experience, knowledge, values and culture, or just for
no good reason at all. Some thoughts are so out of keeping with all those
things, and that can make them seem all the more distressing because
we add some meaning about why we had them (I must be a bad person!)
Habitual and persistent our thoughts seem to repeat over and over, and
the more they repeat, the more believable they seem, then they set off a
whole chain of new related thoughts that lead us to feel worse and worse.
They can follow themes, for short periods, or very often, throughout years
and decades.
Black and Things arent either totally white or totally black there
white are shades of grey. Where is this on the spectrum?
thinking
This is just a reminder of the past. That was then, and
Memories this is now. Even though this memory makes me feel
upset, its not actually happening again right now.
FACT OR OPINION?
FACT OPINION
Evidence to support its truth Based upon a belief or personal view
Undisputed Varies according to individuals
Driven by rational thought knowledge, experience, culture, belief
systems etc
Driven by and reinforced by emotion
It can therefore be helpful to ask ourselves whether what were thinking is FACT
or OPINION.
If its a fact, then we can make choices about what we can or cannot do.
If its an opinion, then we can look at the facts what we do know about
the situation.
Realising that many thoughts are opinion rather than fact makes it less likely that
well be distressed by them, and more able to make wise and calm decisions
about what the best action to take.
Different Perspectives
The probably familiar images of two straight lines (of equal length) and a
candlestick (or two faces) show us that things are often not as they first seem,
and theres almost always a different perspective.
So its the same principle with everything each situation, event, conversation
means something different to all those involved, and to those not involved. We
give different meanings, according to our belief systems, and how we are affected
by the event. We all have our own realities.
Anais Nin said: We dont see things as they are, we see things as we are
We look at situations, events, and interpret what other people say and do,
according to our own set of past experiences, culture, faith, values, all of which
help us form our beliefs about ourselves, about others, and about the world in
general. The meaning we give events, the way we make sense of our world, is
based upon our core belief system.
Our minds are constantly trying to make sense of our world, forming judgements
and opinions about every situation, event, and interaction. Those judgements
and opinions will be affected by our central or core belief system. It is as though
we are looking at the world through distorted or coloured lenses and everyone
has their own personal prescription or colour for their glasses.
In the example above, even situations which others find enjoyable and relaxing,
this particular person will experience it very differently, and feel threatened by
others. A look, word or gesture intended to be friendly and kind, may be
interpreted as They dont mean that. Theyre only trying to be kind to me
because they pity me. Or even, They mean to hurt me. Their mind is
interpreting the situation with the bias of Im vulnerable, others might hurt me,
this is dangerous, Im useless and unlovable. The mind will work to make any
contrary information, fit with those beliefs. This is shown by The Mental
Crusher
The Mental Crusher sits outside the entrance to our belief system, and only
allows information or evidence which fits with our own belief system to enter.
Any contradictory evidence or information (any shape other than a rectangle) is
rejected, or made to fit (crushed into a rectangle). In the diagram, the explosion
shape is about to enter the Crusher. As it passes through (shown by the arrow),
it becomes a rectangle its been crushed and distorted to fit. Therefore, our
beliefs remain unchanged in spite of apparently contradictory evidence being out
there. Paraphrased from p. 58 of Cognitive Behavioral Therapy for Anxiety Disorders by Butler, Fennel & Hackman
(Guilford 2008)
In the case of our earlier example, the information that a person looked at me, is
crushed and distorted (they looked at me funny) to confirm that others dislike
or mean to hurt me.
Within any meeting of people all the individuals will of course have their own
belief system, and will therefore have different perspectives see and think about
things differently - and this will affect the way these individuals interact with each
other. We can learn to be more aware of how our own belief system affects us,
and consider how others might see the same situation quite differently.
The Helicopter
View
SELF OTHERS
What am I What would
reacting to? this look like
What does this to others
situation mean involved?
to me?
STOPP!
Take a Breath
Whats the bigger picture?
OUTSIDER WISE
How would MIND
this seem to What would be
someone the best thing to
outside the do for me, for
situation not others, for this
emotionally situation?
involved?
Seeing different perspectives will help to reduce distressing emotions, help us feel
more confident, enable us to be more understanding and empathic, and improve
communication and relationships. As we challenge our unhelpful thoughts and
biased perspectives, and see things in a more balanced and realistic way, so we
will discover that situations and people can be different to how we usually
interpret things, which can lead us to modify our core belief system, and
therefore bring about lasting positive change.
STOPP!
(www.getselfhelp.co.uk/stopp.htm)
Step 5
Having learned that thoughts are just thoughts, that they're automatic, not
necessarily true, habitual and just appear believable, then we can behave like
Victim 2 in the previous step and learn to challenge our thoughts.
Write down several thoughts from a recent distressing situation. What did those
thoughts say about you, or mean to you? Of all those, which thought (or images)
was the one that made you most upset?
Let's take that hot thought - THE thought that contributed most to making
you feel distressed or depressed. Ask yourself the following questions
about THAT thought:
Look for evidence against the thoughts what tells you this
thought is not totally true, all of the time? What would a barrister /
lawyer / advocate for the prosecution say? What factual evidence is
there? Consider what others would say (witnesses) etc.
Positive Affirmations
Over the years, we tend to get into unhelpful thinking habits , and
H H
Use a statement that starts with I and use the present tense. See the
examples below choose one, adapt one, or make up your own. Make it
something broadly realistic, even if you dont believe it right now.
I am strong
I have strength
I am determined and successful
I am a good and worthwhile person
I am a unique and special person
I have inner strength and resources
I am confident and competent
I hold my head up high
I look good because I am good
People like me I am a likeable person and I like myself
I care about others, I am needed and worthwhile
I am a loving person
I have a lot to be proud of
I have all that I need
I am in control of my life
I can achieve anything I want to achieve
I make wise decisions based on what I know
I have set my goals and am moving towards them
I accept myself as a unique and worthwhile person
My life has meaning and purpose
I am in control of my choices
I am strong and healthy
I am calm and confident
I have many options and can make wise decisions
Everything is getting better every day
I am calm and relaxed
I am healthy and have all that I need
Today is the first day of the rest of my life and I will take
notice of the many positive things this day has to offer
I live a healthy and positive lifestyle
I know I can master anything if I practise it continually
I have my wise mind I can seek inner guidance whenever I need to
My life purpose can be whatever I choose it to be
All is well, right here, right now
NO YES
NOW? LATER?
Do it! Schedule it
STOPP Worksheet
Notice the intrusive or distressing Write your reactions and alternative, healthier
thought, image, memory, responses in this column. What works for you?
What will help? What can you tell yourself?
trigger What do you need to remember at those times?
STOPP!
Take a breath
Step 6
Remember that Playground Bully? Victim 1 believed the bully and became
upset. Victim 2 challenged back and the bully eventually loses his power and
gives up. Victim 3 was quite different. He didn't react at all. He merely
acknowledged the bully, then turned away and went off to play with his
friends.
Earlier, we learned about noticing thoughts, feelings and behaviours, and asking
ourselves questions in order to help challenge our thoughts.
STOP, take a breath, and ask yourself these questions which will help you
defuse or distance yourself from your thoughts:
Perhaps write the thought down, get it out of your head and onto paper
Maybe repeat the thought in a strange or comical voice, or say it very
quickly or very slowly - words can lose or change their meanings
Can I use a metaphor for this situation? (examples on page 52)
H
Learn about
Mindfulness
ACT Worksheet
Photocopy these sheets (or print more from the website) and practise
the techniques as much and as often as you can
STOPP
Defusion Techniques
Mindfulness
Jon Kabat-Zinn
What is Mindfulness?
Mindfulness is an ancient Buddhist practice which is very relevant for our lives
today. Mindfulness is a very simple concept. Mindfulness means paying
attention in a particular way: on purpose, in the present moment, and non-
judgementally.
Mindfulness does not conflict with any beliefs or traditions, whether religious,
cultural or scientific. It is simply a practical way to notice thoughts, physical
sensations, sights, sounds, smells - anything we might not normally notice.
The actual skills might be simple, but because it is so different to how our
minds normally behave, it takes a lot of practice.
We might go out into the garden and as we look around, we might think "That
grass really needs cutting, and that vegetable patch looks very untidy". A
young child on the other hand, will call over excitedly, "Hey - come and look at
this ant!"
Mindfulness can simply be noticing what we don't normally notice, because our
heads are too busy in the future or in the past - thinking about what we need to
do, or going over what we have done.
Automatic Pilot
On automatic pilot, we are more likely to have our buttons pressed: Events
around us and thoughts, feelings and sensations (of which we may be only
dimly aware) can trigger old habits of thinking that are often unhelpful and may
lead to worsening mood.
By becoming more aware of our thoughts, feelings, and body sensations, from
moment to moment, we give ourselves the possibility of greater freedom and
choice; we do not have to go into the same old mental ruts that may have
caused problems in the past.
Mindful Activity
The more we practise, perhaps the more (initially at least) we will notice those
thoughts intruding, and that's ok. The only aim of mindful activity is to bring
our attention back to the activity continually, noticing those sensations, from
outside and within us.
Mindful Breathing
Sit comfortably, with your eyes closed and your spine reasonably straight.
Direct your attention to your breathing.
When thoughts, emotions, physical feelings or external sounds occur,
simply accept them, giving them the space to come and go without
judging or getting involved with them.
When you notice that your attention has drifted off and is becoming
caught up in thoughts or feelings, simply note that the attention has
drifted, and then gently bring the attention back to your breathing.
It's ok and natural for thoughts to arise, and for your attention to follow them.
No matter how many times this happens, just keep bringing your attention back
to your breathing.
Bring your attention to your belly, feeling it rise or expand gently on the in-
breath and fall or recede on the out-breath.
Keep your focus on the breathing, being with each in-breath for its full
duration and with each out-breath for its full duration, as if you were riding the
waves of your own breathing.
Every time you notice that your mind has wandered off the breath, notice what
it was that took you away and then gently bring your attention back to your
belly and the feeling of the breath coming in and out.
If your mind wanders away from the breath a thousand times, then your job is
simply to bring it back to the breath every time, no matter what it becomes
preoccupied with.
Practise this exercise for fifteen minutes at a convenient time every day,
whether you feel like it or not, for one week and see how it feels to incorporate
a disciplined meditation practice into your life. Be aware of how it feels to
spend some time each day just being with your breath without having to do
anything.
With mindfulness, even the most disturbing sensations, feelings, thoughts, and
experiences, can be viewed from a wider perspective as passing events in the
mind, rather than as "us", or as being necessarily true. (Brantley 2003)
When we are more practised in using mindfulness, we can use it even in times
of intense distress, by becoming mindful of the actual experience as an
observer, using mindful breathing and focussing our attention on the breathing,
listening to the distressing thoughts mindfully, recognising them as merely
thoughts, breathing with them, allowing them to happen without believing them
or arguing with them. If thoughts are too strong or loud, then we can move our
attention to our breath, the body, or to sounds around us.
Think of your mind as the surface of a lake or an ocean. There are always
waves on the water, sometimes big, sometimes small, sometimes almost
imperceptible. The water's waves are churned up by winds, which come and go
and vary in direction and intensity, just as do the winds of stress and change in
our lives, which stir up waves in our mind. It's possible to find shelter from
much of the wind that agitates the mind. Whatever we might do to
prevent them, the winds of life and of the mind will blow.
"You can't stop the waves, but you can learn to surf" (Kabat-Zinn 2004).
The Visitor
This exercise helps to develop a mindful awareness of the environment,
of the body, of the breath, and of thoughts and emotions. You can
practice the exercise as a whole, or in parts using any part of the
exercise.
The Environment
As youre walking, or just sitting quietly somewhere, start to notice
things as though you were a visitor to this place. As you look
around you, notice sights, sounds and smells as though you had
never seen, heard or smelled them before. You can imagine you are
a visitor from another area or culture, or from a different species or
even planet. Seeing or hearing things for the first time, from a
completely different perspective. Spend a little time just looking and
listening and noticing.
The Body
When 'Dr Who' regenerates, he immediately checks out his new body.
As a newcomer or visitor, start to imagine being in your body for the
first time. Notice what that feels like what bodily sensations do you
notice? How does it feel to move around, stretching those muscles,
standing up or sitting down. What do those hands feel like as you move them
about, stretching and wiggling those fingers, clenching those fists? As you start
to walk, how is that? What do you notice about your legs upper legs, feet and
toes? Move your head around and notice what you neck and shoulders feel like.
Bend, stretch and move about. What are those physical sensations? Spend a
little time just noticing those bodily sensations, and imagine taking your body
for its first ever walk, or any everyday activity.
The Breath
What would you, as a new awareness or visitor to this new
body, notice about the sensations of breathing, as you breathe
in, then out? Notice the sensations in the abdomen, the chest,
the throat, the mouth and nose. You can notice how your
attention wanders, as thoughts come in, sometimes crowding
in, and your attention can follow those thoughts. Just notice as your attention
wanders, then gently bring your focus back to your breath. Minds do wander,
thoughts will come and thoughts will go, that is the nature of the human mind.
As a visitor, you can stand back, notice those thoughts, feelings, sounds and
sensations, and keep bringing your attention back to your breath.
NOW
Notice: Where my attention is.
Buddha.
Choose an activity to do mindfully throughout the day, for one, two or five
minutes. For example: Drink a cup of tea. Walk. Wash the dishes.
Simply notice whenever other thoughts and sensations come to mind, then re-
focus on your chosen mindful activity.
It is as it is.
Everything Flows. Nothing is fixed. Heraclitus
It will pass.
STOPP
Take a Breath
o Notice your breath as you breathe in and out.
Observe
o What am I thinking and feeling? What are the words that my
mind is saying? Is this fact or opinion? Are the thoughts
descriptions or evaluations? Accurate or inaccurate? Helpful or
unhelpful? What unhelpful thinking habit am I using (e.g.
mind-reading, negative filter, thinking the worst)? Where is
my focus of attention? What metaphor could I use (mountain, tunnel,
playground bully, thought train, beach ball, passengers on the bus)?
o
Pull
o back - Put in some Perspective
STOP, STEP BACK, OBSERVE (the thoughts and feelings, whats happening
to/for the other person).
Notice whats happening your thoughts, physical sensations, emotions, images,
memories. Notice the way youre interpreting what they mean, and how thats
affecting you.
Notice the unhelpful thoughts. What am I reacting to? Perhaps say the thoughts
very slowly, or very quickly, in a squeaky or comic voice, or write them down.
Identify the emotion youre feeling, and label the unhelpful thoughts
o an evaluation
o a prediction
o a feeling or sensation
o a memory
o an unhelpful thinking habit: mind-reading (believing we know or what others are
thinking), negative filter (only noticing the bad stuff), emotional reasoning (I feel bad
so it must be bad), catastrophising (imagining the worst), the internal critic etc.
Learn more and practise mindfulness so that you can be aware of when you are in the
present moment rather than being in your head - perhaps the past or future. Notice what
you dont normally notice sights, sounds, sensations, thoughts, textures etc.
Imagery
Imagery techniques and visualisation has long been used by most if not all cultures of
the world, ancient and modern, and by most therapeutic approaches. Imagery is
considered to be more effective when we are feeling relaxed.
relax
meditate
improve future personal performance and development
bring about future success
gain confidence
improve mood states
reduce distress associated with traumatic memories
gain understanding, insight, inner wisdom
help overcome physical illnesses
improve sports performance
Many of us think visually, or in pictures, and we can develop our perhaps natural
imagery skills to benefit our mental health. We can practise situations in our
imagination, or build our confidence, or maybe learn to relax using imagery.
Finish each visualisation by taking a few moments to bring yourself back into the
room where you are, opening your eyes and looking around, sitting up, and bringing
yourself back to alertness in the 'here and now'.
Sometimes we can get horribly distressing intrusive images that just pop into our
heads, and we have trouble getting rid of them again. The image may be based on a
real memory, or just some random terrible image. These images can trigger strong
physical sensations, and intense emotions of fear, dread, anger or sadness.
We can learn to manipulate the image so that we reduce the distressing feelings:
Imagine putting the image on a TV screen. Now with an imaginary remote
control, make the image smaller, making it more distant, perhaps turn it into
black and white, remove the sound or give it a different soundtrack.
Imagine a plate or sheet of strong clear plastic and put it between your face and
the image. Push that image away from your face, until it gets smaller and is
further away.
Sometimes we can get a bad feeling in our body. Its possible to turn this feeling
around by using our imagination. Ask yourself (example in italics):
And now:
For this feeling to be better, what shape does it need to be? Round
How big? Getting smaller
And what colour would it be? Yellow
What texture or consistency would it be? Warm, light,
translucent
There are many reasons for not sleeping well which may include
distress, physical discomfort or physical illness.
We might have difficulty getting off to sleep, wake up frequently during the night, or
wake early in the morning and not be able to get back to sleep. These all result in our
feeling that we haven't slept enough - we feel tired, tense and are likely to worry
about not sleeping. This worry can then make it even harder for us to sleep well.
If you have trouble sleeping, there are some things you can do to help yourself get a
good nights rest. These include making changes in:
Our environment
Our behaviour
Our thinking
What now?
This is just the start of your journey. You have learned some skills,
and now you need to keep doing them, repeatedly.
CBT is not a magic-wand therapy, it takes hard work and commitment, but you will be
rewarded!
After a while, you won't need to write things down most of the time as you'll find
yourself doing all the steps in your head, you'll get better at it, and be able to do it
quickly.
We too can become competent at making effective and healthy changes, that make a
real difference to our lives and the lives of those around us.
Most of what we've looked at and practised is covered in the STOPP handout.
Photocopy it, or print another copy from the website at www.get.gg , put it on your
H H
Maintaining Progress
Consider the future - what future situations might be difficult for you? What can
you do differently at those times?
What have you learned that's been the most helpful?
What hasn't helped?
What has helped?
What is worth continuing to practise?
What can you do to help or remind you to practise?
What support or help do you need?
Remember and practise the helpful steps you have learned over
and over, and even when you feel you can use them effectively,
just carry on practising!
After a while, maybe after a great deal of practice, you will more easily notice your thoughts
and reactions, realise what you are reacting to, and the meaning you are giving to situations.
You will naturally start to question things, and then see things differently, seeing the bigger
picture. In questioning and seeing different perspectives, so you will feel very differently, and
much more healthily, from the way you used to react.
Practise STOPP! as much and as often as you can the more you practise, the easier
it will be when you need it www.getselfhelp.co.uk/stopp.htm
Practise Mindful Breathing and be aware of where you are putting your
focus of attention
Mindfulness www.getselfhelp.co.uk/mindfulness.htm
Continue to use your Treatment Plan to help you decide what else you need to do
Imagery Self-Help Techniques will help you build on the skills you have learned
Try not to act merely in the moment. Pull back from the situation. Take a
wider view; compose yourself. Epictetus (AD 55-135)
Stay in touch with family and Avoid using alcohol (or non-prescribed
friends - make regular and drugs) to help you cope it will only
frequent contact with them. add to your problems.
What meaning am I giving this? Is Some situations we just cant change. We can
this fact or opinion? How would others see it? surf those waves rather than try to stop them.
Is there another way of looking at this? Allow those thoughts and sensations just to be
How important is it, or will it be in a years time? they will pass.
What can I do right now that will help most?
If you have a problem other than depression, anxiety or anger, then you can read the
information given in these information sheets, as part of Step Two, and then continue the
course:
Stress get.gg/docs/StressSelfHelp.pdf
Low self-esteem get.gg/docs/SelfEsteem.pdf
Chronic pain / fatigue get.gg/docs/Pain&Fatigue.pdf
Paranoia, Delusions &/or voices get.gg/docs/PsychosisSelfHelp.pdf
Substance misuse get.gg/docs/SubstanceMisuse.pdf
Bulimia or binge eating get.gg/docs/BulimiaSelfHelp.pdf
Anorexia get.gg/docs/AnorexiaSelfHelp.pdf
Bipolar Mood Management get.gg/docs/BipolarMoodManagement.pdf
The Depression, Anxiety and Anger self help guides are also available separately:
You can also use the Anxiety disorder specific self help guides:
www.getselfhelp.co.uk/selfhelp.htm
www.selfhelpmp3.co.uk
www.getselfhelp.uk