Setting sail with the ACT life compass

ACT life compass

Image credit: Dr. John Forsyth

Acceptance and Commitment Therapy (ACT) is a type of psychotherapy that takes the stance that avoidance and resistance to internal experiences identified as negative is what causes cognitive distress.  To resolve distress, ACT suggests that we need to employ strategies like mindfulness, de-fusion from our thoughts, and recognizing the self as the context in which inner experiences occur rather than the content of those thoughts and emotions.  The commitment part of the ACT name refers to committing to actions that are consistent with out identified values.

ACT has a tool for this called the life compass.  You can find out more about the life compass and other ACT tools on the website of Dr. John Forsyth.  Dr. Russ Harris’s ACT Mindfully website also has some great resources.

The life compass looks at where you’re headed in ten key life areas: recreation/leisure, work/career, intimate relationships, parenting, education/learning, community life/environment/nature, friends/social life, spirituality, family of origin, and health/physical self-care. 

For each life domain, you’re supposed to come up with intentions that are based on your personal values and reflect the way you would like your life to look in terms of that domain.  As an example, you might consider why learning is important to you and what type of skills or knowledge that you would like to gain that would be consistent with that.  For the friends domain, intentions may include what type of friend you would like to be and what a good friendship would look like.  This process is less about specific goals or endpoints and more about valued directions.

Each direction of the life compass is rates on a scale of 1=10 for the importance (i= on the diagram above) and recent committed action (c=) towards those intentions.  You can also rate current satisfaction in each area.  Pay particular attention to areas where there is a large discrepancy between importance and either action or satisfaction.  Also identify any potential barriers you may face.  Then consider the actions that you can do now that lead you in the direction that your compass points.

Here’s a quick overview of my life compass would look like:

Recreation/leisure

Blogging is my primary leisure activity, and I hope that continues.  It’s very important to me as a form of connection and self-expression, and the amount of time I spend on it reflects that.

Work/career

My illness is a major barrier in this area, and has prompted a significant reevaluation.  My intention now is to continue to have meaningful one-on-one interactions with patients, which fits in with my value of wanting to do meaningful and fulfilling work.

Education/learning

I’m finished my formal education, but I want to continue to learn new things at any possible opportunity, and ongoing learning is a key value for me.  This area is of high importance, and I’m satisfied with how I’ve been doing.

Community life/environment/nature

I like the neighbourhood where I live.  I’ve never been particularly community-oriented in a social sense, but I do feel a sense of belonging where I am.  The natural environment is pretty spectacular, and I guess my attention would be to continue to actively appreciate and be mindful of that natural beauty.

Friends/social life

Almost all of my social interaction is online these days.  For now at least, that’s what works.  I have valued in-person connections with people close to me in the past, but realistically depression gets in the way of that.

Spirituality

I’m not religious, nor am I particular spiritual.  I think what matters to me in this area is recognizing the shared humanity among all of us.  I’m not sure exactly what that would look like in practice, but I suppose showing compassion is part of it.

Family of origin

I would rate my satisfaction in this area a fair bit lower than the importance that I place on it (at least some of the time).  I really don’t know what my intention is, but I know my illness has been a major barrier (for me, not for them).  So all I can really come up with is a big question mark.

Health/physical self-care

I’ve accepted that I have only a limited degree of control over my life.  My intention in this area is to continue to be an active participant in my health, and to incorporate both pro-wellness and anti-illness strategies.  Sometimes it feels like I’m flailing, but overall I think I’m doing the best I can.

Not applicable

Parenting and intimate relationships are not in my life right now and may well never be, but they are also not things that are of high importance to me, so their absence doesn’t bother me.

 

What are some of the intentions that would play an important role in your life compass?

 

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Thoughts as leaves on a stream

beaver dam on a stream

Graham-H on Pixabay

Thoughts as leaves on a stream is a popular metaphor used in acceptance and commitment therapy (ACT) to represent noticing thoughts and letting them pass by without attaching to them.  I like this metaphor, since it’s not about fighting the thoughts or trying to make them go away, but just riding them out.

I got thinking about recently this after reading a post by Meg at Why does bad advice happen to good people?  A person had written a letter to an advice columnist about the same-sex fantasies she’d been having while in a heterosexual marriage, and she was distressed because she didn’t think she should be having these thoughts yet she couldn’t control them.  She was trying her hardest to fight the thoughts, and it just seemed to make the thoughts more intrusive and make her feel worse.

I know there are certainly times when I try to fight thoughts.  Sometimes it’s by ruminating and trying to think my way out of them, and other times it’s by trying to shove them into a box in the corner where, like Pandora’s box, they’ll stay hidden away until something prompts them to suddenly get released back out into consciousness to wreak havoc.

Building on the leaves on a stream metaphor, maybe sometimes are minds are overly eager beavers and instead of letting the leaves float by, they start making a dam to try to keep them awaay.  The thoughts get caught up in the dam rather than being able to float by.  When we try to fight the thoughts, our beaver mind thinks it’s going to be helpful and strengthen the dam, but that just makes the situation worse by getting those thoughts even more entangled.

I think the biggest dam getting in the way in my mind is an amplification of the brain’s natural negativity bias.  We’re hardwired to be on the alert for danger, but after accumulating a lot of negative experiences in recent years my beaver brain has tried to shore up some extra protection.  What that means, though, is that thoughts related to transient, minor safety threats get caught up in my head and stick around far longer than they should.  Even if my beaver brain thinks that’s keeping me safer, it’s really just making me feel worse.

Do you try to let thoughts float by, or are you a dam builder?

Let’s get suppressing

ACT for anxiety disorders book cover

I was browsing the web for interesting therapy materials, when I came across the worksheets for Acceptance & Commitment Therapy for Anxiety Disorders on the website of one of the authors, Dr. John Forsyth.  I’ve never done ACT, but I’ve done a lot of reading about it, and it makes a lot of sense to me.

One thing that I found particularly interesting is the White Bear Suppression Inventory, which I’ve copied verbatim from the linked site; the material is copyright (1994) by Blackwell Publishing Company.  All questions are rated from 1=strongly disagree to 5=strongly agree:

1) There are things I prefer not to think about.

2) Sometimes I wonder why I have the thoughts I do.

3) I have thoughts that I cannot stop.

4) There are images that come to mind that I cannot erase.

5) My thoughts frequently return to one idea.

6) I wish I could stop thinking of certain things.

7) Sometimes my mind races so fast I wish I could stop it.

8) I always try to put problems out of mind.

9) There are thoughts that keep jumping into my head.

10) Sometimes I stay busy just to keep thoughts from intruding on my mind.

11) There are things that I try not to think about.

12) Sometimes I really wish I could stop thinking.

13) I often do things to distract myself from my thoughts.

14)  I often have thoughts that I try to avoid.

15) There are many thoughts that I have that I don’t tell anyone.

 

I was already aware that I tend to use avoidance as a fall-back strategy, but this inventory reminded me just how much I end up doing this.  I would rate myself a 5 (strongly agree) for questions 1, 2, 3, 5, 6, 8, 10, 11, and 14.  Yikes.  Yet with the current state of my treatment-resistant depression, I wonder if this suppression is the only way that I can manage to keep it together most of the time.  That sounds avoidant in and of itself, but I think it’s a legitimate question; with an illness that’s only partially responsive to treatment, are there limits to how much my conscious mind can handle?  And from a mindfulness perspective, is it useful to think about things related to past and future that I have limited control over, or is it better to just keep on chugging in the present moment? I really don’t know, and to be honest, I don’t know that I’m prepared to trust anyone enough to dig into that further.

Did this suppression inventory tell you anything new about yourself, or did it confirm anything you already knew?

 

Image credit: https://www.drjohnforsyth.com/free-resources.html

Psychotherapy alphabet soup

multicolored letters of the alphabet floating in a pool

Some studies have shown that the quality of the therapeutic relationship between client and therapist is a stronger predictor of therapeutic outcomes than the type of therapy used.  However, it seems logical that the type of therapy should at least to some extent match up with how you tend to conceptualize the problems you’re experiencing.  Here is a brief run-down of some different psychotherapy approaches.  This is by no means an exhaustive list, and it doesn’t include things like humanistic approaches  or those therapies that do a deep dive into past issues and attachment.  GoodTherapy.org has a much more extensive list.

ACT: Acceptance and Commitment Therapy

ACT takes the perspective that resistance to thoughts and feelings is the main cause of distress.  It addresses areas such as present moment awareness, acceptance, separating the self from thoughts, and taking committed action consistent with identified values.

CBT: Cognitive Behavioural Therapy

CBT is perhaps one of the best known counselling approaches.  It considers the relationships between thoughts, feelings, and behaviours, and how each of those elements can be changed.  Evidence for and against thoughts is examined with the goal of identifying cognitive distortions that cause distress and replacing them with more realistic thoughts.  As well, new behaviours are practiced to reduce distress and promote more realistic thinking.

CPT: Cognitive Processing Therapy: This is a form of CBT for PTSD, and aims to change cognitions about the trauma that are keeping the person stuck and preventing them from fully processing the trauma.

PE: Prolonged Exposure: This is a form of CBT that aims to decrease fear and trauma responses by exposing the person in a controlled way.  This can be either in vivo (in person) or imaginal (the client is asked to vividly imagine a particular situation), or a combination of both.  It progresses based on an identified hierarchy of feared stimuli.

TF-CBT: Trauma-Focused CBT: Like CPT, this is a form of CBT for trauma, but it is geared toward children and adolescents.

CFT: Compassion-Focused Therapy

CFT is influenced by CBT, and focuses on compassion towards both others and the self.  It can be useful for people struggling with emotions like shame and self-criticism.

DBT: Dialectical Behaviour Therapy

DBT was developed by Dr. Marsha Linehan to address some of the shortcomings of CBT for treating borderline personality disorder.  The dialectic refers to the idea that the way the individual is doing things now is valid and they are doing the best they can, but they would still benefit from change.  DBT is very skill-based, with modules covering areas of mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness.

EFT: Emotionally Focused Therapy

This type of therapy consider emotions to be reflective of underlying needs, and classifies emotions as adaptive, maladaptive, reactive, and instrumental.  Therapeutic tasks are identified based on the client’s particular emotional experiences.

EFT: Emotional Freedom Technique

Not to be confused with the other EFT, this is an approach that utilizes tapping on meridian points while focusing on an issue and then an affirmation.  It draws on concepts from acupuncture and neurolinguistic programming (NLP).  There is not a robust research evidence base to support its effectiveness, although that doesn’t speak to how a particular individual might or might not respond.

EMDR: Eye Movement Desensitization and Reprocessing

EMDR is a type of trauma counselling.  The client uses horizontal eye movements to track the therapists’ fingers, and while this is being done the client focuses on an identified distressing image and the bodily sensations associated with that distress.  A Subjective Units of Distress (SUDS) scale is used to track progress, and as the SUDS score drops the therapist and client work on installing a new positive cognition.

IPT: InterPersonal Therapy

IPT is a short-term, structured approach that focuses on addressing interpersonal problems that contribute to problems with mental health, and building interpersonal communication skills.  Research has supported its effectiveness for the treatment of depression.

MBCT: Mindfulness-Based Cognitive Therapy

This type of therapy is focused on the use of mindfulness to address cognitive distress.  It covers things like acting on autopilot, being mindful of the breath, allowing and letting be, engaging in self-care, and recognizing that thoughts aren’t facts.

SFBT: Solution-Focused Brief Therapy

SFBT works on identifying and developing the skills to create changes and achieve goals.  The therapist asks particular types of questions to guide the client toward envisioning their future and identifying strengths and coping skills.

 

What types of therapy have you tried?  What was your experience like?

 

Image credit: Pexels on Pixabay

Exploring values

ethics infographic

Values: we’ve all got them, but how often do we think about them?  It’s worth checking in with ourselves every so often as to what our values are, and how consistent our behaviour is with those values.  Unlike goals, values are not an endpoint, but rather a guiding direction.  Acceptance and commitment therapy offers some assistance in this values clarification process, and there are some useful worksheets here.

Some of the values that I’ve identified:

  • kindness, compassion, and empathy
  • staying true to myself
  • keeping an open mind
  • curiosity, ongoing learning, and exposing myself to new things/cultures/places
  • independence, autonomy, and freedom of choice
  • being able to express myself
  • having a sense of meaning and purpose
  • respect
  • helping others
  • honesty
  • authenticity
  • challenging stigma
  • being a good furbaby mama
  • working towards wellness, taking care of myself
  • fairness, justice

One thing I’m working on clarifying for myself is whether the importance I place on fairness and justice is purely a value  or whether there’s an element of cognitive distortion (the fallacy of fairness) muddying the water.  Also, I used to have certain work ethic beliefs that have unfortunately not served me well, but they get tied in with my sense of integrity and so I get a sense of dissonance when I go against them.  I used to value helping my coworkers and was happy to inconvenience myself to some extent in order to support my teammates, but as it’s become clear that no one was willing to do the same for me, I’ve chosen to be selfish and only look out for myself.  It’s necessary, but still not really congruent with my values.

Aside from those muddy bits, my values have remained pretty much constant over my adult life, although over time the level of priority I place on each has probably shifted.

Do you ever reflect on your values?  Are there things that you struggle with?

 

Image credit: Maialisa on Pixabay

Book Review: Emotional Agility

Emotional Agility by Susan David book cover

Emotional Agility: Get Unstuck, Embrace Change, and Thrive in Work and Life is written by psychologist Dr. Susan David, and was recommended to me by Chris at Breathe Underwater.  I was quite impressed with this book.  Normally when I’m reading a book I intend to review I take notes as I’m reading of the points that stand out for me.  I ended up with several pages of notes for this book, because there was a lot that resonated with me.

The book is written with a casual tone that makes it feel like an easy conversation.  Research findings and terms from the field of psychology were explained in an accessible way.  The concepts presented resemble the fundamentals of acceptance and commitment therapy (ACT), which I was already familiar with.  Books in this genre can sometimes run the gamut from “out there” to boringly obvious, but this falls into that happy little place of common sense but insightful.

The author presents emotions as something that serve a useful purpose and help us to survive and thrive.  Emotional agility involves responding to those emotions with clear judgment, and opening up a space between feeling and reacting that allows us to make reasoned decisions.  The author identifies four key steps in gaining emotional agility:

  1. showing up: facing thoughts, emotions, and behaviours
  2. stepping out: being able to detach from and observe thoughts and emotions
  3. walking your why: making choices based on core values and goals
  4. moving on: making small tweaks influenced by values, and finding balance on the teeter-totter between challenge and competence

David identifies several common “hooks” that move us from facts to judgment, generating an autopilot response.  These sounded oh so familiar to me.  The hooks included blaming thoughts for one’s behaviour, “monkey-mindedness” (anticipatory thoughts turning into mock conversations predicting expected negative events), assumptions based on past negative circumstances, and wrongheaded righteousness (cutting off your nose to spite your face).  She also describes two problematic responses to stress, which are often earned early in life: bottling things up, and brooding.  I am most definitely a monkey-minded brooder.

The author challenges the idea that people should try to be happy and paste on a smile all the time.  She points out that fakes smiles are actually not the same as genuine smiles; fake smiles don’t produce the contraction of certain muscles around the eyes that are not under voluntary control.  Emotions that are thought of as negative actually serve constructive purposes, and David argues that trying to suppress them is counterproductive.

David explains the benefits of mindfulness.  She encourages us to clearly identify our personal values, as all too often we tend to get swept up by social contagion into mindless decision-making.  She also talked about motivation and how to achieve habit change.

In the teeter totter between over-competence (being excessively comfortable) and over-challenging/overwhelming ourselves, David suggest that we aim for being “whelmed”.  She warned against “dead people goals”, i.e. goals like “not being anxious” that a dead person could achieve.  She suggested that while grit and perseverance can be useful, emotional agility also involves knowing when to give up and move on.

There are chapters specifically devoted to emotional agility at work and raising emotionally agile kids  While she made some good points in the chapter about work, there were a few things that didn’t quite ring true for me; in particular, she suggested that people should speak up about organizational issues rather than staying quiet.  I’ve worked in organizations that actively attacked employees that raised concerns about the status quo, so I’m just not buying this suggestion.

David concludes the book with a series of suggestions on how to be emotionally agile, including accepting yourself with compassion, welcoming your inner experience, accepting that love & hurt and success & failure are inexorably intertwined, and releasing narratives that no longer serve you.  While these suggestions may not be easy, they provide some useful areas to work on.

I would say this book is well worth a read.  Besides being consistent with ACT, there is some overlap with principles of cognitive behavioural therapy (CBT) and dialectical behavioural therapy (DBT), and I think there are useful points that would apply across a variety of mental health conditions.  Two thumbs up for this book!

 

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Mental health worksheets galore

person writing in a notebook

Even if seeing a therapist isn’t part of your mental illness treatment plan (as is currently the case for me), it can still be useful to do some of this kind of work on your own.  There are some great online resources out there to help you do just that.  In this post I’ve included links to some sites that have some practical worksheets and workbooks.  Some of them will make the most sense if you have some background knowledge about the type of therapy, but many are pretty self-explanatory.  Of course the downside of working on these on your own is that you don’t get the objective feedback that a therapist is able to give, but they can still be useful.

Cognitive behavioural therapy (CBT)

CBT is an evidence-based treatment used for a variety of different mental illnesses.  A key element of CBT is identifying evidence to challenge distorted cognitions.  This can be difficult to do without working with a therapist, but there are plenty of self-help worksheets out there to help you if you want to give it a try on your own.

  • Antidepressant Skills Workbook from the Centre for Applied Research in Mental Health and Addiction: This is a good intro for people who are new to CBT for depression, but might feel a little too basic if you are familiar with CBBT
  • CBT Skills Training Workbook: this  is from the NHS, and is focused on low mood and anxiety
  • Centre for Clinical Interventions: this Australia-based organization has CBT-based workbooks and worksheets for a variety of mental health concerns

Dialectical behavioural therapy (DBT)

DBT was developed for use in borderline personality disorder, but it is much more widely applicable than just BPD.  Some of the skills are likely to be useful to many people who struggle with emotion regulation as part of their illness, and books and worksheets can be a good way to learn some of these skills without doing the full course of DBT therapy.

  • DBT Skills Application: a DBT self-help site with links to worksheets focused on various DBT skills
  • DBT Skills Training Handouts and Worksheets by Marsha Linehan: even if you’re not actually in a DBT program there’s stuff here that can be useful.  A quick Google search will point you in the direction of both legit and less than legit copies.

Acceptance and commitment therapy (ACT)

  • ACT Mindfully: Russ Harris’s site has worksheets from all of his books on ACT.  Like the name implies, ACT focuses on accepting emotions rather than avoiding/fighting them, and committing to actions that are consistent with our identified values.  I found some of the worksheets on values clarification to be quite useful.

Miscellaneous:

  • GetSelfHelp: worksheets galore on a variety of topics
  • Psychology Tools: has a wide variety of worksheets, including CBT and DBT-based
  • Therapist Aid: also has a wide variety.  The worksheets are geared for therapists to use with their clients.
  • ThinkCBT: has worksheets based on CBT, ACT, and Compassion-Focused Therapy, and includes resources for OCD

You can find more resources on my post online mental health workbooks.

Do you use any sort of self-help websites, books, or worksheets?  What’s been useful for you?

Image credit: Free-photos on Pixabay

Happiness is a choice, my @ss

happiness.jpg

On a fairly regular basis I come across people online talking about how happiness is a choice.  It bugs me whenever I see it, even when I can tell the poster is trying to be motivational and positive, so I thought I’d dive into that a little deeper.

A quick search on Amazon reveals a multitude of books entitled “Happiness is a Choice”.  A Huffington Post headline claims “This is Scientific Proof That Happiness is a Choice“.  There’s a whole field of positive psychology that focuses heavily on happiness.  Then there’s the law of attraction business that essentially says if you put positive (or negative) stuff out there into the world then you’ll attract positive (or negative) stuff in return.

I call bullsh*it.  Saying that happiness is a choice is just a short hop, skip, and a jump from saying that mental illness is a choice.  It’s one thing to say it’s good to look for the positive, and try to reframe things in a more positive light, but to say that happiness can be had as long as you want it badly enough and try hard enough is a slap in the face to those of us dealing with mental illness.  A common symptom of multiple mental illnesses is anhedonia, or an inability to feel pleasure or enjoyment.  Our symptoms involve our thoughts, emotions, and bodies, making it seem like there’s little that’s under our control.  How does all of that fit in with “happiness is a choice”, pray tell?  I can feel my blood pressure rising even as I write this.

I don’t think these positive psychology cheerleaders are necessarily trying to make us feel badly, but there really does seem to be a fundamental lack of understanding.  The way I look at it, mental illness tends to (at least temporarily) limit our capacity to experience certain things, including positive emotions.  This is not a choice we make, it’s an illness.  We can’t choose our illness out of existence, but with effective treatment we can at least start to gain back the capacity that we lost.  To suggest that it all comes down to a choice, whether that choice be about happiness or mental illness, is cruel and insulting.

Is happiness even a good thing to focus on?  Dr. Russ Harris, an expert in acceptance and commitment therapy, challenges that idea in his book The Happiness Trap.  He argues that being perpetually happy is neither realistic nor desirable, and it is the human experience to feel a range of different emotions.  Instead he suggests that we should work on mindfully accepting we are experiencing, and make choices that keep us more in line with our identified values.  Sticking to values can offer a much more meaningful existence than chasing happiness because it’s what we society thinks we “should” feel.

Probably the reason this idea of happiness as a choice bothers me so much is that it feeds into stigma.  This most likely has more to do with well-meaning ignorance than intentionality, but the end result is the same nevertheless.  If people are being told that happiness is a choice, they may be more likely to think that other emotional states are also a choice, and that can set us back in the fight against stigma.  Mental illness offers us a certain menu of emotional options, and often we can’t control what does or does not end up on that menu.  If happiness was a choice, I would have made that choice already.

 

Image credit: Pixteller

Living in fear: The tsunami of depression

crying woman inside a rainy window

While fear may not be a symptom of depression, it is certainly something that has become tightly woven into the fabric of my illness.  When I am well, I am fearful of when the next relapse might be, when the ground might disappear beneath my feet.  When that relapse happens, I am terrified – here we go again with yet another tidal wave to wash my life away.  And as a depressive episode stretches out, I am scared that I won’t get better, that I will drown in this mental pain.

What is probably the most frightening is the lack of control.  I can be doing what would appear to be all the right things, and I will still get sick.  As the years have passed it has become harder and harder to control my illness, so the fear only escalates.  This current episode has lasted for almost a year and a half, and I am utterly terrified that I will never get my well self back again.  I miss her so much, but she is either gone, washed away in the tsunami of my depression, or drowning in a dark basement somewhere.  If only there was a “find my iPhone” for the real me, to give me a life preserver to hold on to.

A few years ago I was making my case before a review board about why I should not remain committed to the psychiatric ward.  As a mental health nurse, I’m a bit of a research geek, so I was talking about the STAR*D research study, which essentially showed that the more treatment failures a patient has the worse the prognosis.  I argued that my suicide attempt stemmed from “evidence-based hopelessness” (although looking back, I’m not sure why I thought that would help my case).  Perhaps a better way to put it, though, would be evidence-based fear – fear based in the evidence of my personal experience and reinforced by the research evidence I was reading.  If I am already fearful that I won’t get better, it becomes very hard to challenge that kind of thinking.

woman drowningI’ve been learning recently about acceptance and commitment therapy (Russ Harris’s ACT Mindfully site is a great resource if you’re interested in reading more), and contemplating how fear fits in with this idea of acceptance rather than resistance.  Is this fear a form of resistance?  And if so, maybe it’s resistance in a good way – a reason to keep fighting for recovery.  Or maybe acceptance lies in making space for this fear, acknowledging it as a neighbour that’s not going to be moving away any time soon.

As I struggle to tread water in the sea of my depression, perhaps I have to both accept and resist.  Resist the urge to stop struggling and just drown already, and accept that another wave might come at any time and push me under.  In the end, whether I feel fear or not, que sera sera.

 

Photo credits:

Milada Vigerova on Unsplash

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