Behavioural Activation Part 1 – A Common Sense Approach to Mental Health Your Gran Would Agree With

I think the best psychotherapy and well being programmes have common sense overflowing from each practice, intervention or tool. Would your Gran have told you to do this when you were a child? Did the Greeks, Stoics and indigenous cultures do these things either consciously or as part of ‘the Good Life’? If the answer is an unequivocal yes then it’s definitely worth exploring. Behavioural Activation (BA) is certainly one of these common-sense tools. When we feel depressed or anxious we tend to isolate ourselves, stop doing things that make life meaningful and ruminate on our suffering. BA teaches us to challenge this by doing the opposite, making a list of varied activities to nourish our brains and recover our moods. Its not easy when you are depressed but it makes sense.

Mindfulness Based Cognitive Therapy (MBCT) was primarily developed for maintaining recovery from depression. Its creators had previously been experts in Cognitive Therapy and mixed elements of this with mindfulness in MBCT. One aspect was BA and they titled the session that focuses on it ‘How Can I Best Take Care of Myself’ to reflect the compassion embodied in Jon Kabat-Zinn’s original formulation of Mindfulness Based Stress Reduction.

BA came from the behavioural tradition of psychology, and holds that depression stems from a lack of positive environmental factors and/or too many punishing factors. There are different varying approaches to BA, often they start with an analysis of how you are spending your time hour by hour each day. How do these activities impact your emotions and moods? Then identifying positive experiences to add in and negative experiences to remove. This is followed with tracking the impact on your mood of increasing these positive steps and reducing negative factors. In MBCT we identify positive events by two categories: pleasure activities and mastery activities. Pleasure activities are inherently rewarding and involve enjoyment like talking with a close friend, eating nourishing food, listening to beautiful music etc. Mastery exercises give us a sense of satisfaction through mastery of our environment, like tidying our house, planning our monthly spending etc. Of course, there can be some overlap between pleasure and mastery, but it is good to schedule a balance of these activities.

It sounds very simple, but this can be a herculean task when you are depressed. When the weighted shirt of depression is on you, it can be a huge task just getting out of bed. You can’t think straight, your own mind is attacking you with the weapons of doubt, self-criticism and meaninglessness. So how can you use BA to move through the quicksand of depression or the paralysis of anxiety? In the next article I will explore some ideas that have helped me when using BA to work with my own anxiety and depression.

The Acceptance Spectrum

It can feel insulting when someone tells you to accept your anxiety, depression or other mental health symptoms. Especially if they appear to be an academic expert who does not have the intense lived experience of an anxiety or a mood disorder. They haven’t awoken with primal terror as if their heart is trying to beat its way out of their chest. They haven’t carried the weighted vest of depression, barely being able to move, think or eat. They haven’t spent days circulating back and forth between panic, obsession, depression and depersonalization, barely able to function. They are not like us.

However, there clearly are many experts who have experienced this. Marsha Linehan, the pioneering therapist, is a great example of an expert with this severe lived experience. She later went on to develop Dialectical Behaviour Therapy, intending it to be a life raft for the most acutely suicidal patients. Steven Hayes is another; he developed Acceptance and Commitment Therapy (ACT) to help him overcome his panic disorder. Also within the ACT world Russ Harris also experienced depression, his search for meaning ultimately led him to ACT. And Prof Paul Gilbert had his own period of depression and anxiety in the late 1970s. They all used acceptance and compassion to get them out of the quicksand of these emotional pains. But it can be a challenge when someone without this life experience advises you to ‘just accept’ it. How could you possibly accept this heavy, thick, depressive pain or crippling anxiety?

It might feel better when people talk about tolerance. This doesn’t mean you have to like your emotional pain, just as to tolerate a headache doesn’t mean you enjoy the physical pain. Emotion regulation scientists talk about two key techniques: cognitive reappraisal and distraction. They argue that these are healthier tools to tolerate rather than suppress your emotional pain. And they certainly do not suggest you should become best friends with your symptoms.

And then there is the compassionate stance. Here we validate our pain, perhaps reflecting on our shared humanity with others and draw upon a compassionate motivation to take care of ourselves-Acknowledging the pain but with a commitment to alleviate it.

Personally, I have started to look at acceptance as a spectrum. At one end our distress is not welcome and we will try anything we can to get rid of it. At the other end, the pain and distress are welcome to stay as long as they want. We will continue living our lives with them by our sides. We can work our way up to this end of the spectrum and we can help ourselves in whatever way is kind, to build tolerance and push deeper into a state of acceptance. We can focus more on deepening our ability to function with these painful states present, rather than constantly monitoring whether or not they have gone.

I really like Mark Freeman’s analogy of these painful emotions being like the pain and exhaustion we feel when doing physical exercise. When we first start going to the gym, cycling or swimming then the pain, aches, stiffness and exhaustion can be enough to make many of us run to the nearest pub for an ice-cold pint! However, if we can stick through this we can even get to a point when we enjoy the burn, the discomfort becomes a sign of progress, fitness and growth. The same can be true for painful emotions.

Reid Wilson, in the brilliantDon’t Panictalks about different levels of working with anxiety. We start with resisting, saying ‘I don’t want this’, and we gradually move to being more comfortable with the emotion saying ‘I can handle this’. At this stage we can use tools like breathing, relaxing, attentional control or kind self-talk to help us be more willing to be with the anxiety as we turn our attention back to the present. But then we can move to a level of wanting more discomfort and uncertainty and even saying to our panic ‘I want it to be strong, I want it to last, make this sensation stronger’ and then turning our attention back to our valued direction. This brilliantly highlights the acceptance spectrum. It shows the tools we can use to get closer to feeling these emotions and having these thoughts whilst following our values and living our lives. We show our brains they don’t need to sound the alarm.

It’s always worth reinforcing that this type of acceptance does not refer to accepting oppressive external conditions, social injustices, bad relationships or other environmental factors of inequality. It means accepting the aspects we can’t change such as an emotional thermostat set to be on the sensitive side. We can work with others to try to change oppressive external conditions. But for our internal environment we can gradually widen our window of tolerance and lean into our acceptance spectrum.

So how can we work our way along the acceptance spectrum?

  1. Practice mindfulness and compassionate meditation
  2. Stay focused on our goals which express our values. Studies have shown that affirmation of your values can even reduce the release of the stress hormone cortisol in stress tests.
  3. Use kind gentle self-talk in the form of coping statements. Not to get rid of our pain, as that is a futile endeavour, but rather to accept and move into life with our pain at our side. Endurance athletes, emergency services and many more know the power of self-talk to cope with adversity.
  4. Create an exposure hierarchy and gradually progress from less challenging experiences to your more difficult ones, trying to get a sense of ‘I can handle this, I will continue toward my valued directions in life’.
  5. Allow time. Practicing leaning into life and allowing time to pass will build up our acceptance. We see this in our wise elders, often they manifest high levels of acceptance.

We will all likely move up and down the spectrum on different days and periods of our life. We will have lapses and perhaps even relapses when it feels we’ve lost our ability to accept and continue on. Our level of acceptance might be higher for some emotions or thoughts than others. But we can all work at developing this ability whilst we enjoy moving through life with the people we love. Let me know how you experience your acceptance spectrum, I’d love to hear any thoughts you have on this in the form below?

Kind Thoughts and Tricky Brains

When Professor Paul Gilbert developed Compassion Focused Therapy it was in part to solve a clinical Rubik’s cube. Cognitive Therapy helped some of his clients to re-frame their negative depressive thoughts. Their inner critic would utter the usual ‘helpful’ mental stream of ‘you’re useless, you’ll never achieve x or y, you might as well go back to bed’ and the client would spot the ‘cognitive distortions’ in their thinking and re-frame it to ‘you have achieved x or y before, you are doing well with z, why not get up and get on with the day’. And this helpful technique (which dates back to ancient philosophies like Stoicism and is hypothesized to be one of the advantages of human language), would help a lot of his clients. This technique is very familiar to athletes, front line responders and emotion regulation scientists. But some of the most severely depressed clients didn’t seem to benefit. Gilbert explored this further and found they were using a pejorative emotional tone when having these inner dialogues. They were saying ‘come on then, you’ve got lots of friends and family, why are you so depressed, just get out of bed and do it you &*$£+&#!’ So, he trained them to use kind facial expressions and voice tones, to use compassionate imagery, breathing and other tools to bring a kind inner dialogue to themselves. And he found this was much more effective. Since then, Gilbert’s techniques have been validated in a number of scientific studies.

So how can we develop this skill?

  1. The Compassionate Mind Training and Imagery exercises, loving kindness meditation and self-compassion practices can all lay the foundation.
  2. It can also be useful to write down negative thinking patterns in one column and in the other to write compassionate kind reframing thoughts.
  3. The self-compassion break is an excellent short practice to develop this skill.
  4. A practice I like to do is to start with soothing breathing rhythm, follow with compassion meditation or imagery and then spend 5-10 minutes flowing through different compassionate thoughts. These might be focused on a challenge that I am facing or just general self-acceptance and encouragement. I acknowledge the fact that we all have ‘tricky brains’ and are doing our best and then I create a compassionate inner coach to encourage me with compassionate self-talk.
  5. Barbara Fredrickson has a lovely practice called narrating your day with kindness and acceptance or as I like to call it ‘narrating your day in a kind way’. Take a few hours, a morning or a whole day and see if you can make your internal self-talk be kind, encouraging and accepting.

I find that practicing these daily, or a few times a week, means our compassionate coach is likely to show up more quickly next time you spill your morning coffee on your keyboard at work!

The internal critic may still be there as you practice (it probably will be), and we don’t want to fight with it, just give another kind perspective. If you face the painful emotions of fear, anger, sadness etc, can you bring gentle, compassionate coping statements to mind? These could be ‘this is tough but I can get through this’ or ‘I am feeling fear right now so how can I look after myself’. Give it a try and share your experiences below. I’d love to know how this works for you.

Acceptance – One of the Most Useful Skills

Before I focused on mindfulness I used to practice a number of meditation practices which emphasised concentration. They used to teach things like ‘throw thoughts away’ or ‘just let go of emotions’ and the principle that if you developed enough focus then you could overcome all fears, worries and concerns. Well this was all good and well when you were meditating or practicing on a good day, but I found this did not help me in daily life when I was facing strong emotions or overwhelming thoughts. No matter how hard I tried to focus on my breath, positive emotions or how much I ‘let go’ of these negative emotions they would just get stronger and I would be falling back on basic strategies like avoidance, rumination or shutting down in overwhelm. What mindfulness brought, as a missing piece to my practice, was the principle of non-judgemental awareness, acceptance or equanimity toward these thoughts and emotions. It was okay to have these negative feelings and thoughts; I didn’t have to fight them, just hold them with an accepting awareness. I have found this to be one of the most beneficial aspects of mindfulness.

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Firstly, it’s important to emphasise that with acceptance this doesn’t mean that we accept objective phenomena that we clearly need to change. We should not become ‘door mats’ or accept wrong treatment in the name of mindfulness. Here acceptance means that, when we can’t change objective conditions, that we don’t fight against our internal reactions in the body-mind to the present moment. We avoid the push and pull and internal struggle with our reactions and we do this through awareness.
Acceptance/equanimity develops through and over time. This is a really important point, through time spent on the cushion, doing moving mindfulness and daily life practice equanimity will develop naturally with time. It develops when we allow thoughts and emotions to come and go without trying to block, change or get rid of them and instead hold them with awareness. It’s also related to your concentration/stability of mind skills in mindfulness, the deeper you develop the relaxed and effortless concentration of mindfulness the more acceptance you will develop.
Here are some other ways you can increase and develop acceptance skills:

1. Full body relaxation – as best as you can, try to relax your whole body, you can quickly scan from head to toes and relax any areas of tension particularly the muscles around the eyes, the jaw, the shoulders, the breath, legs and arms. If you find any areas of tension you can’t relax then simply observe them.
2. Gentle light awareness – if we can also use a relaxed focus this will help to develop equanimity, this means using just the amount of effort to stay with the meditation but not struggling or effort-ing beyond this. It’s like you lightly ‘rest’ your awareness on the object of meditation and if you drift away then just notice and gently return. You have close to an effortless focus. Try noticing that you are seeing or hearing, that amount of effort to simply notice is all that is needed.
3. Kind gentle speech and loving self-talk – it can be helpful to activate the language part of our brain, you can gently and in a kind tone (silently or out loud depending on where you are) label the emotion ‘feeling, thinking’, or you can talk to yourself with kind loving words like ‘may I be happy, may I be free from suffering’.
4. Notice the aversion or resistance – if you can’t observe something because it is too hard then notice the resistance and gently return your attention to your meditation. This resistance shows up as tension in the body, subtle or strong emotional sensations like fear or anger, heaviness or tension in the head and negative thoughts in the mind. If this is difficult, use an anchor like the breath at the abdomen or the sense of the physical body as a whole and allow your mind to be aware of the anchor and any challenging emotions. If the resistance is really intense then it might be a good choice to practice moving meditation or switch to an action you value that is meaningful (there are times when its more skillful to read a compelling novel!).
5. Time, time, time – just to emphasise again that generally equanimity develops in direct correlation of the time spent practicing, therefore notice it develop over time as the weeks and months go on.

Probably the best meditative practice to develop equanimity is open awareness, sometimes called choiceless awareness or open monitoring. In studies on advanced Zen and Tibetan Buddhist meditators, they were able to regulate their response to pain stimulus the greatest using this technique, and this was directly through equanimity to pain (they use a hot water wrist patch to invoke pain in the neuroscience lab!).

Here is a guided open awareness practice, but remember all mindfulness practices will develop this skill: Open Awareness

Happy practicing!

Jon Kabat-Zinn on Mindfulness

It was wonderful to see Jon Kabat-Zinn talk about mindfulness at the School of Life on the 2nd May 2015. Jon has arguably played one of the most important roles for the promotion of secular mindfulness in society, through the Mindfulness Based Stress Reduction (MBSR) Programme that he founded. MBSR was originally put together to help patients at the hospital where he worked in Massachusetts manage chronic pain, stress and other suffering related to their chronic illnesses – see http://www.umassmed.edu/cfm/ for more details.

Jon covered so much in the session but I wanted to share some of the highlights for me:

Heartfulness. Jon emphasised that compassion and loving kindness are built into the fabric of mindfulness. The awareness that is used to bring acceptance to pain and suffering is kind and compassionate. For this reason he often calls it ‘heartfulness’.

Attending to attention. Mindfulness is connecting with awareness itself, this pure awareness can hold and contain suffering in a way that makes unavoidable suffering more manageable. Negative thoughts and emotions self-liberate in this awareness.

If you find it hard to connect with this pure awareness then by all means use an object to anchor yourself in the present moment like following your breathing.

Rest in Awareness. It is important to try to be soft with our focus, like you are ‘resting’ in the present moment focus.

So be very gentle and relaxed with attention but at the same time focus like your life depends on it. Mindfulness is the balance between deep rest and clear focus.

And finally Jon emphasised become at ease with not knowing. As we train in mindfulness our inquisitive and controlling mind can try to question and understand every little thing. At times we just need to let go as best we can and let the practice take care of the answers.

JKZ

Why do mindfulness?

Before starting any endeavour it is good for us to consider why we are doing it, particularly in terms of what benefits we can anticipate. There are only so many free hours in the day and each one ideally should be used to bring more happiness to ourselves and to others. Mindfulness is no different, and so I always like to begin by describing some of the key benefits. I often classify these under three broad headings:

Enhancing the positive – our brain has evolved to have the quality of neuroplasticity; this means that the way we use our thoughts influences the structure and qualities of our brains. The famous saying goes “neurons that fire together wire together”. One implication of this fact is that positive or negative habits strengthen the associated brain pathways.

Humans have evolved a negativity bias, meaning that we have a tendency to focus on threats as monitoring these will keep us alive (from sabre tooth tigers through to dangerous drivers) and the positive experiences are more of a “nice to have”. This is why if you meet many nice people in one day and then one difficult person it is likely that you will tell your friends about the difficult person and say little of the nice people!

But by using mindfulness to focus on positive experiences, the thoughts, sensations and emotions associated with them, we can strengthen these neural pathways. This can become a positive feedback loop – focusing on positive experiences make us feel good and feeling good enhances our focus, often when we talk about savouring an experience this is what happens. Neurotransmitters that we associate with positive experiences like endorphins, serotonin, oxytocin and dopamine are released through meditative practices and positive life experiences and we can further enhance this by being aware of the process and feelings.

Managing the negative – But as a human being we will also experience negative emotions and in mindfulness we are not trying to suppress these, or trying to always be happy and to deny that negative experiences happen. This is where mindfulness presents a number of skills that are very useful in managing negative experiences. In fact this is a growing area in psychotherapy where mindfulness is being used to manage depression, anxiety, pain management, stress related illness etc. Mindfulness Based Cognitive Therapy, Mindful Compassion Therapy and Acceptance and Commitment Therapy are examples of these approaches. The non-judgemental quality of mindfulness is at the heart of this aspect, the ability to observe our thoughts, sensations and emotions without the secondary reaction, allows us to defuse from the negative emotion. This defusing process allows us to tap into the observer self, which is the part of our mind that is simply aware of experience.

The observing quality of our mind allows us to create distance and space which lessens the emotional pain and gives us more room to see a solution and to be more creative and flexible with our minds. It’s important to note that acceptance doesn’t mean we don’t take action to improve our situation, it just allows us to be kinder to ourselves and cope with the things we can’t change more effectively.

Mindfulness also helps us to breakdown the experience into manageable pieces so the emotion seems less solid – the pieces consist of the different sensations in our whole body, the thoughts and emotions. We also see that these experiences are actually more fluid and constantly changing which helps to give us more freedom and equanimity, the whole cluster of experience is no longer fixed and tangled together in a strong complex. It now becomes a dynamic and more manageable cluster of flowing sensations, thoughts and emotions.

Essentially mindfulness helps us to manage our naturally evolved stress response, what is often called the fight or flight behaviour response which is associated with the sympathetic branch of our nervous system. Along with mental health benefits, we are starting to understand that this also provides physical health benefits, as stress is being seen by the medical profession as an integral part of most illnesses.

The experience itself – this brings us to the practice itself which engages the other side of our nervous system, the parasUSA Aug 2013 008 (2)ympathetic nervous system which Harvard Professor Herbert Benson called the relaxation response. Although relaxation is not the aim of mindfulness, rather awareness of moment-to-moment experience (which may include tension and stress), often as a side product there can be deeper levels of relaxation which are enjoyable in of themselves. The release of the neurochemicals described above, are associated with wellbeing and positive emotions and there are specific meditations designed to generate positive emotions such as loving kindness, compassion, joy and equanimity.

If these benefits sound worth spending 10 or 20 minutes a day to cultivate then why not sign up for our new 8 week course starting in February, check out our website www.themindfulnesscircle.com for more information.