Supercharge Your Therapy Sessions: 35 Essential CBT Tools for Trauma

Everybody, and welcome to this video on 35 trauma informed cognitive behavioral therapy techniques. I'm your host, Dr. Donnellice Snipes. As the title implies, in this video we're going to review 35 Cognitive Behavioral Therapy tools that can be used to help people feel safer and more empowered. Now if you're looking for a specific tool, there are timestamps down in the video notes, just FYI, because 35 is a lot of tools. So that can help you jump around a little bit more if you need to. In terms of the principles of trauma informed cognitive behavioral therapy, the goal is to use people's strengths, build on what they're already doing, help people recognize that they are the experts on their own lives. And tools and strategies they've developed in order to cope with stress, cope with life until now, may not be the most effective, may not necessarily be the most helpful, like in the case of addictions, but they were developed to help that person survive, help them see the survivor in themselves. We want to help them identify secondary effects of trauma like depression, anxiety, poor communication skills, abandonment anxiety. You know, there's a whole host of things help them see how that's maybe related to trauma and promote self care, help them develop tools so they can start moving toward the rich and meaningful life that they envision. The first and most basic tool is a behavioral one and that is to create self safety. We need to help people feel like they are safe so their HPA access or their threat response system can take a break. We don't want to have them feeling constantly hypervigilant, constantly being on guard and have an exaggerated startle response. So if we can help them feel safer at home, in the car, anywhere else they spend a fair amount of time, it's going to reduce the intensity and maybe even the frequency that that stress response system is activated. It's going to help their body start to recalibrate and that is wonderful. When they start feeling empowered, when they start looking at environments, at places and saying, you know what, there are things that I can do to help myself feel safe. That is huge. Now there's a lot of types of safety though, and we need to help them create a sense of physical safety from self and others. Now physical safety from others is pretty obvious. We want them to not be afraid that they're going to be assaulted or hurt in some way physically by another person. But safety from self is also important. We want them to feel, feel like they have tools to deal with overwhelming emotions so they don't engage in self injurious behavior or addictive behaviors or other behaviors that could potentially be destructive, affective or emotional. And cognitive safety from self and others is another type of safety we need to help them develop. Recognizing that that inner critic in their head can feel very threatening, can feel very intimidating a lot of times, and can intensify trauma. Helping them figure out how to deal with that inner critic is another aspect of creating safety as well as helping them develop safety from others emotionally and cognitively. Being able to set those boundaries and say this is how I feel, these are my thoughts. You don't have to agree, but you can't. I'm not going to let you take them from me. I'm not going to let you invalidate my thoughts or feelings. And then environmental safety from self and others or from others. And environmental safety is different than physical safety. Physical safety has to do with my body and not letting people injure myself. And environmental safety means creating an environment in which people don't have to fear for the things that they cherish their belongings. They don't have to worry that somebody's going to encroach on their environment, that somebody's going to take their environment from them, maybe kick them out on the street, for example. So we need to help them look at all aspects of safety and do as much as they can to reduce their feeling of threat and increase their feeling of safety and empowerment. I believe it's also important that people create a rescue pack to have with them. This safety rescue pack can help people feel grounded, safer, more empowered in a variety of situations because you can't possibly plan for every situation and how you're going to feel safer in every single situation. So a rescue pack can be helpful in that rescue pack. I encourage them to create a thought list that has distress tolerant mantras such as I can get through this, this too shall pass. I have friends that can help me whatever distress tolerance thoughts that they find helpful, usually somewhere between three and ten thoughts that they can have that they can just read over when they're feeling distress can be very, very helpful. Activities is something else they can do to trigger that vagus nerve, trigger that relaxation response or sometimes just help them stay grounded or turn their attention completely from whatever is making them feel nervous breathing, slow diaphragmatic breathing will help trigger the vagus nerve. Bubble stuff. Blowing bubbles, blowing up balloons or blowing bubble gum also has the same effect because it slows breathing down and can help trigger the relaxation response. Keeping a phone with them, which most people have now, so that's not too Outlandish, also important. So they have the ability to reach out to a friend, to reach out to someone who can listen, who can provide support, who can help them feel safer. In the event that they don't have anybody, then making sure they have the number of the local crisis line so they have somebody that they can reach out to. Narration is another activity that can be really helpful when people are feeling unsafe. If they narrate what they're doing, it can help them stay grounded, avoid dissociating, and be more aware of what's going on and how they are safe in the moment and sensations. Essential oils or wax tarts are wonderful because sometimes just smelling something that promotes a sensation of relaxation or brings back a positive memory can help trigger that relaxation response, and that can be really helpful. Likewise, having something that they can smell that can displace a trauma, trigger a smell that triggers their trauma can also be helpful. So if there's a particular cologne that triggers memories of their trauma when they're in the store, if somebody walks by, they have that cologne on, then the person can reach into their rescue pack and get one of those essential oils or wax tarts or whatever out and smell that. So it displaces that. It turns their attention to something else if they want to. For people who have a lot of especially olfactory sensory triggers, they may consider using something like Fix vaporub or some other type of rub that lotion or something that is scented and rubbing it right below their nose so they are smelling that pleasant scent the whole time and they're not waiting until they might be triggered, keeping an anchoring object with them, something they can hold, something they can feel, whether it's a. You know, those little tiny stuffed animals, I don't know what to call them, that kids used to attach to their backpacks when I was in school. Those can be helpful because you can stick those in a purse or something, a worry stone or prayer beads or something else that the person can hold. They can fit, feel that helps them feel anchored can be very, very helpful. Sometimes jolting yourself, if you will, out of a particular memory can be really helpful. You can splash cold water on your face. Now, I wear makeup, so I am not inclined to go into the bathroom when I'm feeling stressed and throw cold water on my face because that's going to make my mascara run. That's not a good thing. Ice packs can be helpful, and this was one that you probably aren't going to use a whole lot because they're not reusable. But the instant ice packs can be used if you can't access cold water to put on your wrists, on your neck, or splash on your face to help jolt you out of a particular distress spiral. Some people have particular music that they like to listen to or playlists that they listen to that help them feel empowered, that help them feel safer, that help them calm down whatever feeling they're looking for. And on the other end of the spectrum, sometimes noise canceling headphones can be really helpful. If, for example, one of their triggers is the sound of ambulance sirens. You can't make ambulances not run. Therefore, if they are feeling particularly stressed, having noise canceling headphones can be helpful to block out the sound of that particular trigger. I know the other morning something was going on in our town and it was early morning, so sound was traveling, but no joke for 30 minutes. It was just siren after siren after siren. And for somebody who's triggered by sirens, that would have been pretty, pretty intense for them. The next cognitive behavioral technique is distress tolerance. And if you're familiar with dialectical behavior therapy, you're probably familiar with distress tolerance. I have distressed distilled distress tolerance activities down from accepts and improves, which is what Linehan uses. And they're wonderful. But I've simplified it because a lot of people have difficulty remembering all of those tags. Thoughts, Distress tolerant thoughts, we've already talked about those. And having people develop a list of distress tolerant thoughts that can help them feel safer and more empowered. Activities to reset the HPA axis and improve vagal tone, that is to trigger the rest and digest, to trigger the relaxation response. That can be that diaphragmatic breathing that you do, just breathing or blowing bubbles or blowing up balloons. It can be through vagus nerve massage or where you're massaging one finger behind the ear, one finger right on the tragus, the little flippy flop thing on the ear and just gently massaging. Yawning is another thing. And now that I rubbed my tragus, I'm getting ready to yawn. Yawning is another activity that stimulates deep breathing, but it also triggers the relaxation response. Guided imagery is another tool in the distress tolerance toolbox, if you will. And you notice on the recovery pack that we just talked about, on the rescue pack, I had thoughts, activities and sensations, but I didn't have guided imagery because when people are feeling threatened, when they're needing that rescue pack, they're not wanting to check out, they're not wanting to use guided imagery. They're not going to feel safe, safe enough to transport themselves somewhere else. A lot of times, however, when they are in a safe place, if they're having flashbacks, if they're having intrusive feelings, sometimes it's not even a memory. It's this feeling that comes from out of nowhere. Guided imagery can be helpful. And that guided imagery can take the form of a mental vacation. Going to their favorite vacation spot and identifying five things that they see when they get to that spot. Four things they hear, three things they smell, two things they can feel. That can really help people turn their attention to something that promotes dopamine and relaxation chemicals being released, which can help down regulate that stress response, which is what we're doing with distress tolerance. We're not trying to avoid it. We're trying to down regulate the stress response so the person can get in their wise mind. Another image people can use is one, I just call it safety, whatever that looks like to them. For some people, they envision a force field around themselves. For other people, they have an angel on their shoulder. For other people, they have their God carrying them, like you hear in the poem footprints in the sand. Whatever they envision that helps them feel safer in the moment can be incredibly empowering. And if they're hurt in some way, distress tolerance can be helpful. If they're feeling pain, especially physical pain, they can envision healing, Whether it's, you know, nanobots or their immune cells knitting together, or healing the injured part. They've actually done studies on people with HIV and aids and found that guided imagery that focuses on the immune system actually does increase the. The number of T helper cells, which I thought was kind of cool and sensory. We talked about that briefly here, and we're going to talk about it some more. Because distress tolerance is sort of woven throughout cognitive behavioral therapy. But sensory tools can help people trigger that relaxation response. So that can be smells that help them feel relaxed. It doesn't have to be essential oils. It can be anything that triggers a positive memory or a positive feeling. Like coffee. For me, if I smell good coffee, that's just absolutely amazing. And it triggers that little bit of an endorphin rush and that relaxation response sites, whether it's pictures of their kids or of their dog or of a beautiful landscape, what is it that they can look at that may help them feel calmer or more safer in the moment? Sights, smells, sounds. What can they listen to that might help turn their attention away from their distress for a moment? We're not ignoring it, we are turning our attention away from it. We're taking A break until the stress response can be dampened some, so the person can address it through their wise mind breathwork. I already mentioned this a little bit, but breath work is so incredibly important in therapy, in cognitive, behavioral therapy, in just everything. Well, we need breathing, we need oxygen to live. But slow deep breathing, especially diaphragmatic breathing or belly breathing, actually can help trigger the vagus nerve. They call it respiratory vagus nerve stimulation, or RVNs. So square breathing we've talked about in multiple other videos is when you breathe in for four, you hold for four, you exhale for four, and you hold for four, and then you repeat that a couple of times. When you slow your breathing, it automatically triggers your heart rate to slow down. When you're breathing and your heart rate slow down, your stress response system says, oh, guess I don't need to be freaking out right now. So you're manually overriding. By slowing your breathing, you're manually overriding your stress response. Now, obviously, if there is an impending threat right before you, no matter how slowly you breathe, you're going to be getting other feedback that is gonna keep you from becoming completely relaxed. But even in the face of stress, slowing your breathing can help mitigate that stress response. So you can maintain your quote wits about you a little bit more effectively. So square breathing is ultimately the foundation of what we're talking about. But there's a lot of ways to slow your breathing down. Some people feel like the square breathing or taking a few deep breaths is corny or they don't feel comfortable doing it, whatever. Okay, fine. As I mentioned, yawning is a wonderful way to slow your breathing. And you can force yourself to yawn. You can also massage your vagus nerve and that may encourage a yawn. You can do different vagus nerve stimulation exercises that can trigger yawning laughter when we laugh, especially again, belly, a good old belly laugh. You're gonna take a deep breath in and then you guffaw until you have exhaled. So you're doing a slower exhale. You just don't really pay attention to it. I encourage people to create a playlist on YouTube or I don't know if you can do playlists on TikTok or not, but create a playlist that stimulates that guffaw, that stimulates that good belly laughter that they can turn to when they need to trigger their relaxation response. I mentioned already bubble gum, when you blow a bubble, you're going to blow slowly so it doesn't pop in your face. Bubble stuff. And you can get the little tiny Bubble stuff containers that they use for parties. You can get that at Target or Walmart or online, I'm sure. And you can carry that with you. And so you can just pull it out and blow bubbles whenever. Now, being 50 years old, people look at me like I'm a little odd if I pull bubbles out in the middle of the parking lot and start blowing them. But, you know, if you don't care, then no big deal. Balloons are another thing. And you can do this in your car. Or so if you're having a bad moment, maybe you can go to your car, you've got a balloon there, you can blow it up again. To blow up a balloon, you're going to inhale big and then you're going to blow, blow, blow. So you're slowing your breathing. And those are things you can keep with yourself. Party noisemakers. And I don't know what else to call them. They're the little noise makers that you blow on and they make that horrible screeching sound or whatever, however you characterize it. Kids especially love those because they're loud and annoying. But that can be one other option, or dragon breathers. And that's what I have a picture of here. You can use a toilet paper roll or you can one of those plastic cups, a red solo cup or something. And then you cut strips of tissue paper and glue it to one end and you cut out the other end so it's a tube if you're using a cup. And then when the child is distressed, they can take a big breath and then they can blow and let all that anger out through the dragon breather. And last but not least, fitness trackers. Fitness trackers monitor your heart rate. So instead of thinking about breathing, if you're thinking about lowering your heart rate, well, you've got to slow your breathing in order to lower your heart rate. So some people will use their fitness tracker and they will just sit back for a minute and then they will intentionally slow their breathing so they can reduce their heart rate. When your relaxation response is triggered, your heart rate's going to go down. So that is a clear indication that you have manually overridden that HPA axis. Another one of my favorite techniques is defining your rich and meaningful life. For people to figure out, you know, where am I going? How should I use my energy? What's important for me to focus on? Ultimately, it's important to know where they're going or know where they want to go. So what does that rich and meaningful look life look like for them? And this is just an example of a vision board that I created. You only have so much time and energy. How are you going to use yours? What people are important in your rich and meaningful life? How are you going to use your energy to nurture those relationships? What things like health are important in your rich and meaningful life? And how are, how much energy are you going to use to nurture that career is another one I've got on mine. How much energy am I going to use to nurture that? And what does that look like in my rich and meaningful life? And then again, this is mine. So all my critters and my farm are on here too. But this gives people something to look at and they can start every day looking at this and saying, all right, these are the things that are important and this is how I'm going to allocate. This is how I'm going to spend my energy today or this week. So it helps get them focused. And then if they have to make a decision, if something comes up during the day, they have the ability to reflect. Look at this again and they can just take a picture and keep it on their mobile device. They can look at that picture again and ask themselves, alright, is devoting energy to whatever this is that's come up helping me move toward my rich and meaningful life or is it stealing energy from the things that are important in my rich and meaningful life? So I really love this vision board as a tool not only to have on the wall, but also to have on the mobile device to help people regroup and refocus throughout the day Once they've defined their rich and meaningful life, Then we move on to what Hayes in acceptance and commitment therapy calls purposeful action. Mindfully acknowledging the present. This is where I am right now. This is what's going on. It's not good, it's not bad, it just is. And then how should I use my energy right now? Given my context? What is the most effective way to use my energy to deal with the current situation that will help me move toward the things that are important in my rich and meaningful life? Do I need to address it? Is it something that is in my way? Is it something that I need to do something about? Okay, if so, then let's make a plan. Is it something that really doesn't matter? I'm just getting all tied up about it, but in the big scheme of things, it doesn't keep me, it's not blocking me from moving toward my rich and meaningful life. I've just got gotten distracted by it. Or should I change my reaction to the situation? Moving from anger, for example, to compassion. Maybe somebody does something in my life that triggers my anger, is holding on to that anger, is continuing to be angry at them, helping me move towards my rich and meaningful life. Or is it stealing energy that I could be using, spending on nurturing other relationships, or even having compassion for them? Purposeful action is another tool of empowerment because it helps people recognize that they have options. And that is so important. Now, symptom logs. Bear with me with the symptom logs, because I'm going to show you a few different ways to do it. However, you know, I got some of my foundation knowledge, I got my minor in behavior modification, so that gave me just enough knowledge to be dangerous sometimes. But symptom logs were one of the big takeaways that I got from that. And symptom logs are important because, you know, for example, when you're on a diet, or if you've got small children or a puppy at home, when you are seeing that thing every day, when you're interacting with that thing every day, whether it's yourself, your kid, your puppy, you may not notice incremental changes. And then all of a sudden, one day you're like, whoa, you've grown up. Or, whoa, you've mastered the piano or something. But so the same thing is true with mental health symptoms. When people are dealing with it day in and day out, they may not notice the incremental changes. So symptom logs can be really, really helpful, not only for documenting those baby steps toward their rich and meaningful life, but also to help people see how far they've come. Every couple of weeks, you can look at it and say, okay, let's look at how far you've come. It gives you the ability to look for trends. You can look for triggers for particular symptoms. You can look for vulnerabilities. What things or situations make a person more vulnerable to? Reacting to situations with anger, you know, sometimes something may happen, and it may not bother them at all. They get cut off in traffic, for example. Other times they get cut off in traffic and they just fly into a rage. What's different? Why were they more vulnerable the second time? So symptom logs can provide us a lot of information because it gives us a better peek into what happened. In dialectical behavior therapy, Linehan talks about backward chaining. Ideally, the person completes the symptom log when it happens, but you can do it at the end of the day. Symptom logs need to, at the very least, include the Date it happens. The time is it 8 in the morning? Because some people are more irritable or in a better mood first thing in the morning versus late at night and vice versa. So what date does it occur? What time does it occur? What triggered the symptom? If known or if there were distressful thoughts, what was the theme? What was the intensity of the experience? If they're having a flashback or if they're having an anxiety attack? Was it A1? I noticed it but wasn't a big deal. Was it a 2? I noticed was uncomfortable but I managed to get through it. Was it a 3? It was really difficult to keep moving forward while I was having this symptom or was it a 4? And in a 4 the symptom is just all encompassing and they can't continue doing what they were. It kind of shuts them down for a minute. How long did it last? Was it five minutes or five hours? How did it impact their energy, mood, productivity, relationships? Said another another way, how did it impact those things that are important in their rich and meaningful life? What vulnerabilities and this goes to that backward chaining. What vulnerabilities were present? If they had an anxiety reaction, were they over caffeinated or dehydrated or was their blood sugar low or were they in a particular environment that they tend to find stressful anyway, what did they do to cope? Was it effective and what do they want to try to do the next time? Maybe they want to do the same thing the next time because it was effective, great. If it wasn't effective, they may choose to try to do something else. If the symptom seems ever present, like anxiety. Some people feel anxious all the time. Okay. Have them complete the log every hour that they're awake. Now I know that seems like a lot and if they're working full time, that might not be practical. If they're not working, it's definitely doable. If they're in residential treatment, it's definitely doable. So you can adjust how often they do their check ins, but definitely every couple of hours. Once they get this information, once they've got the data, then it's going to be important to review the logs for themes in triggers and vulnerabilities. I encourage people to make a pictograph of the frequency, intensity and duration of their symptom so they can get an idea of how often is this happening and kind of how bad is it. In this one you can see from 8am to 9am the person was having an anxiety attack. It Lasted for a whole hour, which is why it's as wide as it is. And the entire time they were having it, it was at a level of a three, so it felt pretty dagum overpowering. They still kept moving, but it was really overpowering. And then at 9 o' clock or 9:15, that went away. And then at 10:30 they had another little anxiety attack, but that only was a one and it only lasted for about 30 minutes. And then at 12:30, 12:45, whatever, they had another one that was a big one. I mean it was all encompassing, full out panic attack. And that lasted for almost 30 minutes. So then when somebody brings this in, I would talk with them and I would say, you know, what were the triggers? And maybe at 8am the person's anxiety ramped up because they knew they had to go to work and work is just really, really a huge source of stress right now. Or they knew they had to go to work and they were going to have to ride the subway. And the subway is one of their triggers from their trauma. So their anxiety went up really, really high. But then they got to work at 9 o', clock, everything was okay. They de escalated sweet. And then at 10:30 they had to go to a meeting with their boss and that was a little stressful. They got along with their boss fine, so it's not a big deal, but it was a little bit stressful having to do that. And then at 12:30, that was after lunch was over and they were getting ready to go back to work and they got cut off in traffic and it triggered an anxiety attack that lasted 20 or 30 minutes. Okay, so by looking at this, we can see how long they're lasting. And then we can more granularly look back and go, okay, what's triggering? And see if there are themes that are triggering anxiety at particular times of day or in particular places, because that can help the person gain more awareness and be better able to prepare or adjust in order to reduce their stress. Now you have a lot of these charts laying around. That's great. You may be able to look at them, but it's hard to really get see incremental progress when you're still looking at four or five episodes a day and they're all still pretty high. It's hard to know are we making progress, are we reducing the frequency, intensity or duration? And you know, sometimes it may be obvious, but sometimes it may not be. I use a mathematical formula. So here the first block is 1.25 hours. So for an hour and 25 minutes she was feeling, you know, huge amounts of anxiety. The intensity was at a level of a 3. So you can see 1.25 hours, level of a 3. And then the next one was at 10:30 that lasted half an hour. It was an intensity of a one. And then we have this other one over here that was a half an hour that was in an intensity of a 4. In order to take into account the frequency, intensity and duration, because we're looking for an overall improvement, it doesn't matter whether it's frequency, intensity or duration. I multiply the number of hours by the intensity and add it all up. Then their average anxiety is the number of total hours they were feeling anxious divided by the total intensity. So the mathematical formula here was a 0.36. So if we had to average out her anxiety over the entire day, what we would be looking at is a 0.36. Remember, one is they're feeling it. And ideally we don't want people feeling anxious all day every day. So I'd like to see that a lot closer to a 0.0 than a 0.3. But next week we would go through and add up the data and do this again. Now, for some people this could be too data driven and I get that. So you can skip the mathematical formula if it's not for you, but I think the charts are at the very least very helpful because people can really get a quick vision of do we see things going down. Now, an alternative log. If somebody feels like they are anxious all the time, they've got generalized anxiety, then there's not going to be any particular time that they have a symptom or they have an episode. It's just kind of all the time. So remember I said assessing it on an hourly basis and this is chart on an hourly basis. If you do it every two hours, then it would adjust accordingly. So each hour the person asks themselves, how am I feeling? On a scale of one to four. And we have three hours that it was a three, we have one hour that it was a three and a half. And then you can see that towards the evening, towards the end of the day, it actually went down to a one. We want to ask the person, you know, what was different at 3pm than at 8am what was triggering your anxiety throughout the day and why did it go down at 3pm but also why was it still present at all at 3pm? What else is contributing or maintaining your anxiety? And maybe it's just ruminating or anticipating having to go to work the next day. I don't know. You can do the same mathematical formula here. And for this person, based on that chart, their average anxiety over the course of the day was a 1.88. So they're still feeling some pretty intense anxiety. And we would look for that number to gradually decrease over the course of treatment. The next technique we're going to talk about is systematic desensitization and ownership. And these are similar or similarly related techniques. They're not exactly the same, but I lumped them together. Systematic desensitization and ownership helps the person alter their reaction to triggers or stimuli in the environment. Think about it like an allergy shot for cognitive allergens. It creates an environment of safety and empowerment. When they start realizing that things do not have to control them, then they can start feeling more empowered. They master the ability to use breathing, relaxation and distress tolerance skills to down regulate their stress response when they feel triggered. Just because I smell this smell, just because I see this thing, it may trigger a trauma feeling, but it doesn't have to consume me. I can address it, I can help myself feel safe and I can get control of that situation. So the example I use for systematic desensitization is snakes. Because a lot of people have a fear of snake snakes, but it can be anything. The first step is to learn about the trigger, learn about whatever it is, whether it's snakes or flying, or in the case of trauma triggers, like the smell of a particular cologne, you may not have to learn a lot about that, but you recognize that. Oh, okay, the smell of this cologne triggers a trauma memory. Alright, now what do I do about it? Well, we're going to take away the power of that trigger. We're going to take away the power of that stimulus. So we have the person think about the stimulus and so think about the snake or think about what that smelling that cologne and their anxiety is going to go up, their stress response is going to go up and then they're going to use distress tolerance skills to trigger the relaxation response to dampen that stress response so they can get into their wise mind. Once they're in their wise mind, then they can effectively address the facts of the situation. In this situation at this time, am I safe? I smelled that smell triggered my stress response. All right, I'm going to push down my stress reaction, I'm going to dampen my stress reaction, get into my wise mind in this situation at this time, does that smell represent a threat to me or is it just somebody that walked past me in the store? The important thing is Helping people get into their wise mind so they can effectively evaluate the facts in the current context. Once they can think about a snake and it doesn't trigger that stress response, they've been able to decouple that stress. So just thinking about it doesn't trigger that response anymore. Then think about being in a room with a caged snake. So it's not just some snake somewhere, it's a snake in the same room with you. It's in a cage, but it's in the room. They go through the same process, practicing, imagining that and down regulating their stress response until thinking about being in a room with a caged snake doesn't trigger that response. Think about being in a room with someone else holding a snake. So now the snake's not even in a cage, but somebody else is holding onto it, thinking about that. We're not nowhere near being in the same room with a snake yet. We're just helping the person envision, imagine these situations and learn how to down regulate the stress response to their cognitions, to their beliefs. Think about petting a snake someone else is holding and then think about holding a snake. Once a person can move through all of these things and it doesn't trigger their anxiety response, it doesn't trigger their stress response anymore, then you can move toward, you know, maybe going to a pet store where you're in an environment with a caged snake. And again, there would be more steps to desensitizing to that particular stressor. But it can be really helpful again, not only for snakes or spiders or planes or phobias, but also for other triggers. So people can think about smelling that smell, and then they can get to the point where they can actually smell the smell, and it doesn't trigger that stress response for them. In terms of ownership or immersion. When you're regularly exposed to something and able to manage your response, it loses much of its power. Now, this isn't something that I recommend. I don't recommend flooding for people to do on their own, but it is a technique that people can use, especially with what I call annoyance triggers. It's not a trigger that triggers this cascade, this flood of stress chemicals, but it's enough to trigger a stress response. It triggers their resentment, their irritability. If it is a smell or a saying. Sometimes people have have success making it their own, making it theirs to control. So they start wearing that particular perfume or they start using that particular scent to as a fragrance in their house. I had a client one time who had a significant other that had a particular saying. And every time he heard that saying after they broke up, it just brought back a flood of memories and just triggered his anger. He's like, oh, when people say that, it makes me want to climb the wall. So I encouraged him to for the next week, to use it himself. You start saying that whenever you can. You start saying that, make it your own so it's no longer associated with her. It's something that you do. And then if you don't want to say it anymore after that, that's fine. Associated with positive things like smells, activities, or holidays. If something triggers a stress response, try to pair it with something else positive as much as possible and regularly expose yourself to it while regulating your stress response. And this is one I use for bridges, because I can't get away from bridges where I live. But I don't like bridges. However, I've gotten to the point where I can drive over them and they don't really bother me that much anymore. Systematic desensitization should be undertaken with care to prevent moving forward too quickly and causing additional anxiety or retraumatizing yourself. It always starts with ensuring you feel safe and empowered. And every scenario needs to end with the person feeling safe, empowered, so they feel safe and empowered. They imagine the stressful situation and then they de escalate. Before beginning any type of exposure, even imaginary exposure, it is essential to have mastered the skills of distress tolerance and emotion regulation. Mindfulness is another wonderful cognitive behavioral tool. Mindfulness means turning off autopilot and being non judgmentally aware of your thoughts, feelings, needs and behaviors in the present moment. It helps connect thoughts, feelings and behaviors and promotes prevention and early intervention of distress. Think about how operating on autopilot may contribute to sickness, anger, outbursts, or relapses of depression. So there are a lot of different kinds of mindfulness, and the first one we're going to talk about is personal mindfulness. Start with being mindful as soon as you wake up in the morning, at each meal and before going to bed. And for a lot of people that I work with, I encourage them to set push notifications to remind them to check in and be mindful. I know you need reminders to be mindful, but each time they check in with themselves throughout the day, they ask themselves, how do I feel physically, how do I feel emotionally, and why? What do I need right now to continue feeling great? If they're feeling awesome, great, keep it going or improve the next moment. If they're feeling tired, hungry, run down, anxious, checking in with themselves and figuring out what is it that I need to do to improve the next moment? Grounding can be thought of as another kind of mindfulness, and it's a technique to help people feel connected to the present moment and not swept up by emotions or thoughts. Two of the most common grounding activities are the 5, 4, 3, 2, 1 and the Describe an object in 5, 4, 3, two, one. When the person starts feeling stressed, they identify five things they see, four things they hear, three things they smell, two things they feel, and if possible, one thing they taste. Describing an object can mean holding an object. It can be your phone, it can be your purse, it can be your grounding object and just describing it to yourself, is it cold? Is it hot, Is it soft, Is it bumpy? Whatever sensations you get from it. But that encourages the brain to stay anchored in the present moment, which can help with dissociation, it can help with anxiety, and it can help with triggering that relaxation response as people turn their attention away from the anxiety provoking stimulus to what is helping them stay relaxed in the moment. I find the describe an object is really helpful when I go in to get shots because to this day I am terrified of needles. But that helps me a lot. I'll be holding a grounding object and thinking about what it feels like and all those things. So when I get the shot, I'm not thinking about that. I'm not anticipating it hurting, I'm not tensing up. General mindful awareness encourages people to be aware of the moment, not just themselves, but the moment in general. Become more mindful in your actions as you're doing them. What do you see? What do you hear, what do you smell? When you're out on a walk, have that open awareness where you're just noticing anything that's there. It's not necessarily good or bad, you're just noticing it. You'll be surprised at all the things that you typically probably overlook. And mindful reflection is an activity in which people reflect on their activities at the end of the day by asking themselves, what did I do? And for each of each thing that they did throughout the day, was doing this an effective use of my energy to move toward the things that are important in my rich and meaningful life? Or was doing this, whatever it was, what a happy, healthy, successful person would do? Some people like the rich and meaningful life, you know, does it help me move toward my goals? But other people want to act as if fake it till you make it, as they say. So they ask themselves, was I acting like a person who was happy, healthy, and successful would have acted. Examples. You know, when you're reflecting on the day, if you got sucked into video games for three or four hours, it's easy to do, asking yourself, was this an effective use of my time to move me toward my rich and meaningful life? If you were playing video games with your best friend and it was good bonding time, well then maybe it was. If not, maybe it wasn't. It's up to each individual to decide. Was this important? Is this something that you really like doing? Is it a hobby? Does it promote relaxation? Well, then maybe it was an effective use of energy. You can do the same thing for dwelling on resentments or eating unhealthfully. Was it effective at helping you move towards your goals? Was it something that a happy, healthy, successful person would typically do? An ounce of prevention is worth a pound of cure. Mindfulness is essential to health and well being because it can help you become your own consistently empathetic, responsive best friend. It can help you become more aware of the situation and notice the good and the beauty in in life in addition to the stressors, and also become more aware of how how you're using your energy and whether it is moving you forward or keeping you. Authenticity is the next tool we're going to talk about. And I love authenticity. It means being true to yourself. People often become inauthentic because they're trying to get approval from others. Their self esteem is low, so they're looking for somebody else to tell them they're okay. They may be inauthentic because they're afraid of being rejected, abandoned, or in today's society, canceled. Or they may be inauthentic because they're just operating on autopilot. They're not acting mindfully. They have always just kind of done whatever happens and haven't really stopped to think about, is this me? Is this me being authentic or is this me just being impulsive? I use the metaphor for chocolate chip cookies when I talk about relationships and when I talk about authenticity. When you have chocolate chip cookies, you've got sugar cookies and you've got chocolate chips. Both of them are just fine on their own, thank you very much. One doesn't pretend to be the other. They are authentic in who they are. Now, if you put them together in relationships, when you have two authentic people that join together, you can get something that is potentially infinitely better than either one of those things all by themselves because they enhance each other. They don't complete each other. They're already complete by themselves. They enhance one another. When you're practicing authenticity. It's important to become mindful of your thoughts, feelings, and needs and act in accordance with them instead of being a chameleon. So mindfulness is a precursor to authenticity. It's also important to help people separate approval or disapproval of behaviors from themselves. Not everybody's going to like what you do if you're behaving authentically. Not everybody may like your choices, but does that mean they dislike you or they dislike your choice? It's important for people to explore and address their fears related to being authentic. And a lot of people have fears about being authentic for very legit reasons these days, unfortunately. And if it is because of that radical authenticity or being yourself 100% of the time may not be safe for everybody in every situation. So it's important that they practice being assertive and authentic, Sharing themselves with safe other people first, and then deciding, is it important for me to be authentic here? Is it important for me to be authentic on social media? Is it important for me to be 100% authentic at work? And only the individual can figure that out. And if they can't be a hundred percent authentic, is that in an environment that's healthy for them to be in? And again, only they can decide. But that's part of the empowerment of cognitive behavioral therapy. Helping people recognize that they are good enough, they are deserving of love. They are in a position, they are empowered to help keep themselves safe. And that also means safe from harm from others and safe from others being mean to them, if you will, if they're authentic, from taking away their authentic selves. Authenticity means moving from what? Moving from being aware of thoughts, wants, and needs to acting in a way that's in accordance with them. So if you know that you like Italian over Mexican food or that's what you want, an authentic person would be mindful. They would recognize, hey, I want to go for Italian food. And they would tell people that. They would assert that if you're being inauthentic, then you may know that you have a craving for Italian food. But you know what? No, I don't care where we go. I don't have any preference. Well, that's inauthentic. Yes, you do have a preference. Being authentic can be scary at first and is often advisable to not advisable to suddenly start practicing what I call radical authenticity, which can make the person feel really vulnerable, not suddenly deciding that, okay, starting today, I am going to be 100% authentic all the time. That is a radical shift not only for the individual but for everybody around them. And it could upset the apple cart, so to speak. It may take people a minute to get used to someone suddenly becoming authentic, which can set them up for not so great reactions from significant others. But also, when you're authentic, you're putting your true self out there. You're making yourself vulnerable. And making yourself vulnerable can be extremely scary, especially for people with a history of abandonment, rejection, or trauma. So it is important to use this with care. Yes, it's great when people feel like they can be authentic, but it's something that a lot of times people need to build up to. As people become more authentic, have them notice how it impacts their mental and physical health. Thought stopping is the next tool. Thought stopping helps us redirect our brain and we can engage in thought stopping by simply telling ourselves, no, not now, not thinking about it. Sometimes that helps. Sometimes people need to replace the thought with a mantra, a prayer, or grounding activities to sort of drown out whatever that thought is to turn their attention. If the thought keeps coming back, okay, then ask yourself, what's the benefit to ruminating on this thought? Why does it keep coming back? Why do I keep feeling like I need to think about this? Is there anything that the person can do to address the thought and improve the issue at this moment? So, for example, if you're waiting on test results from the doctor that aren't going to be in for another six days, what's the benefit to ruminating on that? Why does it keep coming back? Is there anything you can do to address the thought in the moment? And the answer is no. You just got to wait and be patient. So sometimes people will write it down and put it into their thought box. A lot of times it can be helpful. For people who have persistent thoughts, ruminations, whatever you want to call, call it, they write these things down and then they schedule 30 minutes a day. That's their worry time. So these thoughts pop up and instead of saying, no, I'm not going to think about it ever, no, I'm not going to think about that right now. I will think about it this afternoon during my worry period. Encourage people to start small. Try to stop having the thought for five minutes. And if they make it to five minutes, then great thought may come back. Let's try 10 minutes now. See if you can make it 10 minutes without thinking about it. And it can be empowering to the person to recognize that they are getting better at learning how to stop some of the those annoying thoughts or those annoying voices that want to chime in perspective taking is another tool. Look. Perspective taking means looking at the bigger picture to understand the reactions of other people as sometimes as well as yourself, you know, stepping back and trying to get a different perspective. There are four P's in perspective taking. Predisposing. What were the background factors that contributed to the behavior, whether it's another person or yours? If the client has a history of trauma, that's one of those predisposing factors that may contribute to them reacting with fear or anger in particular situations. For example, precipitating factors. So you have somebody who's been exposed to trauma, somebody who's endured trauma, and so they already have an HPA axis that's, you know, turned on. They already tend to be more hypervigilant. Precipitating factors are vulnerabilities and contextual factors that precipitate their reaction. They have this history, and then they're in a situation in which they feel somewhat unsafe. And they're in this situation where there's lots of hustle and bustle. Maybe they're at the airport and there's just lots of people going around and bumping into one another, and they start feeling really stressed out because it feels like an unsafe environment. They feel vulnerable. Provocations, what provoked or triggered that behavior? And if you're talking about trying to understand somebody else's reaction, then looking at your own behavior and saying, in what way might I have inadvertently provoked that behavior? And I say inadvertently because a lot of times we may trigger somebody's anger and we didn't even mean to. Maybe we didn't think clearly before we said something, or maybe we have no idea what we did to trigger that person's behavior. But recognizing that there may be something that we did okay, doesn't mean we meant to. And plans. If you reacted with anger or anxiety and you regret it, recognizing where that came from and asking yourself, well, did I have good intentions? Did I go into this situation saying, yeah, I'm just going to be kind of nasty about this, or did I have good intentions? But the predisposing, precipitating, and provoking factors led me in a different way. Same thing with when you're dealing with somebody else. If you're interacting with them and they react strongly to something that you say, it's important to ask yourself, you know, why are they perceiving it differently than I am? What predisposing factors, what historical or experiences might they have had that caused them to interpret this situation differently? In what way might I have inadvertently provoked the behavior and did the person really ultimately have good intentions? They may have not intended to get into an argument with you, but it just, it ended up there. Self forgiveness is the next tool we're going to talk about. Remember that forgiveness does not mean that you agree or condone the situation or what happened, but you're choosing to stop using your energy to beat yourself up. The four Rs of self forgiveness Responsibility. Yeah, you need to take responsibility for the aspects that you're responsible for, but that's it. Only take responsibility for the aspects that you're responsible for. If something happened between you and someone else, as they say, it takes two to tango. There are probably a lot of other factors that were out of your control. Take responsibility for what you're responsible for. The second R is remorse. Well, if you're working on forgiveness, then you do feel remorseful. You feel guilty, but just feeling guilty keeps you beating yourself up. Guilt is self anger. So feeling remorse is your body's way of saying, okay, here's some energy. Now you can use this energy to learn from this situation so you can stay safe in the future, or you can fix the mistake you made. Which takes us to rectifying or making amends. What do you need to do to fix this situation? Make amends or just learn from it? Sometimes you can't fix it. And the final R is releasing past hurt and accepting imperfection. Forgiving yourself and saying, all right, you screwed up. It doesn't make you less lovable. It just means you're human, you're fallible, you're imperfect, and you forgive yourself. You're going to choose to not continue using energy. Beating yourself up for something you have rectified and taken responsibility for. Forgiving others is very similar. Forgiveness still means choosing to stop giving energy to that person or memory that is causing you distress. Forgiveness can involve recalling the betrayal, recalling what happened that is causing you to feel angry or resentful. Explore why you might be afraid to forgive them. Why are you wanting to hold on to this energy? Why are you afraid to learn and let go? Altruism. Visualize forgiving this person as a gift to yourself and your significant others. I'm forgiving this person over here, so I'm not tying all my energy up in it anymore. Which is great because now I have all this energy freed up that I can give to myself and my significant others. Learn from it and adjust your expectations. Sometimes people ain't going to change. Therefore, recalling the betrayal, what happened, and what do you need to learn so you don't get hurt in the future. Living in the AND is another tool that can be helpful for forgiving. You can have a rich and meaningful life and not be able to trust this person anymore. If that's what has to happen, it doesn't mean you're going to continue to be angry at them. You've just learned that they're not trustworthy. So living in the and means you can have a rich and meaningful life and forgive other people. Sometimes it's easier to forgive smaller things first. It can help to empathize without minimizing. You can empathize and try to understand why somebody did what they did, maybe even have compassion or pity for them, but not minimize it. You're not saying, oh, I have pity for you. I understand why it happened and you know, I guess it wasn't really that bad. No, I can empathize with what you were going through and maybe why you reacted with such anger. However, this is how it impacted me and I am not going to diminish the the impact it had on me just because you were going through a bad thing. So I'm going to empathize without minimizing. Safely share your feelings. This isn't always possible, but sometimes it can be helpful to safely share your feelings with that person, or maybe even with your higher power, or just your journal. But sometimes you need to get them out. Sometimes there are things that quote need to be said that are going to keep bouncing around in your head until you can say them. So say them in a safe way and then practice thought stopping. Even after you've chosen to forgive somebody, every once in a while, that resentment or that anger is going to creep back up and you're going to remember what happened. And that's when thought stopping comes in handy. And you can say, nope, handled that already, not going to revisit it. And then the ABCDEs of CBT A and if you remember back to basic cognitive behavioral therapy, this is one of your basic tools. A is the activating event what happened? C is the consequences of the activating event. And we want to consider all of the consequences. Not just your emotional reaction, but your physical reaction, your cognitive reaction. How did it change the way you think about people and the world? Your relationship reaction? How did it change the way you feel about your ability or the trustworthiness of people in the world? So the activating event and the consequences. But between the time that something happens and you get angry or that HPA axis, that stress response gets triggered, you have a litany of automatic beliefs that come from schema, come from past experiences. Your brain's going, okay, let me tell you how to interpret this. A lot of times these beliefs, because they're based on past experiences, may not be 100% accurate in the present context, which is why we go down to D. After you've identified what those beliefs are, then you dispute each one of them based on the facts in the current context. Is this belief still 100% accurate based on the facts in the current context? Once you've identified what is actually true in the current context, then you can evaluate the effectiveness of your reactions for helping you use your energy and time to move toward your rich and meaningful life. So, okay, maybe something happens, it triggers rage in you. You get really angry that somebody did something. You go through your beliefs and you dispute them and you determine, yeah, you know, they betrayed me. It was a big hurt. Okay, so evaluate the effectiveness of your reaction. Is holding on to anger, is dwelling and stewing on anger and holding on to this resentment. Is, is that an effective use of your time and energy to help you move towards your rich and meaningful life? Or would something like forgiveness be a more helpful tool? Cognitive distortions is another basic cognitive behavioral therapy tool that we look at. And there are five, maybe six big ones that frequently come up. When I work with people, and all or none thinking, this person always does this or this person never does this, I encourage people to pay attention to their cognitive distortions, to their extreme language. And if they say always or never, to reframe that and start saying sometimes or often. Look for exceptions. If you say that Jane never calls when she's going to be late, look back, Are there exceptions? Are there times when Jane did call? Personalization means taking what somebody else does personally, it's my fault, or they looked at me with this horrible look, they must be angry at me. What are three alternatives that have nothing to do with you? Magnification or catastrophe, which means making a mountain out of a molehill or assuming that the worst case scenario is going to happen. Look at the facts in the situation based on the facts, how accurate is your belief? Minimization is the same way. And sometimes people will minimize the impact of drinking, for example, and that can be faulty. If they are having. If they're in recovery for alcoholism, they may also minimize their strength and their power and their ability to move towards their goals. They may minimize their own effectiveness. And so it's important to look at the facts. Is it true that you are powerless in this situation? And then assuming can be broken down into mind reading and jumping to conclusions. A lot of times when people grew up in dysfunctional environments, they learn to try to anticipate other people's needs in order to get approval and prevent punishment. And they carry that with them into adulthood. Unfortunately, it's not common to be able to effectively read other people's minds. Open communication is a whole lot more effective. So if you are mind reading, if you're assuming that you know what somebody is thinking or wanting, check it out. What are the facts? What do you actually know versus what are you assuming? Related is jumping to conclusions. Maybe your best friend doesn't text you back or stands you up for lunch, a lunch date that you made three weeks ago. You jump to the conclusion that something terrible happened, and she's, as my mother would always say, lying dead in a ditch somewhere. That's jumping to conclusions. So look at the facts based on what you know. You don't know why they didn't show up for your lunch date. When I'm working with clients, I have a cognitive distortions worksheet that I give them and I encourage them to go through it. When they have stress, when they feel anxious, when they feel angry, when they feel distress, they write down what the activating event was, what the trigger was, and then B is the beliefs. They write down those beliefs, and then they evaluate each one of those beliefs for cognitive distortions. Alternate problem formulation is another cool one, or I think it is. And I use the mnemonic Peace Corps for this. And this kind of puts together a lot of what we've been talking about. So the person identifies the problem. They identify early experiences they've had that may impact how they perceive the situation. So maybe they have. They're anxious around authority figures. That's the problem. Early experiences. We look back at early experiences with authority figures. Not so good. So, yeah, it makes sense why this person might have anxiety around authority figures. A stands for assumptions, rules, and attitudes. What are your assumptions about people who are in authority positions? Based on your early experiences. So you're seeing how this is all starting to connect. Our past helps us try to interpret the present, but it's not always 100% accurate. So we need to understand why am I assuming this to be true. C is core beliefs. What are your core beliefs about people? If you have core beliefs that people are only out for themselves and they'll throw you under the bus any chance they get, then you're going to feel less trusting and probably be more apprehensive than if you think that people are Altruistic E stands for effectiveness of assumptions, core beliefs and reactions. Based on all this stuff in the current context, how effective are my assumptions and core beliefs at helping me function? And then the core part is looking at that context with the facts that I have in this context at this time. What are my options to handle the situation? What resources do I have to help me handle the situation? If I do the things that are within my control that I have options and resources for, what's the probability that things are going to go well? And where can I find support? Another technique that I really like is tragic optimism. And this can be summarized in the mnemonic crabgrass. And I like crabgrass because it is an example of tragic optimism. I don't know if it grows in the northern states, but in the southern states we have this weed that, that we call crabgrass. And it will take over your lawn. It is just a bugger and a half to get rid of, but it tends to be very resistant to heat and weather and it stays green for a really long time. So if your goal is to have a green lawn, crabgrass can be really frickin awesome. If your goal is to have this perfect fescue or Bermuda grass lawn, then, then, yeah, crabgrass is not your friend. But so tragic optimism means embracing the good with the bad, recognizing the current situation and saying, all right, it is what it is. What do I want? Is there hope that it can get better? And so you start out by creating a vision. What is your vision of your rich and meaningful life? Tragic optimism doesn't mean ignoring the bad. It means acknowledging the bad, saying, okay, this happened. This sucks. You know, maybe in my rich and meaningful life, I would be able to work on the farm until I was 80 years old, but hey, I had to have both knees replaced, okay? So my vision of being able to work on the farm until I'm 80 years old May not be doable anymore. So radically acceptance, radically accepting what's going on. All right, I had to have my knees replaced. It is what it is. Therefore, how can I have a rich and meaningful life and have some knees that don't work as well anymore? And that is the R part of crabgrass. So I see what I want, I recognize what is, and then I try to figure out, okay, how can I mesh these two together? How can I still have a rich and meaningful life and accept this adversity? A stands for anticipate the positive. A lot of times we can get stuck in the negative. Anticipating the positive means trying to find hope. Trying to find compromise in what's going on instead of anticipating the worst. B stands for be present, be aware, be mindful of what's going on, how you feel in the moment, and then address it. If, like the example I gave, your vision for your rich and meaningful life suddenly took a hard left turn. Okay, well, acknowledging that and radically accepting it, living in the end, that's all well and good, but you may also have some grief that you've got to deal with. So being present helps you identify and say, I hear all that, I see all that. It's logical, but I also need to acknowledge how I'm feeling right now. G stands for growth and learning. This is an unfortunate experience. How can I use it as a growth experience? What can I learn from it? Order to improve my life. R is realistic goals and expectations. Okay, well, maybe I can't work independently on the farm until I'm 80 years old, but what can I do? I can still have chickens. I may not be riding horses anymore, but I can still have chickens. I can still do some gardening. So those are realistic goals based on the new reality. Radical acceptance of the new reality. A stands for affirm yourself. One step at a time. When something bad happens, we want it to go away, we want to feel better, but we generally don't go from misery to exhilaration like that. So affirming yourself recognizes and acknowledges the positive steps you're taking toward adjusting to this new situation. S is find solutions to the problem, any problems that come up because you're having to make some adjustments, and then the final S is in serenity, accepting what can and cannot be changed. You know, in the example I'm using, you can't get back your 20 year old niece. So if you don't have that, you can't get that back. You have to accept, accept that that cannot be changed and potentially again process it through grief for whatever you need to do. Challenging questions facepalm when we start to feel distressed, when we start to feel overwhelmed, it's important to evaluate our beliefs. What are the facts for and against your belief? Not your assumptions, not emotional reasoning. What are the facts for and against your belief? What additional factors need to be considered, like the context, like the other people that were there, like whatever. What else contributed to the situation and how it turned out? What is the context of the situation? And are you using extreme language? Are you using all or nothing words? P stands for probability or likelihood. If you're having this belief that's catastrophic, that's stressful in nature, what Is the probability or likelihood that the worst case scenario is going to play out. A stands for alternate explanations. What are some alternate explanations for why this might be happening or what might have happened? Because sometimes we assume we know what happened and why it happened. That's not it. I mean, think about a car. You can take it into a mechanic and he says, oh, it's the compressor. And he changes out the compressor and the air conditioner still doesn't work. And he's like, oh, well, what are some alternate explanations? Learn from it and move forward. And moving forward can be really difficult because whatever triggered that feeling triggered that stress response. And it's important to learn how you're safe, learn what you have power over, and recognize that you do have the power to move forward. It may come back and visit you occasionally, but you can stop those thoughts. Radical acceptance. And I love the mnemonic, well, I created it, so face it. F stands for fact, for and against your belief. Radical acceptance means accepting the moment as it is. It is what it is. And if that phrase bugs you, you know, you may want to look at why. But a lot of times that phrase bugs people because they don't like accepting things. They don't like not having complete control over things. But sometimes you don't. It is what it is. Okay, so what are the facts for and against your belief? What is going on right now? A is acceptance. That radical acceptance. Embracing the present and acknowledging that it is what it is and you don't have to like it, but you may not be able to change it. By recognizing this, you eliminate. Should you eliminate, saying, well, it shouldn't be this way or it should be this way. It's not, it just is. Which also helps you reduce the amount of energy wasted. Being angry over something that you don't like in the moment and you have no control over. C stands for control. Once you've identified the facts and accepted them, then you can identify which aspects of the situation you can control, which ones you can't. And the best way to use your energy to cope with the situation. Continue to worry, stay angry, miserable. Is that helpful? What aspects can you control? How can you change your situation or the way you feel about the situation? And then E stands for evaluate the effectiveness of your choices so you're facing it. Successive approximations and scaffolding is another tool that I have used a lot and I really love. Successive approximations means striving to get a little bit better or closer to the goal every single time. So maybe if you're learning how to shoot free throws. You know, the first time you shoot the ball and it just whiffs, completely misses the backboard, the rim, everything all together. All right, well, then you practice. And the next time you get the ball up there and it grazes the rim, that's better. It's closer the next time it hits the backboard, but bounces off. Okay. And then the fourth time you hit it up there and it actually sinks in the bucket. Now, for most people, it's not going to be a 1, 2, 3, 4 like that, but you get the analogy that I'm making. Successive approximations means looking for a little bit of improvement every single time. Scaffolding goes along with successive approximations and means letting somebody do something up until the point they need help. The goal is to prompt successive approximations so they get a little bit better and need a little less help each time. Think if you've ever tried to teach your kid to tie their shoes. You know, tying shoes can be difficult. So the first you want to get them so they can slide the shoe on their foot. That's the first step. And then it's crisscrossing the laces and pulling them tight and then making the bow. Then the rabbit goes around the tree and then pulling the ear through. You know how it goes. When you're trying to teach children to tie their shoes, there's a lot of steps in it, but you want to let them do as much as they can, because that helps them feel empowered, that helps them feel more capable, and that helps them learn how to do it. And then once they get to the point where they're stuck, then you can either talk them through it or take over. And then the next time, hopefully, they'll get a little bit further. But this can be applied to things like tying shoes, washing clothes, learning a computer program, schoolwork, folding a fitted sheet. One of the banes of my existence, or even things like anger management. Hardiness is represented by commitment, control, and challenge. And this is a concept that was proposed way back in 1978, but it's still true and useful today. Commitment means identifying all of the things in your rich and meaningful life to which you are committed, that you are, that are important to you, that you want to devote your time and energy to looking at that. So you may have your house, you may have your garden, you may have your animals and your kids and your friends and your job, and, you know, all these things out here. Well, that's great. At any one point in time, it's likely that every Single one of them is probably not going perfectly. But hardiness encourages us, instead of focusing on the one sliver of the pie that's going bad, to acknowledge the part of the pie that's going bad and recognize everything that's going well, which helps buffer so we don't feel hopeless, overwhelmed, dejected. Sometimes people will do this, can chart this out using a pie chart, where each part of their life that's going good is shaded in green and each part that's not going well is shaded in red. Other times, people have used green and red solo cups, you know, the little plastic cups, and they've put marbles or rocks representing each thing that's important to them in the cups accordingly. And hopefully the green solo cup ends up with filled up more, with a lot more rocks than the red solo cup. So people have a visual representation of, hey, you know, yes, this stuff over here is going crappy, but look at all this stuff that's going well. C stands for control of those things, the ones that are going crappy as well as the ones that are going well. What aspects can you control? The things that are going well, how can you continue to use your energy to keep those things going well? The things that are going crappy, how can you use your energy to help them improve, if at all? And challenge, instead of seeing it as a barrier that keeps you from moving toward your rich and meaningful life, seeing things that are not going so well as a challenge, recognizing the ways that you've endured difficult situations in the past, then like an athlete, constantly strives to get stronger, better, or faster. How can this experience be seen as a challenge to help you strengthen the skills that you already have to get around or over or under this particular obstacle that's in your path? Playing the tape through is another one that I really like. Too often we make decisions or assumptions based on emotions. We feel angry, we feel anxious, we want to fight or flee. So we do things out of anger or anxiety instead of our wise mind. Playing the tape through means considering all the factors and options, both in the short and the long term. So it's kind of like playing a game of chess. Within life, it's important to beta test before acting or reacting. For example, quitting a job. Maybe you hate your job and you want to quit your job. And in the short term, oh my gosh, that would be such a relief. That's true. But play the tape through. What are the long term consequences of quitting your job right now? Or maybe you have difficulty being around people, places or Things that are triggering, or you choose to be around people, places, or things that are triggering. Maybe you're somebody who's in recovery from alcoholism, and you start minimizing and say, and rationalizing and saying, oh, you know, I haven't had a drink in two years, so I can go meet my friends at a bar and I'll just have club soda. That's rationalizing. You want to play the tape through, you think you can, but in the long run, how likely is that to happen? What are the potential consequences of taking that risk? Decisional balance activities are is a chart that's proposed and used a lot in motivational interviewing. And when you practice decisional balance, you encourage people to look at the benefits and the drawbacks not only to change, but also to staying the same. The benefits to change? Well, helping them figure out why is it that they want to change. That one seems pretty obvious. You know, how is it going to help them feel better physically, get more sleep, be healthier, have more energy, feel happier, improve their relationships, improve their finances? You know, okay, all those things. So that one may seem pretty obvious, but then we want to talk about what are the drawbacks to change? And sometimes people look at me like I'm crazy when I ask them that. But the goal is to try to figure out what things might get in their way, what might prevent them from changing, what might make them decide, you know what, it's not worth all this effort. So what are the drawbacks? And we go again through what emotionally? How are you going to feel? What's scary or anxiety provoking about change physically? When we're talking about addiction, one of the drawbacks to change physically is the withdrawal symptoms. Okay, well, how can we mitigate those so they're not quite as intense, so they don't make you as miserable interpersonally, what are the drawbacks to change? Sometimes when people change, it means they lose some friends or change their social circle, and that can be really intimidating financially. What are the drawbacks to change? Well, we're talking about addiction, for example. Residential treatment can be really expensive in the short term, but in the long term, maybe not. And then legally, if there are any legal consequences, and then you do the same thing for staying the same. What are the benefits to staying the same? What do you like about what you're doing now? And then, what are the drawbacks to staying the same? And by going through all four of these quadrants, by breaking it down very granularly, you can help people identify their motivations for change. And then areas that you need to address that might serve as obstacles to change. Dialectics, radical acceptance and cognitive restructuring means embracing the positive and negative aspects of a situation. Dog hair and sometimes I've mentioned in other videos that around my house it feels like I'm trying to brush my teeth and eat Oreos at the the same time. Because we have three dogs and four cats and two teenagers and so our house is always needing to be dusted, which drives me crazy. I, I don't like dust and, and dog hair and everything all around, but I love my animals more and if I have a completely sterile house, that would be beautiful, but I wouldn't have my animals and that would break my heart. I can't imagine living without animals. So yeah, the dog hair not ideal, but the love of my animals is much more important. Feeling vulnerable in a relationship. Well, when you start to care about somebody, you're going to often feel more vulnerable and that can be anxiety provoking. But feeling vulnerable and that little bit of anxiety also means that you care about somebody. So embracing the good with the bad and recognizing you can't have one without having the other or feeling anxiety or distress when doing particular therapy activities, therapy, recovery treatment, whatever you want to call it, often involves debriding at least old wounds. Opening up old wounds and doing it carefully obviously is important, but I've never worked with somebody in the 20 some odd years that I've been practicing that the entire time we've worked together it's been a cakewalk. If we did, I wouldn't be doing my job. The whole goal is to process those issues and those traumas and that bring up sadness or fear or even anger and work through them. So yeah, it's uncomfortable to feel some of those feelings sometimes, but once you process them, then you're able to move forward. So you can't have one without the other. And autobiography can be really helpful and you can do autobiographies a lot of different ways. From the adult self. Assuming you're working with an adult, they write their autobiography. That's the way we usually do it. I've also had people write their autobiography from someone else's perspective. Write your autobiography as if your mother or your grandmother or your best friend were telling me all about you. So it's writing your biography, so to speak. Or they can write their autobiography, autobiography from their child self perspective. And obviously this just goes up through a certain period of time. But going back to maybe when that trauma happened or before that trauma happened, having them write their autobiography from the perspective of that five or six year old, you know, what were they seeing, what were they feeling, what were they experiencing and then seeing how that changes as the child grows. You can also engage in letter writing, and I use the term letters, but in this day and age, you can write old fashioned letters by hand. You can type them, you can do videos, or you can even practice what we call in gestalt therapy, empty chair technique. Any of these, what you're doing is you're getting words and thoughts out of your head and putting them out here. You can write letters to your future self, to your past self, or to other people from your past. Maybe they were really important to you, or maybe they were really traumatizing to you, but you got something to say to them. You can write these letters to any of these people in the voice of your past self. So maybe the six year old that was neglected needs to write a letter to their caregiver. You can write it in the voice of your present self. So as a 26 year old, you can write a letter in the voice of your present self telling your past person what happened or telling your past self what happened. You know you're in the present writing a letter to your past self, or writing a letter to your child self or even your future self. Or you can write it in the voice of your future self. You can imagine yourself as being happy, healthy and in that rich and meaningful life, writing a letter to your present self about the things that you learned or the changes that you made. So how are you different in your rich and meaningful life? There's a lot of different permutations of this and I encourage you to get creative journaling kind of similar. You can journal by just doing a daily reflection like writing a diary. You can keep symptom logs. Some people aren't into the whole prose thing. You can practice mindful journaling. So sitting down in the moment and spending spending 10, 15 minutes writing what you're thinking, seeing, hearing, feeling. You can journal about a particular feeling, happiness. So you're going to write about the things that make you happy or the things that make you angry. You can keep a gratitude journal or journal from the perspective of the inner child, the manager or the firefighter, and these are archetypes, if you will, from internal family systems theory. The inner child is the part of you that may have experienced trauma and is still scared and is still sort of huddling back in the corner. So that child may come out and journal and talk about what it feels like for them. Right now the manager is the part of you that just tries to get things done, done. They tend to be less emotional and more practical and putting one foot in front of the other. But they can get frustrated by the inner child that is, you know, fussing and anxious and needy and the firefighter who is the emotion response, who's constantly trying to just make it stop hurting and, you know, throw water on it. Or you can write it from the perspective of the firefighter that gets exhausted by getting called out all the time. You can do journals in text or in video or audio format. You can change if you're writing it. You can change your writing utensils. You can use a pen or a pencil or a crayon or even charcoal. You can make your journals verbal, where you're writing words, graphic where you're scrapbooking or drawing things. Guided imagery is one of the final techniques we're going to talk about. But guided imagery can be used for emotional or physical pain. People can be helped to envision a dial, like a knob on the television. Guess we don't have those anymore. But you understand on the stove, we still have knobs on a lot of stoves where they're turning it down. They actually turn down the intensity, the volume of their emotional or physical pain. They can envision their emotion or their physical pain as a color. And maybe it starts out as red and then it turns to blue. Or it starts out as completely opaque, and you just can't even see the thing that's hurting. And if it's your elbow, it's your elbow. If it's an emotion, maybe it's your heart. It's red and opaque and you can't see anything. And then as the pain goes away, it becomes more and more transparent until it goes away completely. Nanobots, you can tell I watch science fiction, but. Or your helper T cells or your immune cell system. You can envision your body healing itself. Or sometimes you can envision, like, if you're having anxiety, you can envision a wave coming over you and just whooshing it away. Sometimes it can be helpful to be sitting under a fan when you do that. But guided imagery can take just about any form somebody wants it to take. How would you see this getting better? And then encouraging them, helping them actually see it getting better, envisioning it. You can use guided imagery for anticipatory anxiety, too. If somebody has to do a speech or they're anticipating something that's stressful, or they're anticipating, heaven forbid, the death of a loved one, you can help Them use guided imagery to invent, envision themselves successfully navigating that situation. It may not be, you know, all ribbons and roses and butterflies, but they can start to feel more empowered, feel more capable of handling that situation. You can use guided imagery for growth. You can right before you go to sleep, you can envision what you want to do better or how you want to be tomorrow. Tomorrow you can start reprogramming your subconscious right before you go to sleep. And then when you wake up. Theoretically, that has been imprinted on your subconscious a little bit. Now, it's not going to do things like overnight, but they have done a lot of research that has shown that meditating or using guided imagery to change your subconscious is most effective if done right before sleep. And then guided imagery for sleep. And the old counting sheep thing that most of us told our kids to do is an example of guided imagery. The person is closing their eyes and they're envisioning they're seeing this image of sheep jumping over a fence. And that guided imagery can help them trigger their relaxation response and focus their attention on a pleasant, safe, empowering scene instead of going all over the place and thinking about the meeting they've got tomorrow and what happened today and this, that and the other thing. And health literacy can't end something with cognitive behavioral therapy without talking about education and cognition. So part of cognitive behavioral therapy is helping people understand the connection between their mind and their body or their thoughts and their symptoms, helping them understand the connection between their thoughts, their feelings, how they perceive the world and how they react, and helping them learn and understand the connection between their past experiences and their present reactions. It's also important for a lot of people, especially those who encounter trauma early on, to understand, to be educated about the impact of cognitive development on their perceptions. Children think differently than adults. Children tend to think in all or nothing terms and very personally, very egocentrically. So whatever happened the way I perceive it must be the way it is. Whatever happened is all my fault and it's all or nothing. So if people's perceptions when they were children were formed that way and formed that way around trauma, then in the present they may still perceive things in very extreme terms. So we need to help them understand that those schema that were formed when you were going through that trauma, when you were developing were very normal, because that's how a nine year old, that's how an eight year old thinks in the present. You have different abilities. Your brain actually changes as you get older. So maybe we can revisit that Cognitive behavioral therapy is not appropriate for everybody, but for many trauma survivors, it can be helpful to have practical tools to better understand, address, and respond to their thoughts, feelings, and behaviors in context so they don't feel like these flashbacks and feelings come out from out of nowhere and they're powerless against them. Trauma informed cognitive behavioral therapy always empowers the person to learn about the tool, decide whether it's one that they want to use, and arrive at their own conclusions. When evaluating thoughts, beliefs, and perceptions.