Health Psychology Clinical Tools w/ Educational Topics

IHPTP: Biopsychosocial
Brief Health
Psychology
Treatment Tools
Integrated Health Psychology Training Program
Healthy Minds, Healthy Bodies, Healthy Communities

• Skills for Improving Health and Reducing Stress
• Goal Setting and Problem Solving
• Improved Communication & Relationships
• ACT and Mindfulness for Skills Health and Mental Health in Primary Care
• DBT Skills Health and Mental Health in Primary Care
• Emotions, Emotion Skills & Grief
• Depression and Anxiety Skills
• CBT Skills to Address Health and Mental Health in Primary Care
• Chronic Pain, Migraines and Headaches Behavioral Skills
• Addressing Hypertension
• Smoking Cessation, Cravings and Diet
• Sleep and Insomnia
• Behavioral Health Skills for Diabetes Management
• Psychopharmacology
Table of Contents

Skills for Improving Health
and Reducing Stress

Education and Learning Points
• Stress can be positive and make us stronger but
stress can also ware us down.
• The intensity and length of stress without support
the more it impacts our long-term health.
• Resilience is the ability to bounce back from stress.
We can do things that help us build resilience.
• If we get the right support we can transform toxic
stress into tolerable stress & reduce health risks.
• Things that help build resilience: Psychological skills
or tools to reduce stress, Social support, Diet,
Exercise and Meaningful activities. How could we
support you to increase resilience (Make Plan w/ PT)

• Positive stress happens when we have a stressor
that we know what to do with.
• When our stress system gets stuck on, on stress can
impact our whole life.
• We can learn skills to shift out of stress and help
ourselves feel better when we get into even toxic
stress levels.
• When stress happens the first step is acceptance of
the fact that we are stressed and the second step is
to help our body shift.
• How can you help your body shift? How can you
practice acceptance of stress?

• Stress impacts our mind, our body, our emotions,
how we act (behave) and our spirits for those who
spirituality matters.
• Seeing how stress impacts us can help us learn how
we can accept ourselves when the stress is high and
how to help our selves feel better.
• How does stress impact you?
• Your Mind? – How can you help yourself?
• Your Body? – How can you help yourself?
• Your Emotions? – How can you help yourself?
• Actions/Behaviors? – How can you help yourself?

• The autonomic nervous system has two parts that
balance each other
• These are the ”rest and digest” and “fight & flight”
• When we feel good we shift easily from stress to
rest and back
• When you are at rest the heart rate slows, pupils
constrict, breathing slows, digestion starts up again.
• When you are stressed it’s the opposite. Your heart
rate increases. It can feel like there is not enough
oxygen or breathing becomes shallow and digestion
stops.

• Simple belly breathing helps our body develop
resiliency
• Pain makes us breath in a stressed pattern
• When we are stressed we hold our breath and breath
from our upper chest
• Belly breathing helps our brain shift from stress to rest.
• Practice putting your hand over your stomach and
feeling your belly move as you breath.
• Practice letting your belly soften and your breath
move in your belly.

• Stress impacts almost every health condition we
know of.
• Cortisol is the stress hormone. Our stress hormone
changes our body metabolism and increases
challenges seen on this page.
• When things are difficult it turns up the stress in our
bodies.
• Do you have any health conditions impacted by the
stress hormone?
• How does stress impact your health condition?

• When we are in our window of tolerance stress goes up and
down all day long & we feel capable of handling it.
• When stress gets very high we exceed our window of
tolerance. When we exceed our level of tolerance our front
brain turns off.
• When we exceed our stress levels we can get stuck in
fight flight and feel like we have terror or anger that is
difficult to manage.
• When we have too much stress our stress can lead to
freeze or shut down. When we shut down we can feel
overwhelmed, depression and hopelessness.
• What can you do to come back to your window of tolerance
when you are stressed and past your ability to regulate?

• Triune Brain: When we feel emotions there are three parts. They
relate to the three core structures of the brain. Sometimes
emotions can feel all jumbled up. It is often because one part of
the brain needs support to do its job more effectively. That’s why
we learn skills.
• Brainstem = Emotion Sensation in the Body – Our brainstem
controls how our body feels. It controls breathing, sleeping and
stress levels. When you have an emotion it changes our feeling in
our body. We can use skills to help our brainstem.
• Limbic Brain = Social Emotional Brain – Our limbic brain is about
emotions, emotional connection and social relationships. It
controls the brainstem directly.
• Cortical Brain = Thinking Brain – Our cortical brain gives us
information and ideas. It helps us understand our emotions and
put our world into perspective. Our cortical brain also sooths or
regulates our emotions.

• Emotional Triggers: Events can trigger emotions. This can lead to thoughts, images and
bodily states. Some emotional triggers are extreme. These can lead to intense
emotional bodily states. Knowing these states can help.
• Fight-Flight-Freeze: Are emotional states that work like a filter for memories, ideas, and
actions. For instance in the fight state it is easier to remember things that make you
angry and easier to want to attack.
• Flight: Fight is the biological system that drives anger. We experience fight when we
feel irritable, angry or ruminate on negative events (a brainstem part of emotion). If
you soothe your body you soothe the brainstem.
• Flight: Is the bodily/brainstem experience of fear. It makes us want to get away or
avoid. When we learn to sooth or flight state we can help the world look less scary. It is
like taking off fear colored glasses.
• Freeze: The freeze state is a numbing state. It happens when there is too much. In
freeze we feel detached, out of our body and disconnected. Freeze often has an
emotional quality of shame and a thought that is like “I can’t.”
Anything that pulls your attention into the contact with the world soothes the Freeze
state (looking at colors, smelling, stomping your feet etc.)

• Body States “Fight-Flight-Freeze” change how we
respond to pressure.
• When we are in fight we tend to respond to threats
with an attack. All emotions have an urge. The urge of
fight is to attack.
• When we are in fear we respond to threats by avoiding
or leaving. The urge for flight is to get away.
• The urge for freeze is to disappear or give up. There is a
feeling of being unable to do things or take action.

• Every emotion has several parts.
• There is a bodily sensation, thoughts, a trigger, a beginning
middle and end. Emotions have one more core part. They all
have an urge. The urge of anxiety is to avoid or get away.
• The urge is just information. WE can learn to do the opposite
of an urge “opposite action” or to go with an urge.
• But avoidance can lead to increased anxiety. It is like feeding
a dragon. As you feed it, it gets bigger. It can become so large
it seems hard to manage.
• If however you confront the situation you can begin to take
your power back from anxiety. And reverse the viscous cycle.
• Let’s read the card together. How could you beginning to
work with anxiety to reverse the viscous cycle.

Reversing the Viscous Cycle of Depression

• When we look at depression it is a feedback loop of negative
thoughts, triggering difficult emotions and leading to actions
that can increase the depression.
• At first learning to fight depression it seems counter intuitive.
• When we are depression we feel terrible. These terrible
feelings can get us to stop doing things. Added to that even
when we do things they are exhausting and often don’t feel
all that good.
• However, when we learn to confront the negative thoughts,
accept the fatigue as just a feeling and use “opposite action”
to take action anyway and develop coping skills we can
reverse the cycle of depression.
• People with depression stop. When people stop things pile
up and the intense feelings of guilt pile up.
• Let’s read the card and see what could we do to make a plan
to fight the depression.

• Knowing the Map: Once you have a good map of a place you can find your
way around. The mind is no different. Once we know a good map we can help
ourselves heal, feel better, change and learn.
• Situation: Stuff happens… when it does it triggers a cascade of thoughts,
emotions, and actions.
• Thoughts: Thoughts are any image, word or idea inside our mind. Our
thoughts can trigger emotions and actions. Many thoughts are not
accurate
• Emotions: Emotions are feeling states that tell us about how a situation,
event or idea matters to us.
• Actions: Actions are about what we do. But they also effect what we feel
and think.
• Patient Exploration: Let’s look at one negative thought e.g. ‘I am worthless.’ If
you have that thought how do you feel? How does that feeling make you want
to act? How do you challenge or change a thought if it is not true? Emotions
can trigger thoughts e.g. I feel sad and then think ‘I am worthless.’ Actions can
change how we think and feel. The old phrase ‘fake it till you make it’ points
out how sometimes when we just try we prove to ourselves what we are
capable of.

Pain Education and Learning Points
• A resilient mind can shift from stress to rest.
• Square breathing can help your body shift from
stress to rest.
• Square breathing is when you breath in for 4
seconds, hold at the top of your breath for 4
seconds, breath out for 4 seconds and hold your
breath at the bottom of your breath for 4 seconds.
• If 4 seconds is too long try 2 or 3 seconds until you
can shift up to 4 seconds.
• Square breath is used in military training to help
people in chronic stress function.

When you’re feeling stressed, the last thing you want to do is invite more tension.
However, one great way to relieve tension is to immediately follow it with relaxation. This
is how progressive muscle relaxation works.

• Brain Muscle Connection: When our muscles are tight our body tells
our brain to be stressed. We can help our brain and our stress by
helping reducing the tension in our body.
• Progressive Muscle Relaxation has two ‘curative’ parts:
1. Tensing & releasing muscles (this helps reduce muscle tension)
2. Noticing the change (this helps the deepen the relaxation state by
helping the brain notice the new relaxation).
• Let’s give it a try… In the next five minutes we will go through all the
muscle groups tensing and releasing. Get comfortable in your chair.
Before we start let’s check in with your current stress level. On a scale of
1-10 with 10 being the most ever and 1 being minimal how stressed are
you at this moment.
• Wrap Up: Once the patient has finished ask them to notice where they
are on a scale of 1-10 and if they can feel any changes in their body. Plan
for how to use the skill in patient’s life.

CBT Skills to Address
Health and Mental Health
in Primary Care

• A core belief is a deeply held belief that can be like a
pair of sunglasses that clouds our vision of
ourselves, others and our future.
• Core beliefs are often formed when we were young
or in difficult situations.
• Some core beliefs are helpful and healthy and some
core beliefs can be like a weight we drag around.
• We can learn to challenge a core belief with reality.
• A test to see if a belief is good enough is to ask if it
passes this test: A. Is it true? B. Is it kind? C. Is it
helpful? If it does not pass all three there is a more
true belief.

• Core Beliefs – Are deep seeded beliefs that can drive many
thoughts, feelings and actions. When we get them to shift there
can be powerful changes in our life.
• Self-Others-Future: We all have core beliefs about ourselves,
others and the future. However, some of our beliefs are not true
and many of them are not helpful (or even unhealthy).
• Automatic Thoughts: One way to see a core belief is to see the
automatic thoughts that just pop into your head. Once you see it
you can check the belief.
• Patient Exploration: What are some beliefs you have had about
yourself, others and the future? Are they helpful? Are you turning a
kernel of truth into a big theory of your whole life?
• Try These Skills for Changing Core Beliefs: A. Challenge the core
beliefs against any data that could make them false. B. Put the
belief to this test ‘is it helpful, truthful, compassionate’ if it is not
all 3 it is not a true enough belief.

• Unhelpful Thinking: Our brain can get stuck into
patterns of unhelpful thinking at times. All brains do.
• Stuck on Negative: However, if the brain gets
stuck for a long time or very often it can lead to
depression, anxiety and other forms of suffering.
• Patient Exploration: Look at this list of unhelpful
thinking patters. As you read them which ones
resonate with you as something that might be the
habits your mind has? Thoughts impact our feelings
and actions, how do these patterns impact you?
Let’s look deeper at the unhelpful thinking patterns
that impact you.

• Stuck on Negative: However, if the brain gets stuck
for a long time or very often it can lead to
• Should’ing on ourselves: Should’s leave us stuck and
give the feeling we have already failed. Should
thoughts lead to depression & anxiety in ourselves &
frustration in others.
• Shifting from Should to Could: When you notice a
‘should thought’ shift it with the very powerful word
‘could.’ Could thoughts give us options and possibility.

• Stuck on Negative: However, if the brain gets stuck
for a long time or very often it can lead to
• Disqualifying the Positive: Brains can get in the habit of
ignoring all the good we do. Or even harsher, they can
actively tell us any good we do is not good enough.
• Patient Exploration: Do you at times either discount or
tare yourself down even when you do good things? If
so… How could you challenge/fight that pattern?

• Unhelpful Thinking: Our brain can get stuck into patterns of
unhelpful thinking at times. All brains do.
• Stuck on Negative: However, if the brain gets stuck for a
long time or very often it can lead to depression, anxiety
and other forms of suffering.
• Jumping to Conclusions: Our minds can sometimes trick us
by jumping to conclusions. We can assume we know what
other people think (mind reading) or what will happen
(fortune telling).
• Patient Exploration: Are their times when your mind tends to
jump to conclusions? Have you had times when your mind
jumped to conclusions and you found out it was wrong? How
do you feel when your mind jumps to conclusions?

• Overgeneralizing: This pattern is when you take one event and
make it sound permanent. So maybe someone rejected you
and your brain says, “I will always be rejected.” One of the
good clues for seeing overgeneralization is when your mind
says never or always. Life is complex and rarely never/always.
• Patient Exploration: How does your brain over generalize?
What are some clues that a thought is an over generalization?
How does it make you feel or want to act when your mind has
overgeneralized a situation.

• Unhelpful Thinking: Our brain can get stuck into patterns of unhelpful
thinking at times. All brains do.
• Stuck on Negative: However, if the brain gets stuck for a long time or
very often it can lead to depression, anxiety and other forms of suffering.
• Minimization/Catastrophising: Sometimes our mind tends to ignore
important information. It tries to pretend a really difficult thing is not a
problem. Or it turns a small situation into a much bigger situation. The cure
for this is simply seeing things as they are and accepting them and just
moving forward.
• Patient Exploration:
• When have you minimized something or had your brain make a situation
bigger then it needed?
• One example in panic attacks is that panic fills the body with terrible
sensations but as if that were not bad enough our brains say that we are
‘going to die’ making the bad situation worse.
• How can you recognize when your brain is making a situation smaller or
bigger then needed?

• Stuck on Negative: However, if the brain gets stuck for a long
time or very often it can lead to depression, anxiety and
other forms of suffering.
• Mental Filter: Our mind can start to look for information that
confirms our beliefs already. So if I think I am ‘worthless’ I might
only look for (filter) information that confirms this belief. I might
ignore the many positive things I have done in my life.
• Patient Exploration: What is a negative belief you have? Can you
check to see if there is any information that would make that
belief less true? Write on one side of a paper a list of things that
make it untrue and a list that makes you believe it is true. What
is it like to see information that challenges the belief.

• Unhelpful Thinking: Our brain can get stuck into patterns
of unhelpful thinking at times. All brains do.
• Stuck on Negative: However, if the brain gets stuck for
a long time or very often it can lead to depression,
anxiety and other forms of suffering.
• Emotional Reasoning: Many times we feel bad. But feeling
bad does not make you bad in reality. For instance the
emotion of guilt does not mean you are guilty. The
emotion is just a pointer. You can look and ask what does it
mean.
• Patient Exploration: When has your brain used emotional
reasoning? Did it make your feelings worse? Better? How
could you challenge emotional reasoning?

• Labeling: Labeling can be very a very hurtful habit. Our mind
when it labels us can trigger very difficult emotions and even
worse limit our possibilities to change, grow and succeed.
Labeling is reducing a whole person to a simple label. We are
much more complex then that!
• Patient Exploration: How have you been labeled by others?
Labeled yourself? How did it impact how you feel? How you
acted? How could you challenge labels when your brain uses
them against you?

• Panic is Like a 4 Alarm Fire: Panic is like a 4 alarm fire in the
body. It can feel terrible. However the sensations of panic will
end. They tend to last only a short time unless we water them
with our thoughts.
• Accept Sensations - Sooth the Body – Calm the Mind: The way
out of panic is to accept the feelings just as they are. Once you
do that practicing soothing the body with skills can help. Calm
the Mind through saying these are panic thoughts and I can
challenge them with facts.
• Patient Exploration: What are the most challenging sensations
of panic or anxiety for you? How could you practice acceptance
or soothing with these sensations? What support will help you?
What thoughts get triggered when you have those sensations?
How could you challenge those thoughts or let the thoughts
move through.

• Viscous Cycle of Depression: Once you can recognize the
viscous cycle of depression you can learn to fight depression.
• Overview: At least the first 5 depressive episodes are triggered
by a highly stressful event. The event leads to changes in
thinking, emotions, behavior and bodily sensations.
• Changing the Cycle: Once you know the parts of something you
can learn how to change it. Each of the parts of the cycle of
depression can be ways you can build tools and skills to fight
depression.
• Patient Exploration: Ask patient to explore the parts of the
cycle of depression for them (e.g. triggers, thoughts, feelings,
behaviors, and bodily sensations/vegetative symptoms). Then
pick one or two of the parts of the cycle and discuss skills that
can help reverse the cycle. Help them identify one or two
changes they can make between this appointment and the next.

• Depression Map: Depression is made of thoughts, feelings, physical
symptoms and actions.
• Review Page: Have patient review the page and reflect on what are the
parts of the map of depression that impact them the most?
• Radical Acceptance: Discuss briefly radical acceptance. Validate the strength
the patient has had to live with the symptoms and how acceptance does not
mean liking but allows us to look for new solutions.
• Skills Planning: Discuss skills that can change each part of the map of
depression. Develop with the patient one to two tools for each section of
the map.
• Skills Actions: Choose two skills to work on this week. Step to practice skills…
1. Accept that the feeling or difficulty is there.
2. Validate yourself for trying. And remind yourself it takes practice to
change.
3. Practice the skill
4. Notice any small improvements (even tiny glimmers)

Dialectical Behavioral Skills
Health and Mental Health
in Primary Care

Core Mindfulness Skill – Wise Mind

• Core Mindfulness: Wise mind is a core mindfulness skill in DBT. It helps the
patient find their inner wisdom and begin to trust the part of themselves that
is working for their best. It is a way to turn the mind towards our best self.
• Emotion Mind: Emotion mind is a wonderful mind for playing with children,
holding hands with a lover etc. But emotion mind can take us over. It can lead
to impulsive decisions and damaging relationships. Emotion mind is not the
best mind to do your taxes with.
• Rational Mind: Rational mind is logical, practical and does not care about
emotional needs. It is a great mind to work on math homework, do taxes, or
write a business plan. Rational mind by itself can be diminishing and harsh. It
often misses the real needs.
• Wise Mind: Wise mind connects to your truest self. It combines both rational
mind and emotional mind. While there is a feeling quality to emotional mind,
it does not feel overwhelmed (emotions with quietness). Like if someone
gives you feedback that is hard to hear but you know it is true. It hurts and
there is that wisdom of stillness in it. Wise mind is always aimed at your best
and helpful. You can always ask, ‘is this my wise mind?’ or ’what would my
wise mind say?’

Every event has a chain of causes. Once you can see the links
in the chain, you can change the links in the chain. When you
change the links you can change your life!
Behavioral Chain Analysis

• Behavioral Chain Analysis: Every behavior has a series of causes. If you
can see the causes you can change the behavior.
• The two parts of behavioral chain analysis are
1. Writing the chain of events.
2. Developing skills to change the chain of events.
• Key Parts of an Analysis Are
• Triggering Events
• Actions
• Bodily Sensations
• Thoughts/Cognitions
• Feelings/Emotions
• Patient Exploration: Ask your patient to identify a challenging event or
emotion. Then go back to before the event or emotion and ask about
the chain of events that leads to the emotion or event. Once you
identify the links in the chain ask them to brain storm other things they
could do at each important link on the chain.

• Wave of emotion: Emotions are like a wave. We can learn to
surf them. If we water an emotion with our thoughts it will
get bigger. If we try to block it, it will push back.
• Bodily Sensations and Thoughts: An emotion is a
combination of a feeling in the body and a thought in your
mind.
• You can watch the sensations of the emotions rise up feel
it and simply watch it fall away. No feeling is final. But we
can keep emotions recycling.
• Emotions have a beginning a middle, an end and an
aftermath.
• Practice: Let’s talk about an emotion that you can practice
riding the wave with?

• Emotions: All emotions have an several parts… Thoughts, Bodily
Sensations, Triggers and Urges to act.
• Opposite Action: Sometimes it is important to act with an
emotional urge and sometimes we need to have the ability to act
opposite to the emotion.
• Psychoeducation Note: It is easier to start with a simple emotion
like anger then then move to a more challenging one like sadness.
• Patient Questions (go through at least 3 emotions):
• What is the urge of (Anger– or other emotion)?
• What would acting with the urge of (... Anger)?
• What would it be like to act 100% opposite to the urge from (...
Anger)?
• What would it be like to act in 50% opposite action to the urge
of (... Anger)?

• Wise Mind Accepts: Our wise mind is our guide towards more
ease and a life that matters to use. Our wise mind will look to 1.
accept fully what ever is and then 2. to find a way to feel as good
as possible in spite of everything.
• Ask Wise Mind: Ask your wise mind how to help yourself. A good
question is “what kind of love would help me now.”
• ACCEPTS is a Tool to Survive a Crisis or Difficult emotions. When
we feel distress, emotional or physical, we can reduce the
negative sensations through the skill of accepts.
• Plan for Difficulty: Use accepts to plan to help with difficult
emotions. Read the list of ACCEPTS (Activities, Contribution,
Comparisons, Emotions, Pushing Away, Thoughts and Sensations)
and make a plan to try three things to help you feel as good as
you can the next time there is a difficult emotion or experience.

• Choose to Turn the Mind: We can choose to turn our mind. We can help
ourselves feel better or worse. But it can be challenging to choose to
shift from a negative emotion.
• Shifting from Willfulness to Willingness: Willfulness is giving up, letting
ourselves just act out our emotions, choosing to not try. The shift to
willingness is the shift to being willing to help yourself, to give yourself
good will and to support a good life.
• Pro’s and Con’s: This is a tools to help make the decision about acting…
It can help you shift from wilfulness to willingness. It can be useful when
emotions push us to act in ways that can increase our suffering.
• Patient Exploration: What are the pro’s and con’s of turning the mind?
Think about a difficult interaction or difficult emotions? What are the
pro’s and con’s of giving into an emotion? What are the pro’s and con’s
of making a choice to feel better?

• You are Bigger then Thoughts and Emotions: Who you are is bigger then any thought
or emotion. You are the sky. The emotion is like a cloud. You can learn to detach from
emotions.
• Observe the Emotion: Just see the emotion. See the sensations, the thoughts, the
urges just as they are. Step back with your attention from the emotion. Look at it like
you are watching from a far off hill.
• Experience Fully: Let yourself experience the emotion fully. It will rise up, get more
intense, and then pass away. Don’t increase it with thoughts or reject it by forcing it
down, just let it move.
• Remember You are Not The Emotion: Remind yourself you are not your emotion with
your thoughts. Feel the part of you close to your center that is not the feeling.
• Practice Loving the Emotion: Practice giving love and attention to the difficult
emotion. This will help the emotion heal. Like being with a small child who is hurt, sit
with your emotion.
• Patient Exploration: How could you just observe an emotion? How could you practice
experiencing a difficult emotion? What could you do to help yourself remember you
are not your emotions? What is one thing you could do to practice loving your difficult
emotions?

• Building a Life of Meaning and Purpose: Our goal is to make a life that matters
to us. When we have a life that matters we can live with many challenges.
• Stage I Treatment - Chaos to Control: Early on it feels like our life is on fire. We
feel like they will take us over. Gaining skills helps us move from out of control to
a since of power when we face difficult emotions.
• Stage II Treatment – Quite Desperation: In this face we can help our emotions
regulate but we often are grieving losses and feel alone and desperate. Grieving
and healing the old wounds helps us heal.
• Stage III Treatment – Problems of Life: In this phase we start to make a good life.
We face challenges and difficulties and through these we start to accumulate
positives, trade up our problems and build a good life.
• Stage IV Treatment – Incompleteness: This phase we know that nothing can or
will ever be perfect. We learn to trust the ride and our inner changes. We have a
trust that each moment is enough and yet there are lots of ways to contribute
the others, ourselves and the world.
• Patient Engagement: Ask patients to look at where they are in the DBT house.
Ask them to explore how they are taking steps to move forward and build to the
top of the house. Explore a vision for each stage and skills along the way.

ACT and Mindfulness for
Skills Health and Mental
Health in Primary Care

• We are always paying attention to something.
• Often we are paying attention to the most stressful
thing around, the most stressful body sensation or
thought.
• Experiences come and go. The more we learn to
witch them and ride the waves the more confidence
we get in our ability to face challenges and just get
up and do what needs to be done.
• When we bring our attention into this moment we
get our attention unstuck from the negative stories
and difficulties. It allows for creativity.

• Mindfulness is simply the act of paying attention to your life.
You can do it anywhere and at anytime.
• Attention is an act of care and love towards what ever we pay
attention to. It is like water and our life is like a garden. What
you pay attention to grows.
• Mindfulness is also an attitude we bring to our experience. It is
an attitude of acceptance, non-judging and trust.
• The more we can let ourselves be ourselves the better we feel
in our lives. Let’s read these attitudes and see how they might
impact you.
• How could you practice bringing these attitudes into your
difficult moments, emotions or thoughts?
• Could we practice right now bringing one of these attitudes to
a difficult emotion or situation?

• Thoughts are not who we are. Our minds often can believe
things that are not accurate or helpful.
• Many times we were fed many difficult thoughts about
ourselves that were not accurate but can play back like a
tape.
• When we learn to challenge our thoughts we can make
beliefs that are both true and support our lives.
• Four Questions to Examine Thoughts
• Is it true?
• Is it 100% true?
• How does this thought make me feel?
• What would it be like if I no longer believed this thought?

• Self-compassion… is a powerful tool in healing
• Self-compassion… is a way to give yourself space to be
yourself. It is interesting that the more we can accept
ourselves fully the more we are able to change.
• The three parts of self-compassion are:
• Mindfulness – Mindfulness is just being aware with out
judgement. It is seeing things (and ourselves) as we are.
• Self-Kindness - This is an attitude we can cultivate
towards ourselves and all our thoughts /emotions.
• Connectedness – We all suffer, make mistakes and
experience difficulties. We are not alone.
• How can you practice self-compassion? What are some
difficult emotions or situations you can bring more
compassion into?

• Self-Compassion builds resilience. It helps us make it
through difficult times.
• Research indicates that people who practice self-
compassion get better at it and when we get better
at it even when we have challenges it is easier to live
with them.
• How can you practice self-kindness?
• How can you remind yourself of that you are just
human and recognize that others suffer like you?
• How can you practice just being open to your own
needs? The reality of this moment beyond the
suffering? See our challenges just as they are?

• Self-Compassion: Is the ability to be kind to ourselves and compassionate to
even difficult emotions and experiences.
• Harsh Criticism: Leads to more stress and overwhelm. It also leads to less
chances we really change.
• Change and Compassion: It is the most paradoxical thing that the more we
accept ourselves fully the more we are able to change (paraphrased Carl
Rogers). Compassion gives us the power to change.
• Compassion: Compassion is the act of seeing what is, offering kindness and
commitment to helping. Compassion offers support both for the reaction to a
difficulty and the ability to change.
• Self-Compassion vs. Self-Esteem: Self-Compassion is a kind act to the self.
Compassion has within it the desire to improve. Self-esteem is about feeling
good about who you are. It stops things. Compassion creates the room for
growth and the right soil for change to grow in.
• Patient Exploration: How do you use harsh criticism? How does it help? How
does it hurt? When could you try to practice self-compassion? What are some
difficulties that are hard for you that you could begin the process of developing
compassion for your self?

• When we Fuse we Suffer: When we fuse with negative thoughts it
makes us suffer. The mind is the sky or the ground. The thoughts are
like clouds or rocks. You don’t have to pick them up.
• Fusing is like a bag of rocks: When we fuse with our thoughts and
feelings it is like a bag of rocks we carry around with us. It is tiring and
heavy.
• De-fusing is letting it all go: If we simply stop fighting the feelings and
thoughts they just come and go on their own. When let the thoughts
and feelings come and go they move through and don’t weigh us down.
• Patient Exploration: How can you let the thoughts, feelings and urges
just come and go with out fusing to them? What are some thoughts
that have bugged you? What would it be like to stop fighting them?
Try thinking the thoughts in a funny voice. Try putting them all on a leaf
that just floats on a stream. Try just saying ‘this thought has happened
many times and I’m still here. I have faced it before. I can do it today.’

• Invite them to tea: The truth is if you have faced anxiety, you have
had the anxiety thoughts and feelings many times. Fighting anxiety
or any difficult emotion is like pouring gas on a fire. Once you
accept an emotion fully it looses some of its energy. It still may feel
bad but the battle is less intense.
• Live Life W/ Emotion: Sometimes we can take our anxiety or
depression out to dinner or the movies. We can tell panic “You and
I can go to work today. I have dealt with you before. I am going to
live my best life even when you make noise.
• Make Friends: Know the sensations, the thoughts the way an
emotion makes you worry. Know it well like you would know a
friend. Be tender with it and just let it be. If a friend were crying on
your shoulder you might be able to just sit with them. Try just
giving yourself the same space.

What would it take to drop the rope?
It wont bring the monster any closer then it can get now…

• Have you ever played tug of war with a dog? The harder
you tug on the rope the more the dog tugs back.
• Our negative thoughts are like a monster we are in a tug
of war with. The more we tug, the more it tugs back.
• If we drop the rope, the monster is still a monster and
the thought is still a thought. But if we drop the rope
and stop fighting the thought, the emotion, the bodily
sensation or the imagined future or the past… we gain
back all the energy we were putting into the fight and
we can do things with out hands.
• How are you in a tug of war with your thoughts?
Emotions? Fears? What would it be like to drop the
rope/drop the struggle?

• What Acceptance Is: Acceptance is just seeing what is already happening.
It means you stop struggling against the truth. It frees you up to work
with what ever is. If your car has a flat tire pretending you don’t have a
flat won’t help. Accepting it and looking for solutions will.
• What Acceptance Is Not: Saying you like something, are stuck with it,
giving up or not making changes.
• Acceptance as a Skill: Practice accepting what ever is with your whole
self. Then ask how can I learn what will help?
• What Persistence Is: Taking the next right step over and over. It is doing
small things to accumulate positive events and experiences. It is sticking
through the difficulty and learning experiences.
• What Persistence is Not: Pretending your needs and desires do not
matter, ignoring difficulties, pretending everything is fine.
• Persistence as a Skill: Make a self-care plan for when the going gets tuff
for one of your goals. Connect your goal to your value. Make a list of
people who can cheer you on if your will flags. Be an inner coach noticing
successes and supporting growth.

• Diffusion: Your mind is the sky. Thoughts and emotions are the clouds. No
matter how bad the storm is it will not brake the sky. Diffusion is pulling back
from your thoughts and watching rather then being pulled around by your
thoughts.
• Diffusion Metaphor: (Hold a paper in front of your face) When we fuse with a
problem it is like the problem takes up our whole field of vision. We go to the
store and see the problem, talk with a friend and see the problem. Diffusion is
not like ignoring the problem but putting it under your arm. It is still there but
you can also have your life too!
• Diffusion How: There are many ways to practice diffusion. Some practices are
listed below:
• Leaves on a stream skill (use script or teach skill)
• Watching thoughts like you are high up on a hill looking down at them.
• Finding the humor. Looking at the thought and finding the humor or absurdity.
• Saying the thought to yourself in a funny voice.
• Mindful Attention: watching the experience with curious detachment.
• Do it Anyway: Just do it anyway. Take your anxiety on a walk, q drive or q test…

• Developing Psychological Flexibility: This is the heart of healing and developing a life
that matters. Life is full of difficulty and goodness. The more flexible we are the more
able we are to respond to difficulty and enjoy the good things we have.
• Contact w/ Present Moment: This is being connected to the here and now. Most of our
suffering is in our thoughts or ideas of the past or future. How can we make the most of
this moment.
• Chosen Values: Our values are our guide. They help us choose a path that matters.
When we connect to our values we can solve the deep questions: ‘what am I willing to
endure to have a life that matters to me?’
• Committed Action: This is how we build, sometimes slowly, sometimes quickly to a life
of meaning and purpose. Small values based actions that we are committed to.
• Self as Context: You are not the content of your mind you are the mind itself. Content
(thoughts/feelings etc.) are like clouds. You are the sky. Clouds can’t damage the sky.
• Thought Diffusion: Once you know you are not the thoughts, you can learn to detach
from them. When we are fused with our thoughts they can take us over. When you see
it simply as a thought among many others, you let the thought go by.
• Acceptance and Willingness: When we accept what is we have space. When we are
willing to act it helps us change. If you plant new seeds and water them well a new
garden will grow.

• Values are like a north star: Values are not goals. Goals are a
destination. Values are like a north start that tell you which destination
you want to go to.
• Values Make Life Matter: When we live our values it makes the
challenges feel meaningful. The deep question values ask us are ‘what
am I willing to endure to have a life that matters to me?’
• Overwhelm – Letting Go of Values: When we are depressed, have loss
or anxious it can feel like a crisis. The crisis is like being on a ship in a
storm. You might through some things overboard to survive. Then
when the storm is over you have lost contact with what matters. The
water is calm but it is hard to find your values. Healing is reconnecting
to you values.
• Patient Exploration: What are some of your values? Let’s pick two
values. How are you currently living these values? List several ways?
(therapist support to see areas where PT is living values) What are
some small steps you can take to living closer to your values? How
could your values help you stay connected to treatment?

• ACT (Acceptance and Commitment Therapy) = Psychological Flexibility: Is a series of
processes that help us get unstuck, develop psychological flexibility and build a life
that matters to us despite all the challenges both inside us and outside.
• ACT Made Simple: The three things that ACT challenges us to do are to – Open up,
be present, and do what matters.
• Open Up – This is two parts Diffusion and Acceptance. Acceptance helps us let
what is be as it is so we can work with it. Diffusion gives us space to work with it.
• Be Present – This requires two things Contact With the Present Moment and
Seeing Self is Context. Most of our problems are not in this room. They are in
our minds and thoughts about life. If we contact this moment we get more
access to goodness even when things are hard. Once we see that we are not our
thoughts but the place that thoughts happen we can find a more authentic and
values response to our life.
• Do What Matters – This skill has two parts Committed Action and Values. Once
we know our values we can act on them. Our values are like a north start and
our actions guide the ship.
• Patient Exploration: What ways are you doing each of these things now? Are there
any ways you could improve slightly? Relate these three things to their health or
mental health needs.

• Attention is Yours: We are always paying attention to something. Most
of the the time we are paying attention to the difficult ideas, thoughts,
images and emotions in our mind. When we put that down we can put
our attention on our life.
• Mindfulness is Attention: Attention is like a muscle at first we can’t
hold our attention for long any ware. But if we practice we can put our
attention where we like.
• ‘The Good’ ‘The Bad’ and ‘The ISness:’ There are many good and
difficult things in any moment as well as the fact that you can simply
see things as they are. When you see things as they are they are
neither good or bad. They just are. Your attention can be guided to
focus on things that nourish you.
• Shift Happens: Practice shifting your attentions off of the inner
landscape of thoughts and emotions and on to the here and now. If
you practice it gets easier. Try looking in the moment for something to
be grateful for.

Behavioral Health Skills for
Addressing Hypertension

• Hypertension (HTN) = High Blood Pressure: Hypertension is high blood pressure.
Our blood vessels are like pipes. They should contract and expand but can at
times become ridged or get clogged. When there is too much pressure on a pipe
it increases risk. Hypertension is a risk factor for many diseases.
• Blood Flow: Your blood flows from your heart and gets oxygen in your lungs and
then takes that out to the body. The blood flow brings nutrients from food and
oxygen.
• Systolic Pressure: Is the pressure of the heart contracting pushing the blood
through your body.
• Diastolic Pressure: Is the pressure on your blood vessels when the heart is
relaxed and refilling to pump again.
• Lowering Blood Pressure: Reducing stress, exercising, reducing salt, treating
grief/depression or trauma, better sleep and medications can have a meaningful
impact on your blood pressure.
• Patient Exploration: What range are you in? What is your risk? What are some
ways we could build a plan to reduce your blood pressure? What are some small
actions you could take? Why would they be important to you? What value
would make you want to change?

• Hypertension Changes How You Feel: When your blood
pressure is high it can cause symptoms. Some of these
symptoms can mimic mental health challenges or other health
conditions.
• Change Pressure = Change Symptoms: You can change your
blood pressure and reduce the symptoms.
• Read Your Body + Practice Skill: Along with medication if you
feel (read your body) your blood pressure is high you can
practice a skill to help. Exercise, relaxation, acceptance, yoga,
animal therapy…
• Patient Exploration: What are some of your symptoms of HTN?
How can you notice those and make them an ankor to practice
a skill? What are some ways you can take care of yourself? How
can you change your diet? Reduce salt? Relaxation skill?

• Cholesterol: Is an important part of our health. It nourishes us and
plays a role in inflammation and is essential for the walls of your cell.
Some types of cholesterol are good and some are not so good.
Hyperlipidemia is too many fats in the blood stream and relates to
increased risk that there will be fatty deposits that block one’s blood
vessels.
• LDL = Unhealthy Cholesterol: This is cholesterol that can bind to the
walls of blood vessels and increase the risk of clots and high blood
pressure.
• HDL = Healthy Cholesterol: HDL removes the fatty deposits from the
walls of the blood vessels.
• Balance: You want a higher ratio of HDL to LDL.
• Patient Exploration: What are some of the foods you eat that have
high LDL? High HDL? Are their foods that you eat as comfort foods?
What could you replace in your diet to reduce LDLs and increase HDLs?

• Raise the Good: Here are some foods that can
increase your HDLs.
• Why: Explore what matters in your patient’s life.
Explore core values of patient. Explore why they are
motivated to change. Explore ambivalence to
change. Explore health beliefs.
• Patient Exploration: How often are you eating these
foods? How could you increase some of these
foods?

• Dash Diet: Is a heart healthy diet that can reduce your blood
pressure and improve your overall health.
• Review Card: Ask patient to review card and explore parts of the
DASH diet. Explore fears about change. Motivators for change.
Explore food triggers and the importance of small changes.
• Two Days in the Diet: Ask your patient to explore two days of
food with you. Ask them to explore what they ate on their most
recent stressful day and on the day when they most recently felt
like themselves. Write down the servings and food eaten and
compare it to the DASH diet.
• Patient Exploration/Change Plan: Ask patient to identify one to
two ways they could improve their diet and make it fit the dash
diet more closely. Write down the plan. Problem solve with the
patient about things that might lead to falling off the plan and
how to get back on.

Smoking Cessation,
Cravings and Diet

• Cycle of Addiction: When ever we use a substance or have a
process addiction there is a cycle that leads up to use. Once
you know the cycle you can begin to make a choice.
• Patient Exploration: Read front of card with patient. Ask
patient to explore and explain their cycle of addiction and risk
factors.
• Binging and Addiction Cycle: Explore the types of food
your patient binges on and relate it to the cycle of
addition.
• Explore Use: Choose a recent event and identify cycle in
the last cycle of use.
• Build Skills and Self Talk: Ask the patient to develop a skill or
positive self-talk to address their cycle of addition.

• Healthy Plate: Our society/food industry pushes food that
is not healthy at portion sizes that are not good for us. The
healthy plate has healthy portions.
• ¼ Plate = Meat/Meat Size of Fist.
• ¼ Plate = Starch (Rice/Potato)
• ½ Plate = Vegetable (Pick vegi’s you love)
• 8 oz Glass of Water + consider 8 oz Glass of Milk
• Patient Exploration: Explore what your patient’s current
plate size and portions. Ask your patient what it would feel
like to shift to these portion sizes. Explore how this could
positively impact health. Make a plan for two small
changes that make the plate healthier.

• Weight and Health: Weight and health are related but not
as closely as health behaviors and health. If you build
healthier habits you can increase your health.
• Body Mass Index (BMI): Body mass index is an index of
height and weight. It has some relationship with log-term
health. The Green Zone is the healthiest zone and the Red
is the riskiest zone.
• Body Image and a Body Unhealthy World: Our images in
the media are unhealthy. The goal here is not to push
unhealthy body image but to build health.
• Patient Exploration: Explore ideas of body image and what
is real health with your patient. Explore what your
patient’s health goals are. Explore motivators for change.
Make a SMART goal for change.

Make a Quit Plan to Stop Smoking

• Make a Quite Plan: A quit plan can make you more
successful. A quite plan is a plan that includes a date, ways to
care for yourself, removing triggers and when to get support.
It can include medication and nicotine replacement.
• Read Card: Explore the front of the card with your patient.
• Make a Plan: Write out a quit plan for your patient including
the parts on the front of the card and medication/nicotine
replacement if appropriate. Make plans for follow up
sessions.
• Patient Exploration: Explore motivators (why change), When
change, What change, and Support. Explore triggers and plan
for coping ahead. Explore successful things that may have
help in the past or in other situations.

• Health Improves: The moment you quit your health
starts to improve. Even if you have smoked for
decades your health improves when you stop.
• Read Front of Card: Read through the front of the
card and explore motivators for change. Use the
readiness ruler.
• Explore Fears: Explore fears, history of attempts to
quit and relapses. Explore triggers and hopes for
improved health.

Taking Your Life Back From Smoking

• Motivation + Change Talk = Change: We all have an
inner drive to health. But often we are ambivalent about
change. You can use the readiness ruler as a part of
many forms of changes.
• Using Readiness Ruler: Ask patient how ready they feel
they are to change and to put their finger on that place
on the ruler.
• Change Talk: Increasing change talk increases change.
Ask these two questions to motivate change.
• “Why were you not (say number one lower then they
say)” discuss…
• “What could move you (say one number higher then
they said)” discuss...

• Craving: Right before people relapse there are often cravings. A craving is a
sensation in the body and often a thought. The sensation gets more intense to a
place where a person has a “release thought” e.g. I can have just one…
• Managing Not Stopping Cravings: When you are quitting smoking don’t try to
avoid cravings. Simply accept them and practice the 4 Ds.
• Four Ds:
• Delay: You can put off smoking 5 min at a time for the rest of your life. But
often if a person sets a timer for 5 min the craving is gone by the time that
time comes around. You can tell your self “I could smoke anytime, I have
faced cravings before, I can put it off for 5 min.” Then set a timer and use
another of the 4 D’s
• Distract: If you distract yourself from the negative thought or negative feeling
often you can survive a craving with out relapse. Practice being mindful of
anything else then the craving. Do something if it helps…
• Deep Breath: Stress and cravings go together. If you breath deeply it can
reduce the bodily part of the craving.
• Drink Water: Cools the body. Cools the mind and distracts.
• Patient Exploration: Make a craving plan using four Ds.

Sleep and Insomnia

• Poor Sleep Impacts Our Health: Sleep impacts our overall health. Sleep is
when our body repairs and when our brain repairs. In stage 4 sleep our
body is at rest and we have the highest amount of growth hormone. In
REM we consolidate memory and clear away unneeded neuronal
connections.
• Poor Sleep Impacts Us Deeply:
• Diet/Weight – If we are tired it increases the hunger hormone and
decreases the hormone that signals fullness.
• Pain – If we don’t sleep it changes how our brain perceives pain
making pain sensations worse and medications less effective.
• Emotions – When we don’t sleep makes our emotions more intense
and our mood more irritable.
• Immunity – Poor sleep can impact your body’s ability to fight infection.
• Patient Exploration: Explore with your patient how poor sleep might
impact their health condition, mood or life stress. Explore ways they could
improve their sleep.

• Skills to Improve Sleep: If your body and mind are
tiered enough you will sleep. But you can build skills
to make sleep easier.
• Read Four Parts Card: Read front of card and
explore the four parts of improving sleep. A. Sleep
Aids, B. Behavioral, C. Environment, D. Relaxation.
• Patient Exploration: Explore what a patient is doing
well with sleep. Explore things they can do to
improve sleep. Make a plan and write it down with
your patient.

The Cognitive Cycle of Insomnia

• Braking the Cycle of Insomnia: There is a cycle of insomnia.
Sleep thoughts lead to habits that block sleep. Poor sleep
leads to factors that make mood low, your body stressed and
your mind worried and reduce the ability to sleep. This leads
to too much arousal to sleep.
• Thoughts: Review the thoughts a patient has around sleep.
Review the dysfunctional thoughts on the front of the card
and ask if your patient relates to any of them
• Habits: Explore sleep habits and the way thoughts impact
them.
• Consequences: Explore some of the consequences and
impacts of poor sleep.
• Arousal: Explore how the patient can help their body soothe
so their mind can sleep.

• Sleep Cycles = Sleep: Many times we can look asleep but not be
getting enough of the right sleep cycle. Some medications impact
our sleep cycles.
• Stage 1 = Drifting sleep: You can hear the world but float in and
out.
• Stage 2 = Brief bursts of dreams: Radio can enter dreams and
become part of dreams.
• Stage 3 = Deep sleep: When the body is repaired.
• Stage 4 = Deepest sleep: The mind is quite and growth hormone is
secreted. This helps the adult body repair. Dreams are fragmentary
and not stories.
• Rapid Eye Movement (REM): Is sometimes know as paradoxical
sleep. Your mind is more awake in some ways during REM then
when awake. This is when people have long complex dreams. It is
key for memory formation and psychological health.

Chronic Pain

• Pain the Big Picture: Pain creates a viscous cycle that is
both physical and psychological.
• Physical Vicious Cycle: Pain leads us to avoid movement
and exercise. This in turn leads to the body deconditioning
and having more pain due to lack of physical resilience.
• Psychological Vicious Cycle: Pain leads to irritability, worry
and anxiety. This intern leads to depressed or low mood.
This leads to increased perception of pain (opening the
pain gate).
• Patient Exploration: Now let’s explore ways to reverse
these vicious cycles and how they impact your life. Ask
patient to explore how they relate and develop a plan to
help address the cycle.

• CP-CBT (Chronic Pain - CBT): Pain impacts the whole person and
our thoughts feelings and actions impact pain as well.
• The Cycle: If we have pain worry thoughts they can increase stress,
depression and reduce movement. This can lead to increased pain
through opening the ‘pain gate’ in our spinal cord and by letting
our body decondition.
• Change the Cycle – Change the Pain: If we change the cycle of
response to pain we can change pain itself and help any
medications be more effective.
• Patient Exploration: Explore thoughts and beliefs about pain
(remind them you are not saying pain is in your head). Explore
some of the emotional responses to pain and how they impact.
Explore which pain sensation impact the most? The least? Discuss
how to work with them. Explore behaviors that can amplify pain or
decrease pain.

To Stop the Cycle: Challenge the Thoughts
and Soothe the Body

• Cycle of Stress – Cycle of Pain: If you sooth the body you
sooth the mind. If you sooth the mind you sooth the body.
• Double Edged Sword: If this cycle can increase, stress,
worry and pain then you can use many of the same
principals to reverse the cycle.
• Pain Thoughts/Beliefs: Many times anticipatory stress is
one of the most difficult parts of pain. The fear of pain
coming, getting worse and what might happen in the
future can impact your pain.
• Patient Exploration: Explore reactions to pain, worry
about pain, when the pain is intense the feeling of being
trapped. Explore how they have survived the pain and
skills to reverse the cycle.

• Old Idea of Pain: Our old idea of pain is that there is a neuron (like a wire)
that runs from our foot to our pain center in our brain causing pain.
The Truth: Pain is more complex then the old idea.
• Gate Control Theory (Created in the 1950’s and still holds up today):
There is a ‘gate’ at the dorsal horn of our spinal chord. This ‘gate’ is
managed by the brain. It tells the spinal chord to either open the gate and
let lots of pain signal in or close the gate and not let much signal in. This
makes all medications work harder.
• Things that Open Gate: Stress, Poor Sleep, Fear of Movement,
Arguments, Isolation, Not Moving.
• Things that Close the Gate: Relaxation, Pleasure, Doing Challenging
Things, Stress Reduction, Warm Bath, Shifting Your Attention away from
Pain, Distraction, Social Support, Petting an Animal.
• Patient Exploration: Make a list of things that might open or close your
pain gate. What are the times when you might have the most open gate?
What times in the day is your pain the worst? How could you build more
things that close the pain gate?

The Pain Relief Cycle The Pain Stress Cycle
Strengthening Heart Rate Variability Helps Brake the Pain Cycle & Reduce Stress
Pain
Hold
Breath
&
Brace
Muscles
Tighten
Stress &
Pain
Thoughts
Brace
Against
Pain
Muscles
Tighten
Pain
Lessens
Muscles
Tighten
Breath
Muscles
Relax
Relax
The
Mind
Muscles
Relax

• The pain spasm pain cycle can lead to increasing pain.
• Pain triggers someone to breath shallowly and in the chest.
• We then tense our muscles to brace against the pain.
• The tense muscles begin to hurt more. This makes us breath
more shallowly and tense muscles further. We then make
negative thoughts and have stress based thought patterns.
• We can break this cycle with increased heart rate variability
and improved stress reduction.
• Breathing deeply helps reduce muscle tension.
• Reduced muscle tension reduces pain and helps
medications function better.
• This creates a positive cycle of pain reduction.

Grounding
Exercise
Grounding pulls your mind out
away from pain and into the
world. It brings the mind into
the hear & now.
Look around you identify
and describe…
5 Things you SEE
4 Things you FEEL
3 Things you HEAR
2 Things you SMELL
1 Thing you TASE

• Grounding: Another excellent skill for managing pain or making a
healthy relationship with pain is grounding.
• Attention and Pain: Pain is like a vortex or a whirlpool that sucks our
attention. Its hard to pay attention to anything else when there is a fire
alarm going off in the back ground.
• Pull Attention Off Pain: Grounding skills help you pull your attention
from the pain sensation to the outer world.
• Getting Unstuck: Getting our attention unstuck from pain helps us
reduce stress and increase HRV.
• Pain and Life – Dual Awareness: The skill we can grow is dual
awareness. This allows us to function the best we can with pain. We
can feel the pain and still feel our inner power.

• Health Plan: You can change headaches and migraines
with both medications and health behaviors.
• What kind of headaches impact you?
• Explore symptoms of headache or migraine.
• Headaches Vs. Migraines: Head aches are often a
symptom migraines is an illness in and of itself.
• What Helps: There are lots of things that help both
migraines and headaches. But once a migraine starts it
is hard to stop. Stress reduction eating non-triggering
foods, sleep and identifying triggers can help.
• Patient Exploration: Explore patient’s symptoms,
triggers, stressors and develop a plan.

• Different Head Aches Have Different Patters…
• Review the headache patterns with your patient and
the type of headache they may have.
• Review frquency of headaches and the impact to
life.
• Explore cognitions and thoughts related to
headaches.
• Explore what has worked in the past to help.
• Explore plan that could help.

• Four Parts of Migraine Treatment: These are medications
that can stop a migraine (abortive agent e.g. sumatriptan),
medications that reduce migraines e.g. topamax,
behavioral skills to reduce risk e.g. stress reduction,
managing triggers.
• Managing Triggers: Most people who suffer from
migraines have migraine triggers. The front of the card has
a few list of triggers. Once you know common triggers you
can build a plan to reduce risk
• Patient Exploration: Review triggers that the patient
knows will trigger them, review common triggers and
make a current known trigger list. Enlist patient in
identifying triggers when they happen in their life and add
them to the list.

• Change your brain: Humans are the only animal that
can choose the brain they will have tomorrow. Use
this tool to help yourself feel better when things are
hard.
• Skills to Help: Review the types of skills that can
help and make a plan for each section of the skill.
You can ask your patient to write the skill down on a
paper or draw a picture.

• Grounding: Grounding gets our mind’s eye unstuck from negative sensations,
pain or emotions. It is not intended to relax but to focus the mind outside in
the world. Grounding is a powerful tool to change how you feel.
• Six Grounding Skills:
• Body – Notice your body where it contacts the world, ground, bed or
chair (not the inside of your body that is a relaxation or mindfulness
skill)
• Five Senses – notice one by one your five senses, soothe yourself with
soothing experiences for the five senses.
• Self-Soothe – Take a shower, pet a dog, do something soooooothing…
• Observe – Get out of your stress and into this moment. Look around
notice, name where you are engage, take a picture look, listen
experience.
• Breath – Breath out the stress and into a more grounded state.
• Distract – Distract your self with thoughts, lists, ideas, songs, games,
fixing something make yourself feel as good as you can inspite of
everything.

• Pain Keeps Us Stuck: Pain can keep us stuck in a cycle
where we don’t heal. There is a cycle that promotes
health.
• Improve Function: Along with any focus on improving pain
it is important that you focus on improving function. We
can’t make all the pain gone but can make a good life with
difficult pain.
• Improve Pain: Support yourself to stay conditioned
physically to improve your pain. The best tool to fight pain
is keeping your body healthy.
• Patient Exploration: Explore these cycles of pain. Explore
fears around movement and pain. Make a plan to exercise
and improve health.

• Pain CBT: Pain triggers thoughts, thoughts trigger
emotions, emotions trigger actions which all can
increase pain. But once you know how to increase
pain you also know how to fight pain.
• Patient Exploration: Explore pain triggers,
experience and times. Explore thoughts that happen
related to anticipating pain, in reaction to pain or
about a flare up. Explore emotional reactions and
how to work with emotions like feeling trapped with
pain. Explore behaviors related to pain.
• Make A Plan: Explore how to use these categories to
make a plan to reduce impact of pain.

Pacing and Conditioning Muscle Strengths With Chronic Pain
Rebuilding Resilience With Chronic Pain

• Three Powerful Ps of Pain Management: Pacing – Pacing activity
and rest, Planning – activities to work smarter not harder and
Prioritizing – do what matters and less of the unneeded things.
• Window of Tolerance: Each of us needs time to move and time to
repair. If you have pain you have more time to repair and begin to
recognize time when you have over extended.
• Pain Collapse Cycle: With pain on a good day you might just try to
do everything… This leads to over extention and then having to
rest and recover for a long time maybe days or weeks. This leads to
not doing enough and then our bodies decondition and we have
more pain. Braking the cycle is the goldilocks principle: Just.....
Right....
• Patient Exploration: Review front of card and help patient explore
their bodily and mental signals of when they have more to give,
need to rest and should stop. Explore thoughts and habits around
self-care that could impact this.

Goal Setting and
Problem Solving

• SMART Goals: Are a tool to help you reach your goals, find success and feel
empowered.
• S: Specific – Make your goals specific. Improving health is too broad and
you don’t know if you have gotten there. But exercising 3 times per week is
much more specific.
• M: Measurable – Make your goals something you can measure. If not how
will you know if you succeeded. Exercising 3 times per week for 30 min is a
measurable goal.
• A: Attainable – Make sure you can reach you goal. Rome was not built in a
day. And if you want to reach a complex goal brake it down in to small
measurable goals.
• R: Relevant – Make goals that matter to you and will help you. If you don’t
it will be hard to get yourself to do the steps.
• T: Timed or Time Bound – Make a clear day you will reach your goal. So
exercising 3 times per week for 30 min on Monday, Wednesday and
Saturday at 10 am for 2 months is a stronger goal and you’ll know if you
made it!

• When we have been overwhelmed it can be hard to set goals let alone
work to accomplish things. However, practice skills for goal setting can
help.
• Using the SMART goal tool has helped many people change their life. It
can offer a way for us to step-by-step build towards a life of meaning and
purpose. SMART goals start with picking something to work on. Once you
practice it it becomes a skill you can use all the time.
• It is easier to do with a piece of paper. They can be written anywhere.
Let’s get out a piece of paper and write down one thing that could make
your life a little better.
• SMART goals are specific, Measurable, Attainable, Ready for them, and
Time Bound (accomplished by a date). The clearer the goal the easier it is
to accomplish. When we set unclear goals it sets us up fail and to give up
trying!
• Example: I will increase the amount of exercise I am doing to 30 minutes
3 times per week for one month. The exercise will be walking in the
morning just after I eat.

• We get stuck. Problems can make us feel stuck. When we
do often the problem feels like it gets bigger and bigger.
• When we are depressed, anxious, have pain or other
health conditions it can be hard to solve problems.
• However problem-solving is a skill. We can improve our
problem solving. Companies pay for consultants to teach
them to solve problems. Learning these skills can help
with our moods, emotions or life situation.
• This is a basic six step model for problem-solving. Let’s
pick a problem and practice. Nelson Mandel said – “I
don’t lose. I either win or I learn.” Even if a solution does
not work there are lessons learned!
• It can help to practice this with a friend or a therapist!

Improved Communication
and Health Relationships

• John Gotman is a relationship researcher. He has identified
four behaviors that damage a relationship and can lead to it
ending. Each of the “four horsemen” as Gottman calls them
has an antidote.
• Criticism is being critical about another person. The antidote
is a. A gentle start up (connect before you give feedback) and
b. Complain with out blaming (stick to the facts).
• Defensiveness is corrosive in relationship. The antidote is to
take responsibility.
• Contempt is one of the most damaging ways people
communicate. It is name calling or cursing. The way to stop
this is to build a culture of appreciation in your relationship.
• Stonewalling is shutting down and freezing some one out.
The antidote is learning to sooth yourself.

• Let’s look at the “four horsemen” think about a time when…
• from Criticisim to Gentle Start Up: Someone was critical with
you and then a time when someone used an easy start up?
• from Contempt to Appreciation: Someone attacked you
verbally? Also what it is like when you are appreciated?
• from Defensive to Responsibility: When someone is
defensive with you? And when someone takes responsibility?
• from Stonewalling to Self-soothing: When someone shuts
you out vs. listened even when it was hard.
• Patient Exploration: Now think which of these you do well?
Which you might improve? And if there is one you might want to
work on?

• Love Map = What a person likes, what makes them happy and
unhappy it helps us feel cared for and known. You can make a love
map of a friend, a partner or yourself.
• Shared Fondness = We all need the nourishment of being
appreciated. Relationships need 3 positives to every 2 negatives to
survive and 5 to 1 to thrive.
• Turn Towards = Being interested, listening, reaching out expressing
concern and care.
• Positive Perspective = Seeing the other’s action in a positive light.
• Managing Conflict = We can not stop all conflict but we can fight
well. What makes a healthy fight?
• Make Dreams Come True = Using your energy to help your partner
be their best and have a life they want.
• Shared Meaning = Inside jokes, play, memories, sharing what
matters.

• Abuse (Physical and Emotional): Both physical and emotional abuse
impact your mental and physical health. The bad news is that typically the
cycles of abuse gets shorter, more intense and more risky. You deserve to
have relationships that treat you with respect.
• Cycle of Abuse:
• Tension Building - In the tension building phase there are increased
negative interaction and stress.
• Explosion - This leads to an explosion of physical and mental abuse.
• Denial - Denial is pretending things are ok & putting on a ‘strong face’.
• Honeymoon - After this phase there is a honeymoon where the person
will try to make it up by playing nice or being extra kind. This phase
leads thinking that everything will be ok and trying to avoid ‘triggering
your partner.’ But the tension phase is coming.
• Patient Exploration: Explore the cycle with your patient. Ask them if they
identify with any parts of the cycle. Help them identify strengths, inner
power, allow them to grieve and support connection to services.

• Assertive communication is balancing your needs and the
needs of others. It is communication that respects both
people.
• Passive communication respects the other person but hurts
ourselves and can lead to the build up of resentment. We
also often don’t get what we want.
• Aggressive communication respects our needs at the expense
of the other person. You get what you want but damage the
relationship. This leaves people with out good healthy
supportive relationships.
• Assertive communication is the middle path. We can respect
our own needs while respecting the other’s needs. We can do
this best with “Win-Win Thinking.”

• Keeping Respect for Yourself: In relationship it is important we keep our own
respect. If we give up on our needs to often it can feel like we don’t value
ourselves. If we loose our cool too often we can loose our own trust in
ourselves too!
• The interpersonal effectiveness FAIR help walk the middle path.
• Being Fair – Helps us feel like we can trust ourselves to give others a fair
shake and build self-respect.
• No Apologies – Only apologize for errors. Don’t apologize for having needs,
values, feelings, existing or not liking something.
• Stick to your Values – Our values matter to us. When we don’t live them we
get depressed, anxious or overwhelmed. Values are like a north star in your
life helping you find your way in even challenging moments. Many of us did
not have the right support to learn what our values are. It can be a first step
to write out what your values are in how you treat others and how you want
to be treated.
• Be Truthful – When we tell the truth it is saying to our own heart that our
experience matters and we are strong enough to live with life on life’s terms.

• Keeping Good Relationships: GIVE is a tool to help us keep good
relationships. Relationships are like a garden or a plant. They need the
right kind of sun, water and nourishment. GIVE is a good foundation for a
healthy relationship to flourish in.
• Gentle: Be gentle with those around you. We all are easily hurt. “people
will for get what you said, people will forget what you did, people will
never forget how you made them feel.” M. Angelou
• Interested: We can’t be interested all the time but act interested. It is
important to be able to let yourself give your attention to those you care
about. Even if it’s not your favorite topic people need to be heard.
• Validate: Validation is good food. We all need to be seen. You can
validate an experience with out agreeing. If you look there is always
something to validate. Only validate the valid.
• Easy Manner: Keep your voice low pressure, your stance open and your
speech relaxation. Try to keep a good since of humor and ease even in
challenging topics.

Emotional & Grief

• Emotions have feelings in the body.
• In this study people were asked where they feel
emotions in the body.
• Does this match how you feel in your body?
• Once you know the emotion you can name it, accept
it, express it and regulate it.
• Which emotions are easiest for you to be with?
Which are harder? Which is it hard to recognize?

• Stress…

Symptoms of Grief
Grief Effects the Whole Person

Diabetes Management

• A1c = A three month average of your blood sugar
levels. If it is too high it increases risk of other health
and illnesses. It can also indicate presence of
diabetes.
• Review the chart with patient.
• You can change your A1c with diet, exercise, stress
reduction and taking medications.
• Patient Exploration: What raises your A1c? What
lowers it? What are the things that are hard to let go
of? What are the things that are hard to get yourself
to do?
• Plan: Make a SMART goal to reduce A1c levels

• CBT Map: This is a map of how thoughts, habits,
situations, triggers can all add up to increased
diabetes symptoms.
• Review Map: Review the map with your patient and
have them identify factors impacting their diabetes
and how it functions in their life.
• Develop a Plan: Use the above map to develop a
change plan to reduce symptoms of diabetes.

• Diabetes is a Metabolic Condition: Depression and
diabetes are both impacted by our metabolism.
Depression can make diabetes worse. Diabetes can
make depression worse.
• Depression and Diabetes: Both depression and and
diabetes have common symptoms. Both can make a
person feel down, agitated and have trouble with
focusing.
• Review the Card with Patient
• Patient Exploration: Do you have any of the depression
symptoms? Do you have any of the diabetes symptoms?
Let’s make a plan to help with those using thoughts,
emotions an health behaviors.

• Hyperglycemia = Too much sugar and can impact the
body in the long-term. Sugar if there is too much is
toxic to our eyesight, our nerves and can block our
cells from getting enough oxygen. This can lead to
amputations, peripheral neuropathy and vision loss.
• Hypoglycemia = Too little sugar and it is a health
crisis. A person will loose rationality, cognition and
eventually enter a coma. Eating some sugar is a good
tool to stop this. Having some sugar e.g. hard candy
or glucose tablets in one’s pocket or bag is important.
• Patient Exploration: Review the symptoms of
hypoglycemia and hyperglycemia and self-care.

• Glucose = Sugar and is how our cells get nourished. But it is locked in our
blood vessels with out the key. When we have too much sugar and it is
not getting to our cells it is toxic for our body.
• Insulin = Key and is how the body takes the sugar in our blood stream
and get it to our cells and tissue. When we eat sugar our pancreas makes
insulin. For many reasons our body can stop making enough insulin.
• What Can Help: Reduce sugar spikes can help out pancreas do its jobs
e.g. soda or candy bars. Eat more balanced meals with lots of greens and
less complex carbohydrates (e.g. reduce bread and rice). Increase
exercise to help our body repair and regulate. Reduce stress and mange
stress.
• Checking: checking your blood glucose can help you make good health
choices. It can help you keep your sugar spikes low so your pancreas can
do a better job.
• Patient Exploration: Explore how to develop a plan to reduce spikes,
increase healthy foods, reduce carbs, increase exercise and manage
stress.

• Poor Sleep = Increased hunger hormone and poor
health choices.
• Poor Sleep = Decreased satisfaction hormone and
eating too much food.
• Improving Sleep Can Help: If you improve your sleep
you can improve your body’s ability to regulate sugar,
reduce over eating and reduce negative food choices.
• Patient Exploration: Explore sleep patters, how to
improve sleep, and how to make better diet choices
when one has slept poorly.

• Biopsychosocial Self: We are biological chemicals, psychological experience
and a social being. If you change your social context you change you biology
and psychology. If you change your biology you change your psychology and
social context. Psychotherapy is biological.
• Neurotransmitters: Neurotransmitters are a part of how our brain
communicates. When we are under extreme stress or have challenges we can
have too low chemicals in our brains. We can increase these chemicals with
our health behaviors, psychological skills and with medications.
• Experiencing Neurotransmitters: Each neurotransmitter helps create a part of
experiences. For instance Serotonin creates the feeling of satisfaction and if it
is low people have lots of negative emotions. Dopamine relates to pleasure
and desire for things. When it is low we feel lack of interest in life and lack of
pleasure. Norepinephrine relates to having enough energy. When it is low it
can make us feel like it is impossible to get started or we feel agitated with no
where to go.
• Patient Exploration: Let’s look at these different neurotransmitters and what
they do. See if you feel like some of your symptoms could be related to these
neurotransmitters?

• Chemicals Communicate: Our neurotransmitters communicate
a signal between neurons. You can see in this picture how
serotonin is secreted out and floats over to communicate to
the next neuron.
• Neurotransmitters a Key: Neurotransmitters are a key that
unlocks the other neuron. The right key has to fit the right
receptor.
• Give it Time: When we are depressed or anxious our brain can
brake down the neurotransmitters too quickly. Many
medications slow the process the brain uses to break down
neurotransmitters and giving the brain time to have the
neurotransmitter reach the receptor site on the other neuron.
• Patient Exploration: Ask patient thoughts about medications?
Fears? Hopes? Ask patient what they can do to increase
neurotransmitters through their skills practice.

• Antidepressant Medications: These medications can treat everything
from anxiety, depression, PTSD, chronic pain to irritable bowel syndrome.
• TCA (Tricyclics): These are an older class of medication that impact
multiple neurotransmitter systems. They can be slightly sedating. They
are very helpful with chronic pain.
• Selective Serotonin Reuptake Inhibiters (SSRIs): These medications
impact serotonin. Serotonin helps us feel more satisfied and more at rest.
Serotonin is high when you are feeling full after a good meal.
• Selective Serotonin Norepinephrine Reuptake Inhibitors (SNRIs): These
medications impact both serotonin and norepinephrine changing both
satisfaction and level of energy.
• Other Medications: Newer medications impact dopamine and other
systems. Some of these impact norepinephrine and dopamine (NDRIs).
This changes both access to pleasure and energy.
• Help You Feel More You: Medications do not create the feeling itself.
They make the brain more open and ready for the feeling.

• Benzodiazepines = GABAergic: Gaba based medications can be addictive and
lead to increased anxiety but can help in short-term. They aid with initial falling
asleep but impact sleep cycles.
• SSRIs and Other Anti-Depressents are first line treatment for anxiety.
• Atarax: Works on histamine system. Histamine wakes people up, antihistamines
make people drowsy. The right dose can reduce anxiety. This medication is non-
addictive but can have cognitive impacts if taken for decades.
• Buspar: Is a non-addictive medication that reduces anxiety.
• Gabapentin: Works on a less habit forming gaba system and is longer acting. It
is also a mood stabilizer.
• Pregabalin: Can help with epilepsy, neuropathic pain and GAD. This medication
does not bind to gaba receptors but works on calcium channels.
• Heart/Blood Pressure:
• Beta Blockers – Can reduce the physical aspects of anxiety like heart rate.
• Alpha2A Blockers (e.g. guanfacine) – Can help with anxiety and treat ADHD
as well as managing blood pressure. They have impacts on serotonin as
well.

Integrated Health Psychology Training Program
Healthy Minds, Healthy Bodies, Healthy Communities

Health Psychology Clinical Tools w/ Educational Topics

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