Book review – Why has nobody told me this before? Dr Julie Smith (Mental Health Guidance)

Everyone experiences occasions when their mental health falters.  Whether that is with low mood, motivation, self-doubt, stress, grief, loneliness or navigating change. Many of us are able to get through those tough times but sometimes we need a little extra help. Therapy isn’t needed by or available to everyone. This accessible, no-nonsense, evidence-based and practical book comes from an experienced clinical psychologist. It is a toolbox of essential mental health life skills. I started listening to the audio book but liked it so much I ordered the hardback version too. The author was one of the first to use TikTok to share insights into therapy. During Covid her audience grew to 3 million. Her LinkedIn posts and short videos are also worth watching. So here is an extended book review – Why has nobody told me this before? Dr Julie Smith (Mental Health Guidance).

A tool for psychoeducation

In the business world, much of my time as a consultant is in identifying the possible and required changes and helping organisations to make the transition. Yet organisations are collections of wonderfully-diverse people.

My coaching work focuses on promoting change amongst high performers. My decision to embark on the long training to become a psychotherapist was driven by the desire to provide a deeper level of support. To help free people experiencing mental anguish and allow them the space to develop and fulfil their potential.

Naturally, I have studied many books on counselling and therapy over the years. Sometimes I find a book for non-mental health professionals that I can recommend to counselling clients to support the work we do together in therapy. This is psychoeducation – providing clients with knowledge to develop their understanding and to help them themselves.

And this book is one of them – a mental health toolbox full of life skills to manage emotions in a healthy way, build self-awareness and resilience and grow. Therapy is ultimately about achieving change. The author says: “If we deal with emotions in a healthy way, we not only build resilience but we can thrive and, over time, find a sense of growth”.

On dark places – Dealing with low mood

People often mask low mood. But we are able to influence mood. Mood is affected by physical discomfort e.g. lack of sleep or exercise and poor nutrition. The brain’s job is to save you as much time and energy as possible. This means it sometimes takes short-cuts and makes guesses and predictions. And they can be wrong and lead to low mood.

The way you feel influences the type of thoughts you have (See the CBT therapy model The Hot Cross Bun | Dr Julie Smith (doctorjuliesmith.com). Negative emotions lead to negative thoughts. With low mood, you disengage from things you normally enjoy which makes you feel even worse – so it can become a downward spiral.

The author’s advice on managing low mood:

• Increase self-awareness of each stage of the cycle in thoughts, feelings, physical sensations and behaviour. Reflect on what is causing low mood
• Some people push feelings away or numb them. This provides instant distraction and relief but can cause problems. Explore your coping strategies
• Consider your thought biases (cognitive distortions) – for example: overgeneralisation, egocentric feeling, emotional reasoning, mental filter (only looking for negatives and disregarding positives), “must” and “should” linked to perfectionism and “all or nothing” (black and white) thinking. Notice the biases when they appear. Then explore alternatives – look for a more-balanced perspective
• Gain some distance from your thoughts. Notice them and observe how they make you feel
• When it comes to thoughts, attention is power. Be intentional about which thoughts you give time to. Mindfulness (paying attention to the present moment) is described as the driving lesson for managing the mind. Work that mental muscle.
• Rumination is a key factor in maintaining depression (Watkins and Roberts, 2020). Neural pathways become more established with repeated thoughts. Human connection is possibly the most powerful tool we have to let those thoughts exit after a few rounds
• Practise gratitude – Note three things for which you are grateful each day. Practice turning attention to things that create pleasant emotional states
• Turn bad days into good days. Low mood gives us the urge to do things that will keep us stuck. Focus on making good decisions, not perfect decisions. Low mood wants you to do nothing. Doing anything positive is a healthy step in the right direction
• Consistent small, good habits have an impact
• Don’t kick yourself (self-criticism) while you’re down. Imagine someone you love unconditionally – The depth of compassion that we often show to others but neglect to show for ourselves. Imagine the nurturing voice of a parent, coach or personal cheerleader
• We usually know what we don’t want, but it’s harder to know where we do want to go instead. Try to think about what you do want
• We have a tendency to neglect the basics:
  • When we’re not feeling good we withdraw from friends and stop exercising (both are known to help improve mood). These are defences we should maintain. The psychological impact of exercising outside in nature is starting to be demonstrated by science
  • The importance of sleep – and suggestions for good practice before bedtime
  • Nutrition – eat whole, unprocessed food, healthy fats and wholegrains
  • Routine – repetition and predictability help us feel safe. When you feel low, the thought of facing anyone can be exhausting and overwhelming.
  • Being with others to observe them, interact and build connections can lift our mood. Research shows good quality social support is associated with better outcomes when it comes to mood (Nakahara et al, 2009). Social support has positive effects for both the one receiving it and the one providing it (Inagaki et al, 2012)

On depression, I usually recommend two other books for lay people:

art and science of overcoming clinical depression (2021) by Oliver Kamm” (kimtasso.com)

Lost connections – Why you’re depressed by Johann Hari (kimtasso.com)

On motivation

There’s a difference between procrastination and anhedonia (when we stop taking pleasure in the things we used to enjoy) which is associated with depression. We need to create the desire to do things again. Some form of exercise, however moderate, will pay you back in feelings of motivation.

Stay connected with the goal. Keep it small and focused. Take home just one task and focus on that. When motivation for a long-term goals dips, it helps to have small rewards along the way.

Focusing on what you are not supposed to do turned out not to be a helpful strategy. Stress increases the likelihood that we will instead act based on how we feel right now and sabotage our goals.

The prospect of failure can zap motivation. When we get caught in self-criticism and shame, we feel inadequate, defective and inferior. Often in therapy, we explore the idea of being self-compassionate. Self-criticism is more likely to lead to an increase in depression rather than motivation (Giebert et al, 2010).

How to make yourself do something when you don’t feel like it is a helpful chapter. The skill of acting opposite to an urge, to instead choose a behaviour that is more in line with where you want to go, is a key skill that people learn in therapy (Linehan, 1993).

Grit (Duckworth et al 2007) and perseverance play a vital role in our ability to succeed. On long term goals we have to learn to counter-balance the stress of effort with the replenishment of rest. Make use of small rewards as we work on big goals. Internal rewards give you a dopamine release. Practising gratitude is a powerful tool for longer-term goals that demand persistent efforts. The more we repeat an action the easier it becomes for the brain to do it with less effort in the future.

In therapy, you create crisis plans. Similarly, spending time imagining your future can help. When we create a vivid image of ourselves in the future, it becomes easier to make choices in the here and now that will benefit our future (Peters & Buchel, 2010). This idea is explored further here: Helping people change: Coaching with compassion (kimtasso.com)

Dialectical Behaviour Therapy (DBT) is a therapy that helps people find safe ways to manage intense emotions. It looks at the future we do want and the future we don’t. And helps you explore the pros and cons of both staying the same and working hard on change.

Where do you start on big life changes? The most effective way to resolve a problem is to understand the problem inside out. The aim of therapy is to build your ability to reflect on your experience and how you respond. Use metacognition – to think about your thinking.

On emotional pain

Often people go to therapy as they are having painful or unpleasant emotions. Rather than get rid of them or try to suppress them, in therapy you learn to change your relationship with them, to welcome them, to pay attention to them to see them for what they are and to act in ways that will influence them and change their intensity.

With emotions, don’t push them away. And don’t believe they are facts (merely the brain’s attempt to make sense of the world). CBT helps clients step back from thoughts and feelings and see them for what they are – just one possible perspective. Be curious about experiences in our inner world.

Here the author looks at coping strategies – where you feel emotions in your body, how they relate to thoughts and the impact of acting on your initial urge.

The need to shift from “doing” to “being” is a key part of clinical training as a therapist. This often involves mindfulness – to be fully present with all of your senses in the moment, rather than being sad about the past or anxious about the future. Emotions tell us what we need – the author suggests that when you feel something, give it a name.

Feeling wheel (Wilcox 1982) – a familiar sight to those who attend my training workshops

Learn to self-soothe (Lineham, 1993) – step back and be mindful of the emotion. Ride the wave of the emotion until it comes back down. Feed our body new information that we are safe. A quick way to do this is through your sense of self. Or create a self-soothing box. Human connection helps us to recover from stress more quickly.  Carefully chosen music can have a powerful impact on our emotional state.

Harness the power of words – the language we use can have powerful effects on our experience of the world. Having fewer concepts or words to differentiate discrete negative emotions is associated with higher levels of depression after stressful life events (Starr et al, 2020). When you have a more accurate word for a feeling, this helps to regulate your emotions and in turn means less stress for your body and mind overall.

I produced this video to help understand the emotions you encounter when going through any kind of change change process – Emotions when reacting to change (kimtasso.com)

And although it is an old book (1980) it is one of my favourites about facing major life transitions is Your personal transition – Endings, neutral zone and new beginnings (kimtasso.com) by William Bridges

On Grief

When you are trying to support someone who is grieving do not underestimate the power of simply being with them. The author advises that you to learn about their diagnosis, manage the basics to keep yourself safe, create a safe space to talk, set boundaries, ask open questions and just reflect back what they say.

Any endings that feel significant can trigger a grief reaction. The loss of a job, financial security, loved ones or certainty about the future. Grief is a normal part of human experience. The loss of a loved one is a huge psychological and physical threat and the pain is intense and vast. Unresolved grief is associated with depression, suicidality and alcohol abuse (Zisook & Lyons, 1990).

The stages of grief according to the model by Elisabeth Kubler-Ross (1969) are explained (see this short video which relates to all types of change ) before the tasks of mourning. William Worden (2011) suggests this involves: finding acceptance, working through the pain of grief, adjusting to the new environment and finding a way to keep the connection.

Suggestions include finding something distracting or comforting that allows you a break between the waves of emotion (Stroebe & Schut, 1999). Allow feelings to unfold and be expressed and use self-soothing and grounding skills.

Some may try to stay busy for fear of being overwhelmed if they press pause – so become stuck. The author reassures that it is OK to feel whatever is there. And to take small steps forward every day. There are no expectations of what or how we feel when grieving. If you can’t talk find another way to express feelings – like writing a journal or art projects. It is through the processing of painful feelings that the work of grieving is done. To remember and keep living. To grow around the wound.

Julia Samuel, a grief psychotherapist, set out key structure (pillars of strengths) that supports us to rebuild our live through grief (2017).

1. Relationship with the person who has died
2. Relationship with the self
3. Expressing grief
4. Time
5. Mind and body
6. Limits
7. Structure
8. Focusing

On self-doubt

There’s advice on how to deal with feedback, criticism and disapproval to enhance our life rather than destroy our self-esteem. We are built to care about how we are perceived by those around us and criticism can be a sign that we haven’t lived up to expectations. So it is likely to trigger our stress response as historically rejection from our community was a serious threat to our survival. The “looking glass self” (Cooley, 1902) is the combination of our experience of interacting with others and how we imagine others see us.

People-pleasing is where you consistently put all others before yourself even to the detriment to your health and well-being. And it can result in being unable to express our needs and unable to hold boundaries. If we say “Yes” when we want to say “No” we can become resentful. For some, keeping other people happy becomes a survival skill.

The spotlight effect (Thomas Gilovich and Kenneth Savitsky, 2000) is where we overestimate how much others are focused on us. Those who feel socially-anxious tend to focus on how they are being perceived by those around them (Clark & Wells. 1995). Material on assertiveness may be useful: Assertiveness skills – getting what you want and saying “No” (kimtasso.com)

To deal with criticism:

• Build your ability to tolerate criticism that could be helpful
• Be open to learn from negative feedback that could help you make progress
• Learn to let go of criticisms that reflect others’ opinions
• Be clear on which opinions matter most to you and why

There’s an interesting insight that people who are highly critical of others tend to be highly critical of themselves also. Our tendency to ego-centric thinking means that criticism is often based on the critical person’s view of the world and their rules for loving.

When feedback focuses on a specific behaviour we tend to feel guilty. When it attacks our personality we tend to feel it as shame which is more painful and triggers our threat system and can lead to a rush of anger, fear or disgust. Then we self-attack and the instinct is to block it all out (sometime with addiction). Shame resilience can be learned and is a life skill:

• Know what triggers shame you
• Accept that worthiness as a human being is not dependent on living mistake-free
• Reality check the criticism
• Know which opinions really matter to you
• Know why you do what you do – the person you most need approval from is yourself. So live in line with your values
• Be careful what you say in response to criticism
• Avoid ruminating on negative comments
• Talk to yourself the right way after receiving criticism
• Avoid internalising the critical voice of others
• Talk to someone about it. Secrets, silence and judgements intensify shame

Building confidence often starts with tolerating vulnerable feelings. Confidence is like a home you build for yourself – if you go somewhere new, you have to build a new home. It means we are willing to let fear be present for a while. Courage comes first, confidence comes second. The learning model (Luckner & Nadler, 1991) is used to demonstrate the comfort zone, the stretch zone and the panic zone. More on confidence: Boosting Your Confidence at Work – A Toolbox for Success (kimtasso.com)

It’s interesting that the author argues that you don’t need to work on your self-esteem. Self-esteem generally means being able to evaluate yourself positively and believe in those appraisals (Harris, 2010). She argues that it relies on how you define success and make comparisons with others. She notes that research shows that high self-esteem is not linked with better relationships or better performance. But it does correlate with arrogance, prejudice and discrimination (Baumeister et al, 2003).

She also suggests you ditch positive affirmations. Some research indicates that people with low self-esteem who repeat affirmations they don’t believe makes them feel worse. She suggests becoming your own coach (honesty, accountability, unconditional encouragement and support), rather than allowing your inner critic to run riot.

She suggests learning to sit with sensations of fear without pushing them away. To write down the situation where you would like to develop more confidence – write the most vulnerable situation at the top and then work through the variations. Choose a scenario that presents a challenge but still feels possible.

You are not your mistakes. Most self-doubt is linked to the relationship we have with failure. We need to change our relationship with our own failure and how we respond to the failure of others. But accepting failure is hard in environments where people attack each other for mistakes. There’s advice on how to bounce back from failure. With a final suggestion to ask yourself “When I look back on this time, what choices would I be proud of?”

Being enough – Research shows that those who develop self-acceptance and learn to be self-compassionate are less likely to fear failure, more likely to persevere and try again when they do fail and generally have more self-confidence (Neff et al, 2005). We become self-aware through reflection (Boost training effectiveness by incorporating learning theory (kimtasso.com)) and be attentive to the parts of us that we feel proud of and the parts of us that we may prefer not to think about.

Create a vision of how the idea of self-acceptance would translate into behaviour change for you. There’s a great exercise from Compassion Focused Therapy (CFT) (Irons & Beaumont, 2017).

On fear – Making anxiety disappear

The brain’s job is to detect danger and keep you safe. When you feel anxious your body is working really hard so it is also exhausting. Take control of breathing (breathe slowly) so the fear response subsides.

Things that give us immediate relief from our fear tends to feed that fear in the long term. Every time we cut something out of our lives because of fear, life shrinks a little.  If you avoid the thing you fear, you never give yourself the chance to build up evidence in your mind that you can get through it and survive.

Common behaviours that ease anxiety in the moment, but keep us stuck in the long term:

• Escape
• Anxious avoidance
• Compensatory strategies
• Anticipation
• Reassurance seeking
• Safety behaviours

Ways to calm anxiety:

• Breathing exercises
• Exercise
• Get some distance from anxious thoughts or fact check biased thoughts
• Positive self-talk and reframing
• Facing death and acceptance

On stress – making it work for rather than against you

Stress is constructed through the same mechanism in the brain as emotions (Feldman Barrett, 2017). Stress and anxiety are both associated with states of alertness – but generally anxiety with fear and stress with responding to the threat of immediate danger.

Stress is when our brain is preparing us to do something. The release of cortisol enables the quick release of energy (glucose) into bloodstream for fuel. Adrenal release helps to fight bacterial and viral infection in the body.

Stress helps you to perform at your best – enabling us to reach our goals. The stress response is best when it is short term and limited. When stress becomes sustained over long periods, our brain tends towards more habitual behaviours that demand less energy. Our ability to control impulses, remember information and make decisions becomes impaired.

Burnout (feeling emotionally exhausted, drained, detached from others and feelings of lack of competence) is a response to excessive and prolonged stress at work when there are no periods to rest and restore in between. There is often a mismatch of control, reward, community, fairness and values involved.

The author helpfully lists the signs of chronic long-term stress and offers some questions to help you explore whether you are experiencing it. There’ also a diagram of the stress curve considering the relationship between pressure and performance.

To help you, there are breathing exercises – with an emphasis on longer out breaths which counsellors use with clients who need to calm their systems s a result of trauma. It also advocates turning to others and the connection and protection of others is just as much a part of our survival instinct as fighting or escaping the threat.

Research also shows that when we focus on caring for others in times of stress, it changes our brain chemistry in such a way that produces feelings of both hope and courage (Inagaki et al, 2012). This uses the tend-and-befriend stress response. Social isolation in itself places the mind and body under great stress.

Those who build their life on self-focused goals are more vulnerable to depression, anxiety and loneliness. Whereas those who structure their goals on something bigger than self tend to feel more hopeful, grateful, inspired, excited and experience better wellbeing and life satisfaction (Crocker et al, 2009).

There’s also guidance on using meditation for stress. There’s research that some forms (eg Yoga Nidra) are shown to reduce stress, improve sleep and increase general well-being. Even just 11 minutes.

Mindfulness – paying attention to the present moment and observing sensations as they come and go – is also mentioned as a tactic with examples with walking, showering and even brushing your teeth. And there’s a prompt to help yourself to feel awe.

In a section on mindset there’s research showing how we think about stress affects how we perform under pressure – such as shifting from perceiving it as a response to a problem to viewing it as an asset (I describe reframing here Two big guns of communication – face time and reframing (kimtasso.com). A common example is reframing fear into excitement. There’s evidence from elite performance coaches on how you use language (particularly concrete and factual) – to focus and give direction. Using “how to” statements can also help. There’s a note that in high stress situations we tend to get tunnel vision. And we overreact to the prospect of failure.

On a meaningful life

“I just want to be happy”. Humans are not built to be in a constant happy state but to respond to the challenges of survival. There’s reference to the book “The happiness trap” by Russ Harris which explains how your emotions are like the weather: constantly moving and changing, sometimes predictably, sometimes suddenly and unexpectedly. Sometimes pleasant and sometimes hard to endure.

Some people start therapy because they feel lost in life. The author draws the distinction between goals and values. And often this is associated with a disconnection from core values (this theme is explored further in the book Lost Connections). Values are a set of ideas about how you want to live your life, the kind of person you want to be and the principles you want to stand for.

There’s guidance on working out what matters – simple exercises to gain clarity on your values. There are exercises from Acceptance and Commitment Therapy (ACT) – where you assess how closely you feel you are living in line with your vales. The values star exercise in particular.

How to create a life with meaning looks at the importance of relationships. It dispels myths of relationships and provides an overview of attachment theory. I’m a big fan of Bowlby’s attachment theory – but the 2010 book “Attached” by Dr Aamir Levine and Rachel Heller was found to be a more accessible and helpful guide to many friends.

One insight is that relationship researcher John Gottman (Gottman and Silver, 1999) suggests that for both men and women the overriding factor that determines how satisfied they feel in their relationships (by 70 per cent) is the quality of their friendship.

Advice on building meaningful connections:

• Be self-aware, curious and compassionate
• Resist the urge to pull away when big emotions arise in a relationship
• Complain in a respectful way (see Assertiveness skills – getting what you want and saying “No” (kimtasso.com) )
• Retreat and then repair after a relationship rupture
• Focus on the things we admire and appreciate about them (cultivate gratitude)
• Seek shared values and meaning

The final chapter is about when to seek help. And the answer is any time you are concerned about your mental health.

Other posts relating to mental health

A general law of interpersonal relationships? (kimtasso.com)

Building Resilience – Regulation, Reframing, Relationships and Reflection (kimtasso.com)

Lost connections – Why you’re depressed by Johann Hari (kimtasso.com)

art and science of overcoming clinical depression (2021) by Oliver Kamm” (kimtasso.com)

Crazy busy – Book review – Dealing with stress (kimtasso.com)

Emotional Regulation – A key element of Emotional Intelligence (EQ) (kimtasso.com)

Change management and creativity – the adaptive third (kimtasso.com)

Book review: Nudge: Improving decisions about health, wealth (kimtasso.com)

The Human Edge – How curiosity and creativity are your superpowers (kimtasso.com)

Team management issues – Managing up, boundaries and broken relationships (kimtasso.com)

Managing client complaints – Process, anger and apologies (kimtasso.com)