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Nick-E’s Mental Health Management Guide
Bit of a different type of content here!
I am fully aware that my site is primarily focused on the realm of physical fitness and wellbeing so to have something like this is a bit rogue and out-of-left-field. However, as I am someone that has struggled considerably with my mental health (and as such am acutely aware of how ultimately meaningless the pursuit of fitness and strength is without a concurrent pursuit of stable mental health), I figured it was still relevant enough to put on the site.
I have had the privilege of learning a lot about mental health over multiple years of therapy, and at some point collected all of my relevant knowledge into one place to share with others I knew. I then realised after having this resource for some time that it would be useful to more people were I to have it visible to a wider audience by putting it on my site.
To be absolutely clear, I am NOT a licensed mental health professional. There is nothing formal about this document. It is simply a collection of things I have learned from years of therapy and living with complicated mental health for many years that I have found extremely helpful personally, and have since seen work well for those around me too.
Without further ado, here it is!
Part 1: The Science of How it all Works
Below is a simplified model of the brain, called the ‘Triune Brain’. It is split into three sections.
At the bottom you have the brainstem, or ‘lizard brain’. It is the part of your brain that is responsible for all the automatic processes that keep you alive (e.g. controls your breathing, your heart rate, your blood pressure, moving food through your intestines, etc.). We’re going to start with a quick overview of these processes (Trust me, the reason for this will become obvious if you bear with me and read through)
The Body in Safety and in Threat
So the automatic processes that your lizard brain control can be split into two main categories:
Sympathetic (or ‘Fight-Flight’) activity
Parasympathetic (or ‘Rest-Digest’) activity.
Sympathetic activation occurs when your body needs to be motivated into action, usually to ensure your survival in the face of an immediate threat. Conversely, Parasympathetic activation occurs when its time to relax, eat, have sex, sleep, etc. It’s for when things are cool and you are safe!
The following image is a little summary of what Sympathetic and Parasympathetic activity does to all the different parts of your body. (You may need to zoom in to read!)
So as you can see, things like elevated heart rate, opening up your airways, secreting epinephrine/adrenaline are all things that will help you to run the heck away if you see a bear in the woods.
Conversely, when its time to chill, your digestive system is going, you are salivating, your sexual organs are working, and your heart doesnt need to beat a mile a minute because you’re probably just hanging out.
For the purposes of understanding and managing anxiety, it is important to understand these two processes, because the body reacts the same way to all stress, but to varying degrees. The responses your body creates to run from a bear are just a more severe version of the same body responses that occur when you get nervous about an upcoming exam, or worry that your friend or partner is upset with you.
Learning what these responses are will make it easier to recognise them when they happen (important for later).
So we know what the body is doing when it feels safe (parasympathetic) vs under some kind of threat (sympathetic). What does the brain do in the same situations?
The Brain in Safety and Threat
Let’s revisit the Triune Brain now.
Above the lizard brain you have the limbic system, or ‘monkey brain’. This is the part of your brain responsible for all of your emotions and instincts.
Next, up at the top we have the cortex, or ‘human brain’. This is the part of the brain that is responsible for all the higher brain functions that humans do a lot better than other mammals, like language, abstract thought, and most importantly, rational thinking.
When you are relaxed, centred and you feel safe, both the logical (human) and emotional (monkey) parts of your brain are active and working well together. You can feel your feelings while also taking the time to really think about and consider your thoughts; you can critically evaluate things around you and make reasoned judgements about them.
But what happens if you do not feel safe? Well when you are in danger, time is of the essence and snap judgements need to be made as quickly as possible to maximise your chance of survival. The priority is not being the most correct and well considered, it is being the most alive. As a result, your brain defaults to innate, learned survival responses.
Essentially, information completely skips over the human brain and the monkey brain is fully driving the bus. Whatever has worked best historically in similar situations is implemented immediately without a second thought. This is illustrated with the below image.
Now, for a majority of human existence where the most common threats we experienced were constant, tangible physical threats to our lives (lions, tigers, bears, oh my, etc.), this was an EXTREMELY helpful process for keeping us alive. Imagine how likely it would be for you to survive if this is what happened instead:
“Hmm it appears theres a tiger there. Tigers do tend to be dangerous, but I can’t know for sure if that tiger would DEFINITELY eat me. I mean, he might be full. Or maybe he’s just going on a nice stroll to stretch his legs. There’s always the possibility that he might eat me but I think I’m going to really hash this out with a solid Pros and Cons list before I decide what to do”.
Clearly, the immediate reaction strategy is king in the scenario of immediate physical threat.
But in the modern world, nearly all of the threats we experience are so much less tangible and more abstract.
- Real or perceived disapproval by loved ones or coworkers
- Stressful world news events
- ‘Failing’ in any context that matters to you
- Interpersonal conflict
- Feeling harshly judged by others
- Breaking up with your significant other
- Engaging in uncomfortable social situations
- The risk of being fired from your job
- Not doing well in an exam
- Having chronic pain or a chronic illness
None of these things are solved in the same way you’d solve encountering a tiger in the wild. There’s no meadow or cave you can sprint off to where you no longer have to experience these feelings. A lot of them are ever-present in the back (or front) of your head for a continuous period of time.
However, all of these problems only occur in a society that has existed for the tiniest blip of time, relative to the entire timeline of the evolution of the human brain. That means the brain simply has not had time to evolve to cope with the increasing complexity of our world, and it is still using primitive responses meant for simple, concrete threats to deal with complex, abstract threats.
A lot of these problems absolutely NEED your human brain to be working hard to come up with solutions to them. At this point, what was an incredibly useful process for survival for so much of the history of our species, becomes exceptionally unhelpful.
When faced with such a complex and intangible threat, your body mobilises to run or fight, but when theres no place to direct that energy because the problem can’t be solved that way, it can gradually wear you down and burn you out, drive you into panic, leave you feeling paralysed and helpless, or lead you to numb yourself with whatever behaviours, activities or substances are available to escape the constant feeling of threat, even at a cost to yourself.
What this means, is that developing strategies to interrupt that threat response when it occurs and get our human brain back online is pivotal to not being dragged down and hurt by a process that is meant to help.
Autonomic Nervous System Un-simplified:
So let’s revisit this concept of Sympathetic vs Parasympathetic activity. When I first explained it, it sounded a lot like if one system was turned on, then the other was necessarily turned off, and vice versa.
The reality of the situation is that both systems are always running, and their activity relative to eachother can be conceptualised like an old timey set of weighing scales.
To illustrate this concept in a slightly more scientific way, consider that sympathetic activity is like turning the volume UP on your body, and parasympathetic activity is like turning the volume DOWN. The ‘volume’ of your body in this sense is generally referred to as ‘physiological arousal’. (This is not the same as ‘sexual arousal’. In discussions on this topic you will commonly see the term ‘arousal’ to refer to this concept specifically, rather than sexual arousal).
On this graph, The Y axis is how active and highly functioning a part of your brain is, and the X axis is the ‘volume’ of your nervous system, or ‘arousal’.
The red line, labelled ‘Prefrontal Capacities’ can be considered the ‘Human Brain’, as we’ve defined it, and the Pink line labelled ‘Posterior cortex and subcortical capabilities’ can be considered the ‘Monkey Brain’ as we’ve defined it.
At the lowest levels of arousal, imagine you’ve just woken up in the middle of a nap. You are groggy, and probably couldnt do any complicated thinking til you’ve woken up more. If someone asked you a math question or a riddle, you’d probably just say ‘what? Go away.’ and pull the covers over your head to get them to leave.
As arousal increases, your human brain activity peaks. You’re highly alert, firing on all cylinders. Imagine you’re playing a timed trivia game or performing very well in an exam that you feel very prepared for.
However, as arousal increases beyond this point, the scales start to tip. The Monkey brain activity starts to increase as the Human brain activity starts to decrease. Between this point and the crossover labelled ‘Point 1’, imagine a scenario where you are feeling pretty stressed and seeing it affecting your thoughts a little, but you’re able to reason with those thoughts and they’re not causing you to get riled up. Let’s call this phase the Build-up.
Once you cross ‘Point 1’, you are officially in Threat Mode and whatever signals you are getting from your emotional monkey brain are fully drowning out the rational human brain. At this point, imagine totally irrational runaway anxiety that can’t be soothed, simple miscommunications with others that turn into massive conflicts or upset, catastrophic and/or black-and-white thinking, etc.
For a lot of people struggling with chronic anxiety/panic/trauma, you can spend most of your waking life in threat mode, and you can get so used to being this way, that it can be supremely difficult to even realise that you’re in that mode.
The key, then, to managing anxiety/stress/trauma responses/etc. Is to be able to:
- Identify when you are in either The Build-up or in Threat Mode (identifying the body feelings of being in fight-flight, identifying common behaviours you do when in threat, etc.)
- Decrease your overall Arousal (Either increase your Parasympathetic activity, or decrease your Sympathetic Activity)
- Manually increase the activity of your Human Brain so you can begin to think rationally again
- Do what is within your control to address the imbalance between life stressors and life soothers (usually, you cant just choose to remove stressors, so usually this step means to add more soothers)
Specifically in that order.
And that is exactly what the following guide will outline:
Part 2: Emotional Crisis Management / Self-Soothing Protocol
For the remainder of this guide I am going to term the state that we’re trying to move out of, an ‘Unhelpful Threat Mode’ or ‘Unhelpful Threat State’. This is because even in the modern day, the classic threat response can still be helpful in instances of immediate physical threat (e.g. a car is speeding towards you and you need to get out of the way, you are being chased by someone who wishes to hurt you, etc.).
An unhelpful threat mode, conversely, is when you are triggered into it but the supposedly adaptive body and brain responses triggered do not help you in any way, or perhaps even hinder you/cause problems for you.
Step 1: Noticing
So the first step to resolving an unhelpful threat mode is to notice that you are in one.
Most of the time the reason you stay in an unhelpful threat mode for long periods of time is because you do not notice it, and the threat mode just self-perpetuates by you riling yourself up continuously.
If you are looking at this guide for the purpose of using it to self-soothe, you probably already know that you’re in an unhelpful threat state, but in general, here is a non-exhaustive list of examples of indications that you’re stuck in a fight-flight form of unhelpful threat state:
- Fast, thumping heart beat
- Feeling a bit dizzy
- Feeling nauseous
- Feeling restless, an inability to sit still
- Hypervigilance of your surroundings
- Sweating as though you’re exerting yourself despite being still
- A tight feeling in your chest or feeling short of breath (in absence of any illness or pathology)
- Intense and constant self-criticism (self-directed fight response)
- Exhibiting individual behaviours you know to only exhibit when under extreme stress
- Mouth feeling dry (in absence of dehydration)
Important to note that you do not need to have all of these at once. You may have just a handful of them at any given time, and there are some that you personally may never experience. The important thing is to learn what you personally experience when you’re in an unhelpful threat state, and write those down somewhere to remember them.
(This is a concept not covered in the initial theory section, so if you do not know what this is, please check out the footnote bonus science section at the bottom of this document)
Conversely, here are a few signs that you’re stuck in a Freeze version of an unhelpful threat state:
- Feeling emotionally numb
- Having no motivation to do anything
- Not enjoying things you usually enjoy
- Having trouble getting out of bed
- Depersonalization; feeling disconnected from yourself, your emotions, a feeling of ‘watching yourself from the outside’
- Derealization; feeling disconnected from the world, like the world feels fuzzy or does not seem real
- Feeling like you are moving more slowly than usual
- Feeling like moving takes not only more mental effort, but more physical effort
- Feeling foggy headed and unable to concentrate or think in depth about anything
A lot of the characteristics of an unhelpful Freeze response look very similar to classic definitions of depression.
Step 2. Bottom-Up Approach
(To learn why these next two sections are called ‘Bottom-Up and Top Down’ approaches, check the footnote bonus science section at the bottom of the document)
The foundation of Bottom-Up soothing is to increase parasympathetic activity to drown out the sympathetic activity, and outweigh it to get your arousal back down, taking you out of the unhelpful threat state so your human brain can take over the driver’s seat and you can begin to think rationally again.
Where most of your automatic bodily processes are ONLY automatically controlled, your breathing is something that can be either automatic or manual, so you can actually directly impact your autonomic nervous system by breathing manually in a way that stimulates your parasympathetic nervous system.
Phone Apps For Breathing Protocol:
Here are two examples of phone apps that I have used to do this breathing protocol. If you can’t find or don’t like either of these apps, simply look for an app that allows you to make your own custom breathing timer with an interval for inhale, hold, exhale and hold all separately.
(ACCEPTING SUGGESTIONS FOR GOOD APPS FOR IOS/APPLE PHONES, AS I DO NOT KNOW ANY)
Structure of Breathing Protocol:
The 3 components of a breathing protocol that have been shown to maximally increase parasympathetic activity are:
- Breathing between 4 and 6 breaths per minute
- Exhaling twice as long as you inhale (2:1 exhale:inhale ratio)
- Pausing at the end of your exhale
Whatever you do, if it fulfils those 3 criteria, you’re good. However, a structured example that has worked for me and many people I’ve shown it to is:
- 3s inhale, 1s hold, 6s exhale, 2s hold (5 breaths per minute)
- 4s inhale, 1s hold, 8s exhale, 2s hold (4 breaths per minute)
Version A is a great one to start with, as it won’t feel too artificially deep. However, once you’ve been doing this for a number of weeks and your lungs adapt to the process, you may wish to increase it to Version B. It feels quite good, in my opinion.
Start with whatever duration you find doable. I wouldn’t recommend starting with any less than 3 minutes, but anything is better than nothing.
Personally, I start with 5 minutes, and if needed, repeat that 5 minutes as many times as required to elicit the expected outcome (detailed below) if I have time.
Because this breathing protocol is designed specifically to stimulate your parasympathetic nervous system, there are actually a couple of objective markers you can use to determine whether the breathing has ‘worked’, or whether you have done it for long enough to elicit a real effect.
The main effect you are looking for is the compulsion, or perhaps involuntary act of swallowing saliva. The reason for this lies in the list of body responses outlined in the ‘theory’ section above:
When your body is in a predominantly sympathetic state (e.g. fight-flight, threat mode), salivation is inhibited. When you are stressed, you swallow saliva significantly less often because your body simply isnt producing saliva much if at all.
Therefore, if while you are breathing you notice yourself regularly swallowing saliva, this means you have been successful in significantly stimulating your parasympathetic nervous system.
The other signal you can use as an ‘expected outcome’ of this protocol, if you are coming from a fight-flight mode, is the act of yawning. The comprehensive reasons that we yawn as a species are extremely complex and not fully understood, but in short you don’t really tend to yawn when you are in fight-flight mode. Therefore, if you are yawning, especially if you are yawning with abnormal regularity during the breathing protocol, you can be sure you’ve made an impact to your nervous system
Step 3 + 4. Top-Down Approach (Noticing + Rationalizing)
Noticing Sensations: (5-4-3-2-1)
To start off the top-down approach, if you are dealing with either panic or dissociation that is making you feel disconnected from your body (you may not even notice this if you’re used to chronic stress), do the 5-4-3-2-1 Grounding Technique.
This involves taking the time to notice:
- 5 things that you can See
- 4 things that you can Feel
- 3 things that you can Hear
- 2 things that you can Smell
- 1 thing that you can Taste
If you are in a really severe state, not only is it important to notice these things, but to really consider them and perhaps even describe them in detail. The more detail you put into this, the harder you’re getting your human brain to work trying to conceptualise things, put them into language, create images of them in your head, etc. All things only the human brain can do.
For example, when looking for things I can see at the time of writing this:
“I can see a bottle of soy sauce on my shelf in the kitchen. It is quite a tall bottle and it can hold 500ml of soy sauce. It starts wide and then gets narrow ⅔ of the way up, it has a label wrapped around it that is probably made out of plastic, which is red and brown with Chinese characters on it. It has a gold lid.”
You can always do it quickly by just listing things, but I find it’s several orders of magnitude more effective if you really take your time on each item.
Noticing Thoughts (Thought Record + Feelings Wheel)
This section is best completed via a worksheet called the ‘Thought-Feeling Record’ that I was given by my therapist and then customized a bit for myself
The process of the worksheet goes as follows:
- Noticing the trigger or situation you’re in
- Writing down all the thoughts and images coming to your mind
- Critically examining those thoughts and images
- Writing down all your feelings
- Connecting those feelings with named emotions
- Rational and/or Compassionate Re-framing of the thoughts/images
- Coming up with ideas for Self-Care/Self-Soothing activities to do
- Rating how you feel after all of that out of 1-10
Access the Thought-Feeling Record Here. When you’ve clicked on it, in the top bar of the new window, Go to “File >> Make a Copy”, so you can fill it out yourself.
When critically examining your thoughts and images, you might find it useful to have a look at this list of Unhelpful Thinking Styles that are common to fall into when you’re in an unhelpful threat mode.
When naming emotions/feelings in the worksheet, you might find it useful to have a look at this Feelings Wheel if you’re not used to articulating your emotions.
NOTE: This is a feeling record I use for my own mental health management and so there are a lot of prompts for the different sections that I find helpful for tying in other useful models/concepts that you might not be familiar with, such as mentalisation, schema modes, attachment style, etc. If you are not familiar with these concepts, simply ignore those prompts and engage with those you know and feel comfortable engaging with.
Step 5. Self-Soothing Activities / “Self-Care”:
At this point, if you have brought your body out of threat, you have re-framed and rationalised your situation/trigger, but you still feel bad, vulnerable, etc. then the next step is to do some helpful self-soothing activities.
I qualify this as helpful self-soothing, specifically because there are a lot of self-soothing activities that can work in the moment but are more broadly unhelpful to you, bad for your wellbeing or incompatible with a functional lifestyle like abusing drugs or alcohol, self harm, etc.
In terms of what helpful self-soothing activities exist for you, the advice gets a bit less specific and is a bit more individual to you. If you know of nice activities you can do to take care of
Having said that, this might be an area where you’re at a loss for ideas if you have trouble with self-compassion, are not used to doing “Self-Caring” activities (word put in quotes because some people like and some people strongly dislike that term for this concept). As such, here’s a list of a few examples of things that I have done before to good effect:
- Taking a bath (bonus points for bubble bath with candles)
- Making yourself a tea or hot chocolate
- Taking a nap (if your current state is not characterised by feeling stuck in bed/sleeping too much)
- Making/Ordering yourself a nice comfort meal
- Go for a walk if it’s nice outside or safe to do so
- If not, sit by an open window and breathe some fresh air
- Listening to music that makes you feel calm and happy
- Praying or engaging in any other similar spiritual practices if you are religious/spiritual
Other examples can come from the following thought experiment:
If you knew someone you loved and/or cared a lot about was feeling sad/vulnerable/however you are currently feeling, what nice thing might you feel compelled to do to help make them feel better? Do that for yourself, if you can!
Self-Soothing Protocol Summary:
- Notice you are in crisis.
- Find a place that you can be alone and won’t be interrupted, if possible, somewhere you feel safe
- Find a place that you can be alone and won’t be interrupted, if possible, somewhere you feel safe
- Perform 3-5 minutes of the Breathing Protocol
- As a reminder, 3-1-6-2 or 4-1-8-2 (inhale-hold-exhale-hold) are standard recommendations but you can tinker to whatever feels comfortable for you as long as it is:
- 4 – 6 breaths per minute
- Exhale twice as long as inhale
- Brief hold at the end of the exhale
- If you have time, repeat this 3-5 minutes over and over until you get either the saliva swallowing or yawning indicator
- As a reminder, 3-1-6-2 or 4-1-8-2 (inhale-hold-exhale-hold) are standard recommendations but you can tinker to whatever feels comfortable for you as long as it is:
- To manage feelings of physical anxiety or dissociation, notice all of your senses with the 5-4-3-2-1 Grounding Technique
- To manage distressing thought patterns, notice your thoughts and feelings with the Thought-Feeling Record, possibly using the Feelings Wheel and Unhelpful Thinking Styles list, if helpful.
- Complete the rest of the Thought-Feeling Record to reframe/substitute your distressing thoughts with more rational and/or compassionate alternatives
- To finish, do something to add more ‘life soothers’ to your immediate situation (this can be called ‘self-care’ if that term is appealing to you)
e.g. taking a bath, making yourself a tea or hot chocolate, snuggling up in a blanket, making yourself a nice comfort meal, listening to music that makes you feel calm and happy, praying or similar spiritual activity etc.
Not all steps need to be completed every time, as you may find that for more minor threat states, 5 minutes of breathing is more than enough to get you back into a clear brain mode, but simply complete as many steps as you need to genuinely feel better.
Sometimes I will get halfway through the Thought-Feeling record and realise my brain is already out of threat state, and I just go on with my day!
Bonus Science Footnote Section
‘Hypoarousal’, Freeze Responses, Polyvagal Theory:
In the educational sections we’ve covered so far, we’ve used the terms Fight-Flight and Threat Mode more or less interchangably, but there’s another level that is conceptualised within the framework of something called ‘Polyvagal Theory’, and that is the Freeze response. Here’s a graphic I found that explains it visually quite nicely.
The idea here is that when arousal increases past a threshold, as we know, you enter fight-flight, but if that response does not work and the threat remains or increases, eventually your body goes to the last resort for survival, which is to freeze.
Putting it in context, if you run from or try to fight a tiger, and you fail to escape threat by doing this, then the next best way you can try to prevent further harm is to play dead and hope they leave you alone.
If you were reading the signs and indications of fight-flight and freeze, and thought to yourself “well gosh, both of those feel like they describe me recently”, it’s likely that your arousal is just fluctuating between the two zones and actually looks like this, which is totally possible:
The terminology of ‘bottom-up’ and ‘top-down’ soothing refer back to the model of the Triune brain.
In the case of a threat mode, your Monkey Brain is the thing that’s keeping that threat mode bubbling over, but it can be interrupted if it receives input that suggests we are not actually in danger, either from below (Lizard brain) or from above (Human Brain).
Therefore, lizard-brain-focused attempts to soothe the monkey brain are called Bottom-up, and human- brain-focused attempts to soothe the monkey brain are called Top-down, to reflect this.
Therefore, Bottom-Up soothing is the attempt to modify the bodily effects of the threat mode so the lizard brain will communicate with the monkey brain to say ‘Hey. Things are ok.’. In this guide, that method is through a specific breathing protocol.
In Top-Down soothing, you should always start with a process of ‘noticing’ or self awareness.
This is because (as shown in the figure below) the structure in the human brain responsible for self-awareness has direct connection to the monkey brain (amygdala), but the part of the human brain responsible for rational, critical thinking does not.
That means when you are in a threat mode, you cannot rationalise yourself out a threat mode, but you can ‘notice’ yourself out of a threat mode, and then follow this up with rationalisation to solidify your efforts or solve whatever problem caused you to enter the threat mode.
Informal Reference List:
(PRIMARY SOURCE) 5 Years of Therapy, personally
The Body Keeps the Score – Bessel Van der Kolk
CPTSD: From Surviving to Thriving – Pete Walker
Polyvagal Theory – Stephen Porges