Access to mental health care in the U.S. is riddled with barriers, including shortages of mental health care providers. These concerns are not new, and are staggering when you consider that 53 million adults in the U.S., or 21% of the population, had a mental health illness in 2020 and 14 million adults, or 5.6%, had a serious mental illness. Mental health advocacy organizations maintain that many people can’t access mental health care when they need it the most and underscore that millions go without care every year.
In fact, a U.S. Government Accountability Office report published in March found those who do attempt to seek care can find that mental health care providers aren’t accepting new patients or that there are long wait times to see them. These challenges can lead to higher health care costs, delays in receiving care, and difficulties in finding providers close to home. Given this landscape, what’s a person to do if they’re going through a tough time and can’t access professional help?
What to do if you can’t access mental health care?
“I think skills are incredibly important because I do think part of the benefits of therapy are having a space to process and have someone listen and provide hopefully some reflections and insights and encourage insights,” said Kathryn Gordon, a clinical psychologist and author of The Suicidal Thoughts Workbook: CBT Skills to Reduce Emotional Pain, Increase Hope, and Prevent Suicide. “But it’s also helpful to have specific things that the person can do on their own, either when they’re no longer in therapy or in between sessions.”
Gordon added that many skills can be taught outside the context of therapy when there is limited access to care through self-help books, free apps such as Virtual Hope Box and COVID Coach, YouTube videos, and podcasts. Here are skills that can help you learn healthier behaviors, self-soothe during stressful situations, and teach you how to speak to yourself with more compassion.
Focus on identifying your emotions
According to Gordon, one of the most basic and important skills people can learn is how to identify their emotions. While this may sound easy enough, the psychologist explains that some folks don’t stop and think about their emotions. They may only know whether they feel good or bad. However, once an individual identifies an emotion, they can experience a sense of relief or clarity about knowing what they’re feeling, which allows them to self-validate.
For instance, if a person pinpoints that they’re angry when something happens, they can then seek to understand why they feel angry and find a solution.
“It also is the first step to identifying, what do I need?” Gordon stated. “If I feel angry, do I need to assert myself in some way? If I feel lonely, do I need to reach out and connect to someone? Identifying feelings is the first step, I think, to the next step, which is: What do I need right now to tend to this emotion?”
Practice mindfulness
In a similar vein, mindfulness, which is taught in dialectical behavioral therapy, or DBT, can also be very useful. Dialectical behavioral therapist Britt Rathbone, the founder and director of Rathbone & Associates in Maryland, said that mindfulness is about being aware. If people aren’t aware of what provokes the moods that give them urges to engage in behaviors that can be harmful, they can’t take steps to change those behaviors.
Noticing thoughts and feelings is a part of mindfulness, Rathbone explained, and can be learned by using language in a slightly different way. For instance, instead of saying, “I hate that person” or “That person hates me,” Rathbone suggests addressing that thought from another angle. Try: “I’m noticing the thought that I hate that person” or “I’m noticing the thought that that person hates me.”
“What we’re doing there is, instead of you are your thoughts, we’re widening that lens a little bit and creating a [situation where] you are observing yourself having thoughts,” Rathbone said. “Because thoughts aren’t facts. So, if you can step outside the thought, then you can observe it, and then you can decide what to do about it in a way that’s different than if you’re in the thought.”
By noticing the thought, the feeling, or the urge, the therapist points out that people have more room to consider how they are going to respond instead of going on autopilot, which is based on old learning. While autopilot is good most of the time, Rathbone said, it can sometimes get people in trouble when they fall back on learnings that are no longer effective or helpful.
Do the opposite of what your emotions tell you
Another skill that is taught in DBT is opposite action. In Rathbone’s words, opposite action is a tool people can use when emotions turn into moods. While he stressed that all emotions are normal and that everyone experiences them, an emotion turns into a mood “when we nourish them, when we feed them, when we engage with them.”
Opposite action is a skill that can be used when people have a mood or an emotion that doesn’t fit the facts and gives you the urge to do something that may be counterproductive or even harmful in the longterm. In those cases, Rathbone says people have to check the facts and do the opposite of what their emotions are telling them to do.
As an example, he said to imagine someone who is sad because they had a setback and wants to just lay in bed. While grief is a normal emotion in that situation, is lying in bed for long periods of time a good coping strategy?
“If we start listening to [the emotion] and we never get out of bed and don’t get up and do things again, then it’s going to turn into depression. And then it gets harder, and you dig deeper and deeper and deeper into this hole,” Rathbone said. “And so opposite actually starts to kind of turn that spiral up again so that you’re getting active, getting around people, and then your mood starts to improve.”
Monitor your self-critical thoughts and mental dialogues
During tough times, self-critical thoughts and negative dialogues are the last thing we need, especially if we want to improve. Valentina Stoycheva, a clinical psychologist and owner of Stress & Trauma Evaluation and Psychological Services (STEPS) in Huntington, N.Y., said that no one ever changed their behavior because they shamed themselves into doing so.
Stoycheva stressed that it’s really important for people to have self-compassion for themselves when they’re learning how to recognize and observe their thoughts and feelings with less judgement. At times, she’s found that after being taught this skill, patients come back and tell her that they didn’t even realize how negative and offensive they were to themselves.
“That’s really super important because if you want to change anything and you’re constantly shaming yourself and putting yourself down, it’s going to be much harder,” she said. “A good strategy here is to ask yourself, ‘What would you say to a friend who’s in the situation and feeling like you’re feeling right now?’”
Avert a crisis with self-soothing
People who find themselves going through a really rough moment might benefit from self-soothing, a DBT skill for distress tolerance. As Rathbone explains, many of the clients he sees might do something in a rough moment, such as using drugs, that could change their life forever or hurt them in some way. In those situations, folks have to bring down the intensity they’re feeling.
“If you think about mood on a scale of like 0 to 100, when you get past 80 or so, you’re not thinking straight,” he explained. “Mood has taken over and you’re likely to do something impulsive and emotional.”
With self-soothing, therapists aim to teach individuals to do something different in that moment to avert the crisis and get them through it. Self-soothing can include a range of activities, according to Rathbone. Some folks like to pet their dogs, listen to fun music, watch a movie on Netflix, go for a run, or even play a video game.
While people love this skill, Rathbone warns that it’s not the final solution. The urges people felt will come back, which is why once they’re calmer they have to start problem-solving. If not, you can end up stuck in a cycle of avoidance behaviors to cope.
Focus on what it is in your power to change with radical acceptance
Another distress tolerance skill taught in DBT is radical acceptance, although Rathbone points out that it can be a bit harder for people to learn. It’s easy to remember because the name is intuitive. Radical acceptance is the idea that things are the way that they are, and because fighting reality will only make you miserable, we should accept reality as it is, even though it’s painful.
When people are distressed, a lot of times they’re fighting reality, he explained. However, once we accept reality, we can then focus on what is truly in our power to change. As a simple example, Rathbone said to imagine someone was really upset because they wanted it to rain so they could water their garden. The person has no control over whether it rains or not but is still upset and doesn’t think about the other options available, such as watering the plants manually or buying plants that don’t need as much water. If the person doesn’t accept that it is indeed not raining, they’re not going to find another way to water the plants and will keep suffering.
Make self-care a part of your daily routine
While self-care is a huge buzzword these days, Stoycheva says its real meaning when it comes to mental health is very misunderstood. Self-care is not getting a massage when something hurts, she stressed, but rather taking steps to make sure one is consistently OK. This can include working out regularly, consistently going for walks, or setting aside time for reading, or talking to a friend who soothes you.
“Some of these things that help you need to be part of your routine,” Stoycheva said. “[You need to make time] for them, not only when you’re in a crisis.”
She also pointed out that these self-care activities are often the first things that go out the window when people are burned out—and yet, this is counterintuitive, as self-care activities are a buffer against burnout.
Set good personal and emotional boundaries
Learning how to have good boundaries is also an important skill to maintain good mental health. According to Stoycheva, having good boundaries includes not taking on others’ feelings as your own and not trying to fix others around you. Both tendencies can lead to a lot of distress.
When Stoycheva sees patients, she will sometimes ask them what changes they would like to happen in an ideal situation. In cases where the person says they wish their child or partner would stop doing some thing or another, she stops them and explains that while she really wishes that could happen, those aren’t things the person is in control of. She then tries to reframe the individual’s mindset and asks them: What things can you focus on that you’re in control of? In this way, she helps them create emotional boundaries.
Try thinking about the issues you’re dealing with and setting them into two piles: the issues you can control and the issues out of your control. Once that’s done, Stoycheva says, focus on the pile you can control.
Be aware of your triggers
Although the word “trigger” is thrown around a lot, it can actually refer to many things in mental health. Stoycheva explains that triggers can be scary situations, certain people, certain places, or even certain notions. It can even be a TV show that portrays something distressing that may be happening in your life. Knowing your triggers is important so people can minimize their exposure to them or prepare themselves if they’re inevitable.
In the case a person does get triggered, they shouldn’t pretend it didn’t happen because chances are they’re going to have a reaction.
“It’s better to anticipate it and take more care,” she said. “So, this happened, I’m triggered. Let me go read a book for a moment. Let me go calm myself down.”
Check the evidence behind negative thoughts
As anyone who has experienced chronic negative thoughts knows, they can be a bit like whack-a-mole. It’s unlikely that they will ever completely disappear, but luckily, there’s a skill to keep negative thoughts in check. Gordan explains that one effective way to address negative thoughts is to look for evidence for and against that thought to determine whether it’s accurate.
Say, for example, the thought is that you’re a horrible person, she said. In that situation, we should ask ourselves a few questions. First, what’s the evidence for that thought? What’s the evidence against that thought? Is there a more accurate way to say this so that it can reduce that intensity of these negative feelings?
“If I’m thinking I’m a horrible person because I made a mistake or something like that, the evidence supporting it might be, ‘Well, I made a mistake.’ The evidence against it is that [it] doesn’t reflect on me overall,” Gordon said. “I might think about some positive things that I’ve done that are not horrible person behaviors. And so, then I might land on a new thought that’s more accurate, that’s like, ‘I’m not happy that I made that mistake, but overall, the evidence points to me being a decent person who’s trying, and everybody makes mistakes.’”
Know that this too shall pass
When it comes to dealing with distress, clinical psychologist Gordon echoed Rathbone and suggested people do something that’s physically engaging or feels positive to help them get through that tough moment. However, she also pointed out that it’s important for folks in these situations to remember the effect time has on distress.
“Thinking about how even if you didn’t do any of those comforting self-soothing things, you’ll feel better just because our moods fluctuate. And so sometimes that can help people get through distress, too,” Gordon stated. “Thinking, ‘OK, this doesn’t feel good right now, but maybe in an hour or two it won’t feel as bad.’”
When to seek professional help
Rathbone, the dialectal behavioral therapist, stresses that the key to any skill is practice. While some people may believe mental health skills should work immediately, that’s just not how it works—you have to teach yourself how to do things differently by drilling and practicing.
Furthermore, mental health care is not “one and done,” Rathbone explained. It’s like fitness. If you exercise, you can get fit, but if you stop, you’ll get unfit. Most importantly, it’s important to know when practicing these skills on your own is not enough: Anyone experiencing suicidal thoughts or prolonged distress seek professional help immediately.
Stoycheva suggests visualizing yourself as a thermometer. On the bottom, the thermometer is green. It’s followed (upwards) by yellow, orange, and red at the top. Green means you’re good. You feel OK, you’re happy, and you’re relatively calm, even though you may have some challenges. Next up is yellow, which indicates there are some stressors. You don’t feel great, but you’re managing, and you can see the way out. It’s hard, but you’re going to get it done.
On top of yellow is the orange zone, which is where things start to get concerning, according to Stoycheva. People at this point feel like they’re not in control and feel helpless. They’ve either been feeling low for a couple of weeks now or feel like they can’t seem to regulate their anxiety. Folks in this mindset know they’re not OK and might start to isolate. They don’t want to talk to people because it’s overwhelming and don’t want to go anywhere. In some cases, they may be using substances to soothe themselves or engage in behaviors that are unhealthy or unusual for them. Other times, their eating might be dysregulated.
“Those are usually times to reach out,” Stoycheva said. “It means that your nervous system has been overtaxed, and you’ve tried to white-knuckle it on your own. Even if you’re having those thoughts of, ‘I’ve got this, I can do this on my own,’ your body is telling you that you shouldn’t have to do this on your own. Because you can be the strongest person in the world, you can be able to lift 300 pounds, [but] this one is 350. And you can’t lift it by yourself.”
