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Overcoming Stress, Worry and Low Mood

Course

Participant Workbook

Workshop 2

The aims of this workshop are:

• To understand the link between our behaviour and the way we think and feel • To identify different types of unhelpful behaviours • To use the hierarchy of fear and activity monitoring sheets to help identify

areas for improvement • To use graded practice and problem solving technique to change behaviour • To practice relaxation using visualisation

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Workbook Section 1

The Human Performance Curve The human performance curve represents how the demands placed on us affect our performance in everyday life. Too Little Demand Too little demand means there is insufficient challenge and our available coping resources are not being utilised, there is lack of stimulation which may give rise to boredom, a lack of purpose and meaning to life and at times feelings of depression or low mood. Too Many Demands or Breakdown Too many demands gives rise to uncomfortable pressures and feeling of having too much to do – the person runs on constant overdrive but without achieving results as expected. The demand far exceeds our coping resources and the individual becomes physically and mentally exhausted. If this persists then breakdown may occur Optimum Level of Functioning Optimum functioning in everyday life occurs when the challenges we face do not exceed our ability to cope, but give sufficient stimulation to make life balanced, interesting and manageable. There is a sense of satisfaction and achievement. You tend to feel pleasantly tired at the end of the day.

Human Performance Curve

If you are depressed increasing the amount of activity in your day, particularly the achievement and pleasure you experience can be key to your recovery. Likewise for those that are stressed or anxious understanding how to use your time more effectively to maximise the sense of achievement and pleasure that you get is vital. In order to do this in both cases you need to understand how you use your time now. Later on in this booklet a number of methods are introduced to help you to understand how you spend your time at the moment as well as some tips for using your time better.

How you think and behave can determine how you cope with stress

Pe

rform

ance

Too little Too Much Demand

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Thoughts e.g. anticipating failure (negative

thoughts)

Behaviour e.g. avoidance of feared things

and places

Physical symptoms

e.g. sweating and racing heart

Both depression and anxiety can have a huge impact on how you behave. For example you may stop doing things you enjoy, reduce contact with friends and family or perhaps start drinking or using other substances as a way of coping. Many of the changes in behaviour that depression and anxiety bring about will maintain the anxiety or depression and in some cases may make you more anxious or depressed. Therefore changing the way we behave is a good way of breaking the cycle of depression or anxiety. You will remember earlier on in the course we described the cognitive behavioural model of anxiety and depression. This highlighted the important relationship between behaviour, thoughts/cognitions and physical feelings and the idea that making changes in just one of these three areas could impact on the other two areas and reduce the symptoms of anxiety or depression. The Cognitive- Behavioural Model of anxiety When people become stressed or unhappy their behaviour can change in many different ways. Some examples are listed below, which apply to you? Avoiding dealing with important practical problems Avoiding situations that bring about upsetting thoughts or memories Brooding over things Avoiding answering the phone or opening letters

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Using alcohol or other substances to block out feelings Becoming excessively clingy or dependent Seeking a lot of reassurance Risk taking behaviour There are many different changes in behaviour that can be seen as a result of anxiety or depression, if none of the above apply to you list a two or three changes that you have seen in your own behaviour in the space below. 1. 2. 3. The changes in behaviour that are commonly seen with anxiety and depression can be put into three different categories.

1. Avoidance Behaviour These types of behaviour are more commonly seen amongst those that are stressed or anxious. Individuals will often try to escape, leave or avoid situations, people or places that make them anxious. In the short term this may reduce some or the symptoms of anxiety, however it can lead to an increasingly restricted lifestyle as more and more situations become avoided. Furthermore by avoiding certain situations we confirm the belief that we can’t cope with those situations, therefore depriving ourselves of the opportunity to prove that we can face our fears and survive, this then reduces our confidence. The diagram below demonstrates how we can get trapped in a cycle of avoidance.

2. Unhelpful behaviours

These behaviours, like avoidance behaviours, are used to reduce the level of anxiety experienced in certain situations. These behaviours may take the form of reassurance seeking from friends, family members or a health professional. Or checking behaviour e.g. checking the doors are locked multiple times despite having just locked them. You may also use alcohol, food, drugs or other substances to block out how you feel, or bury yourself in work or social activities to avoid facing your problems. Ultimately using

Anxiety and worrying thoughts

Unhelpful behaviour – Avoid stressful situations

Worsen how I feel e.g. feel more frightened and unable to cope

Problem Worsens – e.g. loose confidence, reduce activity, become isolated.

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safety behaviours can result in a loss of freedom and confidence as you start to believe that you can’t cope with difficult situations without these safety behaviours.

3. Reduced activity

This is most often seen amongst those with low mood or depression. Sometimes when people are depressed it can be very difficult to carry out even quite routine tasks. For example individuals may stop cleaning the house or answering the phone, they may stop going out or doing hobbies. But ultimately whilst you may not feel you have the energy or motivation to do these activities, avoiding them will make you feel more unhappy or depressed and therefore reduce your activity further. In order to break this cycle it is important that you start to increase your activity level, particularly of pleasurable activities or those that give a sense of achievement.

Activity Monitoring If you are low, increasing the amount of activity in your day, particularly the achievement and pleasure you experience can be key to your recovery. Likewise when people are stressed or anxious, understanding how to use your time more effectively to maximise the sense of achievement and pleasure that you get is vital. In order to do this you need to understand how you use your time now. Later on in Section B of this booklet you can use the Activity Monitoring Diary as a way of understanding how you spend your time at the moment, this may give you some ideas for making changes that will have a positive impact on your mood.

Activity Monitoring Diary (see page 13) The aim of the activity schedules is to record what you are doing each day and to attribute a measure of how much pleasure and how much achievement you gained from each task and to look for patterns in your week, (which tasks effect you which way and at which times of the day or week do they feel better and worse). Note -We are never doing nothing; even if we are sleeping all day, just put ‘sleeping’ and rate how much achievement and pleasure we get from it.

Low mood and depression

Unhelpful behaviour – Reduce activity

Worsen how I feel e.g. feel more unhappy. Have fewer positive experiences

Problem Worsens – e.g. loose confidence, reduce activity further.

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Pleasant Activities, Activity Monitoring and Mood

Our mood is directly related to the way we behave and think and we can find ways of gaining control over it by doing things that make us feel better. Satisfaction and happiness are feelings we experience when we are doing pleasant or challenging activities with positive outcomes. It can be helpful to think of everyday events that may make you feel good e.g. talking to a friend. Activities which are pleasant, challenging or make you more physically active (if you are not already) play an important role in sustaining a positive mood and if they fall below a critical level your mood is likely to become increasingly depressed. When you look through your completed Activity Monitoring Diary. Ask yourself these questions: Did you do a sufficient number of pleasant, challenging activities? Were there enough activities that had high scores for enjoyment? Did you spend too much time doing nothing or very little? Did you spend too much time doing chores with little time to rest, relax or enjoy things? What might you do to achieve a balance between things you have to do and things you enjoy? What type of activities might be useful to add in to your week?

1. Pleasant social interactions- open, honest conversations with friends, cuddles or a warm bath with baby or partner.

2. Experiences that make us feel useful e.g. successfully learning to do something new, being able to settle the baby when no-one else can.

3. Activities that are incompatible with feeling depressed- laughing, sleeping well, being relaxed Here are some ideas for pleasant activities. Can you think of some that would be good for you?

Pleasant activity ideas

1. Being in the countryside 2. Writing in a diary 3. Listening to music 4. Relaxing 5. Going out for the evening 6. Going to see a film 7. Cooking a meal 8. Being with someone you love 9. Sitting in the sun 10. Learning a new language 11. Having friends to visit 12. Spending the day with family 13. Reading 14. Talking on the phone 15. Having a bath 16. Being in the garden 17. Driving 18. Going to a restaurant 19. Having a coffee 20. Having a day out 21. Going for a run 22. Taking children to park 23. Being with someone who makes you laugh 24. Going to gym 27. A day trip with the kids 28. Swimming

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Hierarchy For many people one of the reasons they have stopped doing some of these pleasant activities as well as other activities, is that they find them too difficult as these situations provoke an anxious response in them therefore they start to AVOID these situations. For example some of you may have stopped having friends to visit because social situations cause too much anxiety. Unfortunately, as the cycle of avoidance demonstrated, once you start avoiding activities your confidence drops and so your anxiety increases. In order to break this cycle and to start increasing your confidence it’s important to start reintroducing some of those feared activities. An excellent way to do this is using a Hierarchy approach.

Once you have completed your hierarchy the least feared situation (i.e. the activity ranked number 1) then becomes the target for change. Using the tips below you can start to reintroduce the activity you have ranked as the easiest or increase the amount you do that activity. Once you have successfully reintroduced the easiest activity on your list and you no longer fear entering into that situation, then focus on the activity ranked number 2. Continue this process of reintroducing difficult or feared activities until you have worked all the way through your hierarchy. TIPS FOR INCREASING ACTIVITY LEVELS & FACING UP TO AVOIDANCES USING THE

HIERARCHY APPROACH

• Use your coping strategies – distraction, relaxation, controlled breathing, positive thoughts etc – to help you stay calm while practicing each item on your hierarchy.

• It is very important to do the task until the anxiety you have has died away. If you stop when you are still feeling anxious you will only reinforce your belief that you can’t cope with the situation.

• Practice needs to be regular and frequent. Practice every day if possible. Don’t leave long gaps between practice sessions – if you do it is easy to forget what you have achieved and you can learn to fear the situation again, which makes facing it harder.

• Realistic goals – make sure you set yourself realistic goals. Don’t try for too much too soon.

• Break tasks down – If you reach a task that is too hard, try breaking it down and practising small parts of it.

Hierarchy (see page 14)

The Hierarchy approach involves identifying as many activities as you can that you have stopped doing as a result of anxiety. Then each of these activities gets ranked according to the amount of anxiety they provoke, i.e. least anxiety provoking situation scores 1, then the next scores 2, then 3 etc. It is important at this stage to be as detailed as possible, so for example if it is social situations that are feared then specify if large groups of people are more or less intimidating than small groups, or if strangers are easier or harder to talk to than friends or colleagues.

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• Beware of subtle avoidance – You may think that you do not avoid anything, but if you examine your behaviour you will probably find that you are doing things that count as avoidance without realising it. For example, putting things off, not facing problems, not accepting invitations, and so on.

• Don’t let fear win – Don’t be put off by feeling anxious. Be sure to allow sufficient time to practice, and remember that you are learning something that needs to be mastered, and you are bound to feel anxious if you try something difficult.

• Don’t belittle your successes. Encourage yourself when you achieve a target, as you would encourage someone else who was learning something new.

PROBLEM SOLVING AND DECISION MAKING

Problems big and small occur throughout our daily lives. Most of them can be solved and sometimes we resolve them automatically without being aware of what we have done. For example, if someone asks you what you would like to do, they give you a list of what is available and you choose the activity you would like. Below are the four stages to solving a problem, these same techniques can be used to help overcome unhelpful behaviours for example avoidance and inactivity as well as to help overcome other problems you might be faced with. The four stages are:

1. Define the Problem You need to answer the following questions:

• What is the problem? • When is it a problem?

• Where is it a problem? • Why is it a problem? • With whom is it a problem? • How often is it a problem? • What is the result of the problem?

This will enable you to describe in detail the nature, intensity, severity, frequency, duration and current consequences of the problem.

2. Planning In order to plan how to tackle the problem you need to:

• Consider the possible solutions. • Ask yourself what would someone else do if they were me? • List the pros and cons. • Make a decision about which solution suits you best.

3. Implementation Put the solution into practice. If you do not try, you will never know if you could be successful or whether you can achieve a reasonable solution to the problem.

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4. Evaluation Evaluate the degree of success. Don’t look for 100% perfection as that may not be achievable. If you have achieved something you have been partially successful and need to recognise that. It is easy to overlook achievements and this can undermine your confidence for the next time. You may need to try again, further define what the problem is or consider another solution. Further tips for problem solving The “Problem” should be specific – not something too vague like “I am unhappy” You then need to ask the questions posed in stage one – What? When? Why? etc. Own the problem by using the word “I”. Taking ownership and responsibility for your part of the problem will make you feel more in control. Putting all the blame on others will block any change. Brainstorm possible solutions In order to help you achieve a solution, use a piece of paper and write down all the possible solutions. Then throw out any solution that is unhelpful and unworkable. Pick one or two helpful solutions and start working on them. It may be helpful to enlist the help of a friend or relative for more ideas when brainstorming. For example A person wants to locate a friend but cannot remember the address. Possible solutions might include:

• Phone directory enquiries • Look in an old address book

• Look in a local telephone directory • Ask a mutual friend • Do nothing • Wait for your friend to contact you

In effective problem solving or decision making it is also important to consider the following factors: Behaviour – How do you normally behave? Don’t assume that because you have always done things in a certain way that you cannot try something different. Thoughts and attitudes – Do you have any negative or destructive attitudes, either towards the people concerned or towards yourself or the problem itself? If so, can you moderate or change these as (thinking negatively makes it difficult to achieve a positive result)? Feelings – Even though you may be feeling physically or emotionally uncomfortable it does not mean life has to go on hold or that you cannot solve the problem. Use your deep breathing exercises and relaxation techniques and don’t forget to congratulate yourself once you have achieved a solution.

Time Management Effective time management is a useful tool to help minimise stress and fatigue. We only have a limited amount of time each day so it is good to be clear about how we want to use the time.

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Good time management means setting goals and planning to tackle the most important tasks first – not wasting time on low priority jobs or spending valuable time on things outside our control and which we cannot change. To help you be in control of time, rather than allowing time to control you, here are some time management tips: Remember that having too little to do can be as stressful as having too much to do - time management also involves including something purposeful, interesting and meaningful into your time.

First think about how you usually use time In order to manage time effectively, you need to know how you currently use your time. For a day or two, note all your activities and how long each one takes. To help you do this you can choose between the Time log or the Weekly activity record at the end of this section. Having done this, you can check for any parts of your day that could be managed better.

Plan Make time for planning. Ten minutes spent thinking about your day is well worthwhile. Make a list of all the tasks you need to do, both big and small, and cross them off the list when they have been completed. When planning your day allow time for interruptions and unforeseen delays and allow time between projects to catch your breath. Remember to plan time for pleasure, leisure and relaxation as well.

Prioritise all the jobs needing to be tackled

Without setting priorities it is very easy to rush about without completing tasks and end up feeling exhausted. Or you may feel that there is so much to do that you become overwhelmed and do not get started on anything. Prioritise all the jobs on your list into four categories: A = Absolutely essential B = Better done today C = Could wait D = Delegate or Don’t do Then tackle the high priority absolutely essential tasks first. If a job does not have to be done today it is all right to leave it for another more convenient time.

Learn to say No Many people find it difficult to say no to requests and often take on more than they can cope with. Managing your time involves not taking on tasks that you do not have time to do, or setting limits as to when you could do the task. Learn to say “No I do not have the time” or “Yes, I can help you, but do not have the time until tomorrow.” Both these answers help you to be in control of your time.

Do not be a perfectionist Looking for perfection in yourself or others only invites disappointment and will increase demands on your time and cause stress for all concerned. Remember that you can make a mistake and that “good enough” is good enough.

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Do not put off decisions Unresolved problems and unfinished business are a source of tension and use up your energy unnecessarily. If you have time and all the facts you need, tackle the business now.

The 5 tips for time management:

DO: PLAN, PRIORITISE and PASS

DO NOT BE A: PERFECTIONIST or PUT OFF THINGS THAT NEED TO BE DONE

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Workbook Section 2 Activity Monitoring To establish how you spend your time and to identify activities that bring you pleasure, or a sense of achievement complete an activity monitoring sheet. For each hour you should record what you have been doing and rate this activity for how much pleasure (P) or sense of achievement (A) it bought you. Scale=0-10 where 0= no P or A and 10=intense P or A.

Time Monday A P Tuesday A P Wednesday A P

6am 7am 8am 9am 10am 11am 12midday 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm 12am-6am

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Filling in the Activity Monitoring Diary will help you to highlight those activities that do bring you pleasure and a sense of achievement. • Introduce activities that are achievable, don’t rely on others, this maximises the chance that you’ll succeed in completing your chosen activities

• Take an outside-in approach, this means doing the activity regardless of how you feel. • If you really feel you can’t manage something then tell yourself that you’re going to do the activity for 5 minutes and if you still can’t manage

it then you will stop. Often you will find that just 5 minutes of activity will lift your mood enough for you to carry on.

Time Thursday A P Friday A P Saturday A P Sunday A P

6am 7am 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm 12am-6am

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Hierarchy of Difficult Situations

Make a list of all the things that make you anxious, and/ or things you avoid. Consider this in detail. If social situations cause your anxiety, be specific – how many people in a room make you anxious, does it depend on where you are? Or who you are with? Make each item on the list as specific as possible. Then arrange each item in order of how difficult it is to face using the ‘rating’ column starting with the least anxiety provoking. This is your anxiety hierarchy.

Things that make me anxious

Rating

1.

Most anxious

2.

3.

Fairly anxious

4.

5.

Least anxious

Pick the least anxiety provoking situation from your hierarchy of difficult situations and over the coming week try to reintroduce this activity using the tips on page 9.

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VISUALISATION

MOUNTAIN PATH Settle back comfortably and close your eyes …. take a deep slow breath and slowly exhale ….repeat this twice more, as you breathe out – imagine you are breathing away all tension and stress …. mentally scan your body for tightness and tension …. and just let relaxation replace any tensions …. allow relaxation to take over. Now imagine yourself leaving the area where you live …. leave the daily hassles and the fast pace behind …. imagine yourself going across a valley and moving closer and closer to a mountain range …. imagine yourself in the mountain range …. you are going up a winding road …. find a place on the road to stop …. you find a path to walk up …. start walking up the path …. find a comfortable place to stop on the path …. at this place take some time to examine all the tensions and stress in your life …. give the tension and stress shapes and colours …. look at them very carefully and after you have done this, put them down by the side of the path …. continue walking up the path until you come to the top of a hill …. look out over the hill …. what do you see? …. find an inviting, comfortable place and go there …. be aware of the sights, smells and sounds …. be aware of how you are feeling …. get settled and gradually start to relax …. you are now feeling totally relaxed …. experience being relaxed totally and completely …. (pause for three to five minutes) …. look around at your special place once more …. remember this is your special place to relax …. you can come here anytime you want to …. bring your attention back to this room and tell yourself that this visualisation is something you have created, and you can use it whenever you want to feel relaxed.

This relaxation is best spoken with appropriate soft music playing in the background. You may like to make your own relaxation tapes and record this for yourself.

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Vicious Cycle of avoidance

Anxiety and worrying thoughts

Problems worsen. eg loose confidence, reduce activity, become isolated

Worsen how I feel- more frightened and unable to cope

Unhelpful behaviour- start to avoid stressful situations

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Vicious Cycle of inactivity

Low mood or depression

Problems worsen. eg loose confidence, reduce activity further

Worsen how I feel- more unhappy. Have fewer positive experiences

Unhelpful behaviour- start to reduce activity

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THE HUMAN PERFORMANCE CURVE

Performance

Too little demand

Optimum functioning

Fatigue,

exhaustion, burnout

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TIPS FOR INCREASING ACTIVITY & FACING FEARS

• Use your coping strategies – to help you stay

calm while doing graded practice. • It is very important to do the task until the

anxiety you have has died away. • Practice needs to be regular and frequent.

Practice every day if possible. • Realistic goals – make sure you set yourself

realistic goals. Don’t try for too much too soon. • Break tasks down – If a task is too hard, try

breaking it down and practising small parts of it. • Beware of subtle avoidance – You may think

that you do not avoid anything, but if you examine your behaviour you will probably find that you are doing things that count as avoidance without realising it.

• Don’t let fear win – Don’t be put off by feeling

anxious. You are learning something that needs to be mastered, you are bound to feel anxious if you try something difficult.

• Don’t belittle your successes. Encourage

and reward yourself when you achieve a target.

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Activity Monitoring Exercise

How did you spend your day? Briefly describe what you were doing at the various times listed in the left hand column. Then rate each one according to how much pleasure or achievement you gained (0= none and 10 =maximum possible)

Time

Activity (describe in a few words)

Achievement 0-10 (Rate from 0 minimum-10 max)

Pleasure 0-10 (Rate from 0 minimum-10 max)

5am

6am

7am

8am

9am

10am

11am

12 midday

1pm

2pm

3pm

4pm

5pm

6pm

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List of frightening Situations

Things that make jane panic

Rating

Most frightening

Fairly frightening

Least frightening

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Scenario Jane has come on this course because she has begun to feel more and more stressed and tense. She feels very nervous about going out to busy crowded places like shops especially if they are “ closed in”. These feelings are worse if she is alone and a bit better if she has a friend/family with her for support. At the moment she avoids going out much because she has had panic attacks in busy, crowded places and they really scare her. She doesn’t feel she can cope with the panic attacks anymore and so avoids all of the places that might make her panic. She can go to the local shop but not a supermarket, she used to love city centre shopping but hasn’t been for ages because she is worried about having a panic attack. Scenario Jane has come on this course because she has begun to feel more and more stressed and tense. She feels very nervous about going out to busy crowded places like shops especially if they are “ closed in”. These feelings are worse if she is alone and a bit better if she has a friend/family with her for support. At the moment she avoids going out much because she has had panic attacks in busy, crowded places and they really scare her. She doesn’t feel she can cope with the panic attacks anymore and so avoids all of the places that might make her panic. She can go to the local shop but not a supermarket, she used to love city centre shopping but hasn’t been for ages because she is worried about having a panic attack. Scenario Jane has come on this course because she has begun to feel more and more stressed and tense. She feels very nervous about going out to busy crowded places like shops especially if they are “ closed in”. These feelings are worse if she is alone and a bit better if she has a friend/family with her for support. At the moment she avoids going out much because she has had panic attacks in busy, crowded places and they really scare her. She doesn’t feel she can cope with the panic attacks anymore and so avoids all of the places that might make her panic. She can go to the local shop but not a supermarket, she used to love city centre shopping but hasn’t been for ages because she is worried about having a panic attack. Scenario Jane has come on this course because she has begun to feel more and more stressed and tense. She feels very nervous about going out to busy crowded places like shops especially if they are “ closed in”. These feelings are worse if she is alone and a bit better if she has a friend/family with her for support. At the moment she avoids going out much because she has had panic attacks in busy, crowded places and they really scare her. She doesn’t feel she can cope with the panic attacks anymore and so avoids all of the places that might make her panic. She can go to the local shop but not a supermarket, she used to love city centre shopping but hasn’t been for ages because she is worried about having a panic attack.

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VISUALISATION

MOUNTAIN PATH Settle back comfortably and close your eyes …. take a deep slow breath and slowly exhale ….repeat this twice more, as you breathe out – imagine you are breathing away all tension and stress …. mentally scan your body for tightness and tension …. and just let relaxation replace any tensions …. allow relaxation to take over. Now imagine yourself leaving the area where you live …. leave the daily hassles and the fast pace behind …. imagine yourself going across a valley and moving closer and closer to a mountain range …. imagine yourself in the mountain range …. you are going up a winding road …. find a place on the road to stop …. you find a path to walk up …. start walking up the path …. find a comfortable place to stop on the path …. at this place take some time to examine all the tensions and stress in your life …. give the tension and stress shapes and colours …. look at them very carefully and after you have done this, put them down by the side of the path …. continue walking up the path until you come to the top of a hill …. look out over the hill …. what do you see? …. find an inviting, comfortable place and go there …. be aware of the sights, smells and sounds …. be aware of how you are feeling …. get settled and gradually start to relax …. you are now feeling totally relaxed …. experience being relaxed totally and completely …. (pause for three to five minutes) …. look around at your special place once more …. remember this is your special place to relax …. you can come here anytime you want to …. bring your attention back to this room and tell yourself that this visualisation is something you have created, and you can use it whenever you want to feel relaxed.

This relaxation is best spoken with appropriate soft music playing in the background.

You may like to make your own relaxation tapes and record this for yourself.