This manual was developed for the Stress Management group held at Campbelltown Mental Health Service. It was written by Clinical Psychologists in the Behaviour Research and Therapy Unit, having researched a range of literature on the treatment of generalised anxiety.

WHAT IS ANXIETY?

NORMAL ANXIETY

Everyone has experienced some degree of anxiety in response to stressful situations. For example, an important exam, being startled by a strange sound, or a near miss in a car is enough to get your heart beating very fast and your stomach chruning! The stressful situation will differ from one person to the next. For example, one person may find it stressful to be in a large crowd, another to be alone. The stress reaction is appropriate and usually passes once the situation is over. Some stress reactions may last longer, but they decrease over time.

For some people anxiety or stress starts to interfere with their day-to-day living, making it hard for them to cope with even normal pressures. When this happens we call this an "anxiety disorder". Anxiety disorders are common in the general population, yet only about 4-5% seek treatment for anxiety complaints each year. This probably represents only about a quarter of those who actually do experience clinically high levels of anxiety. Those who do not seek treatment for anxiety may try to cope by using alcohol or medication, or by avoiding the stressful situation. Many people may experience physical symptoms such as high blood pressure, headaches, or digestive problems, and yet not even realise that these are symptoms of anxiety.

ANXIETY DISORDERS

Clinicians often find it useful to classify anxiety disorders into several categories. Some of these include:

Generalised Anxiety Disorder:

Generalised anxiety is when someone begins to get stressed about more and more situations and gets into a habit of worrying too much. The worry may be about everyday events, such as job responsibilities, health of family, finances, possible harm to children, or minor matters, such as household chores, or being late for appointments. The worry is usually out of proportion to the real likelihood of the event occuring or its impact if it does. This continuing worry causes anxiety which lasts for many months, and worsens in times of extra pressure. Some symptoms of this anxiety may be restlessness, feeling "on edge", tiring easily, problems concentrating, irritability, muscle tension, or problems sleeping.

Phobias:

Phobias are characterised by excessive and unrealistic anxiety when facing feared objects or situations, that others may find harmless. Even though the person may realise that the fear is excessive, they avoid the feared object or situation or endure it with intense anxiety. Examples of phobias include:

Agoraphobia is anxiety about situations from which it would be difficult or embarrassing to 'escape', or in which help may not be available if panic is experienced (e.g. shopping centres, bridges, buses, trains, supermarket queues, being alone).

Social phobia is anxiety about social or performance situations (e.g. public speaking, parties, small groups, dating, speaking to authority figures).

Specific phobia is anxiety about particular objects, or situations (e.g. blood, small spaces, heights, insects, animals).

Panic Disorder:

Panic attacks are sudden episodes of intense fear or panic, associated with feelings of impending doom (e.g. fear of heart attack, fainting or going crazy), and physical symptoms such as shortless of breath, pounding heart, muscle tension and choking sensations.

It is possible to suffer from more than one type of anxiety disorder at the same time. Fortunately, these anxiety problems can be treated effectively. With the right type of treatment they can be controlled, and the impact on daily living reduced.

SYMPTOMS OF ANXIETY OR STRESS

Symptoms may either be physical, psychological, or a combination of both.

Physical Symptoms:

Increased heart rate;

Rapid, shallow breathing or hyperventilation;

Headaches;

Excessive sweating;

Muscle tension;

Dry mouth or throat;

Digestive problems (e.g. diarrhoea, constipation);

Nausea;

Tiredness, fatigue;

Loss of energy.

Psychological Symptoms:

Excessive worry;

Loss of self-esteem and confidence;

Depression;

Irritability;

Loss of concentration;

Feeling overwhelmed;

Loss of motivation.

SOURCES OF STRESS:

Stressors are sources of stress or "triggers" which elicit a stress reaction. We can roughly categorise stressors into two types: external and internal sources of stress.

External stressors are those that occur in our environment and may be beyond our immediate control. These may include situations like criticism at work, the car breaking down in heavy traffic, getting burgled, or the death of a loved one.

Internal stressors are those that we personally create that worsen our anxiety levels, such as negative attitudes, unhelpful thinking, poor use of time, and not dealing with problems effectively. Thinking that worsens anxiety may include needing to be loved by everyone, being unable to say no to requests for the fear of rejection, and being perfectionistic. These are the most common sources of stress, and yet they are also often ignored or overlooked when we think about reducing stress in our lives.

As each of us has different past experiences, future expectations and present circumstances, we differ in our sources of stress. From a young age, we begin to learn ways of reacting to certain situations through our own experiences, and watching other people. If the experience are unpleasant we are more likely to fear these situations and then avoid them. For example, if you grew up with an unwell parent, you may tend to worry excessively about your health.

Often a number of stressors may combine to make us feel distressed. In the space below, list as many anxiety provoking situations that you can think of. They may be either external or internal stressors.

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ANXIETY PROVOKING SITUATIONS

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"GOOD" AND "BAD" STRESS

Not all stress is harmful. We all need a certain amount of stress in our lives in order to motivate ourselves to perform ceratin everyday tasks like meeting deadlines at work, or studying for an exam. If we did not feel some degree of anxiety we would not be able to perform our best on tasks. The Yerkes-Dodson Law illustrates how this works:

A low level of arousal or anxiety increases alertness, and enhances performance to a point. Once a critical threshold of arousal or anxiety is reached (i.e. the point where we begin to feel overwhelmed), increasing arousal will then interfere with our performance, (e.g. getting a mental block during an exam or forgetting the words of a speech at a gathering because of anxiety).

COPING WITH ANXIETY

Just as people feel distressed in different situations, they also have different ways of coping with stress. Some people cope better than others in the same situation because they use more helpful coping strategies. These skills are largely learnt from those around us, and are strengthened by continuous practice.

Some coping strategies are listed below. Not all of them are helpful as they may lead to more stress in the future.

Negative coping styles:

avoiding stressful situations;
excessive worrying;
putting things off;
becoming depressed;
excessive use of alcohol;
excessive use of prescription or recreational drugs;
becoming irritable;
withdrawing from others.

Positive coping styles:

facing your fears;
using relaxation techniques;
using problem-solving and goal-setting;
changing negative thinking;
controlling worry.

SUMMARY

Our past experiences and current expectations teach us to see situations in a particular way. If we think situations are overwhelming or stressful, we may develop physical and/or psychological symptoms which may lead to further stress and anxiety. By learning to cope more effectively in those situations, we are less likely to become stressed or anxious, and therefore are less likely to suffer from the symptoms of anxiety.

Homework task:
1. Complete your anxiety provoking situations

REDUCING STRESS LEVELS

In the last chapter we looked at some of the negative effects of high levels of stress and anxiety. In this chapter we will be discussing ways in which you can reduce your stress reaction by changing lifestyle habits and learning relaxation techniques. In later chapters we will be presenting other specific techniques for reducing stress levels, such as goal-setting, problem solving and time-management.

LIFESTYLE CHANGES TO REDUCE STRESS

Maintaining good physical health is important for managing stress. If we don't get adequate sleep, exercise, or nutrition, we are physically stressing our bodies. This can make us more vulnerable to physical illness and anxiety symptoms.

Sleep:

Too much or too little sleep can make you irritable and less able to function in daily activities. People need different amounts of sleep, but most require between 7 to 9 hours per night. Some need less sleep while others may need more than 9 hours in order to function effectively throughout the day. The important point is whether you generally feel refreshed after waking up. If not, then you may need to examine your sleep patterns more closely.

One way of doing this is to write a "sleep diary" for a few weeks so you become aware of your sleep patterns. For example, do you have difficulty getting off to sleep or staying asleep? Do you wake up too early in the morning? Do you suffer from frequent nightmares? Some hints that may assist sleep include:

avoiding alcohol and caffeine in the evening;
not having large meals immediately before bed;
having relaxation times throughout the day;
not sleeping during the day;
having a relaxing routine before going to bed;
doing some exercise during the day;
allowing time for sleep (i.e. giving yourself enough hours for a refreshing sleep even if you don't fall asleep immediately or have waking periods throughout the night).

Exercise:

By exercising regularly, people can increase their physical and mental tolerance to stressful situations. research has shown that exercise decreases anxiety and depression, and improves sleep, appetite and concentration. Exercise can also be a good way of releasing tension and easing boredom, and often improves your sense of control and self-esteem.

A number of theories suggest people generally feel better after exercise because:

increased oxygen flow to the brain in those exercising regularly has been shown to lower anxiety and depression levels, when compared with people who don't exercise;
exercise triggers the release of "endorphins" or substances linked to feelings of wellbeing;
exercise can distract attention from worries and unpleasant feelings.

If you have not been exercising regularly, start gradually by walking each day, and then build this up over time. You will benefit from exercising for even 20-30 minutes, three times a week. If you are not used to exercising, perhaps seek a medical check-up to assess where to start.

Nutrition:

Eating sensibly is an important step in maintaining health and managing stress. People who don't manage their stress effectively may overuse stimulants such as caffeine, alcohol, tobacco, and sugars. Stimulants all accelerate the flight or flight response discussed later this chapter.

Caffeine is found in coffee, tea, 'cola' soft drinks, and chocolate, and affects the nervous system, leaving you feeling "hyped up" and anxious. Switching to decaffeinated coffee would be beneficial, or reducing the number of cups you have to 3 to 4 per day. Even if you are not consuming a lot of tea or coffee your body may be sensitive to the small amounts.

Alcohol is often used to escape anxiety and everyday stressors. It initially acts as a sedative or relaxant, however a few hours after a drink it acts as a stimulant, and actually makes you more vulnerable to anxiety. Alcohol is an ineffective way of coping in the long term because as you become tolerant to the effects of alcohol you will need to take increasing doses to get the same "anti-anxiety" effects. Long term use may also produce physical damage throughout the body, and can lead to more problems such as withdrawal symptoms, marital conflicts, work absenteeism and social embarassment.

Tobacco is very addictive and contains nicotine which is also a stimulant. Giving up smoking will improve physical health and consequently reduce stress. The cigarette breaks taken throughout the day can be used to practice more effective relaxation strategies.If you do choose to give up smoking, seek help from a smoking clinic, especially if you have been a smoker for several years.

Sugar
It is important to eat a range of foods from the 5 major food groups to maintain physical health. To cope with their anxiety, many people "comfort-eat" foods that are highly processed and contain large amounts of sugar and fat (e.g. chocolate, cake, lollies, chips). These 'simple' sugars boost blood sugar levels, and therefore energy, temporarily. However, this soon drops to a lower level than originally, so people enter a cycle of regularly boosting their energy levels with repeated sugar inputs to combat tiredness. 'Complex' sugars found in foods such as bread, cereal, fruit and vegetables, alternatively, give people a more constant level of energy throughout the day as these sugars digest more slowly.

USE OF RELAXATION TO REDUCE STRESS

Flight or Fight Response:

The flight or fight response is the body's natural response to any perceived danger or threat. When people think they may be in danger, chemicals are released in the body which activate the nervous system, and trigger the physical reactions of anxiety. Changes such as increased muscle tension and heart rate, rapid and shallow breathing, perspiring, and becoming more alert or vigilant are all designed to help us protect ourselves. When in a physically threatening situation where the individual has to run or fight to get away from the danger, this response is helpful and the person will quickly calm down again once the danger had passed. However, the response is not helpful when it is caused by excessive worrying alone, as the body will continue to release the chemicals, and the anxiety will continue.

In some people, the flight or fight response occurs often throughout the day which means they are in a state of constant arousal or stress. In others, the response may be excessive so that it takes a long time for them to calm down. Over time, the effects of many stressors begin to build up until they reach a "critical threshold". When the stress level reaches this critical threshold, people will begin to feel out of control of their anxiety and any small stress may trigger offa number of severe anxiety symptoms.

We can increase our ability to cope with various situations and stressors by regularly decreasing our general level of arousal or anxiety through relaxation, and thereby preventing the anxiety rising to the critical threshold. By learning how to relax effectively, and reduce residual tension in the muscles, people for and manage their anxiety in situations that may otherwise stress them. This relaxation involves both controlled breathing and muscle relaxation.

Controlled Breathing

As discussed, one of the effects of the flight or fight response is overbreathing or hyperventilation. This disrupts the body's balance between oxygen and carbon dioxide, and triggers changes such as dizziness, hot flushes, tiredness, tight chest muscles, and other anxiety symptoms. If you are generally anxious throughout the day, you may be frequently overbreathing, which will keep you constantly aroused. Many people are not aware that they hyperventilate. You may be hyperventilating when anxious by breathing too quickly or deeply, by sighing or yawning execessively, or by breathing through your mouth rather than your nose. Reducing hyperventilation and controlling your breathing is extremely important in controlling your stress levels.

To control your overbreathing, as soon as you begin to feel anxious or before tackling a difficult follow this technique:

Hold your breath and count to 10;
When you get to 10, breathe out and say the word 'relax' to yourself;
Breathe in and out slowly in a six second cycle. Breathe in for three seconds and out for three seconds. Say the word relax to yourself every time you breathe out;
Just take normal breaths, not deep ones, but make sure you are breathing through your nose and using your diaphragm muscles, and not shallow breathing using your chest muscle;
Continue breathing in this way until the symptoms of overbreathing have gone, and you feel calmer.

Progressive Muscle Relaxation

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Find a comfortable, quiet place to sit down and try to ensure that you will not be interrupted for about 20 minutes;
Close your eyes and focus on your breathing keeping it slow and even. Say the word "relax" to yourself as you breathe out;
Tense up your right hand by making a fist. Focus on the tension in your right fist and forearm. Slowly release that tension as you breath out saying the word "relax" to yourself. Repeat this exercise now with your left hand, focussing on the tension and then releasing it as you say relax;
Now move your attention to the muscles of your face. Begin by tensing up your forehead by raising your eye brows, holding the tension and releasing it. Then one by one tense the other facial muscles by making a frown, followed by squinting your eyes, pushing your lips together, and then clenching your jaw. Each time hold the tension and then gently release it as you say the word "relax" to yourself;
Go through the other muscles in your body, working through the muscles of your neck, shoulders, back, chest, abdomen, lower back, thigh muscles, calf muscles, ankles, feet, and toes;
When you finish, scan through your body and make sure most tension has been released. If some areas are still tense, you can spend extra time just relaxing those places;
You can deepen the feelings of relaxation you have by picturing a peaceful scene, one which makes you feel quiet and relaxed. Picture it as clearly as you can: the colours, the smells, the sounds, saying to yourself "relax" every time you breath out;
Slowly open your eyes and try to maintain that feeling of relaxation for the rest of the day.

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Homework tasks:

Consider any lifestyle changes you may need to make;
Practice controlled breathing at least 5 times each day;
Practice progressive muscle relaxation daily.

Use the self-monitoring forms provided on the next page as a way of keeping track of your progress in coping with stress.

BREATHING/RELAXATION PRACTICE RECORD

Scale of tension:
0........1........2........3........4........5........6........7........8........9........10

0 =none
2=slight
4=moderate
7=much
10=extreme

day relaxation breathing comments
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GOAL SETTING, TIME MANAGEMENT AND PROBLEM SOLVING

These are very practical skills for effective stress-management. Like all skills, they take time and practice to master, but once you have done this, you will notice how easy they are to do on a regular basis.

GOAL SETTING

Goal-setting is important for reducing stress because by deciding on specific short and long-term goals it allows you to:

know exactly what it is you want to achieve in the future, in what order, and within what time frame. This helps to structure your time and ensures that you fit in the things you may want, despite the constant demands on your time;
know exactly when you have achieved a certain goal so you are able to reward yourself. If you only have vague goals such as "get healthy", it is harder to know when you reach that goal than if it is specific, such as "exercise 5 times a week".

Long and short term goal-setting

The process of goal setting involves recording long term goals and then breaking them down into realistic, achievable short term actions. This process is meant to be flexible: your list of goals this year may not necessarily be the same as your list in five years.

While goal setting, try to use these three categories:

Personal Goals - These are goals that you personally wish to achieve, and differ from other goals you might have that benefit other people or organisations. For example, doing a course or a hobby.
"Work" Goals - These are goals related to your working life (e.g. career or motherhood).
Social or Family Relationship Goals - These are goals which involve relating to other people, (e.g. planning a dinner party or spending more time with someone).

Think of the goals in these three areas you would like to have accomplished in the next 10 years. This may take some time to think about, but listing them will help you plan how to arrange your time in order to achieve these goals.

10 YEAR GOALS

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Personal Goals

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Work Goals

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Social/Family Goals

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Now break these long-term goals into shorter goals (i.e. actions in the next 12 months that work towards your 10-year goals). For example, if going overseas is one of your long-term goals, you can set a target to save a certain amount in the next 12 months towards it. Be as specific as possible about your 12 month goals in the different categories.

12-MONTH GOALS

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Personal Goals

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Work Goals

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Social/Family Goals

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Now decide your goals for the next month that work towards the longer term goals.

1 MONTH GOALS

Now review your shorter term goals to check that they lead towards achieving your 10 year goals. Ensure your goals are realistic within the timeframes allocated, as setting yourself impossibly high goals may create stress. Being aware of what is possible and within your capabilities allows you to effectively plan ahead and control your stress level.

TIME MANAGEMENT

Now your goals are decided, it is important that your daily activities guide you towards these goals. Often people rush from one task to the next, trying to fit much into a day, which creates more stress than necessary. It is important to organise your daily activities into a 'to do' list, so you can prioritise tasks and allocate sufficient time to getting them done. Write down all the tasks you want to do today, covering the three categories, to ensure you're working towards all the types of goals.

Daily 'To Do' List

Personal Activities

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Work Activities

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Now priotise the day's activities, by marking:

'A' next to the tasks that absolutely must be completed by the end of the day;
'B' next to the tasks that should be completed in the next day or two, and;
'C' next to the tasks that can wait for a few days.

Assign yourself no more than three 'A' goals in any category, or you may create extra stress for yourself by trying to fit too much in to the day.

People often set themselves several tasks without considering how long each of these will take to complete without rushing. Review your daily goals again and consider how much time each of those tasks is likely to take. Work with your 'A' activities first then write in any 'B', then 'C' activities that will fit in to the day. Remember to include time for travelling, conversation, and thinking in your calculations. Also include some "buffer" time for unexpected events or activities, (e.g. receiving unplanned phone calls), and recreation time.

Personal Activities
Time allocated

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Work Activities
Time allocated

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Social/Family Activities
Time allocated

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Check that these tasks are possible within the specified time period. Otherwise, modify the activity to fit the time period or extend the time allocated.

Practicing these skills regularly will make them quicker and easier to perform.

PROBLEM SOLVING

We all have to deal with problems regularly and the ways in which we each attempt this varies. Some ways of solving problems are more helpful than others in the long-run. Not dealing with problems as they arise can lead to feeling helpless and frustrated, and increase stress and anxiety.

Some unhelpful ways of dealing with problems are:

Ignoring the problem and hoping it goes away;
Worrying excessively without thinking of any solutions;
Relying on someone else to solve the problem;
Becoming too distressed to deal with the problem.

A more helpful way of dealing with problems is to try and solve them yourself with a step by step method.

Step 1: Define the Problem

The more clearly you can define exactly what the problem is, the easier it will be to think of effective solutions. You may find what initially began as one problem is actually a number of smaller problems or concerns, and you can deal with each of these individually.

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Step 2: Possible Solutions

Write down any solutions to the problem that enter your head. Do not judge whether the solution is practical at this stage, so it does not matter how 'wacky' the ideas you come up with are. Research shows the more solutions you can provide, the more effective your final solution is likely to be.

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Step 3: Choose the Best 3 Solutions or Combination of Solutions

Review the list of possible solutions, noting next to each its advantages and disadvantages. Consider the possible consequences of each. Select three options which seem the best and which you would be prepared to give a try.

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Step 4: Select a Solution to try

Now decide which is the best solution to the problem at this particular time and write it down.

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Step 5: Decide how and when will you implement this solution

Decide when the best time and place to carry out your solution or combination of solutions will be. Setting a time frame will ensure you don't put off trying the solution.

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Decide what will need to happen for you to know that the solution is working:

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Decide when will you check on its progress:

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Now try the solution!

Step 6: Review your efforts

Now that you have tried that solution to the problem, review your efforts to decide whether it was effective. Use the scales below to assist you in this:

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Easy to carry out                       Neither easy nor difficult	  Difficult to carry out

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Very effective to carry out         Neither effective nor ineffective	   Ineffective solution

If things did not work out as expected, make sure that the problem was defined in the first step. Then modify the solution or try an alternative one from the earlier list.

Modified solution:

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Homework tasks:

Continue practicing controlled breathing and relaxation.
Set some long-term and short-term goals.
Try daily time management.
Use the steps to solve a problem.

NEGATIVE THINKING

This chapter looks at the link between thoughts, feelings and behaviour, and the way they interact to maintain anxiety. People's styles of thinking develop through their life experiences, and continue to affect the way they perceive events.

THE A-B-C MODEL OF THINKING, FEELING AND BEHAVING

Our emotions are not so much a result of events or other people's reactions to us, but rather what we tell ourselves about these and reactions. This is explained by the A-B-C model:

Events (imagined or real)
Thoughts
Reactions (emotions and behaviour)

Events are situations which you react to, such as being criticised or being caught in traffic. It may be a situation that has just occured (e.g. argument with your partner) or is expected (e.g. planned job interview). Alos, if you imagine an event occuring it may trigger the same reaction as a real event (e.g. if you imagine your mind going blank during a speech it can cause anxiety similar to that you'd feel if you were really there).

Thoughts are the result of our attempts to make sense of everyday events. They occur quickly and often we are not even aware of them. The kind of thoughts we have are based on belief systems we each build up over time as a result of life experiences. The same style of thinking tends to occur automatically each time we face certain events, so we develop fixed patterns of thinking.

Reactions are whatever feelings or behaviours result from your thoughts. People have different thoughts about the same event and therefore will feel and act differently as a result.

It is not the event (A) which causes the reactions (C). It is your thoughts (B) about the situation that cause the reaction. In other words, B, not A, produces C.

For example:

A man, a woman and a schoolboy are waiting at the bus stop and the bus is late (A). the man reacts by thinking "I'll be late for my meeting"(B), and therefore feels anxious and angry(C). The woman thinks "I knew today was going to be a bad day, I can't get anything right"(B) and feels depressed(C). The schoolboy thinks "Cool, an excuse to get to school late"(B) and feels pleased(C).

When thinking is unrealistic, it generally causes more anxiety than necessary. Anxiety will increase in people who tend to see things as worse than they need to be. They develop unhelpful habits of thinking about situations that upset them, and often expect the worst. This can actually bring on the "worst" situation.

Negative, unrealistic thinking may be about:

) Yourself and your ability to cope (e.g. "I'll never get control of this anxiety");
) Interpreting current events or situations (e.g. "I spilled the coffee, so I can't show my face around here again");
) Future events (e.g. "no one will ever listen to my opinions").

COGNITIVE THERAPY

This is a method by which you can learn to change your way of thinking so that you can interpret situations more accurately, and therefore reduce your anxiety.

The process of cognitive therapy involves:

Learning to identify your negative thoughts;
Questioning the evidence upon which these thoughts are based;
Replacing the negative thoughts with more realistic and helpful ones;
Correcting the underlying irrational belief systems that cause us to misinterpret events.

Negative thinking styles continue because we don't test how rational they are. Just as we learn negative thinking styles, we can also learn more positive, rational ways of thinking.

COMMON IRRATIONAL THINKING HABITS

Black and white thinking is interpreting experiences at one extreme or the other, rather than in various degrees (e.g. success or failure; "terrific" or "terrible");
Overgeneralising is believing that because things have gone wrong in the past, they will continue to go wrong. (e.g. "failing one exam means I'll never pass one again");
Magnifying the negatives in a situation (e.g. "the vegetables were lukewarm, so the whole night was a failure");
Catastrophising is turning situations into "life or death" issues and focussing on the "what ifs?" (e.g. Headache means a brain tumour);
Overestimating failure and underestimating success (e.g. "I won't.."; "I can't..."; "even if I get this job I won't be any good at it");
Setting unrealistic expectations and inflexible rules which must be met by yourself and others to avoid failure (e.g. "I must..."; "I should...");
Personalising is thinking that everything people do or say is in some way a reaction to you (e.g. "dad's in a bad mood; it must be my fault");
Mind-reading is assuming what others are thinking without any real evidence (e.g. "they're talking about me"; "he must think I'm stupid"; "she's interrupted me twice, so she must think I'm boring");
Converting positives into negatives is not giving yourself credit for your achievements (e.g. refusing to accept compliments or downgrading your efforts if praised);
Mistaking feelings for facts is when you confuse feelings with reality (e.g. "because I feel hopeless, I am hopeless").

In the next chapter, we look at ways to correct these faulty thinking patterns. Newer, more adaptive, less stressful ways are learnt and can replace negative thoughts by increased awareness and constant practice.

Homework task:

Try to become more aware of the way in which your interpretation of your abilities to cope and of various situations may actually be contributing to high levels of stress.

Start by recording your thoughts in a daily thoughts diary. There are a couple of ways of doing this:

Write down the negative thoughts as soon as they occur. This is the most accurate way of recording and challenging negative thoughts, as you are likely to forget your exact thoughts about a situation over time.
If you can't record your thoughts immediately, set 15 minutes aside each evening to recall the events that have made you anxious during the day. Write down the thoughts you had before, during and after the event. Never leave this until the next day as you'll have a new set of anxious thoughts to deal with on top of the previous day's.

We recommend you use an exercise book to keep an ongoing account of your thought patterns. Use the following headings to start identifying and recording your thoughts:

Date          Situation          Emotions                  Negative Thoughts

CHANGING NEGATIVE THINKING

Over the past week you will have been writing down the kind of negative thoughts that you have when you become anxious. Once you have identified what these thoughts are, you can learn to change them to make them more helpful and realistic.

CHALLENGING NEGATIVE THOUGHTS

Once you have identified what the negative thought is that is making you anxious you can challenge it by asking yourself the following questions:

Reality Testing
1. What evidence or support do I have for believing this?
2. In what ways might I be distorting reality?
3. What is fact in this situation and what are my own feelings and interpretations?
Alternative Explanations
1. Is what I believe the only or best way to explain what is going on, or are these other, more realistic explanations?
2. Would everyone in a similar situation think this way?
Changing Perspectives
1. What reasonable grounds do I have for believing that:
  - I should or must be or do things a certain way?
  - others should or must be or do things the way I think?
  - situations should be the way I want them?
Putting it into Perspective
1. Are things really as bad as I'm making out?
2. What's positive about this situation?
3. How likely is it that the worst will, in fact, happen?
4. What is most likely to happen?
Goal Directed Behaviour
1. Are these thoughts helping me achieve my goals or not? (i.e. What are the advantages and disadvantages of thinking this way?)

Challenging your negative thoughts is most effective if you write down the thought and the challenge. As you do this regularly, the challenging becomes more automatic, and you can prepare for stressful situations in advance by practising challenges in your head. You will also find your mind automatically directs itself to challenge negative thinking as your skills improve.

Another way of checking how realistically you've interpreted a situation is to check with someone who is close to you how the've interpreted the situation. The other person may help you discover alternative explanations.

IRRATIONAL BELIEF SYSTEMS

As you continue monitoring your negative thoughts you can become aware of certain thoughts that occur repeatedly. These thoughts are your signal to the underlying belief systems that are triggering them. Remember that the belief systems are learnt from all your experiences, and they determine how you will interpret, or think about situations. If you have irrational beliefs about situations they may be causing you unnecessary distress that can be reduced by changing the belief. Below are listed some common irrational beliefs and the results they may have on you.

Irrational Beliefs

I must have constant love and approval from all people who are important to me Therefore:
- I don't express my opinions or desires
- I avoid all conflict
- I hold back my feelings-positive and negative
More rational beliefs:
It's not possible or necessary to always have the approval of others for everything I do. When I express my feelings I should not expect others to always agree. I am a worthwhile person - I do not need other's constant love and approval for this.
I must do everything perfectly and competently in order to feel good about myself. It is a tradegy if I fail at anything. Therefore:
- I worry a lot, all the time
- I try to avoid doing anything new for fear of failure
- I avoid talking to people because I might not have anything worthwhile to say.
More rational beliefs:
I cannot expect to do everything perfectly; it is not possible or necessary. If I fail at something it shouldn't make me feel bad about myself. I'm onlu human. If I don't try new things through fearing failure I may miss out on enjoyment.
It is an awful disaster when things do not go the way I would like them to go and I just cannot bear it. Such things should not happen to me. Therefore:
- I complain and whine about this tradegy
- I criticise others, especially certain groups (e.g. men, women, bosses, young people)
- I act helpless and unable to cope, like a victim
- I am uncooperative without saying I disagree with the way things are done
More rational beliefs:
I cannot expect things to always go my way. I can tolerate if they don't.
People who hurt others or do 'wrong' things are bad and worthless. They deserve to be punished. Therefore:
- I question people's motives excessively
- I treat "bad people" aggressively and ignore any good qualities in them
- I punish myself when I hurt others or make a mistake because I believe this means I'm bad and deserve punishment
More rational beliefs:
If someone does something wrong or makes a mistake, it doesn't make them ALL bad. It does not help me to keep a realistic outlook if I constantly look for bad motives in people. I can make a mistake and not be "bad" or deserve punishment.
If something seems dangerous or frightening, I should become terribly upset and concerned about it. Therefore:
- I worry for no reason and can't see things in perspective
- I get upset, I stop thinking clearly and am less able to handle the situation if it is really dangerous
- I fear being with others, either individually or in groups
More rational beliefs:
If I feel, or am, in danger, I can still keep perspective and think clearly about the situation. I need to exercise caution but not let my emotions override my ability to think logically.
There is always a right and perfect solution to human problems. It is a disaster if I cannot find this correct solution. Therefore:
- I keep looking for the perfect solution, and feel stupid if I cannot find it
- I refuse to accept the way things are, and rather complain that things should not be this way
More rational beliefs:
There may be no perfect solution to problems. I can choose the solution that is most likely to be successful under the circumstances.
Negative feelings are caused by external pressures: People have little or no control over their emotions. Therefore:
- I believe that I am a "born worrier" or have just always been depressed
- I believe that I am unable to change my usual responses
- I worry excessively about the effect of my words or actions on others
More rational beliefs:
I have learnt this response over time and can learn more effective responses. I can control my emotions by making sure I think rationally about situations. I don't directly cause other's emotional reactions - they have their own beliefs and interpretations about events.
It is easier to avoid difficulties and responsibilities than face up to them. Therefore:
- I 'blow up' frequently because I believe I must have immediate relief from my irritations and worries rather than planning lomg term solutions.
- I avoid dealing with unpleasant emotions or asserting my rights
More rational beliefs:
I can deal with difficult situations when they occur, and plan solutions effectively. I can tolerate unpleasant emotions while actively seeking solutions for difficult situations.
What happened to me in the past will keep on having an inevitable effect on my feelings and behaviour now and in the future. Therefore:
- I fail to learn more effective patterns of behaviour and thinking
- I become passive and apathetic
More rational beliefs:
I can learn more effective ways of thinking and behaving. I am not controlled by my past.
Happiness comes from inaction by passively enjoying yourself. Therefore:
- I wait for things to happen rather than actively taking control
- I wait for others to make decisions for me
- I don't try to contribute anything to my own happiness
More rational beliefs:
I can contribute to my own happiness. I can take control of situations rather than relying on others to do so for me.
I should be dependent on others - I need someone stronger than myself to rely on. Therefore:
- I feel incompetent
- I become passive
- I spend excessive effort pleasing the person I am dependent on, out of fear of losing him/her.
More rational beliefs:
It's nice to have someone near who cares but I don't need him/her to cope. I do things for others because I want to, not out of fear that I will lose them.
I should become quite upset over other people's problems. Therefore:
- I worry excessively for them
- I avoid sharing my concerns in case other people get upset
More rational beliefs:
I can listen but I can't take responsibility for other's problems. I can't take responsibility for other's reactions when I express my concerns to them.

Homework tasks:

Pick one example of a time you feel anxious during the week and record it below.

Think back to the last time you felt anxious or stressed and try to recall the kinds of thoughts that were going through your mind before you got anxious.
__________________________________________________________________________________________
__________________________________________________________________________________________

Now try to identify the kinds of thoughts you had when you became stressed and the symptoms began. These thoughts often involve wondering whether the symptoms will get worse or whether you can cope.
__________________________________________________________________________________________
__________________________________________________________________________________________

Now try to identify the kinds of thoughts you had after the stressful situation, and thoughts about facing the situation again.
__________________________________________________________________________________________
__________________________________________________________________________________________

Now see if you can challenge these thoughts so that they become more realistic and will help you cope in future in a similar situation.
Before the event: ____________________________________________________________________________

_________________________________________________________________________________________
During the event: ____________________________________________________________________________

_________________________________________________________________________________________
After the event: ____________________________________________________________________________

_________________________________________________________________________________________
Try challenging last week's recorded negative thoughts. Continue also to keep your thoughts diary this week, this time challenging as well as identifying the negative thoughts. Use the diary below.

Date        Situation       Emotions            Negative Thoughts      Realistic thoughts

DEALING WITH WORRY

There will be times when your thoughts about a situation are rational because they are based on a real problem or difficulty. The trouble is not in the way you interpret the situation, but the way you keep focussing your attention on the problem. This excessive worrying makes it difficult to concentrate on anything else and affects your ability to remember new information.

When you are faced with a real problem, try to solve it where possible, using the problem solving strategies introduced earlier in the manual. If you are unable to solve the problem and you are thinking rationally about the situation but still worrying excessively, try some of the techniques to control worry outlined below.

DISTRACTION TECHNIQUES

When worrying thoughts keep coming into your mind it is impossible to stop them just by trying to push them out of your mind or not thinking about them. This actually makes you focus more on the worries than less (e.g. try NOT to think about what you had for breakfast! Could you do it?) A better solution is to focus your attention on something else.

Think about a time when you were absorbed in an activity you enjoyed a lot, or took up all your attention. You probably wouldn't have been worrying at that time, because it's difficult to think properly about more than one thing at the same time. So to control your worries, don't tru to push them away - distract yourself by focussing your attention on something else. There are many ways to do this:

Focus your attention on the breathing exercise you learnt earlier.
Focus your attention on what is happening around you, using all your senses: sight, hearing, taste, touch, and smell (e.g. ask yourself questions like "what can I hear?", "What am I touching?", and "What can I smell?"). Give yourself a psecific task (e.g. guess the age of everyone in the room).
Focus your attention on an object, describing it to yourself in as much detail as possible (e.g. what is it made of? what is it for? etc..)
Perform some form of mental activity. Read a book or complete a crossword. Alternatively, count back from 1000 in 7's, think of animals beginning with each letter of the alphabet, or remember a favourite walk in detail.
Concentrate on pleasant past memories (e.g an enjoyable holiday) and fantasies (e.g. what you would do if you won lotto).
Do some physical activity (e.g. exercise, wash the car, walk the dog, do some gardening).

Activities which don't need much thought can be made more absorbing by combining them with others (e.g. listen to the radio while doing the ironing).

LEARNING TO CHANGE YOUR FOCUS

It's not always easy to change your focus, particularly when your worries have a lot of emotion attached to them. However, being able to focus your attention on something else is a skill that will improve with practice.

To learn more flexible in switching your focus, try this exercise:

Sit quietly and close your eyes;
Focus your attention on sounds within the room, such as the ticking of a clock, or the sounds of the television or radio, and continue to do this for a few minutes;
Focus your attention on sounds outside the room, such as traffic from a nearby road, the wind in the trees, or voices of people in the next room, and continue to do this for a few minutes;
Switch your attention from one sound to another and continue to do this for a few minutes;
Finally, focus on as many different sounds as you can at the same time; expand your attention and try to absorb all the sounds.

When you first try this technique you may find unwanted worries will still flood into your mind. When this happens don't try to push the unwanted thoughts out of your mind, just bring your attention gently back to what you were focussing on.

THOUGHT-STOPPING

At times we need to interrupt the worry cycle before we can refocus our attention. To do this, find somewhere quiet and deliberately think about your worrying thought. When it is firmly in your mind, jump up and shout "STOP!" At the same time imagine a stop sign in your mind. (make the command loud - the idea is to shock you into interrupting the thought.) After you shout STOP, focus your attention onto something else (e.g. a pleasant memory) or practice your rational thinking. later, when you're more familiar and skilled at this technique, and other people are around you, shout STOP to yourself inside your head, while visualising the stop sign. Instead of shouting STOP, some people wear a rubber band around their wrist and flick it to interrupt their worrying. Then the attention is switched to something else.

SET A "WORRY" SESSION

It may help to set aside a specific period of time during the day just to worry. The idea is that once you have concentrated on working through the worry it's less likely to bother you. So set aside 15 minutes to think only about the worry. Write down your concerns - this helps put them in perspective - and use problem solving if you can apply it to the concerns. Once you have done everything you can to resolve the worry, change your attention to something else using one of the above techniques. Some people like to "worry" in the same place each day (e.g. a particular chair or room) to "attach" worrying to this place, and don't allow themselves to worry anywhere else.

Homework tasks:

Try these techniques during the week when you're worried to find which technique you are comfortable with and is effective for you.
Continue practising your breathing and relaxation techniques.
Continue identifying and challenging your negative thoughts.

DEPRESSION AND STRESS

Moods are a normal and important part of our everyday experience, but are different from major depression. From time to time everyone feels "down". However, normal moods tend to last only hours or days, while symptoms of depression are usually more intense and long-lasting. Consequently, depression tends to interfere more with everyday functioning.

Almost everyone experiences depression at some point in their lives. About 13% to 20% of the population suffer symptoms of depression that need some type of psychological treatment. Depression may occur throughout the whole lifespan from childhood, and is more common in women than men.

There is no single cause of depression, but instead it is the interaction of various factors including biological make-up, past experiences, the current situation and social or family supports. In some people, depression may be reactive, which means it is trigerred by experiences or situations such as losses (e.g. loss of a loved one), stressful events (e.g. possible retrenchement) or illness (e.g. virus). Reactive depression may disappear within a relatively short time once the cause of the stress is resolved. In other people, depression may occur for no apparent reason, due to a biological cause.

When people are highly stressed they are especially vulnerable to becoming depressed, due to fears they will never overcome their anxiety symptoms. Once they become depressed, they begin to think more negatively, and are then less able to cope with stress. Both the anxiety and depression symptoms then increase.

SYMPTOMS OF DEPRESSION

Depression may range in severity from mild feelings of sadness and disappointment through to intense states of despair. Depression involves a range of physical and psychological symptoms which may differ for each person in both nature and severity. The symptoms include:

Mood
Feeling:
sad or gloomy
irritable and unable to cope with everyday demands
guilty
emotionally numb and empty
unable to enjoy activities
anxious
despair

Thoughts
thoughts of self-worthlessness
self-critical
low self-confidence
thoughts of guilt and self-blame
negative expectations about the future
thinking you can't cope
suicidal thoughts
poor concentration and memory
imagining others are putting you down

Behaviour
reduced activity levels
social withdrawal
increased dependency on others
frequent crying or difficulty crying if you want to
agitation and inability to stick at things for long
increased use of alcohol and drugs
slowed behaviour

Motivation
lack of motivation
continually delaying things
lack of a sense of achievement and purpose
lethargy and fatigue

Physical
aches and pains
gastric problems
loss of appetite leading to weight loss or overeating
difficulty sleeping or excessive sleep
reduced sexual interest
menstrual irregularities
feelings "off" and fatigued

TYPES OF TREATMENT

Depression is often treated effectively using anti-depressant medication. Some problems with medication however, are : -not all people find it effective; some people get side effects; some people object to taking medication; and some become dependent on medication and fear getting worse if they stop taking it.

An alternative treatment for depression uses an approach (cognitive-behavioural) similar to the treatment of anxiety (i.e. by changing unhelpful behaviour and negative thinking). This approach is especially useful as it teaches skills that can be used both now and in the future to control depression.

CHANGING WHAT YOU ARE DOING

The cycle of depression and doing less activity

When feeling depressed people generally lack motivation and energy so they begin to do less. Every day activities may feel like a huge effort, they may get tired easily, and may not enjoy doing things they used to enjoy. Thoughts such as "I can't be bothered", "I feel too depressed to enjoy myself", or "I won't try as I will fail anyway" cause people to do less activity, to put things off, and to avoid socialising with others.

As a result of doing less:

people feel more helpless and less capable of achieving anything so their self esteem suffers.
they have less opportunities to get enjoyment or satisfaction from things.
they don't meet their responsibilities, so receive criticism from others, and feel guilty about letting them down.
they feel frustrated and angry with themselves, and others, if they are criticised.
they generally lose their skills to accomplish tasks and to relate to others.

These factors make people feel even more depressed, and therefore the effort to attempt tasks seems too great. They reduce their activities even further, and become trapped in a cycle as shown below:

low motivation
low self esteem

depressed mood
           do less activities

lose skills & confidence
get less satisfaction
feel frustrated and guilty

What motivates us to be active

People are motivated by being rewarded or 'positively' reinforced for what they do. Through doing less activity people are reducing the positive reinforcement they usually receive. This may come from:

the enjoyment of just participating in a task
the satisfaction of completing tasks or reaching goals
praise of thanks from others's for our efforts

The more activities we do, the more likely it is that we will gain the benefits of positive reinforcement, and that will motivate us to do the activity again. For example, an activity such as going for a walk can give a feeling of enjoyment or achievement, that motivates us to look forward to doing it again soon.

The benefits of becoming more active

The more you do, the more you will feel like doing because of the positive reinforcement
You are providing yourself with an opportunity to enjoy yourself
You will improve your confidence by having a go at something, and then by practising to improve at the task
You will feel like you have more control over your environment
You are more likely to get a break from negative thoughts if you get involved in activity. You can focus your attention away from yourself and your problems.
You can test out whether the negative thoughts you are having (e.g. "I'll fail anyway") are tru or not. If you don't try you won't know what you can and cannot do, and you will continue believing that the negative thoughts are facts.
Being physically inactive (e.g. staying at home all day) stops you receiving stimulation from the environment which can make you feel good.
Lack of activity will make you feel more tired. If you become more physically active (e.g. exercise) you will improve your physically health and your concentration, so things will feel like less of an effort. This can also improve your sleep quality, so you will feel less tired.

How to become more active

The rule in becoming more active is to do the opposite of what your depression tells you! If you feel like staying in bed, then get up! Do not let your mood control how you act. Remember you will receive the reinforcement (e.g. enjoyment or achievement) when you do the activity, not before, and that reinforcement will help motivate you to do the activity again.

Start to become more active by planning specific activities each day. Activities may be ones you don't particularly enjoy but they will give you a sense of achievement (e.g. household tasks). However make sure you also plan activities that you will enjoy (e.g. hobbies, exercise, going out). If you have difficulty thinking of what you may enjoy, think back to the kind of things you used to enjoy before you became depressed. Or think of a hobby you've always wanted to try, or a place you've wanted to visit. Don't immediately assume you won't enjoy it - have a go, in small steps at a time if necessary.

Gradually plan more and more activities in your day until your routine becomes more like it used to be before you became depressed. make sure, however, that there is a balance of activities you "have to do" (e.g. get children ready, pay bills) and things you "want to do".

CHANGING NEGATIVE THINKING IN DEPRESSION

Just as it can worsen anxiety, negative thinking will also worsen depression. Depressed people think of themselves as worthless or inadequate. They think of their current situation as overwhelming and unlikely to improve, and their future as hopeless. This negative thinking can be identified and challenged in the same way that thoughts producing anxiety can be challenged. That is, identify patterns of negative thinking styles that are making you depressed (e.g. black and white thinking) and challenge these with more rational and positive thoughts (e.g. "What is the evidence for this thought", or "what are the alternatives"?).

There are particular belief systems that can leave you vulnerable to depression. Remember that belief systems are learnt from all your experiences. If you were brought up in a family that help strong beliefs about the importance of achieving, striving for perfection, keeping the peace, or having others approval, you may have accepted such beliefs yourself, without questioning how helpful they are for you. In themselves these beliefs are not unhelpful, as they can help motivate you to achieve goals. However when they are taken to an extreme, so you have to achieve these things even if impossible, in order to feel worthwhile, then they create stress and feelings of failure. The following list describes these extreme belief systems and how to challenge them.

)Self esteem based only on achievements
Many people believe that only by achieving certain goals will they be worthwhile. This forces them to constantly drive themselves to achieve. They put great pressure on themselves to reach goals and don't acknowledge their efforts or enjoy themselves along the way. If they are unable to achieve certain goals they are likely to feel that they are not worthwhile, and these negative self thoughts can lead to depression.

Challenge:
To challenge this belief system you need to:
- allow yourself to get satisfaction from what you're presently doing, as well as from future goals. Be aware of what you have now, and what daily pleasures you have.
- remember that your worth is not just based on what you do, but who you are. Think of the qualities you have that make you a worthwhile person (e.g. sense of humour)
)Self esteem based on perfection
Many people don't feel satisfied unless they are getting "perfect" results in whatever they do. There is a difference between getting satisfaction from aiming to do well, and having to do well. Having to do things perfectly leads to frustration at constantly trying to keep to unrealistic high standards. Because it is impossible for people to be "perfect" all the time, these standards cannot be met, leaving people feeling like failures. Over time, these repeated disappointments may lead to feelings of hopelessness and depression. People with this belief often think others expect such perfection, and won't approve of them unless they make these efforts.

Challenge
The challenge here is to let yourself aim for less perfect results and thus reduce frustration by:
- becoming aware of how unrealistic yours' or others' expectations are, and that you don't have to meet them. You don't become a more worthwhile person just by doing things perfectly - you just become overworked.
- considering mistakes as opportunities to learn better ways to approach such situations in the future, rather than as failures. Seeing mistakes as normal or human, and allowing yourself to make them.
- lowering your standards. Rather than aiming for 100% and focussing on the standard of your performance all of the time, try aiming for 80%, so you enjoy yourself and relax more. If you let yourself be less "perfect" you are also less likely to put off doing things or to spend too long on particular tasks.
)Self esteem based on approval from others
People with low self-esteem tend to see themselves as they believe others see them. As a result they become too dependent on others' approval and believe their own opinions don't count. They are therefore vulnerable to being influenced by others' attitudes and moods.

Challenge:
It is important to be able to cope when others criticise or do not approve of your actions, by:
- remembering that you can't have everyone's approval all the time as people may have different opinions and values from yours. It is only necessary to decide what's important for you.
)Believing the world should be fair and just
Believing that you're entitled to total happiness, success and justice is setting yourself up for disappointment and resentment. The world is not always fair, and things don't always go as hoped.

Challenge:
This belief can be challenged by learning to tolerate frustration in unfair situations, by:
- remembering your own thoughts and interpretations cause your feelings, not the unfair events themselves. Complaining that the world is unfair, yet taking no action to cope, increases feelings of helplessness and anger, and serves no purpose.
- realising there are times you will not get what you want or deserve in life. This happens to everyone. Ensure that you are not catastrophing - over time the events may not seem as important. Ensure your expectations are realistic, and your goals are flexible.

DISTRACTION TECHNIQUES

Distraction techniques, as described in previous chapters, can be used as a way of focussing your attention away from the unnecessary worry which can worsen depression. You can then start to think more clearly about ways to problem-solve any difficulties you may be experiencing, and then challenge negative thinking.

Homework tasks:

Continus practising breathing control and relaxation.
Continue wrting down your negative thoughts in your diary, and challenging them. This week write down thoughts that make you feel depressed as well as those that make you anxious.
Think about your activity level during the week, and whether you need to plan some extra activities you will enjoy to improve your mood.

FACING STRESSFUL SITUATIONS

Over the past few weeks you have learnt a number of skills to control your anxiety symptoms. Now you can use these skills to face situations that make you anxious, and that you may have been avoiding.

EXPOSURE - THE WAY TO FACE FEARS

Exposure means simply facing your fears instead of avoiding situations that produces them. It is natural for people to avoid situations that make them anxious. However, once you start avoiding, more and more situations will make you anxious, as you lose confidence in facing any stressful situations. For example, if you become fearful of driving and start avoiding it, you lose confidence in your driving skills. Your activities, such as visiting friends or going shopping, are then also limited, and over time your confidence in doing these activities may reduce.

It is important to understand how exposure works, to believe that it will bring results, or you may find it difficult to motivate yourself to keep facing your fears. You can expect your exposures to be uncomfortable - you need to experience anxiety in order to use your skills to learn to control it. You will learn you can deal with some discomfort when you know there's a reason for it. The reasons for doing exposures are:

) To challenge unhelpful beliefs
When you avoid situations that produce fear, you never get to learn that you can enter the situation and function better than you expected. Catastrophic expectations (e.g. I won't be able to cope) can never be proved wrong if you don't try to deal with the feared event. If you've been highly anxious in a particular situation before, it may be especially hard to go into that situation again. However, you might be pleasantly surprised to find that it's not as bad as you expected it would be, now you have more skills to control your anxiety. You'll probably find there's relief in facing the fear, because you know you're doing something positive to help yourself. Thus, you'll feel stronger, more in control and less afraid.
) To habituate your body to anxiety
"Habituation" means gradually getting used to things that once made you anxious. With repeated exposure your body begins to react more calmly in the feared situation. For example, if you're startled by a sudden noise (e.g. tree branches banging on your bedroom window from the wind), you're body reacts very quickly with symptoms like racing heart, tenses muscles, rapid breathing. However, if the noise occurs regularly and you come to expect it, your body and mind will eventually stop responding so strongly. Similarly, the situations that you are avoiding will cause less of an anxiety reaction each time you face them, as they become more familiar and you know what to expect.
) To build confidence
When you face your fears and achieve what you had planned, your confidence grows. When you get a number of successful experiences behind you, it motivates you to continue dealing with other feared situations.

CREATING A HIERACHY OF FEARED SITUATIONS

The first step in facing the feared situations is to make a list of them (below). Now rate each situation on a scale from 0-10, where 0 is "causes no anxiety" and 10 is "causes worst anxiety ever":

|____________________________________________________________________________________________|

0                                                                                          10

(NO ANXIETY)          (MILD ANXIETY)           (HIGH ANXIETY)           (WORST ANXIETY EVER)

Situation	Rating (0-10)
________________________________________________________________________________	______________
________________________________________________________________________________	______________
________________________________________________________________________________	______________
________________________________________________________________________________	______________
________________________________________________________________________________	______________
________________________________________________________________________________	______________
________________________________________________________________________________	______________
________________________________________________________________________________	______________
________________________________________________________________________________	______________
________________________________________________________________________________	______________

Now rewrite the situations in numerical order(from lowest to highest):

Situation Rating (0-10)
________________________________________________________________________________ ______________
________________________________________________________________________________ ______________
________________________________________________________________________________ ______________
________________________________________________________________________________ ______________
________________________________________________________________________________ ______________
________________________________________________________________________________ ______________
________________________________________________________________________________ ______________
________________________________________________________________________________ ______________
________________________________________________________________________________ ______________
________________________________________________________________________________ ______________

You now have your own hierachy of feared situations. This allows you to work systematically through the least to worst anxiety-producing situations, using your anxiety-management skills to cope. As you become more confident using these skills in the easier situations, you can then move on to the more difficult situations.

PUTTING IT INTO PRACTICE

Types of exposure

Exposure can be carried out in your imagination and in real life (in vivo).

Imaginal exposure:

Imaginal exposure is useful to prepare you for exposure in the real situation. Practising the situation and how you will cope, in your mind, can assist you to feel more confident about facing situations that feel overwhelming. Below are guidelines for using imaginal exposure:

Sit comfortable in a quiet place where you won't be interrupted, and close your eyes. Relax for a few minutes by using your controlled breathing. Think of the situation you wish to face, and imagime yourself entering that situation. Try to make the situation as real as possible by involving all your senses. Include details such as: what is the temperature?, what can you hear?, what can you smell?, what are you touching?, can you feel your heart beating?, what are people around you doing? Imagine everything involved in facing the situation including: the actions leading up to the feared situation, the actual situation, and any thoughts or feelings after the situation. Go through it in your mind as if you are actually living it.

If you imagine the situation in detail your anxiety level will rise. This is necessary for exposure to work. Usually the anxiety will rise to a moderate level, and then decrease again as you realise you can cope in the situation, and it's not as bad as you expected. If the anxiety rises to a high level use your controlled breathing and rational thinking skills to calm yourself. Each time you imagine the situation, your anxiety should get lower and lower. Keep repeating the scene until anxiety drops to 3 or less (out of 10).

Use the exposure diary at the end of this chapter to record all your imaginal exposure practice.

Once you become confident facing the feared situation in your mind, you can expose yourself to it in real life, using the same skills to cope.

Real life (in vivo) exposure:

Exposure in real life involves the following steps:

Choose a situation on the hierarchy, starting first with the easier tasks.
Use imaginal exposure to prepare yourself for the situation.
Use your skills in controlled breathing and relaxation to get yourself as calm as possible.
Prepare your thinking about the situation by identifying negative thoughts you would expect to have before, during and after the task. Challenge these thoughts beforehand so you have prepared more realistic and positive statements you can use when facing the situation.
Enter the situation, giving yourself plenty of time so you can perform the task in a slow and relaxed way. Expect your anxiety to rise. It means the exposure is working. Remember, the anxiety won't harm you and it will drop, and meanwhile you can cope with it.
Monitor your breathing rate regularly (e.g every 5-10 minutes). Use controlled breathing and thought challenging to manage your anxiety, remembering that you can't expect to reduce it to no anxiety.
Stay in the situation until you feel yourself calming down. You may wish temporarily to find a place to sit down and practice your breathing (e.g. if you are driving pull over to the side of the road and calm yourself down before continuing). But don't leave the situation out of fear, or it will be even harder to have the confidence to face the situation again.
Keep a diary of your exposure tasks. This allows you to structure your exposure tasks. It also gives your skills, so you are better prepared for the next exposure.
Reward yourself for facing these feared situations.

Choosing the next exposure task

The general rule is that you should attempt situations that are 75% sure that you can successfully cope with. If you don't feel 75% sure about a situation you are probably attempting something you are not ready for. It does not mean you need to avoid the task; instead, you can break the task down into smaller goals. For example, if catching the train to the city on your own in peak hour is one of your exposure tasks and you expect your anxiety to be really high (9 or 10/10), start with small steps and build up to it. You could work through steps like these:

catch a train just one stop with a friend at a quiet time of the day.
do the same trip by yourself.
do the same trip at a busier time of the day.
gradually extend the lenght of the journey and the number of people likely to be on the train. With repeated and regular practice you will build up to travelling into the city.

Move on to the next step only when the first task has been successfully completed and you feel confident of moving on.

How often should you practice?

You need to face a situation regularly and repeatedly until you overcome your fear. The general rule is: the more you fear it the more frequently you should confront it. many fears need to be practiced at least 3 or 4 times a week at first otherwise your fear will rise again by the next time you do it. Once you have overcome most of the anxiety in that situation you can practice less often. If you are having a 'bad' day don't put off doing exposure, instead just repeat the step you have already achieved and feel confident with, rather than trying a harder step. Don't ever avoid the situation or you are building on the fear that you are trying to reduce.

Homework tasks:

1. Choose the easiest tasks from your exposure hierarchy to work on this week, and then record your practice in the diary below.

Exposure Diary

Date/Time

Situation

Anxiety level (0-10)

Anxious thoughts

Challenges or coping statements

CONTINUING YOUR EXPOSURE

By now you should have tried some of the easier steps on your hierarchy, and may be ready to progress to harder steps using the same skills to manage your anxiety. If you had difficulty with the steps you planned, however, consider the possible reasons given below.

COPING WITH DIFFICULTIES TIES DURING EXPOSURE

Difficulties in exposure are usually from poor use of anxiety management skills or poor planning of goals. Consider whether either of these may be related to your problems in facing your fears.

) Anxiety management skills
Ask yourself:
- have you been regularly practising controlled breathing so you can use it before, during and after exposure?
- are you checking your rate of breathing regularly during exposure, so you can slow it down at the first signs of anxiety?
- are you practising muscle relaxation often, especially before entering your feared situation?
- are you aware of the negative thoughts that you may have in the situation so you can challenge them before, during and after the exposure? Do you need to write the more rational thoughts on small cards to carry with you so you can look at them as your anxiety increases to remind you not to think negatively?
- are there background stressors in your life that need to be problem-solved so your general level of anxiety is lower (e.g financial problems)?
- are you physically stresses (e.g. illness, lack of sleep, overworked, premenstrual tension)?
) Planning exposure tasks
Ask yourself:
- are you trying to progress too quickly or too slowly? Are you 75% confident of success? If your goals are too hard or too easy you will not make progress.
- does the next task on your hierarchy seem too difficult? You may need to create smaller steps, each gradually getting harder, so you build up confidence about facing the task you are 'stuck' on.
- do you need to practice each exposure task more often or for longer periods of time before moving on to more difficult ones? Remember gradual but regular practise is the most successful.

Make sure you reward yourself for your progress.

SETBACKS

Setbacks (or a return of anxiety symptoms in certain situations), can occur even if you are making good progress. They are often related to temporary external stressors (e.g. illness, school holidays, work deadlines). The setback causes many people to become very upset as they fear they have gone back to how they were before they started treatment. It is very rare that this happens however, as you have lots of skills you never had previously to manage your anxiety. Usually once the stressor has passed, you will find it easier to cope with situations again. Therefore, if you do have a setback, you will find it easier to cope with situations again. Therefore, if you do have setback, don't make it harder to cope by thinking the worst. If you keep practising your anxiety management skills, you'll find you can deal with the stress more effectively, and you will still be making progress. You will also be preparing yourself to deal effectively with future stress.

HOMEWORK REVIEW

In the space below, list successes and problems you experienced with last week's exposure task.

Task:______________________________________________________________________________________

Successes experienced : _______________________________________________________________________

__________________________________________________________________________________________

Problems experienced : _______________________________________________________________________

__________________________________________________________________________________________

Possible solutions : ___________________________________________________________________________

__________________________________________________________________________________________

Now thinks about how you can apply these solutions to this week's exposure.

Homework tasks:

Continue practising last week's tasks until your anxiety levels are reduced to 3 or below (out of 10). When you are ready, move on to the next task on the hierarchy. Continue keeping your record of the exposure tasks. If you experience difficulties, review the likely causes - and plan whatever changes you need to make the exposure more successful - as we've done in this session.

Exposure Diary

Date/Time

Situation

Anxiety level (0-10)

Anxious thoughts

Challenges or coping statements

RELAPSE PREVENTION

over this course you have learnt ways of coping with your stress and anxiety. Regular practice of these skills will make them easier for you to use in different situations.

It is important to remember that as you continue to improve, it is quite normal to have good and bad days. There may be days, or even weeks, when symptoms flare up. At these times you may feel like you are slipping backwards. You may notice that symptoms you managed to get rid of or control start to re-appear for a variety of reasons. There may be other times when symptoms actually decrease more than expected. Despite these fluctuations, over time, symptoms tend to gradually decrease. This is the normal "recovery curve", and recovery from physical and psychological problems tends to follow this pattern.

If the anxiety symptoms increase to such an extent that you feel unable to cope, it is called "relapsing". When your anxiety is high, it is important not to "give up" and expect yourself to get worse. If you take control of your anxiety early, it is less likely that you will relapse. As soon as you notice that your anxiety is building up, try to work out what may be trigerring or causing the return of the symptoms, and then use your skills to bring the anxiety level down again.

HOW TO PREVENT RELAPSE

There are many things you can do to prevent relapse:

Look after your physical health by getting enough sleep and exercise, and eating nutrious meals. Limit your intake of stimulants like tea, coffee, cigarettes and alcohol. Recognise that you may be more vulnerable to anxiety if you have not had enough sleep, or if you have been physically ill (e.g. suffering a virus), and don't expect as much from yourself at these times.
Keep practising your relaxation exercises and breathing control skills even when you do not feel particularly anxious. Lack of practice can result in these skills getting rusty, so you will be less likely to be able to control your anxiety when you need to.
Assess situations before plunging into them. If you know you will be anxious in certain situations, prepare your mind and body by using anxiety management skills. Also continue to approach high anxiety situations in a gradual way, building up confidence in your ability to cope, step by step.
Do not suddenly stop taking your medication, as this can lead to the return of anxiety symptoms. If you wish to stop, discuss how to reduce it with your doctor.
Remember that negative thinking and poor self esteem can lead you to feel more anxious and less able to cope. Continue using positive thinking exercises to maintain a realistic frame of mind. Also, recognise your successes and reward yourself for coping with your anxiety symptoms.

These are skills that you will need to continue doing regularly to manage your stress. If your anxiety is getting high, check back over this to work out which skills you may have stopped using, and then start practising these again. Finally, go through this whole manual whenever you need, to remind yourself to practise all the coping strategies.

Homework tasks:

Over the next four weeks, you will have the chance to practise these skills on your own. Continue working through your hierarchy, so your fears of certain situations will reduce, and your anxiety management skills will improve. Note any successes or difficulties you experience, so you can bring these up at the follow-up group.

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STRESS MANAGEMENT

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STRESS MANAGEMENT MANUAL

Contents

Generalised Anxiety Disorder:

Phobias:

Panic Disorder:

BREATHING/RELAXATION PRACTICE RECORD