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Overcoming Stress, Worry and Low Mood Course

Participant Workbook

Workshop 5

• To look at ways we can challenge negative thinking • To become familiar with the use of a thoughts diary • To promote an awareness of the importance of anger management in

ensuring psychological well being • To discuss early warning signs of anger • To discuss blocking techniques • To identify and challenge ‘hot’ thoughts • Teach Autogenic Relaxation

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Controlling Worrying Or Negative Thoughts Last session we suggested that there were 3 things you need to do to control worrying or negative thoughts:

i. Catch (recognise) your worrying thoughts

ii. Challenge them

iii. Change them. Replace them with more realistic/positive thoughts. So far in the course we have focussed upon catching and challenging negative thoughts. In this session we will move on to examine challenging negative thoughts in more detail and how to make thoughts more realistic /positive.

Negative thinking is often a bad habit which has been developed over a long time, like any bad habit needs to be challenged. Last session we showed you how to recognise your thoughts and begin to challenge them using a basic thoughts diary. This session we have added a more detailed thought diary for you to try and use (see Section B), this should make your efforts to challenge your thoughts more effective. The following are some suggestions of the kinds of questions you can pose to challenge negative thoughts when you are trying to fill in column 5 (‘evidence against my negative thoughts’) in the negative thought diary.

Questions to use in Challenging Negative Thinking: Tip Box

• What is the evidence for this thought? What makes me think this way?

• Is there any evidence against this thought? Is there anything to suggest it might not

be entirely accurate?

• Is it logical or realistic? Is it fair?

• Is this an ‘unhelpful thinking style’?

• What are the advantages and disadvantages of thinking this way?

• How would someone else view this situation?

• How would I have viewed it if I was not feeling low or stressed or anxious?

• If a friend had this thought, what would I tell him or her?

• If I was feeling ok would I be having this thought?

• What is the worst that could happen? (how would I cope ?)

• Does it help me or hinder me from coping with the situation.

• What would be the effect of thinking less negatively?

• What’s the worst that could happen? How likely is it to happen? Even if it did could I

live through it?

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Rules for Living

What are Rules for Living? Rules for living are developed over a lifetime, some may be passed down by families or friends and others may absorbed through life experience, for example by noticing what is approved/disapproved of, or what is praised/criticized. Rules can be helpful, they can help us make sense of things and even survive “ I must look both ways before crossing the road”. However, some rules instead of helping us to make sense of the world, trap us in unhelpful patterns and can stop us from achieving the things that we would really like to. They can place near impossible demands upon us as human beings, for example a rule like: “It is shameful to ever show any sign of weakness” might restrict a person from showing the softer or more vulnerable side to their personality. These extreme and unbending rules can become like a human straight-jacket, they can make you feel that approval, liking, love and intimacy are all dependant upon you acting and behaving in a certain way. Examples of Unhelpful Rules for Living

If someone dislikes me, it means I am not a likeable person.

It's better to do nothing, than to risk making a mistake.

It is shameful to show any sign of weakness (often applied to self but not others).

Only the highest possible standards are good enough.

If I disagree with someone, they won't like me.

If I ask a question, people will think I am stupid.

Unless I always get it right I will never get anywhere in life and will be viewed as a failure”

If I let people get close to me, they will hurt or reject me”

“If I ask for help others will see me as weak and exploit me”

How can you recognise Rules for Living?

Unhelpful rules are rarely formally taught, we don’t really stop and think about them and

may not even be able to put them into words. However we live our lives according to them

and are often only aware of them when they get broken. Perhaps this is easiest to recognise

when we get angry: for example if you hold a rule like “everyone should wait for their turn”,

you will get angry if someone jumps the queue to get on a bus, whereas if you hold a rule

like “each person for themselves” you may not.

The connection between negative thinking and rules for living

Our thoughts are influenced and shaped by our rules for living, you may notice that you

have some repeated thought patterns appearing in your thought diaries that may relate to a

rule for living. Negative thoughts about ourselves are often triggered when one of our rules

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is broken. For example: someone who has a rule about doing things perfectly, may feel

extremely bad when he/she makes a mistake, their thoughts may become dominated by

being uselessness and their mood may become very low. Our thoughts therefore can be

seen as a reflection of broader rules for living that we hold.

An example of Rules for Living and how they affect

thoughts and behaviours

RULES FOR LIVING

CRITICAL INCIDENT OCCURS WHERE RULES ARE BROKEN

NEGATIVE THOUGHTS

EMOTION

“I must protect myself at all costs from a risky, dangerous world or I will be harmed”

“I mustn’t make any mistakes or others will think I am a failure”

“I am a failure”

“I can’t cope”

Low mood Anxiety

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Rules for Living tend to group into 3 types: 1) Approval based e.g. I must be liked. 2) Achievement based e.g. I must win. 3) Entitlement based e.g. It is my right. Approval based will often lead to depression if they are not met, but they can lead to anxiety, or anger, in anticipation of failure. Achievement based will cause a lot of anticipatory anxiety, and violation will cause depression. This will tend to depend on where the responsibility is placed (locus of control), so that the thought: 'I am and always will be a failure' leads to depression, but: 'It was their fault, it was not a fair test' will lead to anger. Entitlement based almost invariably lead to anger if violated. This is often followed by 'it is not fair'. There is no absolute right or wrong but it is important to get a balance

Changing your Rules There are 4 main ways to do this:

a. The Downward Arrow Technique- this is simply a number of questions you can ask yourself (see p 8)

What does this mean to me?/ Say about me?

Why would that be so awful?/ supposing that happened what would it mean to you?

And what would that mean/ say about me? b. Cost- Benefit Analysis of Rules -weigh up the advantages (benefits) and disadvantages (costs) of your beliefs/ rules (p9)

c. Develop rules that are more helpful to you (p9-10)

d. Notice and challenge unhelpful/ negative thoughts in a thought diary- You have already been doing this! We started this work in session 2. You may find that there are recurring themes that you end up challenging in your negative thoughts diaries- keep it up! This is positive as recurring themes may relate to underlying rules that you hold about the way you should live.

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If this were true, what would it mean to me? Why would it be upsetting to me?”

a. Example of The Downward Arrow Technique

One way to do this is the downward arrow technique. In this technique, you question the thoughts and see where they lead you. First identify a negative thought. e.g. You are studying for an exam and getting over-anxious.

Thoughts Questions to ask yourself

In this example the questions asked have enabled the person to discover a rule for living: “If I do not have other people's approval I will not feel happy or worthwhile”. If you discover rules like this, you then need to ask yourself if they are helpful to you or not.

Many of your rules have more advantages than disadvantages and are helpful and positive for us. Where you find that your rules are unhelpful you may want to challenge them.

If I don’t study any harder I may blow it

If I blow the exam, I may fail the course.

“If I failed, why would that be upsetting to me?”

This would mean I was a failure and people would think less of me.

“If this were true, and people did think less of me, why would this be upsetting?”

If I do not have other people's approval I will not feel happy or worthwhile.

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How do I know which rules are helpful or unhelpful to me? An approach you could use is a cost-benefit analysis. Here, you weigh up the advantages (benefits) and disadvantages (costs) of your rules Example

Rule “I must always be a success in life to be worthwhile” 1. Can you think of advantages to thinking this way? 2. Can you think of any disadvantages to thinking this way? b. Example of a Cost- Benefit Analysis of Rules Advantages Disadvantages 1) You will work very hard. 2) Your value system will be similar to that of many other people. 3) Life will seem simple and clear to you. You know exactly what you have to do to be a worthwhile person. 4) When you succeed at something you will feel good.

1) You will always be on a treadmill having to earn your self-esteem. You will always be worrying about future failure. 2) You may feel lots of anxiety and avoid doing things from fear of failure. 3) It may stifle creativity. 4) Any failure may make you feel depressed because you will feel you are not worthwhile or loveable. 5) Even when you do succeed you are likely to see other people even more successful and feel inferior to them. 6) You may not pursue what you want in life because you're too busy working out how to be successful.

a. Develop rules that are more helpful to you When you have found a rule that is unhelpful, write it down (even if you don’t really like seeing it). Then write down a new rule that is the opposite of the old one, or more positive than the old one, or more realistic than the old one- you must make sure this is not negative in any way. The key thing is to find a new rule that makes sense to you personally and allows for the possibility of changing how you feel about yourself. If this is difficult try to think about positive aspects of yourself. This will prompt you to think in a more balanced and less negative way. Ask yourself the question: “Like the rest of the human race, I am short of perfect but along with my weaknesses and flaws, I have strengths and qualities, which are….”

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Write down: Old rule :……………………………………………………………………….. New rule :………………………………………………………………………..

Your next task is to start to act as if the new rule is true and start to observe the outcome. You should monitor this in a diary so that you have a record of how you are. Initially this will be hard because your old rule has been in operation for years and it will take sometime before you begin to feel comfortable or believe your new rule- this is normal!

Acting according to my new rule - diary

Date/time Situation What I did The outcome: what i noticed, felt, thought, learned

Try this “Rule Book” Exercise Think about thoughts you have been recording in your diaries or pick a thought that keeps popping into your mind and makes you feel bad. Choose a particular thought to work on: 1.Thought……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… 2. What does this mean to me?/ Say about me? ……………………………………………………………………………………………………………………………………………………………………………………………… 3. Why would that be so awful ? …………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………….. 4. What would that mean/ say about me? …………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………. 5. Can I recognise a rule?- What is it ? ………………………………………………………………………………………………………………………………………………………

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6. What are the advantages of this rule?………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………… 7. What are the disadvantages of this rule ?……………………………………………………………………. .…………………………………………………………………………………………………………………………………..………………… 8. If there are more disadvantages than advantages? Do I want to try and change it?

Yes / No (circle) 9. If yes, use ‘Developing helpful beliefs/rules’ guidelines and new rules diary.

Anger Management ‘Anybody can become angry – that is easy; but to be angry with the right person, and to the right degree, and at the right time, and for the right purpose, and in the right way – that is not easy’ Aristotle (384 – 322 BC) Nicomachaen Ethics Anger is a normal human emotion and if it is managed in the right way then it can be both useful. Anger forms part of the ‘flight-fight’ response – our instinctive response to challenging or dangerous situations. Anger can motivate us to defend ourselves or act as a warning sign that something is wrong and that something needs to change. However in order to benefit from the emotion of anger we need to be able to control it. When we find ourselves becoming more angry than necessary or unable to control our anger it can cause problems and add to the stresses of life or it can make us feel more negative about ourselves, the future and those around us. We can respond to anger in three ways:

1. Vent it 2. Bottle it up (depression is sometimes called anger

turned inwards on the self) 3. Manage anger by thinking it through

The third option is the focus of this session. The aim is to give you strategies and techniques for controlling your anger so that you are angry with the right person, to the right degree, at the right time, for the right purpose and in the right way.

In order to control our anger we need to understand what contributes to it e.g. the influence of alcohol, drugs, chemical additives, being tired, hungry, the personal rules we hold and thoughts we have. It is also important to understand the difference between ANGER and AGRESSION and VIOLENCE. ANGER is an emotion or a feeling, AGGRESSION and VIOLENCE, however, are behaviours or ways of acting when angry. Aggressive and violent behaviours often have negative consequences either for self or others, therefore it is often beneficial to prevent anger resulting in aggression or violence.

In order to prevent us from resorting to aggressive and violent behaviour or using other unhelpful coping strategies we need to recognise that anger is something that

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rises, we do not become angry ‘all of a sudden’ (although it may seem this way), if we can recognise the rise of anger then we are more able to control it. If we become aware of our anger early enough then we can prevent aggressive, violent and unhelpful responses.

Anger Thermometer

The anger thermometer is a way of illustrating the progression of anger from calmness, through to outright fury and rage. As our anger moves up the thermometer we experience different signs and bodily symptoms e.g. Heart beating fast, becoming hot, not being able to think clearly, tense muscles, clenched jaw/fists etc. As we become more angry we move into the ‘red zone’ at this point it is very difficult to control our anger as the symptoms of this level of anger mean that it is difficult to think clearly and to make rational decisions.

Take some time to think about your own signs and symptoms of anger and think about how they change as you become angrier. Write on the anger thermometer on page in section 2 of this booklet the signs and symptoms you experience and how they change or the order you experience them in as you become angrier. It may also be useful to establish where your ‘red zone’ is – this is that point at which your anger is likely to cause you or others difficulty.

Early warning signs and blocking techniques Once you have filled in the anger thermometer you should have a clear idea of your own early warning signs that you are getting angry. Being able to identify these early warning signs means that you can pre-empt an angry outburst and you can use techniques to block the anger and prevent it escalating further. These are instant activities that you can use in the heat of the moment (i.e. activities that don’t rely on others, and don’t’ require a great deal of planning). Examples include: Walking away Keeping quiet/”biting” (holding) tongue Count to ten/count backwards Breathe slowly and concentrate on your breathing Distraction Focus on un-tensing muscles

Imagery – have a specific calming image prepared and think of this when you find yourself getting angry

Use of humour See if you can think of any more blocking techniques that would be useful to you, it can be any activity that you can do straight away that is going to prevent the anger escalating.

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Another useful technique is to use Cooling Statements. Cooling Statements such as ‘take it easy’, ‘cool it’ , ‘chill out’, ‘ignore it’, ‘slow down’ can all be useful things to say to ourselves in situations where we feel anger levels rising. However it is important that these statements and the other blocking techniques are used once you have learnt to identify when your anger is still in the early stages. These statements and techniques will only have an impact on you before the physical effects have really taken hold. If the anger escalates too far then you will not be able to think clearly enough to use these techniques. List at least one cooling statement or image that you could use to prevent your anger escalating.

What makes us angry? Most of us can list a number of different things that can trigger an angry response in us, but this list will undoubtedly vary from person to person. A situation that leaves one person in a rage may have no impact on another person. Furthermore someone may get irate about something that on a different day they don’t respond to at all. This is because the way we look at a situation (i.e. the thoughts we have about it) determines whether or not we feel angry. For example someone stepping on my toe may make me angry or it may not make me angry. If I believe them to have done it deliberately I would probably be angry; if I thought it was an accident I probably wouldn’t. So it is not the situation itself that produces the anger, but the way I see it (i.e. interpret or appraise it.) Examples

Situation Thought Feeling

Arrange to meet a friend for lunch, she/he is 10 minutes late

Something bad has happened, they’ve been in an accident Fear, Worry

How disrespectful, they clearly don’t value my friendship – how rude

Anger

They’re probably a bit delayed, I’ll wait a bit longer and then I’ll ring them

Neutral

They must be trying to make a fool of me by keeping me waiting, they are so rude and disrespectful. I haven’t got time to waste waiting for them, who do they think they are.

Fury

Situation Thought Feeling

Neighbour plays loud music.

I really like that music, it’s great that I live in such a vibrant, energised area. I must go round and borrow that CD sometime

Happy

That music is too loud for me. I’ll go and ask them to turn it down a bit.

Neutral

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I really don’t like that music, I wish they wouldn’t play it so loud

Irritation

What a hideous noise coming from next door. They do it just to annoy me. They are so inconsiderate, they’re trying to make my life hell.

Irate

I can’t cope with that music, I can’t escape that noise. I’m so useless, I can’t even stop some kids playing their music.

Hopeless and unhappy

The examples above illustrate how our thoughts can impact on how angry we feel in different situations and also how the same situation could leave you feeling different emotions if you have a different thought. This is an idea that you should have become familiar with during the earlier stages of the course. As with the management of other psychological difficulties, such as depression and anxiety, it can be useful to identify the negative thoughts that lead to an angry response. In the chart below describe two or three situations that have resulted in anger, briefly describe the situation, what you thought at the time and how you felt rating the amount of anger from 0-10 where 0 is no anger at all and 10 is absolutely furious. The thoughts that are associated with anger can be described as ‘HOT’ thoughts

Situation Thought Anger Rating

Balancing HOT thoughts with COOLING thoughts

It is important to remember that in all situations there are many different ways of thinking about it. So if you find yourself having HOT thoughts and getting angry when you don’t want to, it can be useful to think of alternative ‘COOL’ thoughts to get more of a balance. For Example:

Situation HOT Thought COOLING Thought

Arrange to meet a friend for lunch, she/he is 10 minutes late

They must be trying to make a fool of me by keeping me waiting. They are so rude and disrespectful. I haven’t got time to waste waiting for them, who do they think they are.

This isn’t personal, he/she probably got held up somewhere. He/she is not the best time keeper, but he/she doesn’t mean to be rude. I can probably wait another 5 minutes, if he/ she hasn’t arrived I’ll give him/ her a ring and arrange to meet another time.

Try this technique on your own HOT thoughts. If you find it difficult try some of these tips:

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• Imagine what an outsider would think,

• Imagine if the situation was reversed and, for example, you were late – what would

you hope your friend was thinking?

• Think about how strongly you believe your HOT thought

• Are there any other explanations for the circumstances you find yourself in?

• Think about similar situations you have been in, have you ever found your initial

thoughts about a situation were wrong or inaccurate?

• Finally ask yourself what benefit the HOT thought has for you? Does it help you to

get a good outcome from the situation?

By challenging your initial HOT thought with a COOL thought you can ensure a more considered response to the circumstances and prevent the anger escalating. This can be used in conjunction with the blocking techniques as the blocking technique can give you the time you need to challenge your HOT thoughts. If you can recall ‘HOT’ thoughts that you have had in the past try coming up with some alternative ‘COOL’ thoughts to neutralise their effect. Then start using the diary in section 2 to identify situations that trigger anger, the thoughts the situations produce and then try to neutralise them with COOL thoughts as soon as possible.

Situation HOT Thought COOL Thought

Summary

The ABC of Anger Control

A - AWARENESS – of early warning signs of angry thoughts and Personal Rules of potentially difficult situations

B - BLOCK the arousal by using a pause technique

C - CHALLENGE the angry thought or personal rule

- CHANGE the angry behaviour

- COMMUNICATE effectively

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Workbook Section 2

A. RELAXATION

Practice the following relaxation at least 3 times over the next week

Autogenic Relaxation

Autogenic relaxation simply means focusing on two aspects of the relaxation response – increased blood flow and decreased muscular tension. It does this by concentrating on two things that we feel when relaxing: warmth – which is a sensation we experience when more blood reaches the extremities, such as the arms, legs, hands and feet and heaviness which is what we feel when the muscles are relaxed. Autogenic relaxation does not require you to force anything. Just let yourself go. Become aware of how, when and where you are tense and allow the tension to melt away. Let any distracting thoughts go through and out of your mind. Autogenic relaxation can be done lying down or sitting in a supportive armchair.

What to do When you are comfortable, lying or sitting, take a deep, diaphragmatic breath. Exhale gently and notice that first pleasant feeling of relaxation. There is no need to move during autogenics unless you want to make yourself more comfortable. Simply unwind, allowing yourself to focus on the sensations of relaxation. The following phrases help you to do this. Say them to yourself 3 times, pausing after each repetition. Take your time, keeping your breathing regular, calm and relaxed. I am at peace with myself and fully relaxed My right arm is heavy (if left handed you may want to start with your left hand) My left arm is heavy My right leg is heavy My left leg is heavy My neck and shoulders are heavy Take a deep, full breath and unwind even further My right arm is warm My left arm is warm My right leg is warm

My left leg is warm My neck and shoulders are warm My heartbeat is calm and regular My breathing is calm and regular My stomach is warm and calm My forehead is cool and calm Take some time to enjoy the sensations of relaxation; when you are ready say to yourself - I am refreshed and completely alert

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B. NEGATIVE THOUGHTS DIARY Complete the Negative Thoughts Diary below using the questioning negative thoughts checklist (overleaf) and tip box (p.4) to help you fill in the “evidence against” column in the diary. When rating mood/emotion between 0-100, 0 = as good as it could be and 100= is as bad as possible.

Negative Thoughts Diary

1.Situation What were you doing or thinking about?

2. Emotion What did you feel? How bad was it, (0-100)?

3. Negative Thoughts What exactly were your thoughts? Underline the strongest thought. How much did you believe each of them, (0-100)?

4. Evidence For Write down only factual evidence to support this conclusion

5. Evidence Against Ask yourself the questions in the Tip Box (p 4) and write down the answers here

6. Balanced Thought Write a balanced thought, weighing up the evidence in columns 4 and 5 How much do you believe the negative thoughts in column 3 now (0-100)? How do you feel now (0-100)?

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QUESTIONING NEGATIVE/UNHELPFUL THOUGHTS CHECKLIST

1. What is the evidence? (or is this just an opinion?) What is the evidence that supports this thought? What is the evidence against this thought?

2. Is there an alternative explanation?

Is there any other way of explaining this thought? 3. What is the effect of me believing the thought? What could be the effect of changing my thinking? 4. Am I thinking in an unhelpful/negative way? e.g.

Am I thinking in all or nothing terms? Am I condemning myself as a person on the basis of a single event? Am I concentrating on my weaknesses and forgetting my strengths? Am I blaming myself for something which is not my fault? Am I taking something personally which has little or nothing to do with me? Am I expecting myself to be perfect?

Am I using a double standard – how would I view someone else in the same situation?

Am I paying attention only to the black side of things? Am I jumping to conclusions? Am I over-estimating the chances of disaster? Am I exaggerating the importance of events? Am I assuming I can do nothing to change my situation? Am I predicting the future? 5. What would I tell someone else if they were in the same situation? 6. What would a friend/parent/partner say to me about this thought? 7. Would I be thinking this way if I was ok/well?

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Challenging your own thoughts

• Why do I believe this thought?

• Is there any other way I could think about this?

• Is my thought based upon evidence or

just opinion?

• What would my best friend/ partner say?

• What would you say to a friend who had this thought?

• If I was feeling ok would I be having

this thought?

• What is the worst that could happen? (how would I cope ?).

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Scenarios for challenging negative thinking

1. JULIE Situation -Is chairing a work-related meeting away from her office base-she has forgotten to take the minutes of last meeting and has to proceed with no minutes Thought- “I am hopeless, always making mistakes. I am useless at my job, I should leave” 2. SIMON

Situation – Refuses to help a friend decorate a room in his house by saying he is away for the weekend (he is not) Thought- “I am a selfish person, I lied to my best friend, I don’t deserve to have any friends at all” 3. MARY Situation – Has been feeling low for sometime and is not answering telephone calls from family or friends Thought- “I am a totally incompetent, a waste of space, I can’t even answer a telephone, I will never get out of this awful depression” 4. JOHN Situation –Went shopping to Cribbs Causeway on Saturday with his family- he had a panic attack and they had to take him outside for 20 mins to calm down and then go home without getting their shopping. Thought- “I am a failure, what kind of man am I to panic in a crowd of people, how will my family ever respect or rely on me to take care of them?”

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Anger Thermometer

Fill in your own anger thermometer. Identify your own signs and symptoms that you are getting angry and plot on the diagram how your symptoms progress.

Initially it can be quite difficult to identify the thoughts linked to anger, as usually we become aware of the angry feeling before the angry thought. Keep a note in the diary below of times when you get angry, write down your hot thoughts and then challenge them with cold thoughts using the techniques you have learnt in the session and in the booklet.

Extreme Anger/Fury/Rage

Complete Calm

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Physi

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Em

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Situation

Date

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The ABC of Anger Control

A - AWARENESS :of early warning signs :of angry thoughts and Personal Rules :of potentially difficult situations

B – BLOCK- the arousal by using a pause technique C - CHALLENGE the angry thought or personal rule - CHANGE the angry behaviour - COMMUNICATE effectively