How to cope with Coronavirus / Covid-19 and Self-Isolation or Quarantine (with print-outs)

We know that when humans live in situations where they are under a threat (like Coronavirus / Covid-19) it can have negative consequences on their psychological health. Those under threat might have disrupted thought processes and heightened risk perception, increased emotional reactions, increased perception of their own vulnerability, increased suspicion and distrust of others, reduced perceived control of situations and reduced social interactions. We also know that after ‘outbreaks’ of other diseases that depression rates go up and anxiety and panic can be triggered.

In response to these difficulties, we’ve collated a list of ways in which we can all look after our mental wellbeing, and that of those around us, from respected health authorities and sources.

How to Cope

Coping with coronavirus for the General Population

  • If you feel worried about coronavirus or Covid-19, then try not to watch, read or listen to news articles about it. If you must find out information, focus on what you can do to protect yourself and your loved ones and limit it to once a day for a short amount of time.
  • Look after yourself but also support others if they need help.
  • Share and talk about the stories of people who have recovered or who have supported someone with the virus. Offer appreciation for and celebrate those who are caring and supporting people affected.
  • The virus is affecting everyone from all ethnicities and walks of life. Be empathetic to anyone affected by it.
  • Don’t refer to people with the coronavirus as ‘victims’ or ‘cases’; they’re humans with their own identities who are a lot more than the virus that they have been unlucky enough to catch.
  • If you are healthy and have time, volunteer to support those who are self-isolating or those who are supporting people who are infected with Covid-19.

Coping with coronavirus for care-workers and health workers

  • It is normal to feel more stressed at times like these; it doesn’t mean you aren’t coping or you’re weak.
  • Take time to look after yourself physically and mentally.
  • Rest, eat, hydrate, stay active with exercise and maintain contact with people you love and trust, avoiding alcohol, tobacco or drugs.
  • Some people may want to avoid you because they think being in your presence might increase their risk of catching the virus. If this happens, try to stay in touch using digital methods and share your experiences with colleagues; they’re probably going through the same.

Coping with coronavirus for Managers

  • Communicate clearly and accurately in ways which everyone can understand.
  • Be a role model for self-care.
  • Rotate workers regularly, pair colleagues up so they have support, particularly when in the community.
  • Check that people are having enough breaks
  • Be compassionate to those whose families are affected; they might need more time out than others.
  • Signpost colleagues to places they can get physical and mental health support.
  • Ensure that colleagues are trained in basic psychological first aid.

Coping with coronavirus for those looking after children

  • Help children express their emotions through talking, play and art in a safe place; this will bring them relief.
  • Explain how to prevent infection in terms they understand, and explain why it is important. Use visual reminders and help them practice handwashing if needed.
  • Try to keep children with their parents or guardians if possible. If separated, then ensure they maintain contact through digital means or age-appropriate social media.
  • Try to be honest, in ways they can understand about what is happening and update them when there are changes to the situation as appropriate.
  • Try to keep their routine; ensure they have activities to keep them occupied.
  • Be a role model for how to cope in times of stress; they will often copy you, and if you are calm then they will reflect this.

Coping with coronavirus for those looking after older adults

  • At times of stress, older adults with physical or mental health conditions may become more anxious, agitated or withdrawn. Provide emotional support and consult local health services if needed.
  • Share information about what is going on and how to reduce risk of infection in ways which they can easily understand. Explain why it is important. Repeat if necessary, with patience.
  • Use visual reminders and help them practice handwashing if needed.

Coping with Self-isolation
Quarantine has been shown to prompt symptoms of post-traumatic stress, anger and confusion. After coming out of quarantine people have experienced stigma, financial difficulties and boredom. Even if you’re not in quarantine but are self-isolating, humans are not designed to live in social isolation.

Social isolation is linked with higher rates of depression, anxiety and mental and physical health conditions. If you are self-isolating, then you have probably changed your daily routine too; maybe you’re working from home, not going to college or school and not going to the same activities you used to. Reducing activity levels in this way is also linked with low mood and depression.

Below we’ve listed FIVE key principles of wellbeing which might help you cope with your self-isolation period.

Connect with others
Even though you’re not going to see people face to face, stay connected. Speak on the ‘phone, text, message, email, Skype or FaceTime. Maybe you can reach out to someone you haven’t spoken to for a long time. You can support each other emotionally, distract yourself from negative thoughts and emotions and still make plans for when the health risks have reduced.

Be Active
You might not be at the gym or ParkRun but it will help to stay active. Can you dance in your room to your favourite track? Can you do a yoga session you find on YouTube? Can you do a few sit-ups? Can you walk up and down stairs? If you Keep your body moving it will help your body stay in good condition and will lift your mood too. It’s also essential for a good night’s sleep.

Learn New Skills
You might feel bored at home without your normal routine. To avoid boredom and lift your mood, try learning a new skill. There are plenty of videos on YouTube for different hobbies and apps which can help you learn a language. Maybe you have some books which you always intended to read? Now might be the time to finally get round to practicing playing that instrument you started years ago! Learning a new skill gives us a sense of achievement and mastery which increases wellbeing.

Give to Others
This can be difficult when you’re not leaving your home but there are still ways to give back. You might want to volunteer for a charity helpline. You might want to offer your skills to a charity you support. Maybe there is some fundraising you can take part in. It might be as simple as helping someone you know solve a problem they have or simply listening to them on the ‘phone. Giving to others has been shown to make us happier than when others give to us.

Pay attention to the present moment
This is also known as mindfulness. It means practicing noticing what is happening right now rather than worrying about the past or the future. One way of doing this is to go through your sense one by one asking “What can I see? What can I hear? What can I feel (emotionally and physically, both inside your body and outside)? What can I smell? What can I taste?”. Take time to really find a range of different sensations, and notice when they change.

Here are some further tips which studies have shown will help you maintain mental wellbeing:
Eat regularly, and drink water: even if you don’t have an appetite, your brain needs fuel.
Keep a routine: by getting out of bed at the same time and going to bed at the same time you reduce the risk of sleep problems. Have a shower or bath just like you would normally. Get dressed for the day, even if people aren’t going to see you; the closer to normal your routine is, the easier it is for your mind and body to adjust.
Take time away from screens: Current advice is that we should turn off your screens and give your body and mind time to become less alert at least an hour before bed.

Advice Leaflets for printing

I’ve created some easy-to-read documents which you can print out and provide to any of your contacts you you think might need some tips on how to stay well, psychologically during the coronavirus outbreak.

For the general public: Coping with Covid19 Public

For staff: Covid19 Staff Advice for Coping

Sources:
World Health Organisation: BPS – COVID-19 Psych Perspectives
British Psychological Society: WHO – mental health considerations and COVID-19
Associations of Clinical Psychologists
NHS

Mindfulness: The top 5 best mindfulness apps

Mindfulness has been trendy for a while, but it’s a bit more than just a fad!

The NHS have approved its use with a variety of mental health difficulties. Most often prescribed for use with recurrent depression, frequently cited as helpful with anxiety, some studies show it helps with managing chronic pain; so if these are things you struggle with, it’s probably worth a go.

What is Mindfulness?

Originating as a non-religious version of buddhist meditation, mindfulness is a mental state achieved by focusing one’s awareness on the present moment, while calmly acknowledging and accepting one’s feelings, thoughts, and bodily sensations.

What does that actually mean in the real world?

NOTICE

Firstly, to be mindful is to notice what you’re experiencing. It might be that you notice how your body feels (i.e. tiredness), or what thoughts are racing through your head (i.e. worries about tomorrow). It might be that you feel some emotions (i.e. sadness) or you might notice an urge to do something (i.e. stand up and leave the room). You can also be mindful about what you can sense, like the sounds, smells, sights, tastes, temperatures and textures around you. Often mindfulness meditations will ask you to notice your breath, as that is one things which is always present.

ACCEPT

Secondly, if you’ve noticed something, then you accept it for what it is and try not to change it or judge it. For example, you might notice that your heart is beating quickly. Rather than judging it as ‘unhealthy’ or taking deeper breaths to try to control it, you would simply observe it and perhaps you might be curious about it, but that is all.

GUIDE BACK

Thirdly, if your brain does wander off into the content of some of your worries, or if your brain starts to judge some of the things you’ve noticed, then there’s no need to berate yourself. Gently, kindly, calmly, mindfully, choose to direct your concentration or attention back to the present moment. Often this is most easily done by re-focussing on the breath or your body.

The process is summarised by the acronym SNACK:

Sounds straightforward, so how do I learn?

It is straight forward but although it’s logical, mindfulness is a skill that needs to be learnt. For years our brains have been focussing on the past and the future and not the present; so you have to learn to be mindful.

Mindfulness is often taught in classes by mindfulness teachers who guide you through a mindful meditation. More and more, now, it is taught via CDs, YouTube and apps. Below I’ve listed some great resources but importantly, I’ve listed the Top 5 mindfulness apps 2018, as tested by me.

Once you’ve learnt the basic principles, you can then practice mindfulness wherever you are and at whatever time you choose.

Where do I find Mindfulness courses near me?

There are often plenty of free taster courses available in your local area, most classes will allow you to go along for the first class to see if it’s for you.

Some NHS services in your area provide free classes; to find a service, type in your location in this link.

MeetUp also provides links to Mindfulness courses in your area, some of which are free. You have to register first, but that’s free and then you can find every type of course, not just mindfulness.

The Top 5, Best Mindfulness Apps 2018

1. Headspace (click here for: Android / iOS)

This app is free upfront but for access to more material it’ll cost ya. The cheapest way to access the full version is to become a member of Anxiety UK (click here) for £30 and you get free Headspace access (which normally costs £70 a year)

2. Mindfulness Daily (iOS)

Free and simple. Great for beginners and has short sessions of 5 minutes but 21 different tracks so you won’t get bored.

3. Smiling Mind (click here for: Android / iOS )

This app is free and perhaps best for a wide range of ages, it has mindfulness tracks for children too, as well as adults

4. Insight Timer (Android / iOS)

This is free and has the most content. There isn’t just mindfulness on here so you’ll have to search around but there’s plenty to get going with and a lot for the more experienced mindfulness-er

5. 10% Happier (Android / iOS)

Free for the first bit and then you pay. Best for the sceptics, the busy people and those who don’t think mindfulness work on them in a million years.This app doesn’t just have mindfulness exercices, it has other techniques too but it’s put across in a no-nonsense way.

Best Mindfulness Website with free mindfulness audio tracks and resources

These sites have free audios for you to listen to online or download. Some of them also add and update their resources regularly so you’ll never run out!

Free Mindfulness (click here)

Frantic World (click here)

Mindful.org (click here)

Best Mindfulness book

Mindfulness: A Practical Guide to Finding Peace in a Frantic World by Mark Williams and Danny Penman (click here)

This seems to be a best seller, time and time again. It comes with a free CD too.

Best Mindfulness CD

Guided Mindfulness Meditation Audio CD by Jon Kabat-Zinn (click here)

This guy is the father of mindfulness so you’re in safe hands.

Anna Batho is a qualified Senior Psychological Wellbeing Practitioner, Trainee Clinical Psychologist working for the NHS and private therapist working in London and based in Stoke Newington, Dalston and Hackney.

Cognitive Behavioural Therapy – Tips For Therapists

Here are some tips taken from the CBT bible, Back to Basics, by Beck to help therapists carry out their work in the most effective way. 

Clients can be fearful of what to expect from treatment so it will help to set an agenda at the start of each session. This also allows you to curtail any tangential and less relevant diversions once the session has started. It will also help them to adjust to the structure of each session and to reach the end of the session at an appropriate point. In doing is it is important to also ask them what they’d like to address in session (problems, worries, concerns, what came up in the week?) so that they get an opportunity to discuss these issues.
If a client starts to talk for too long, interrupt them gently but check they’re OK with it. If they continually do this then make sure that you are making an effort to: 

  • socialise them to the agenda
  • ask them for a brief summary
  • ask them to write down agenda points for the session as part of homework
  • compromise by offering them 10 mins or a limited period where they can offload first then summarise
  • ask them to choose which issue to focus on 

Summaries

Summarise are essential and need to include:

  • You summarising what they’ve said 
  • Them summarising what the key learnings are and reasons for doing things 
  • You summarising each section of each session 

Homework

Homework is important because it brings lots of opportunity for learning and embedding learnings into the client’s memory; it also is essential if the client is to work independently. However often, clients struggle to complete it. They are more likely to do it if:

  • The client has the rationale for why it’s helpful
  • Homework is reviewed each session 
  • You talk through how to do it in session, or start it in session 
  • You ask about obstacles that will get in the way and problem solve that
  • Get patient to write down homework 
  • It is chosen in a collaborative way
  • You address negative thoughts about homework 

Homework can be:

  • Behavioural Activation
  • Thought record 
  • Challenge thoughts 
  • Problem solving 
  • Relaxation / assertiveness / time management 
  • Behavioural Experiments
  • Reading 
  • Prep for next session / do standard questionnaires
  • Using their summary or revised though or mantra cards  

Other helpful approaches to homework can be:

  • Get them to put frequency and deadlines on it 
  • Get them to do a decisional matrix of pros and cons of what will happen if they don’t do it
  • If they can’t do it, ask them to note down the thoughts that were getting in the way 
  • Pair the activity with their routine, i.e. do it straight after lunch  
  • Get person, diary, post its or phone to remind them to do it
  • Ask them to call the office and let you know when they’ve done it

Ask them how likely they are to do it and get them to envisage doing it. Ask them when and how they will do it, and what thoughts, feelings and behaviours will happen, and ask for what barriers may get in the way.

If they are unlikely to do it because of negative thoughts then role play it, with you arguing for doing it (the intellectual side of it) and them arguing against doing it (the emotional side of it) and then reverse
roles. If they make negative predictions and this stops them doing homework, then set them up to do a Behavioural Experiment, to see if it happens.

For Behavioural Experiments, get them to predict their feared outcome but also get them to figure out other reasons for that outcome if it did arise, just in case it does arise. Get them to write that down.

If their reason for not doing homework is:

Time: Problem solve this but also give the example of if they needed a blood transfusion they would find a way to do it. Explain that the homework situation is not life threatening but it shows that finding time is possible. Explain that it’s only during these sessions, not forever and also that it won’t take that long.

Energy: ask them how long they think homework will take. Challenge any unrealistic expectations and explain that you don’t need much energy to do it. Ask them to test their prediction of them being exhausted afterwards and report back to you.

Perfectionism: Explain that CBT and the homework is a skill to be learnt, and that no one can do it rig first time and that the getting it wrong is part of the learning process. You could even ask them to do it deliberately wrong
the first time to get them used to not striving for perfection but for growth.

Endings:

Clients may struggle to adjust to the end of treatment. To help them adjust, talk about it from the start
and manage their expectations that this support will not be forever, explaining that the aim is to get them to be their own therapist.

Put an emphasis on their effort and progress
throughout so they have a sense of self-efficacy before you talk about endings. Help them reframe their negative thoughts about endings
.

List the tools they’ve learnt with them:

  • Breaking problems down into chunks 
  • Brainstorming solutions 
  • Testing thoughts 
  • Thought records 
  • Relaxation 
  • Scheduling activities 
  • Distraction and refocusing 
  • Hierarchies of avoided tasks to build confidence 
  • Credit lists 
  • Decisional matrix 

Help them envisage realistic setbacks
and formulate a plan of action for when they occur. 

Schedule booster sessions if needed but get them to prepare by writing down how they’re using coping strategies along the way.

Problems occur in:

  • Diagnosis 
  • TA 
  • Structure and pace 
  • Socialisation 
  • Dealing with nats 
  • Accomplishing goals 
  • Processing of content 
  • Biology 
  • External environment 

Fix them by doing this:

  • Complete a more thorough diagnostic evaluation
  • Double check your formulation and discuss is with your client
  • Read up on their issues
  • Ask them for feedback on their experience working with you
  • Go over their goals for therapy
  • Consider your own negative though
  • Review the CBT model and discuss issues about understanding and applying this with the client
  • Check their understanding of the treatment plan and if they’re happy with it
  • Check the client’s understand of their responsibilities
  • Work on the key thoughts, feelings and behaviours in each session
  • Change pace, intensity, level of empathy, amount if coaching vs didactic approach, difficulty of session structure and homework
  • Refer for neuropsychological testing if something organic may be at play

    www.happii.uk is a website providing information about mental health and wellbeing. Happii.uk is provided by Anna Batho, a therapist working in High Wycombe and providing therapy in Amersham and the wider Buckinghamshire (Bucks) region.You can contact her here.

    CBT – Core Beliefs

    Core beliefs in CBT

    We all have central beliefs are about ourselves and our relations to others; they are like short cuts to which we revert, time after time. The problem arises when they become maladaptive, and in which case they often highlight an underlying belief about us being one of three things: unlovable, helpless or worthless.

    They often originate in our childhood experiences, and can be related to our personality. For example, a child whose siblings are cruel to them and whose mother does not defend them, may start to believe that they are worthless. If their personality is perhaps more introvert, then they may never speak of their feelings to their mother which means they might never get the ‘your safety and wellbeing is important to me’ response which would quash the thought that they are worthless. So the belief continues.

    These beliefs surface during times of psychological distress when they become activated. At times like this we will start to see, in the world around us, only the information which supports the core belief; we almost start to build a case for it being true.

    What is hard, particularly when working as a therapist with such clients, is that these beliefs are not often articulated or easily articulated. If this is the case then we can follow the following structure:

    1. Hypothesise which category of core belief they fall into
    2. Present this idea to the client
    3. Educate the client about core beliefs
    4. Understanding the childhood origin of the belief
    5. Understand what maintained it through time
    6. Understand how it contributes to difficulties currently
    7. Monitor its activation in the present

    We would call them ideas at the first stage and explain that there are two options, either they ARE incompetent (or unlovable or worthless) or they BELIEVE they are incompetent (or unlovable or worthless) and thus act incompetently. We would then explain about how core beliefs stop the good stuff getting through and illustrate this by asking them for an example of when this happened in the last week, i.e. when some evidence to the contrary happened but they wrote it off.

    We would then help them gather information to strengthen a more accurate core belief by:

    • Ask them what their core belief was before they got depressed
    • Ask what their strengths are
    • Notice data and label that as strengths
    • Ask for positive experiences from last week
    • Keep a credit list of things that the client is doing ok on or receiving love for
    • Ask them for contrary evidence continually
    • When they are displaying positive behaviours ask what that means about them and what it is about them which makes this happen
    • Give positive feedback about their skills and behaviours
    • Ask them to gather evidence too (they might need a reminder to do this; a bracelet, a post it, reminder in phone)

    Of course there are ways of doing this and I’d like to explain this in a bit more detail.

    We might get the client to fill out a Core Belief worksheet which comprises the evidence supporting the new core belief of (for example) “I’m competent but human” and also the evidence supporting the old core belief of (for example)“I’m incompetent” BUT with a reframe afterwards which allows them to broaden the perspective.

    I would also use an extreme example of an incompetent (for example) person that they know and ask what that person is doing. I would then ask how they are different from that person.

    I might use a story or an example of someone famous to illustrate similarities between them and elicit how the wouldn’t judge the example unfavourably so illustrating how it is not logical why they should judge themselves in such a way i.e. Cinderella wasn’t bad just because she got abused.

    It is also possible to use the emotion a client displays in session. So when the client is emotional, we might explore why and what the core belief is behind it and then ask about where they feel it in the body. Then we might ask them to remember a time when they were younger when they experienced this same feeling. Then we would discuss it and ask about how the other people in the situation were behaving and whether their actions were right. We might also ask why they and others might have acted that way. Then we might role play the situation with you, the therapist, as the young client and the client as the other person in the memory.

    We could also do the same as above but using imagery instead. I might interview the younger client, getting them to imagine the scene when they were young, asking for details and ask for thoughts, feelings and behaviours, so that it intensifies the effect. Then I would ask if the older version of them can come into the scene to talk to them. I would get them to choose where they should stand and whether they’re holding hands etc. Then I might get the client to talk to themselves as the old client to young client, talking them through the conversation, i.e. saying older client, ask the younger client what’s wrong, now what would young client say? etc.

    I would stop when the client is feeling a bit better and ask them to rate how believable (emotionally and intellectually) the old belief is and now the new belief. I would then take them back to the present day exercise and ask them how the same principle applies.

    More Techniques

    There are other CBT techniques which can also be used alongside this to help the client both manage real problems,and  help them cope with core beliefs and overcome some core beliefs:

    • Problem solving
    • Making decisions using a decisional matrix
    • Asking them how they refocus away from their core beliefs and onto their daily life
    • Distraction (such as walk, tv, newspaper, music, call someone, email someone, clean, do finances, go to the shop, bath, prayer)
    • Complete thought records
    • Measure mood intensity during activities to find patterns and to show that things do fluctuate
    • Relaxation
    • Mindfulness
    • Graded tasks of overcoming fears bit by bit
    • Role playing to learn social skills and practice beforehand
    • Draw a pie chart to show the imbalance of time spent on things they don’t want to be doing vs ideally what they’d like to be doing (in arenas of fun, social, work, hobbies etc) and then ask how they feel about adjusting, then asking them to test their prediction.
    • Determining their responsibility for success, i.e. Get them to identify other reasons for failure (such as luck, other people’s actions, weather, lack of resources and training) and put this in a pie chart and then re-evaluate the core belief after this
    • Ask them to compare themself to themself at their worst rather than comparing themselves to others (by explaining that it’s not reasonable to compare to others without depression for example)
    • Get them to write a credit list through the week of positive activities or things which were hard but ‘I pushed through anyway’

    Imagery

    Clients might not relate to the idea of core beliefs as thoughts but might call them memories, mental pictures, imaginings, fantasies, images, visual ideas.

    Techniques which we use with images differ slightly:

    • Completion: I would explain that the image normally stops at the worst point, and get the client to imagine what happens next and after that and again and so on and try to guide them to see themselves coping, can say “what do you want to imagine happens next?”. If it ends in catastrophe, then we might ask for the meaning of this and this might highlight another core belief.
    • Jumping ahead: I would ask them to jump to the completion of the event they are imagining and imagine the detail of it and ask how it feels once they’ve done this
    • Coping: I might ask them to go through the image again and imagine themselves coping the next time
    • Changing the image: I would explain they’re the director of the upsetting scene and ask them to imagine how they wish it would happen next. I would then discuss what they could do behaviourally to make this more likely.
    • Reality test the image, using evidence to critique it
    • Repeat the image and ask how it changes every time
    • Substitute the image, as if it was on TV and then change the channel or volume or colour

    We can also induce images to help us challenge a thought, for example:

    • Imagine a year from now what will you be doing, ask them for details from when they wake up and notice how the thought doesn’t often appear
    • Imagine the prediction and then ask them to imagine what they will do to help themselves cope
    • Imagine the consequences or what life will be like in 6m, a year, 5 years
    • Get them to imagine more encouraging surroundings and faces and equipment around them

    Hopefully, this article will have given you more of an understanding of core beliefs within a CBT framework, but more importantly how, as therapists or individuals, we can challenge the unhelpful ones to help us live happier lives.

    www.happii.uk is a website providing information about mental health and wellbeing.

    Happii.uk is provided by Anna Batho, a therapist working in High Wycombe and providing therapy in Amersham and the wider Buckinghamshire (Bucks) region. You can contact her here.

    CBT – Intermediate Beliefs

    Intermediate Beliefs are different from core beliefs and encorporate rules, attitudes and assumptions. We formulate these gradually through treatment, not right from the start. 

    It can help to explain that different people have different beliefs because of different personalities and experiences, and that they may make things hard for us but that we can unlearn them. 

    Examples are:

    Rule: I should do things myself

    Attitude: it’s terrible to ask for help

    Assumption: if i ask for help I’m incompetent”

    To uncover them, we would normally start with the Hot Cross Bun or Five Areas model but would also start to ask ‘what does this mean’  when we’re exploring a clients negative thoughts.

    We might ask what childhood events might be related to the core beliefs ? What events might have initiated and maintained the core belief?

    Then we might ask “how did you cope with this painful core belief?” i.e. which intermediate beliefs such as assumptions,  rules and attitudes have you developed in response to the painful core beliefs? 

    When thinking of how to elicit intermediate beliefs we can:

    • Ask outright “what is your belief about X?”or do you have a rule about that?

    • Look for themes and ask them if their belief is X

    • Use the downward arrow technique to dig further into the issue by repeating similar questions such as ‘what does that mean?’ / ‘what does that mean about you?’  / ‘what’s the worst part about X?’ / ‘what’s so bad about X?’   / ‘if that’s true so what?’ 

    • Start first half of a sentence and ask the client to finish it, such as “ if I haven’t done this properly then it means I am…”

    • They might come in the form of Negative Automatic Thoughts (NATS) 

    It’s important only to work on beliefs that are distressing and believable by client, and so in order to uncover those out can help to get them to rate its distress level. 

    Easier to challenge intermediate beliefs

    Typical coping strategies for dealing with these core beliefs are detailed below and are paired together to illustrate how we might use the extreme opposite coping strategy:

    • Avoid negative emotion, or display high levels of emotions

    • Be perfectionist, appear helpless

    • Be responsible, avoid responsibility

    • Avoid intimacy, seek intimacy

    • Seek validation, avoid attention

    • Avoid conflict, provoke it

    • Control situations, abdicate

    • Be childlike, authoritarian

    • Please others, distance self, be selfish

    It is worth looking at the advantages and disadvantages of holding the belief, before challenging them. 

    Then, when the client decides to work on then it can help for the clinician to plan it first by writing some new alternative beliefs for the client before they start doing their own. The clinician can be more persuasive than collaborative now than with challenging NATS. 

    When challenging beliefs, clinicians should ask patients how much they believe it on an intellectual and then on an emotional / gut level.

    Ways of challenging beliefs:

    1. Socratic questioning:

    Is there another way of viewing X?

    If I did X in this (similar situation) would I still be Y?

    Is it possible that in doing X I can be z?

    If we have 2 people, 1 does X and one does y but the consequence is z, which is more positive?

    2. Behavioural Experiments 

    3. Cognitive continuum:

    Useful for all or nothing thinking. Put things on a scale from 0% to 100%,  i.e I’m a failure. So put self at 0% initially. Then ask if there’s anyone doing worse than you. Put them at 0. Then ask whether there’s someone doing even worse than them, or who doesn’t try or who doesn’t turn up or who couldn’t be bothered to enrol at uni even and add those onto the scale then reevaluate where client sits on scale.
    4. Intellectual / emotional role plays:

    They play part of emotional brain, you play part of intellectual and argue both sides of the belief. Then swap over so hey have to be the intellectual side of things
    5. Using others as a reference point:

    A)Talk about someone else who doesn’t mind for example if they don’t get all As. Ask what client thinks their belief is. Ask if the client agrees with this belief about the other person. Ask whether the belief could apply to the client too. Ask if there is anything different about the other person vs client that makes the rule inapplicable?

    B) talk about someone who has the same belief and whether the client would agree with their belief about themselves and how they would guide them to think differently

    C) role play where client has to convince someone else that the belief isn’t right

    D) imagine they had a child or are speaking to a child, what would they want the child to believe? How does that apply to them?

    6. Acting as if:

    Ask the client what they would do if they didn’t believe it at all, what would they do differently. Ask them to act as if they didn’t believe and then report back.
    7. Self disclosure:

    Say,  “ X happened to me but I don’t think that makes me y, do you?”

    As homework, ask them to read the beliefs and new beliefs and re-rate them for believability every day. Get them to stop when they’re below 30%. 
    www.happii.uk is a website providing information about mental health and wellbeing. Happii.uk is provided by Anna Batho, a therapist working in High Wycombe and providing therapy in Amersham and the wider Buckinghamshire (Bucks) region.You can contact her here.

    Acceptance and Commitment Therapy – Separating Thoughts from Feelings

    Our thoughts and feelings can become fused, and when they are, they become distressing to us, but we don’t have to let them rule our actions and the meaning we get from life. 

    Fusion happens when we create the following within our minds:

    • Rules
    • Reasons and justifications
    • Judgements
    • Thoughts about the Past
    • Thoughts about the Future
    • Thoughts about the Self

    It is often created by the chattering mind, but this is not all there is. There is also the part of the mind, the observing self, which notices it. And it is this which allows us t defuse our thoughts from our feelings. By defusing our thoughts and feelings we can reduce the distress we experience.  The key process to understand here is Defusion.

    To defuse, we can start simply by using phrases such as “what is my mind telling me? what is my mind doing, what am I noticing my mind saying?” Which allow us to distinguish between the mind and our own self. We can talk about the mind as an entity distinct from our self, and simply by writing things down it allows us to distance our self from thoughts.

    Then ask ourselves, “how helpful is that thought?”, “is it helping me get to where I want, or will it keep me stuck?”.

    Ask yourself how fused you are to these thoughts, i.e. “How caught up am I with the thought?”, “do I notice how hooked in I am after that thought?”

    Defusion Techniques

    1. Say aloud your NAT. Then say “I’m having the thought that (NAT)”. Then say “I’m noticing that I’m having the thought that (NAT)”

    2. Say aloud your NAT. Sing happy birthday in your head but use the NAT as the words. Use the voice of a cartoon character to say the NAT

    3. Repeat the harsh word from the NAT again and again until it becomes a meaningless word

    4. Imagine the NAT on a computer screen, then play with the font and spacing etc

    5. Imagine a stream and leaves floating on the steam, every thought is out on the leaf and watch it float away in its own speed, if you notice a feeling, then put the “here’s a feeling of impatience” on a leaf. Bring yourself back. Don’t try to control their speed.

    6. Focus on breathing. Then notice thoughts. Where are they in space? What form do they take (sounds, pictures), moving or still, what is above and below? Continue to notice and make observations about your thoughts

    Letting Go Metaphors

    Sometimes leaves on a stream don’t do it for you, so maybe use the other letting go metaphors as below:

    • Bubbles
    • Clouds
    • Suitcase on conveyor belt
    • Birds
    • Trains, cars
    • Waves
    • People walking by

    Remember it’s not about getting rid of thoughts or not feeling anxious, it’s letting them be and not fighting but gaining distance. It can help to thank your mind for having a thought, because Negative Automatic Thoughts (NATs) are natural and there to protect us evolutionarily. 

    Go through examples of when we didn’t act on thoughts, I.e. Didn’t punch the bad driver, didn’t quit our job, so thoughts don’t have to control action, we can have the thought and do something different anyway.

    Chessboard Metaphor

    It can help if we imagine that our thoughts are like black and white chess pieces, battling back and forth. We can simply be the chessboard; in touch with the thoughts but not battling.

    The chessboard metaphor allows us to picture the observing self but there is an exercise which illustrates it in situ:

    Continuous You Exercise

    • Notice X (thoughts, feelings, sensations, one after the other )
    • Be curious, what do you notice about it?
    • Notice how yes, there is X but there is also you noticing X
    • If you notice X you cannot be X
    • X changes (from happy to sad, from positive to negative, from pain to numbness) but the you who notices X does not change, since you were a child there has been you, and you continue to be you.

    Homework

    A great piece of homework can be to:

    • Write thoughts on card
    • On back summarise them all into a title of the film, i.e. “The Useless Jane story”
    • Read them through, then read the title on the back, what does it do?
    • Now whenever you have a NAT tell yourself “oh look at that “Useless Jane” story again”
    • And also take the card and carry it with you.
    • 5 times a day read the thoughts then the title

    For low self esteem, put the bad thoughts on a card and hold it close to your face then on the other side put the good thoughts and hold it close to your face, making the point that neither really allow us to connect with the world around us.

    www.happii.uk is a website providing information about mental health and wellbeing. Happii.uk is provided by Anna Batho, a therapist working in High Wycombe and providing therapy in Amersham and the wider Buckinghamshire (Bucks) region.You can contact her here.

    Acceptance and Commitment Therapy – Committed Action

    When we are faced with challenging situations, distressing feelings, emotions and even pain and fatigue it is important to continue living a life which is as close to our values as possible. This can allow us to gain meaning, achievement and enjoyment from life despite these obstacles. 

    Values 
    Values can be imagined as a direction, not a goal; for example, a marriage is a value or a direction but a wedding is simply a goal. Values are ongoing guides for life which do not disappear once we have achieved a goal.

    To discover your value, first pick an action, that you can do (such as raise a family). When doing it, ask yourself, how do you want to do it?, what qualities or strengths do you want to display during it?; these are qualities that would apply even if you were paralysed, or changed your action. Examples of values can be generosity, hard work, fun etc.

    Remember that values don’t need justification because they are universal and your choice.

    Disneyland Metaphor

    To help us understand the idea of values, imagine two children in the back of the car on their way to Disneyland. 

    Kid One: are we there yet?

    The Other Kid: takes his time to begin noticing, exploring, learning about the world outside the car

    The other kid is living alongside his values, because despite the wait for the exciting goal of Disneyland, he is able to be in the moment and apply his values to the journey on the way to the goal. 

    Challenges

    When you’re trying to identify your values but a difficult situation (X) keeps distracting you or getting in the way:

    • Notice your thoughts, then feelings and sensations
    • Try to open up around each of them, breathe, think about the things around that thought, feeling or sensation
    • Tune in to what X (for example, cancer) means to you (for example it means I can’t look after my kids)
    • What sort of role (for example, mother) do you want to be playing in life?
    • What does a good role (mother) look like? (For example, caring, fun)
    • So if you were being a good role (mother) what would you be doing with regards to X? (For example, using my waking hours to talk with my kids)
    • So if you were not being pushed around by your negative thoughts and attached to those emotions, what would you be doing with regards to X? (For example, spending less time thinking about cancer and more time with my kids)
    • Can you make room for the bad thoughts and feelings to do the kind of things that it takes to be the good (role)?

    With values, take it slow and really dig beyond them. Also check that it’s your values not society’s values, so ask, “if I waved a magic wand and everyone approved of everything I did no matter what, what would I choose to do?”

    However it is worth mentioning that values are best held lightly, because at times we need to sacrifice one value in order to service another. Values need to be prioritised because if one value is, for example, ‘caring for others’, but our parents are abusive to us, then we have to prioritise a different value of ‘self protection’. It’s like holding a dice; the values are different sides of the dice and we can’t always see them all, but as life changes, so we realise different values and bring different values to the forefront.

    Committed Action / Do What It Takes

    After we have uncovered our values we need to translate values into activities which are flexible enough to allow for our own difficulties. 

    1. Choose a domain to change
    2. Choose values
    3. Develop goals guided by values
    4. Take action mindfully

    Step 1: Domain (choose 1):

    • Work
    • Health
    • Education
    • Social
    • Parenting
    • Partner
    • Family
    • Spiritual
    • Community
    • Environment
    • Leisure
    • Personal growth

    Step 2: Complete this sentence: Values underlying my goals in this domain are:

    Step 3: Create SMART (specific, measurable, achievable, relevant, and timebased) goals:

    • Immediate (24 hours)
    • Short term (next few days and weeks)
    • Medium term (next few weeks and months)
    • Long term (next few months and years)

    Tips:

    • Public commitment – tell someone you’ll do it
    • Ask yourself: What’s the tiniest step you can make towards that goal in the next 24 hours?

    What if though, after trying these actions that we discover that they are unrealistic goals? If we are upset that we are not able to reach a goal, then remind ourselves that when we notice a gap between reality and our desire, it is of course pain that follows. But we have an option of following the pain and inaction or making room around the pain for action. Ask ourselves:

    • In the next 24 hours is this possible?
    • So what can we do in the next 24 hours that means we can live by these values on our way to our longer term goal?

    Reason for inaction

    Our mind always gives us reasons not to do things and waiting for it to decide that we can do something is fruitless. We decide not to do things because:

    • F: Fusion to Negative thoughts
    • E: excessive goals where resources are not sufficient
    • A: avoidance of discomfort
    • R: remoteness from values

    Solution to inaction:

    • D: Defusion
    • A: Acceptance
    • R: Realistic
    • E: Embracing values

    Remember that we can take action even though our mind tells us not to. 

    Imagine that the person you most love in the world has been kidnapped. If you do what you’ve said you’ll do they’ll be set free. Would you do it even though your mind is telling you not to? Of course you would.
    So your rich and meaningful life has been kidnapped, it has happened over time, you haven’t realised it, you missed the ransom note, you’ll never get to see this life again unless you take action. Are you going to do it?

    When stuck for motivation:

    Ask yourself, where are you on a scale of 1-10 in terms of leading a rich and fulfilling life? If it’s low, then ask yourself what’s getting in the way of that? Then problem solve how to overcome that barrier. If high, then maybe it’s time to stop using this therapy. 

    Edinburgh Bike Metaphor

    If you discover that you actually like your unhelpful behaviours which might be getting in the way of living your values or reaching your goals then think about how you might get to Edinburgh if you were riding a rickety bike. Yes, you’d get there but what state would you be in when you get there?

     www.happii.uk is a website providing information about mental health and wellbeing. Happii.uk is provided by Anna Batho, a therapist working in High Wycombe and providing therapy in Amersham and the wider Buckinghamshire (Bucks) region.You can contact her here.

    Bereavement, Grief, Mourning and Loss

    So I went on a training day about bereavement and loss, because many of the people I treat have experienced one of these, and for some of them it is this loss which stops them from moving forward. I felt I needed the training because I haven’t gone through that much loss myself and I wanted to understand their perspective a little better and how to help them.
    What surprised me was that we learnt that we don’t need someone to die to feel bereaved. We can feel that loss at so many things; divorce, diagnosis of a long-term illness, redundancy, when children fly the nest; I could continue ad infinitum. And as a result I learnt that whilst I (luckily) haven’t had so many people die with whom I’m close, I have experienced some of those other losses and this can help me, and others, understand some of what people feel when they feel bereaved.

    The most important lesson I learnt is that grief can be delayed or immediate, severe or mild, prolonged or brief because we are all different. And because of that, we should approach those who are grieving with an open mind, without assuming we know what has happened, what they are experiencing and what they will be going through.

    How grief works (or doesn’t)

    We can use different terms to signify grief but I think the best explanation of what it is is as follows:

    • Bereavement = what happens to you
    • Grief = the feeling afterwards
    • Mourning = what you do

    To help us understand grief and mourning we use different models.
    The one with which most of us are familiar is the Kubler-Ross model of grief which explains that following a loss, we go through different stages of grief as follows (but not in a any particular order):

    • Denial – when we act as if the loved one has not gone, or avoid talking about it

    • Anger – we feel angry that this has happened to them and us and dwell on the injustice

    • Depression – we feel low and hopeless, demotivated to do anything because what is the point?

    • Bargaining – we think of the ‘what if’s and the ‘if only’s which would have prevented it happening in the first place or which might bring them back or prevent worse happening in the future

    • Acceptance – we accept that what is gone has gone and we continue with life despite this loss

    A lot of us might be able to relate to this model. The difficulty with this model is that it suggests that the stages are part of a process which we go through in order to achieve something or to come out the other side. But for people who have lost someone, there is often no other side, their world is changed permanently and there is no resolution.

    The simplest model of grief and mourning is the Dual Process Model of grief (Stroebe & Schut). It explains that when we’re grieving, we move from action to emotion and back again, continuously. For example, we might be consumed with sadness in the morning, but then in the afternoon we might call the funeral directors, but by the evening we might be crying uncontrollably again and then the next week we might decide to take the deceased’s clothes to the charity shop. It suggests that it is natural for us to engage in a little bit of both which I think helps us give ourselves permission to cry, to take time to dwell on things and then to throw ourselves into something practical.

    A further model is the Biographical Model of grief (Walter) which simply suggests that as we talk about the lost person, and what happened and what they were like, it helps us understand and process what has happened and ‘write the last chapter’. This can help us come to terms with what has happened so that the distress we experience is reduced.

    Another model which helps us understand grief is the Fried Egg model of grief. It explains that, if we imagine our grief to be the yolk of the egg and the white of the egg is the rest of our life, most of us would expect the yolk part to decrease over time; from this:


    To this:


     

    Not so. What changes is not the yolk (the grief), but the white (the rest of our life). Sometimes the white gets smaller so that all we can see in our life is the grief.


    Sometimes the rest of our life expands, so that there is more white, and so, whilst the grief has not diminished, it is, proportionately, a smaller part of the total of what we are experiencing and focussing on.

    In brief; our grief remains but our life expands. I love this model. It’s simple and makes sense and it pays respect to what is lost and does not ask us to ‘move on’.

    There is an element of truth in all of these models.

    When grief gets more complicated

    Some people may have difficulty with some of the things which we do to cope, normally because they are concerned for your wellbeing and may interpret your behaviour as you being stuck in a certain stage of grief and that you are not ‘moving on’. I think this would only normally be a problem if you are struggling to recognise the reality of the loss or the fact that you can’t change the situation after a significant amount of time.

    The reality is that when we lose someone, we are at higher risk of mental and physical health problems. So it doesn’t hurt for others to keep an eye out for you, or indeed you for yourself.

    Multiple, unexpected or untimely bereavements and lack of support can have a bigger impact on those who are left. These complications can chip away at your capacity to cope, no matter how resilient you are.

    If you know someone who is grieving ask yourself:

    • Do they feel supported or isolated?

    • Are they able to talk about feelings with family and friends?

    • If the death was predicted, were they able to plan and talk about their expectations beforehand?

    • Are they still in denial?

    • Are they still angry?

    • Are they experiencing financial or medical difficulties or another life change at the same time?

    If the answer above is yes to any of these then the path of grief can be impeded and they may benefit from further support.


    What helps when grieving

    Support

    When we talk about what’s best to do when grieving, the simplest answer is “do what you need to do”.

    It means, really, that there is no formula for grieving well, because everyone is different, everyone copes differently and everyone finds different things meaningful or helpful.

    We heard of a client who took her childhood teddy to a church the morning after she miscarried a child. We were told of someone who kept their grandma’s room as she left it for a year. If it helps you cope. Do it.

    It’s also worth remembering that death often affects more than one person and family dynamics are complex. Everyone has different needs, expectations and desires from the beloved and others affected by the grief and this can cause conflict and confusion. It is normally impossible to manage all of this or help everyone at the same time or in the same way, so try not to make assumptions and be realistic about what you can do.

    Importantly, though, the single, most positive factor in encouraging a healthy grieving journey is being able to talk, unconditionally, without judgement, about the loss with someone who listens.

    For those supporting someone grieving it can be daunting.

    “What should I say to someone grieving?” is something I’ve often asked others when talking with grieving individuals.

    What helps, is knowing that if what they need most is someone who listens, we don’t even need to worry about what to say; someone who listens does not give advice, because responses don’t make people better, connections do.

    So reaching out to them, being there, or simply saying something like “I don’t even know what to say right now I’m just so glad you told me” can be enough.

    When we talk about listening, it’s not just letting someone talk but trying to understand what is happening for them. Doing this takes empathy, and it needs to come from within you (which can be exhausting) but it is, in brief:.

    • Perspective taking – try to reach where they’re coming from

    • No judgement – your opinion is not needed right now

    • Recognising emotion – try to see what they are feeling, it might not be simple sadness

    • Communicating that you recognise it – letting them know you’re understanding a little of what’s happening for them

    Be mindful though, that the differences between us and the person we are supporting also make a difference to how we interpret the loss, so it’s important to be reflective and aware of this so that we can come ‘alongside’ and not project our perspective on others.

    What can also help is validating and normalising what they’re going through so that they don’t feel so alone, or like they’re going out of their mind. This might come from you, but equally, support groups for those who have experienced similar situations can be hugely helpful.

    Rituals

    Rituals or traditions, or symbolic gestures which we do after a death can help because they mark in a symbolic way a transition from one position to another. They can be almost like a stake in the ground communicating to the world, yourself and others that something has happened and thus the world has changed but that now you are moving on your way forward.

    Some different rituals which people might find helpful are:

    • Burial within 24 hours

    • Washing the body and preparing for the deathbed

    • Playing certain music

    • Sending cards

    • Planting trees

    • Letting balloons off

    • Making memory boxes

    • Funeral

    • Sprinkling ashes

    • Flowers set somewhere

    • Writing a letter

    • Lighting a candle

    I hope that this article has conveyed what I feel are important and useful ideas in understanding and helping support people who are bereaved.

    www.happii.uk is a website providing information about mental health and wellbeing. Happii.uk is provided by Anna Batho, a therapist working in High Wycombe and providing therapy in Amersham and the wider Buckinghamshire (Bucks) region.You can contact her here.

    The best Cognitive Behavioural Therapy apps / CBT apps

    There’s lots of evidence that Cognitive Behavioural Therapy (CBT) is effective at treating anxiety, depression, phobias, hypochondria, PTSD and eating disorders.

    Trouble is…whilst it’s free on the NHS, the waiting lists are huge; where I work, clients have to wait up to 6 months for treatment in some cases! Of course you can pay, but it’s pricey, sometimes up to £80 per hour session.

    So?  How can you access CBT quickly and affordably?  The answer? CBT apps!

    Below I’ve reviewed a few of the key apps for various disorders to help you find the best CBT apps on the market.

    CBT-i coach – click here for free sleep app

    The best insomnia app, built by Stanford University in the US and the National Centre for PTSD, so some good credentials. Features a sleep assessment, psycho-education about what to do to boost your sleep, a sleep diary to help you track your progress, alarms and reminders to encourage you to adhere to your prescribed sleep times and sleep prep behaviours, check lists for preparing your environment for sleep, caffeine management tool, motivational tools to help you get out of bed and go to at the prescribed time, relaxation exercises and tracks.

    Mind Shift – click here for free anxiety app

    Great app for managing anxiety, packed with some really useful techniques.  Features psycho education on anxiety, mindfulness exercises, relaxation audio tracks where you can choose from a female voice or male, visualisation exercises.  There are also tailored modules on managing test or exam anxiety, social anxiety, dealing with conflict, managing panic, dealing with perfectionism and performance anxiety.   Each of these modules includes a page to measure your own anxiety, a choice of  more helpful / rational thoughts to guide your thinking away from negative thoughts and towards realistic thoughts, the chill out tools listed above, but probably the most powerful advice is the Active Steps which provide lists of really effective worry management, panic management, graded exposure tips, behavioural experiments and preparing for big events.  The app also includes limited inspirational quotes.

    Mood Tools – click here for free depression app / therapy app

    This app has so much information on depression, the causes, types, but more importantly it has potted guides on how to treat depression, including guides on how to use the following evidence -based therapies on yourself, without a therapist.  Just pick one!

    • Cognitive Behavioural Therapy -although it focuses on challenging thoughts rather than modifying the behavioural side of things which is in a different section for some odd reason
    • Acceptance and Commitment Therapy – how to learn to live with difficulties
    • Dialectical Behaviour Therapy – this is more useful for more complex difficulties like personality  and attachment disorders so I’m surprised it’s in here for depression but the information is great to apply to many disorders
    • Suicide Prevention – quite extensive plan to help keep yourself safe from self harm and suicide and a crisi plan for if things get too much
    • Lifestyle Changes – not a recognised ‘therapy’, more of an intervention but nevertheless very powerful, including suggested activities on socialising, exercise, nutrition, sleep and sunlight

    The app also includes a depression test so you can measure how severe / frequent your depressive  symptoms are, videos on mental health, guided meditation tracks, relaxing tracks, an interactive thought diary (basically the one below) and suggested activities to boost your mood and interactive rating tasks.  It even helps you find a therapist from the BABCP website which is the accreditation organisation for therapists.

    The app isn’t as interactive as some others however, which is a bit of a shortcoming, although it is so jam packed full of information that you’d be mad to not download it.

    SAM app – click here for free stress and anxiety management app

    A very interactive app written by the University of West of England so some smart cookies.  Includes an anxiety tracker, a social media ‘cloud’ where you can network with others, a space to list your anxiety provoking situations, but best of all lots of relaxation exercises, psycho-education about anxiety, some great interactive anxiety reduction exercises and tips, an app to audio-record your thoughts and listen to them back again.  Takes a while to find your way around but you can create your own ‘tool kit’ of your favourite techniques.

    Thought Diary – click here for free thought challenging app

    Very simple cognitive restructuring app which will be useful with most disorders. The app asks you to write down the situation you’re in, the emotions you’re experiencing and the level of distress they are causing, it then prompts you to identify the negative thought you have, and then to pinpoint the way in which the thought may be distorted.  It then gives you a choice of statements which can challenge the distorted though and then  prompts you to re-write an alternative point of view and reassess how distressed you then feel as a result.

    Hope these free CBT apps help you, if there are any issues with the links, please let me know.

    www.happii.uk is a website providing information about mental health and wellbeing.
    Happii.uk is provided by Anna Batho, a therapist working in High Wycombe and providing therapy in Amersham and the wider Buckinghamshire (Bucks) region.
    You can contact her here.

    How to Relax – Progressive Muscular Relaxation

    People with anxiety difficulties are often so tense throughout the day that they don’t even recognize what being relaxed feels like.   Progressive Muscle Relaxation is a scientifically proven way to help you relax and to teach your body how to recognise the signs of stress, tension and anxiety.

    Do it regularly (try once a day at the start) and it can help you:

    1. re-calibrate your body back down to zero tension
    2. prevent a stress reaction to stressful life situations
    3. learn to notice the early warning signs of tension so you can nip them in the bud

    Or, alternatively, you can use it on an ad-hoc basis to help relax during stressful times, help you get to sleep, or help you recover after a particularly bad time.

    Tips:

    • Set aside about 15 minutes to complete this exercise.
    • Find a place where you can complete this exercise without being disturbed.
    • You do not need to be feeling anxious when you practise this exercise. In fact, it is better to first practice it when you are calm.
    • Find a quiet, comfortable place to sit, then close your eyes and let your body go loose. A reclining armchair is ideal. You can lie down, but this will increase your chances of falling asleep.
    • Wear loose, comfortable clothing, and don’t forget to remove your shoes.
    • Take about five slow, deep breaths before you begin.

    How To Do It

    You will be systematically tensing and then relaxing each muscles group in your body, one by one.  here’s how to do it.

    TENSE YOUR MUSCLE

    The first step is applying muscle tension to a specific part of the body. First, focus on the target muscle group, for example, your left hand. Next, take a slow, deep breath and squeeze the muscles as hard as you can for about 5 seconds. It is important to really feel the tension in the muscles, which may even cause a bit of discomfort or shaking. In this instance, you would be making a tight fist with your left hand. It is easy to accidentally tense other surrounding muscles (for example, the shoulder or arm), so try to ONLY tense the muscles you are targeting. Take care not to hurt yourself while tensing your muscles. You should never feel intense or shooting pain while completing this exercise. Make the muscle tension deliberate, yet gentle. If you have problems with pulled muscles, broken bones, or any medical issues that would hinder physical activity, consult your doctor first.

    RELAX YOUR MUSCLE

    This step involves quickly relaxing the tensed muscles. After about 5 seconds, let all the tightness flow out of the tensed muscles. Exhale as you do this step. You should feel the muscles become loose and limp, as the tension flows out. It is important to very deliberately focus on and notice the difference between the tension and relaxation. This is the most important part of the whole exercise. Remain in this relaxed state for about 15 seconds, and then move on to the next muscle group. Repeat the tension-relaxation steps. After completing all of the muscle groups, take some time to enjoy the deep state of relaxation.

    THE MUSCLES TO TENSE

    During this exercise, you will be working with almost all the major muscle groups in your body. To make it easier to remember, start with your feet and systematically move up (or if you prefer, you can do it in the reverse order, from your forehead down to your feet).

    1. Foot (curl your toes downward)
    2. Lower leg and foot (tighten your calf muscle by pulling toes towards you)
    3. Entire leg (squeeze thigh muscles while doing above) (Repeat on other side of body)
    4. Hand (clench your fist)
    5. Entire right arm (tighten your biceps by drawing your forearm up towards your shoulder and “make a muscle”, while clenching fist) (Repeat on other side of body)
    6. Buttocks (tighten by pulling your buttocks together)
    7. Stomach (suck your stomach in)
    8. Chest (tighten by taking a deep breath)
    9. Neck and shoulders (raise your shoulders up to touch your ears)
    10. Mouth (open your mouth wide enough to stretch the hinges of your jaw)
    11. Eyes (clench your eyelids tightly shut)
    12. Forehead (raise your eyebrows as far as you can)

    THE SHORT VERSION

    Once you have become familiar with the “tension and relaxation” technique, and have been practicing it for a couple weeks, you can begin to practise a very short version of progressive muscle relaxation. In this approach, you learn how to tense larger groups of muscles, which takes even less time. These muscle groups are:

    1. Lower limbs (feet and legs)
    2. Stomach and chest
    3. Arms, shoulders, and neck
    4. Face

    So instead of working with just one specific muscle group at a time (e.g., your stomach), you can focus on the complete group (your stomach AND chest). You can start by focusing on your breathing during the tension and relaxation. When doing this shortened version, it can be helpful to say a certain word or phrase to yourself as you slowly exhale (such as “relax”, “let go”, “stay calm”, “peace” “it will pass” etc…). This word or phrase will become associated with a relaxed state; eventually, saying this word alone can bring on a calm feeling. This can be handy during times when it would be hard to take the time to go through all the steps of progressive muscle relaxation.

    www.happii.uk is a website providing information about mental health and wellbeing.
    Happii.uk is provided by Anna Batho, a therapist working in High Wycombe and providing therapy in Amersham and the wider Buckinghamshire (Bucks) region.
    You can contact her here.