A Self Help Workbook for People with Anxiety

Acknowledgements This workbook was produced by members of the South Worcestershire Primary

Care Mental Health Team and Psychology Department. Special thanks to Sally

Denham-Vaughan, Dr Andie Lees and Lynda Smith.

Disclaimer

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How to use this pack

This anxiety management pack uses Cognitive Behavioural Therapy or CBT. CBT is a type of therapy used to help people cope with all sorts of problems, including anxiety and depression. The “cognitive” part deals with thoughts and how they are linked to anxiety. The “behavioural” part deals with how what we do affects our anxiety.

This workbook will enable you to work through your anxiety week by week. Each week you will be asked to complete worksheets. These will help you to stay motivated and show you how you are getting on.

The pack is divided into six parts and should take up to six weeks to work through:

Section 1 explains what anxiety is, helps you to set goals and explains relaxation and breathing techniques.Section 2 explains the cognitive behavioural approach, relaxation techniques and lifestyle advice.Section 3 explains avoidance and how to begin to confront the things that make us feel anxious.Section 4 helps you identify, challenge and replace your worrying thoughts.Section 5 explains life skills that can help to reduce your anxiety.Section 6 explains how to cope with setbacks and bad days.

At the end of the pack there are suggestions for further reading and contact details of organisations that you may find helpful.

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Contents

Section 1 What is anxiety 5-22Goal SettingRelaxation and breathing

Section 2 The CBT approach. 23-32Lifestyle

Section 3 Avoidance and exposure 33-36

Section 4 Worrying thoughts 37-44

Section 5 Life skills 45-50

Section 6 Coping with setbacks 51-55

Further reading 56

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Section 1What is anxiety?

Anxiety and fear are normal human emotions. Fear is the natural response to danger or stress, and helps us survive by preparing our bodies to deal with threatening situations. It acts as the trigger for our bodies to release adrenaline, which makes the body work faster and harder so that it can cope with danger by either fighting or running away. This is known as the "fight or flight" response, which is automatic. As soon as you sense a threat, this response occurs. This was very useful in prehistoric times when there were many dangers such as wild animals, and prehistoric man needed to react to these quickly. The “fight or flight” response helped us to be ready to run away or fight immediately after sensing a threat, and so helped us to survive.

Today we don't have to worry about wild animals attacking us. However, there are other dangers, which mean we still need this response. For example, if you are crossing a road and see a car coming quickly towards you, the “fight or flight” response occurs.

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These are some of the physical sensations and mental processes that can result from having all this adrenaline in our system.

These symptoms are very helpful in dealing with the threat as they are the body’s normal coping mechanism. However, fear becomes a problem when we have difficulty turning these reactions off. You may find that you have become trapped in a cycle of worrying about your

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Dry mouth

Muscles become tense

Heart races

Rapid breathing

“Butterflies” in stomach. May have sudden urge to

go to the toilet.

Weakness in legs. Trembling.

Rushing sound in ears. Faint feeling.

Our minds become very focused on the source of

anxiety. Blushing

Nail biting

Sweaty palms

feelings, and this can escalate into a habit of feeling anxious a lot of the time.

The diagram on page 8 shows how this habit can develop into a vicious circle of anxiety and panic.

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Cycle of worry

Can lead to

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Situation or event

Release of adrenalinePhysical symptoms of anxiety e.g. heart palpitations

Frightening thoughts

More adrenaline triggered

Start to feel even more anxious

More physical symptoms

You may start to panic

Perception of situation or event as stressful or dangerous.

Why me? Everyone experiences anxiety and has anxious thoughts sometimes, but it is more of a problem for some people than for others. There are a number of reasons for this:

1. Personality Some people may be more vulnerable to developing problems with anxiety because of aspects of their personality. For example:

People who are self-critical and have very high standards. Those with low self-confidence who imagine others will judge

them harshly. Those who tend to think negatively and imagine the worst. Those who are always rushing around (possibly looking after

others) and never rest.

2. Family history It is possible for anxiety to be learnt. For example, a child who sees his mother getting very anxious when seeing a spider may develop a phobia about spiders. However, it is important to remember that it is possible to overcome fears and worries, even when there is a long history of them.

3. Life stresses Events in our lives, both present and past, can increase our chances of developing anxiety-related problems. Stressful events, either short-term, such as losing a job or taking an examination, or long-term such as ongoing physical illness, or financial worries, can all cause

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anxiety-related problems. We may deal with stressful situations by changing our habits, such as withdrawing from

life. This can mean that, over time, anxiety about facing situations can increase. However, stressful events are not always negative. Moving house, going on holiday or the birth of a child can be just as stressful as negative events.

Anxiety can also be triggered by past events. If a similar situation is encountered again it can stir up the same feelings of distress. Anxiety may be triggered following a life event such as bereavement, divorce or by moving house. After such events people may not be able to express difficult feelings and this can lead to anxiety.

4. Coping skills People have different ways of coping with problems. Some people find it helpful to keep busy and distract themselves. Avoiding the problem, or using smoking, drugs or alcohol to cope, can bring short-term relief, however, this can actually increase the problem in the long-term.

Types of anxietyAnxiety affects people differently. The following are the most common forms of anxiety and you may recognise yourself in the descriptions that follow:

Generalised Anxiety

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People with generalised anxiety feel tense, anxious and uneasy most of the time. They worry about a variety of situations and events and tend to overreact even to mild stresses. Physical symptoms include:

Restlessness Fatigue Problems concentrating Tense muscles Insomnia

PhobiasPeople with phobias have specific and intense fears triggered by particular objects or situations. Even though the sufferer may know their fear is irrational it still causes them to feel anxious.

There are three types of phobias.

Simple phobias - fear of a particular object, animal or situation. E.g. fear of spiders.

Agoraphobia - fear of unfamiliar settings, such as open spaces, crowds and travelling. This may lead to a fear of leaving the home.

Social phobia or social anxiety – fear of public or social situations. For example eating or drinking in public, going to the shops and parties.

Health anxiety

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People with health anxiety are preoccupied with the fear of becoming ill. This results in an increased sensitivity and awareness of bodily sensations. Sufferers of health anxiety may worry these symptoms are indicators of a serious illness, such as cancer. Where health related fears are a problem, you may find yourself making repeated trips to the GP to gain reassurance that you are not physically ill. It is important to check out possible physical causes with your doctor. However, once your GP is satisfied that there is no physical cause, it is more helpful to focus on treating your anxiety.

Panic disorderPanic disorder is characterised by sudden, distressing attacks of anxiety (panic attacks). Symptoms include:

Nausea Dizziness Difficulty breathing Heart palpitations Chest pain

Panic attacks may last for a few minutes and may occur frequently during the day or night. Some people experience feelings of being outside the body, of the world not being real, and of losing control and may feel as if they are dying.

Problems with compulsive behavioursSome people become focused on certain mental images, which may have been triggered by events or situations, which seem threatening and are anxiety provoking. In order to avoid these situations, they carry out certain acts or “rituals”, which may be very time consuming. Common rituals include:

Avoiding or touching certain objects

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Washing excessively Repeatedly checking things e.g. whether the door is locked

Whilst these rituals can reduce anxiety in the short-term, they can keep it going in the long-term, and may therefore interfere with normal daily life.

What do I want to change?

The first and most important part of any self-help program is to recognise that there is a problem and set goals for what you want to achieve. By working hard to achieve these goals you could change your life for the better. Accept that it will take time to change and begin to take small steps towards the end goal of being more in control of your anxiety.

Your goal must be important to you. Make your goal small enough to be achievable but still a

challenge. Your goal needs to be concrete and specific. For example, avoid

goals such as, "I want to be more sociable and happy", as this is too big and it will be difficult to measure the achievement.

Break your goal down and be as specific as possible. For example, "I aim to meet my friends once a week."

State what you will do instead of what you won't do. For example "I will spend 10 minutes everyday practicing relaxation exercises," rather than, "I will not rush around anymore."

Goals involve hard work but the rewards are worth it. With perseverance and practice you can get there!

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Write down at least three (and no more than five) goals to work on during this programme. These may change over time but it is important that you think clearly now about what you are trying to achieve.

1._______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2._______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3._______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

We understand that you cannot change things until you know more about the problem and chapter 2 explains anxiety in more detail.

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RelaxationWhen we are anxious, we experience uncomfortable sensations. These physical symptoms can cause us to feel even more anxious.

Symptoms of anxiety Worry about symptoms

Relaxation techniques can help to break this cycle. For example, you may find that watching television or listening to music helps you to relax. However, in order to completely relax your body it is important to learn and use relaxation techniques. Learning to relax is not always easy and is a skill that takes practice. The exercises below will help you to learn to relax step by step.

Before you begin:

Decide when you will practice the relaxation exercise and try to keep to this time every day.

Choose a quiet place to practice where nobody will disturb you.

Do not practice if you are hungry or have just eaten; or if the room is too hot or too cold.

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Start the exercise by lying down in a comfortable position, wearing comfortable clothes. As you become more practised you may wish to try the exercise sitting or standing.

Try not to worry about whether you are relaxing successfully. Just have a go and let it happen.

Try to practice the relaxation technique at least once every day. The more you practice the easier it will become to relax.

You may find it helpful to record your progress. Use the sheets provided at the end of this chapter to record your experiences. This will help to see whether the technique is working for you.

Exercise 1: Progressive muscle relaxation

Before you begin read through the exercise so that you are familiar with the routine. You may find it helpful to record the instructions onto a tape, get a friend to read them to you or try to memorise them.

This exercise aims to help you learn to recognise when your muscles are tense and when they are relaxed. The exercise begins with the hands and arms and works through different groups of muscles, ending with the feet. At each stage you should try to focus on the feelings in the part of the body you are working on. Tense the muscles as hard as you can and concentrate on the feeling of tension, taking care not to strain any muscular injuries or vulnerable parts of the body. Hold this for about five seconds and let go for about ten seconds, relaxing the

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muscles as much as possible and concentrate on the feeling of relaxation.

1. HANDS Make a tight fist with your right hand.Relax.Make a tight fist with you left hand.Relax.

2. ARMS Keeping your hands relaxed, bring your lower arms up towards your shoulders.Relax.Let your arms and hands rest by your sides or be supported by the chair.

3. SHOULDERS AND NECKRest your chin on your chest. Shrug your shoulders as hard as you can. Circle your shoulders and then let them drop.Relax and repeat.

4. FACE Tense your face by screwing your eyes up and tenseyour jaw by biting your teeth together.Relax and repeat.

5. CHEST AND ABDOMENTense you stomach muscles by pulling your tummy in tightly. Slowly breathe out. Relax and repeat.

6. LEGS AND LOWER BACKKeeping the rest of your upper body relaxed, squeeze your thighs and buttocks together.Relax.Point your toes towards the floor and then bring

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them back up.Relax.

7. WHOLE BODYScan your whole body, from head to toe, for any tension. Relax any muscles that feel tense. Continue breathing calmly and evenly.

MINDThink of something soothing and restful. For example lying on a warm beach, a place that makes you feel safe, or anything that helps you to relax. Breathe slowly and feel yourself becoming heavier and heavier.

Do not stand up straight away. Continue to rest for a few minutes and when you are ready, move slowly and gently stretch. This exercise needs to be practised regularly until you always feel relaxed at the end. When this happens you may wish to try using the exercise whilst sitting or standing, or in different situations. This may help you to cope with symptoms of anxiety when they occur in daily life.

Exercise 2: Cued RelaxationAs you become more experienced in using Exercise 1(usually after around 4-6 weeks), you will find it easier to tell when your muscles are relaxed and when they are tense. At this point you can try Cued Relaxation. This involves using your relaxation skills when you need them throughout the day. When you begin to feel your muscles becoming tense, this may be your cue, or reminder, to use your

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relaxation skills. You may find it useful to build up cues around your home and work. For example, you could put a rubber band around your wrist so that every time you see it you will be reminded to check how relaxed you are. However, it is important to develop cues that suit your lifestyle. Cues will remind you to:

Check whether any of your muscles are tense Check your breathing Use relaxation skills Think of a calming image or relaxing place Think of a relaxing word, such as “calm” or “peace”.

Frequently Encountered ProblemsMany people experience some difficulties when first trying these exercises. These can be easily overcome. Some of the most common problems are:

Muscle cramps – Although these may be painful, they are not dangerous. They can be overcome by tensing the muscles more gently or for a shorter period of time. A warm room may also help.

Wanting to laugh – At first you may feel self-conscious and feel like laughing. However, as you become used to practicing the exercises this feeling will pass.

Falling asleep – If you find yourself falling asleep when using the exercises it may be better to practice sitting down. You could also try holding something (that will not break) so that it will fall and wake you if you fall asleep.

Unable to relax – Many people experience this problem when they first start to use relaxation techniques. Do not try to relax too hard as this may lead to increased tension. Make

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sure you relax in a place that is comfortable and where you will not be disturbed.

Breathing

When we are stressed or anxious our breathing can become shallow and quick. This is called hyperventilation and is a normal response to stress and anxiety. However, hyperventilating can cause the oxygen levels in the blood to become too high and the carbon dioxide levels too low, leading to frightening feelings such as dizziness, chest pains and a feeling of being unable to catch your breath. These feelings can often make us feel more anxious. If you start to hyperventilate and experience feelings of panic it may help to focus on breathing out slowly, in order to get the oxygen/carbon dioxide levels in your blood back to normal.

You can help to control your breathing by practising the exercise described below. If you have a history of breathing difficulties e.g. asthma please seek advice from your GP before trying this exercise.

Controlled breathing

1. Place one hand on your chest and the other on your stomach.2. Breathe in through your nose, filling your lungs completely so

that you feel your stomach rise. Try to keep the movement of your chest to a minimum.

3. Slowly and evenly breathe out through your nose or mouth. Let your stomach muscles relax.

4. Repeat, and try to get a slow rhythm going by breathing in for a count of 2 and out for a count of 3.

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In order to be able to use the techniques described when you feel anxious, it is important that you practice them regularly. You should aim to practice for at least 20 minutes a day for 6 weeks.

Before next week…

Try to think about and write down your goals. Begin to use the diaries provided to record your relaxation.

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Section 2

The Cognitive Behavioural Approach

Everyone experiences anxiety differently. Before you can begin to manage your anxiety, you need to understand what triggers it, what physical symptoms you have and ways in which you behave as a result. Often we believe that it is our environment, or situations affecting our life, that affects our mood. However, it is actually how we respond to those situations that affect how we feel. The Cognitive Behavioural approach focuses on the following five areas or our life, as concentrating on any one of them can influence our mood.

Environment –Life events or situations affecting our life, past and present.

Thoughts/Cognitions – When anxious, we are more likely to experience worrying or negative thoughts. These thoughts are also likely to contribute to or worsen our anxiety.

Behaviour – Things we are more likely to do when anxious e.g. avoidance.

Physical symptoms – For example, tense muscles. Feelings – Mood or emotional responses such as anger,

happiness or sadness.

It can be helpful to target any of these five areas, as they are all interlinked. A change in one area will have an impact on the other areas. It will be helpful to fill in the following diagram in order to highlight factors currently affecting your life and how they are linked.

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CBT Maintenance Cycle

Environment

Monitoring your anxiety

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ThoughtsWhat am I thinking about the

situation?

FeelingsHow am I feeling about

the situation?

BehaviourWhat do I do when the

situation arises?

Physical SymptomsWhat happens to my body in this

situation?

EnvironmentWhat specific situation/s make me feel

anxious/upset?

It can also be helpful to record times when you feel anxious using the anxiety monitoring diary sheets provided at the end of this chapter. Try to fill these in as soon after feeling anxious as possible, as it is easy to forget how you felt.

It may be difficult to write down exactly how you felt, but this will become easier with practice. Looking back at your diary sheets will help you to understand what triggers your anxiety, what your bodily sensations are, and what helps you to cope.

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LifestyleWhen we are anxious or stressed our emotions can vary. Sometimes we may feel overwhelmed and at other times we can feel cut off from our emotions.

Overwhelmed

Cut off

There are several skills we can use to help balance our feelings. We can help to do this by making small changes to current eating patterns and lifestyle. We recommend that you follow the lifestyle advice given in this pack for the duration of the programme. However, you should not make any changes to your diet if a doctor or specialist has prescribed you a particular dietary regime e.g. for diabetes.

1. Eat three meals a day

Symptoms of anxiety can be made worse if you do not eat regular meals. The reason for this is that eating regularly maintains a stable blood sugar level. Breakfast is especially important! You may find it useful to record what you eat and drink in the diary at the end of this chapter.

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2. Eat a balanced diet

Eating foods with a high fat and/or sugar content results in a short period where your blood sugar level is high, followed by a low blood sugar level. Eating foods that are high in fibre help to keep your blood sugar levels stable and can help to reduce some symptoms of anxiety.

3. Caffeine intake

Drinking a lot of tea and coffee (more than five cups a day) or other drinks that contain caffeine, such as coca cola, can increase feelings of anxiety. Smoking can increase the strength of this reaction. You should try to

reduce the amount of caffeine in your diet for at least four to six weeks. You may experience withdrawal symptoms, but these should only last for three to four days.

4. Limit your alcohol intake

It may be useful to monitor the amount of alcohol you drink. Although alcohol can temporarily help with the symptoms of anxiety, drinking to relieve stress can quickly become a

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High fibre foods e.g. fresh fruit and vegetables, oats, cereals, wholemeal bread, brown riceProtein e.g. meat, fish, eggs, pulses and beans

EAT MOREHigh fat foods e.g. fried food, cakes, pastry, cream, and butter.High sugar foods e.g. fizzy drinks, biscuits, sweets

EAT LESS

habit and could lead to dependency. As a guideline you should drink no more than ten units a week if you are a woman, and no more than sixteen units a week if you are a man. One unit of alcohol = half a pint of beer OR single (25ml) measure of spirit OR small glass (120ml) wine.

5. Try to reduce the amount you smokeYou may feel that smoking relaxes you. However, the nicotine in cigarettes actually increases the strength of your anxiety reaction, so it is important to reduce, or preferably, completely stop smoking.

6. Take regular exercise Exercise is extremely important in helping to overcome feelings of stress and anxiety. Activities such as jogging and swimming, as well as day-to-day activities such as

gardening and housework can all be beneficial. Make sure that you build up slowly if you are not used to exercise. Choose an activity that your body is able to engage in, particularly if you have any physical difficulties.

7. Avoid rushing aroundRushing around can increase your feelings of anxiety as it causes adrenaline to be released into the body. Sometimes you may not be able to avoid rushing around, but if you can, slow down and this will allow you to relax more.

8. Find time to do enjoyable thingsIt is important to spend time doing things you enjoy. This could be anything from buying yourself a bunch of flowers or listening to music

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to going to the cinema or inviting friends over. (For ideas see list of enjoyable things to do at the end of this chapter.) Spending time doing things you enjoy can help you to relax.

Learning to prioritise daily tasks can help to get things done and still leave you with time to do the things you enjoy. It can be helpful to write a list of what you need to do, prioritising in the following way, and tick jobs off when they are completed:

A Need to do today (includes doing something pleasurable)B Need to do this weekC Could be done whenever time becomes available

9. Social SupportIt helps to have someone to talk to and confide in. Having good quality social support can help protect us against the ongoing stresses of life. A good network of friends, workmates or family will help protect against developing emotional problems when faced with stressful situations.

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10. Self supportWhen we feel overwhelmed there are several skills we can use to help manage our emotions.

Distraction

It can be important to experience a certain degree of anxiety in order to begin to manage it effectively. However, if this emotion becomes overwhelming it can be helpful to use distraction techniques. Such methods can help focus our attention away from the symptoms of anxiety. There are three types of distraction techniques:

1. Physical exercise e.g. going for a walk or tidying a room in your house.

2. Refocusing This means concentrating on things around you e.g. counting the number of people you can see with brown hair or looking in shop windows.

3. Mental exercise e.g. reciting the words of a poem or a song or imagining a safe place, including details such as colours and sounds. For example, imagine a fantasy world that is calming and beautiful and let your mind go with it.

Any activity that absorbs your attention can be useful for distraction. It is important to remember that, like all skills, distraction techniques take practice. However, remember that it is important to use distraction techniques only when you really need them, i.e. when you feel overwhelmed. Overusing these skills can lead to avoidance (see chapter 3).

Self soothing

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You may find it helpful to do activities that involve each of the five senses. For example:

VisionLook at a picture you like.Light a candle and watch the flame. HearingListen to the sounds of nature- birds, leaves in trees.Listen to a relaxing piece of music.SmellSpray your favourite perfume or aftershave.Smell the trees and flowers on a walk.TasteEat something that is extra special to you.Chew some gum.TouchMassage lotion into your hands.Stroke a pet.

It can be helpful to make a list of things you find soothing and use it when you start to feel anxious or upset.

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Before next week… Start to follow lifestyle advice. Begin completing the anxiety monitoring diary. Start to look at

what triggers your anxiety and how these make you think and feel. Are there any patterns?

If you feel it would be helpful. Begin to fill in the eating and drinking diary.

Continue to practice relaxation techniques.

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Section 3

Avoidance and Exposure

When we are afraid of a situation or object we often try to avoid it. Avoiding situations that make us feel anxious can temporarily reduce the symptoms of anxiety. However, the more we avoid a situation, the more anxious we become about facing it in the future. So, although avoidance can seem to help anxiety, it actually makes it worse in the long run. An important part of overcoming anxiety is learning to approach, or expose ourselves to, the situations or people that make us anxious.

It can be helpful to develop a hierarchy of the situations, events or people that cause you to feel anxious. A hierarchy is a list written in order of the strength of your fear. It starts with the most feared situation or event and ends with the least feared. You can then work through the list starting with the least frightening situation and gradually working your way up towards an end goal.

For example:

Goal: To be able to go shopping in the supermarket alone.

HARDEST 5. Going to the supermarket, alone, when it is most busy.

4. Going to the supermarket, alone, when it is quiet.

3. Going to the local shop, alone, when it is busy.

2. Going to the local shop, alone, when it is quiet.

EASIEST 1. Going to the local shop, with someone, when it is quiet.

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Start with the easiest thing on your list (step 1) and aim to practice this for an hour every day. When you feel your anxiety has reduced, start on the next step on your list and keep going until you have confronted all the things on your list. Sometimes it can help to start by simply imagining yourself in the feared situation before really entering it. Asking a friend, who you trust, to help you confront the things on your list can also be helpful. Some days you may find it hard to keep practising the things on your list, but it is important to keep trying and to reward your successes. It can be helpful to keep a diary using the sheets provided at the end of this chapter.

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For example:

GoalTo drive alone on a motorway

Rate how anxious you felt before and after the task using the scale below: 0 2 6 8No anxiety A little anxiety Much anxiety Extreme anxiety

Steps completed Anxiety before Anxiety after

Mon: Drove for half an hour on country road with my wife.

Tues: Drove for 1 hour on country road with my wife.

Wed: Drove for 1 hour on country road with my wife.

Thurs: Drove for 1 hour on country road with my wife.

Fri: Drove for 1 hour on country road alone.

Sat: Drove for 1 hour on country road alone.

Sun: Drove for 1 hour on country road alone.

7

6

3

1

6

3

2

6

4

2

1

4

2

1

Before next week…

Continue to follow lifestyle advice and anxiety monitoring diaries.

Continue to practice relaxation techniques

Start with the easiest step on your hierarchy and begin to practice this

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Section 4

Negative Automatic Thoughts

When we feel anxious our thinking can become

irrational and unhelpful. These thoughts can be worrying and upsetting and are sometimes called “negative automatic thoughts”. Everybody has these unhelpful thoughts sometimes; however some people are able to challenge and replace them with more helpful, rational thoughts. An example of an unhelpful thought is, “I am going to make a fool of myself” or “I am having a heart attack”.

Identifying your worrying thoughts

It can be helpful to identify your anxious thoughts so that you can begin to challenge them and thus reduce you anxiety levels. Below, try to write down some of the worrying thoughts you have had.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

At first it may be difficult to recognise your worrying thoughts and you

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may not even be aware of them. This will become easier if you write down your thoughts every time you become anxious. When you start to recognise the types of thoughts you have when you are anxious you can begin to challenge them and find more helpful ways of thinking. You can begin to challenge your worrying thoughts by using the questions below.

Challenging your worrying thoughts

1. Choose a worrying thought that you often experience and write it below. ___________________________________________________________________________________________________________________________________________________________________________________________________________

2. What is the evidence for this thought?

____________________________________________________________________________________________________________________________________________________________________________________________________________

3. Is there another way of looking at the situation?

___________________________________________________ _________________________________________________________________________________________________________________________________________________________

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4. How would someone else think about the situation?

____________________________________________________________________________________________________________________________________________________________________________________________________________

5. Am I trying to read other people’s minds?

____________________________________________________________________________________________________________________________________________________________________________________________________________

6. Am I trying to predict the future?

____________________________________________________________________________________________________________________________________________________________________________________________________________

7. How will worrying change the situation?

____________________________________________________________________________________________________________________________________________________________________________________________________________

8. Is this thought helpful or self-destructive?

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____________________________________________________________________________________________________________________________________________________________________________________________________________

9. What is the worst that could happen? How likely is it to happen? How would I cope?

____________________________________________________________________________________________________________________________________________________________________________________________________________

By answering these questions for each of your worrying thoughts you may start to recognise ways in which your thinking is unhelpful. Use the sheets at the end of this chapter to apply these questions to each of your worrying thoughts when they happen.

There are a number of common thinking errors:

Catastrophising (looking at the worst thing that could happen). Over-generalising (thinking that one bad experience in a

situation means I will always have a bad experience in similar situations).

All-or–nothing thinking (for example, I’m either a total success or a total failure).

Magnification (blowing things up out of proportion). Selective attention (ignoring the positives and concentrating

on the negatives). Jumping to conclusions

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Think about whether any of these thinking errors apply to you. It may help to read the following example.

Situation: Person arriving at a partyWorrying thoughts: I’m dreading this. I was so anxious at the last party I went to I couldn’t talk to anyone. It’s bound to be like that again. No one will find me interesting.Thinking errors: Overgeneralising. Thinking that just because the person couldn’t talk to anyone at the last party, it would be the same at this one. Jumping to conclusions. Thinking that no one will find the person interesting without any evidence. Catastrophising and Selective Attention. Looking at the worst thing that could happen and ignoring possible positives.

Replacing worrying thoughts By recognising the thinking errors you make, and when you make them, you can begin to challenge and replace your worrying thoughts with more helpful ones. Here are some worrying thoughts with examples of how you could replace them with more positive ones.

I’m useless.Nobody’s perfect. Like everybody else I’m good at some things and not so good at other things.

I’m going to get anxious and I’ll look stupid in front of everyone.I probably feel more anxious than I look. Even if they can tell I’m anxious, they might understand how I’m feeling.

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I can’t cope.I can cope. It may be difficult but I’ll manage.

Practice replacing your worrying thoughts by completing thought diary at the end of this chapter. See example below.

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Worrying thoughts diaryDate and time

Situation Worrying Thought(s)

What exactly were your thoughts?

Rate belief in thoughts

(0-10)

More helpful response

Re-rate belief in worrying

thought(s) (0-10)

Shopping in the supermarket

I feel anxious. Everyone is looking at me

10 I probably feel more anxious than I look. People probably wont even notice.

6

Belief ScaleNot believable at all Definitely believable ________________________________________________ 0

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Frequently Encountered Problems

I find it difficult to recognise my worrying thoughtsWhen you start to feel tense, ask yourself “What’s going through my mind?” Try to write down any thoughts as soon after you have them as possible.

I can’t remember how to challenge my thoughts when I need to.Try writing the questions you use to challenge your worrying thoughts on a card that you can carry with you.

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It doesn’t seem to be workingLearning to challenge your worrying thoughts takes practice. Eventually replacing your worrying thoughts with more rational ones will become automatic. Some days it will be harder to challenge your thoughts than others but keep trying and don’t let it add to your worries.

Before next week… Continue to follow lifestyle advice and anxiety monitoring

diaries. Continue to practice relaxation techniques Begin to try and identify and challenge your worrying thoughts

using the diary sheets provided.

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Section 5

Life SkillsThis section will focus on assertiveness, time management and problem solving. All these skills combined may help to improve your confidence and manage your anxiety.

Assertiveness

The following categories summarise ways in which we relate to other people.

Passive – When we are behaving passively, we do not communicate our own needs. The other person’s needs come before our own and we can end up feeling like a victim.

AND/OR

Aggressive – When we are behaving aggressively we give the impression that our needs and views are more important than the other person’s. When behaving aggressively we do not consider other people’s points of view.

Assertive – When we are behaving assertively, we communicate our needs openly and directly and listen to other people’s points of view whilst maintaining respect for our own needs and other people’s.

To help you communicate assertively:

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1. Listen to what the other person is saying and show them that you have heard and understood even if you don’t agree with what they are saying.

2. Say what you think and explain how you’re feeling.3. Explain clearly what you would like to happen without

apologising or being aggressive.

We may behave unassertively because: We are worried the other person may get angry and we want to

avoid getting into an argument. The other person might think we are selfish and may not like us.

This may lead to: Feeling hurt, angry, frustrated and humiliated. Loss of self-confidence. Stress

By behaving assertively: We respect ourselves and other people. We are able to have more control over our decisions. We increase our self-confidence. Other people know what we think, need and feel.

It is important to remember: You have the right to say “no” to people without feeling guilty. Other people have the right to say “no” to you. Saying “yes” when you mean “no” can cause you to feel stressed

and resentful. Be firm but polite.

Exercise

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Write down a situation in which you would like to behave more assertively._______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What thoughts or feelings might stop you from behaving assertively?_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How might you overcome these thoughts or feelings to behave more assertively?_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Time Management

As mentioned earlier, rushing around can increase your feelings of anxiety. Therefore it is important to manage your time and prioritise your responsibilities. (See A, B, C

approach on page 29). Before you can begin to do this it may be

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helpful to think about how you currently use your time. This can be done by completing the weekly activity schedule sheets at the end of this chapter, which may highlight how much time you spend doing different activities. Tracking your activities can also help you see how they affect your mood. The following week try to plan each day, setting goals and prioritising jobs. Remember to plan time for pleasurable activities and relaxation as well.

Problem SolvingAlthough we often resolve problems automatically, sometimes they can overwhelm us. The following stages may help you to break the problem down.

1. Define the problem – What is the problem? Why is it a problem?

2. List possible solutions – What might be the pros and cons?What might you tell a friend if they were in your situation?

3. Decide on a solution and plan how you will put it in place– How and when will this be done?Who will be involved?What is my back up plan?

4. Put plan in to action

5. Think about whether the plan worked -If it did, congratulate yourself.If not, try to work out what went wrong and rememberthat the task may not have been 100% achievable.Expect some disappointments but praise yourself for

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trying.

Before next week…

Continue to follow lifestyle advice and practice relaxation techniques.

Continue to identify and challenge your worrying thoughts. Complete the weekly activity schedule provided.

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Section 6

Coping with setbacks

Everyone has good days and bad days and moderate anxiety is a normal part of everyday life. You may have setbacks but it is important not to see these as a failure. It can be helpful to think back over what you have learned from this pack, try to anticipate difficult or stressful situations that might set you back and think about how you might use what you have learned to cope with them.

1. What have I learned from this pack? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. What ideas and strategies have been useful to me? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. What can I do to build on what I’ve learned? (e.g. attend groups/courses, use skills in everyday life) ____________________________________________________________________________________________________________________________________________________________________________________

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______________________________________________________________________________________________________

4. What will make this difficult for me? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. What can I do to overcome these difficulties? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6. What might lead to a setback for me? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

7. If I had a setback what would I do to cope? ____________________________________________________________________________________________________________________________________________________________________________________

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______________________________________________________________________________________________________

8. What possible early signs of relapse do I need to watch out for? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

9. What do I need to do if I experience these? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

If a setback does occur:

Remember your coping strategies Don’t assume you will become as anxious as you were before

you began the pack. Try not to leave the situation before you have used skills to

reduce your anxiety. Try not to avoid situations that make you feel anxious. If this doesn’t work, try using a hierarchy of “graded exposure”

(see chapter 3).

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If your anxiety becomes constant or excessive again and you feel unable to cope you may be beginning to relapse. If you feel you might be starting to relapse, ask yourself the following questions:

What caused me to feel anxious? Am I getting enough exercise and rest? Am I eating properly? Am I practicing my relaxation and breathing techniques? Am I taking on too much at once?

People may be more likely to relapse and be more vulnerable to anxiety when they experience emotions such as low mood, sadness, anger and loneliness. These feelings can make us more likely to avoid difficult situations, leading to increased anxiety about these situations. Recognising and predicting these emotions can help to prevent your anxiety increasing again. You can also help to prevent relapse by entering situations that might make you feel anxious. Using your new coping skills in feared situations can increase your confidence in dealing with the situation, increase the chance that you will cope successfully, and lead to an increased quality of life.

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Further reading

Greenberger, D. & Padesky, C.A. (1995) Mind Over Mood. Guilford.

Kennerly, H. (1997) Overcoming Anxiety. Robinson.

Butler, G. (1999) Overcoming Social Anxiety and Shyness. Robinson.

Davis, Robbins, Eshelman & McKay (1995) The Relaxation and Stress Reduction Workbook. New Harbringer.

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