Don t Panic Alone Pick Up the Phone

Transcription

1 Don t Panic Alone Pick Up the Phone A workbook for people with low mood and anxiety linked to COPD Mike Scanlan Michelle Holmes Sue Wood

2 Welcome to the COPD Project Dr. Mike Scanlan, Sue Wood work in The Wellbeing Team, part of the NHS in Northamptonshire. We are working together with colleagues at GP surgeries, the community and the local hospital to develop a course aimed at helping you to manage your COPD and develop new strategies to help you to feel relaxed and enjoy life more. There are significant benefits in working as a group with other people who know what it is like to live with COPD and each person will have his or her own helpful strategies to share. It may be that you will be able to support each other emotiony during and after the course has finished. The booklet that accompanies the course is not written in such a way that we have to work closely to the content. The booklet accompanies our learning. In essence the course is split into two sections. Over the first few weeks we will focus on helping you to create the calm needed to work psychologicy. We will then shift the focus to help you develop a range of psychological strategies that can help you manage your condition with more confidence and compassion. Remember you are the expert in your personal experience of having a COPD, so we will be using your expertise too! We have received funding from the Department of Health to set up and run courses for people diagnosed with COPD and likely to feel anxious, panicky, and low. We look forward to getting to know you and learn from you and the other participants during this course! 2

3 Introduction who we are Mike Scanlan, PhD is a Nurse Consultant in Changing Minds with a broad background in mental health and combines clinical work with training, research and developing innovative projects. Mike played a key role in developing new services for people with common mental health difficulties and developed a number of training packages for healthcare staff. Mike delivers a wide range of therapies including Mindfulness, EMDR, Compassion Focussed Therapy, and sleep groups. Sue Wood works in The Wellbeing Team as a Psychological Wellbeing Practitioner (PWP) and with people who experience common mental distress such as depression, low mood, anxiety, and panic. Sue qualified as a General Nurse in 1987 and has experience of working with carers. Sue is passionate about working with people who have a long-term health condition, such as those who have had a stroke, COPD and diabetes, and also feel anxious, low, or panicky. She has recently helped to deliver a module to qualified staff about working with people who have a long-term condition and common mental distress at the University of Nottingham. Contact details Mike Scanlan Clinical Lead mike.scanlan@nhft.nhs.uk Sue Wood sue.wood@nhft.nhs.uk Project Lead / Your Group The group will run every Thursday starting at and lasting about 40 minutes In between the group sessions we will phone you to answer questions or discuss things you don t want to talk to the whole group about You will see this picture symbol when there is an activity for you to do, we will discuss the activity in the group session before you need to start it 3

4 Confidentiality We suggest that you consider whether you want someone with you during the phone sessions or would rather do them in private We will not pass on any information about you to anyone else except with your consent as discussed during your assessment If you wish to make contact with any other participants between group sessions or once the course has finished please contact us and will ask the other participant if we can share their phone number. What we need you to do We encourage you to actively participate in the group sessions; the others will want to learn from you too! Commit to joining every session, this may mean you will need to change appointments or other commitments that occur at the same time Practice your homework regularly between sessions Complete a set of questionnaires weekly before each group session Group programme Over the course of the next few weeks, we will be talking about the following: The Benefits of Breathing Exercises and Relaxation Understanding How Living with Breathlessness can Affect Every Part of Your (and Your Partners) Life Learning to be More Realistic and Become More Compassionate with Yourself How Doing More Can Help You Feel Better and Less Tired! Managing Your Worries and Stopping them making you feel worse 4

5 Questionnaires For us to be able to show the benefits of the group on your health and wellbeing we ask you to complete some questionnaires; they will be familiar to you as they are the same ones you completed during your assessment session. The questionnaires are at the end of this booklet. We will also ask you to complete a feedback questionnaire at the end of the course to tell us what you have found helpful and what we can do to improve the group. The questionnaires will provide some (anonymous) information to the NHS and Department of Health including the outcome of this treatment. If you have any questions or if you are unsure about completing them, please contact Sue, you don t need to wait for the next group session. What Next? You will have a visit from one of our practitioners once the group sessions have finished. You will complete the set of questionnaires again and have the opportunity to share your workbook if you wish, discuss your experience of the course; how you are feeling and options for additional psychological support should that be appropriate. We will be developing some Master Classes that you can join in with these will be about topics such as improving your sleep; Tai-Chi; adapting to living with long-term conditions and mindfulness. Once dates are confirmed you will be invited to join, they will also be delivered as a phone conference or with audio-visual equipment when we have the equipment to do so. You will continue to receive your usual treatment that may be from a nurse, Rocket Team or GP We will contact you in six months to offer review appointments to see how you have used the strategies you have learnt and how you are feeling. We encourage group participants to maintain contact with other group members to continue the friendships and support you have developed. Home Practice Each week we will talk about the practice that will be helpful for you to do, this will include: Practicing the breathing and relaxation exercises Completing the relaxation diary Practicing mindfulness exercises Listening to the CD 5

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7 Part 1 Helping you to create the calm needed to work psychologicy The Benefits of Breathing Exercises and Relaxation We know it is important to relax but it is hard to imagine how you can feel relaxed when you find it difficult to switch off and can t catch your breath. We tend to be not very good at taking time out for ourselves, but usuy feel better when we do. When you have a health condition like COPD, it is also common to feel anxious. Feeling anxious or panicky can affect how you breathe fast, slow or show and changes in your breathing can make you feel more anxious or panicky. Using breathing and relaxation exercises can help you to relax. Many people who have COPD report experiencing a fight or flight reflex that will not shut off even when there is no present danger. The autonomic nervous system, the part of you that is responsible for the automatic control of organs and systems of the body, is comprised of two main pathways: the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS). The SNS s role is to stimulate the body s functioning which causes an increase in both the heart rate and stroke volume of the heart as well as a constriction of the blood vessels. This is what happens when the amygdale, the brains fear centre fires-up the fight or flight response. We are then ready to battle or run for our lives. You might think of this reflex as functioning like a cars accelerator pedal. In contrast, the PNS serves to calm the system. When danger has passed, the PNS decreases the heart rate and stroke volume and dilates the blood vessels. This is more like a car s brake system. Unfortunately, the PNS may not always work well for people with COPD particularly at times of breathlessness and the SNS may be working overtime. This creates an unhealthy imbalance. Research is showing that this nervous system imbalance can be associated with emotional stress as well as a worsening of most forms of COPD. Over the next few pages, you will find a number of breathing and relaxation exercises for you to try which will help you spend more time in PNS activity. Relaxation is a bit like exercise and you may need to try a few different ways before you find what helps you most, and remember the benefits will increase with practice! You can combine two or more relaxing exercises. 7

8 Breathing Exercises When practising your breathing exercises, try to keep your upper body neck, shoulders and upper chest relaxed, with your hands resting on your lap or the arms of a chair. Breathing Exercise 1 - Pursed Lip Breathing Q. Have you noticed how athletes breathe when short of breath? A. They blow air out of their mouth by puffing out their cheeks. This is a normal, quick and easy response to breathlessness and a way of improving your breathing patterns. How does it help? Pursed lip breathing helps you to empty your lungs of old air and make room for the new air It can help you to control your breathing by slowing down your breathing rate and keeping your airways open longer Your breathing will then take up less effort You will begin to feel more relaxed Pursed Lip Breathing 1. Sit up straight and relaxed in a chair 2. Breathe slowly in through your nose, try and keep your mouth closed 3. Purse your lips as if you are going to whistle, and breathe out slowly make your out-breath twice as long as your in-breath It may help to count one, two as you breathe in and one, two, three, four as you breathe out 4. Avoid forcing your breath out or holding your breath 5. Practice 4-5 times each day 6. You can practice this breathing technique when you are short-of-breath, either at rest or with exertion, or if you feel nervous or apprehensive Key Point: if you begin to feel lightheaded while using this breathing technique, slow your breathing 8

9 Breathing Exercise 2 Diaphragmatic Breathing Your diaphragm is a big muscle under your lungs that ows air to flow into your lungs when it moves. People with COPD tend to breathe without using their diaphragm effectively and tend to use the muscles in their upper chest and shoulders instead. Your breath is shower if you use the chest and shoulder muscles and there is a tendency to breathe more quickly and feel more breathless. How does diaphragmatic breathing help? It strengthens your diaphragm It co-ordinates the movement of your diaphragm when you breathe Your breathing will become less of an effort You will need less energy for breathing Diaphragmatic Breathing Exercise 1. Lie on your back on your bed with your knees bent, you may want a pillow under your knees for comfort 2. Place one hand on your tummy (abdomen) 3. Place the other hand on your upper chest this hand should be kept as still as possible throughout the exercise 4. Breathe in through your nose making your tummy move out, keeping your upper chest as still as possible 5. As you breathe out through pursed lips as if you are going to whistle let your tummy f inwards Practice this exercise for 5-10 minutes, 3-4 times each day. Graduy increase the time you spend exercising and increase effort by placing a book on your chest. You can continue to develop this exercise by practising while sitting or standing. Key Point: expect to feel tired when practicing this exercise, as you will need to use more effort. Keep practising and you will be rewarded when your breathing becomes easier, and requires less effort. 9

10 Relaxation Exercises Relaxation Exercise 1 The Body Scan The body scan is a mindfulness meditation that helps you to become familiar with your body and more able to work with body sensations, discomfort, pain and stress. It can help to improve concentration and relaxation. As you are doing the body scan, simply notice and accept whatever is happening in your body at that moment sensations, mood or thoughts. If you become distracted, just carry on where you left off. You can practice the body scan before stretching or tensing techniques, or use it on its own as a method of relaxation. Body Scan Exercise Sit or lie in a comfortable position, away from distractions or disturbance. Close your eyes, becoming aware of your body Take a few long deep slow breaths Starting at your toes and working to the top of your head, scan your body noticing any uncomfortable areas Notice how your toes feel, are they hot or cold? Comfortable or uncomfortable? Stay with these feelings for a few seconds Allow your attention to move through the bottom of your feet to your heels, notice and explore how each area of your body feels as you bring your attention to it Take your time working your way through your whole body, moving through your legs, tummy, back, chest, arms and each part of your face. Finish at the top of your head. Well done! You ve completed your first bodyscan 10

11 Relaxation Exercise 2 Progressive Muscular Relaxation Progressive Muscular Relaxation (PMR) can help you to become aware of tension in your body and to relax your mind and body. We are often not aware that our muscles are tense, this exercise can help you to recognise how your muscles feel when they are tense and also when they are relaxed. You might find it useful to use the body scan before this exercise Find a comfortable position, either sitting or lying where you will not be disturbed, and close your eyes Take several deep slow breaths and let go of your inhibitions Focus your mind on each of the following body parts in turn, concentrate on tensing them as hard as you can, hold for a few seconds then release. Pause for a few seconds before moving on to the next part The tighter you tense, without causing pain, will give you the most benefit from this relaxation exercise > Feet > Ankles > Lower legs > Knees > Upper legs > Bottom > Lower back > Lower abdomen > Sides of torso > Tummy and back > Chest > Shoulders > Upper arms > Lower arms > Wrists and hands > Neck > Head and face When you have completed this technique, spend a few moments enjoy the feeling of relaxation that you have achieved before bringing yourself slowly back round. 11

12 Relaxation Exercise 3 Stretching Stretching exercises help to keep your muscles toned and supple and can help to prevent aches and reduce tension. Key point: Don t continue with these exercises if you experience pain or the stretching becomes too uncomfortable. Stretching Exercise While these exercises do not need any specific instructions as any muscle can be stretched to relieve tension, you may find it useful for a full body stretch to start by stretching your back. Lie in a comfortable position, you can use pillows to support your head and knees Stretch your back as far as you can without discomfort Keeping your back stretched, begin to stretch other parts of your body stretch your legs, feet and toes; then your arms hand and fingers; followed by your neck head and face until your body is at full stretch Hold for a count of 5 And relax! Repeat as necessary Keeping a Record of your Relaxation and gaining benefits from breathing and relaxation exercises You may not notice the benefits of these exercises immediately as relaxation does not always come natury to us, try the different exercises and keep practising It is recommended that you aim to practice at least four times a week for a minimum of 30 minutes Use the Relaxation Diary on the next page to record your level of relaxation before and after each exercise Look back at your diaries to monitor your progress If you do not find a method of relaxation that is helpful after 2-3 weeks, speak to your guide about an alternative therapy 12

13 Relaxation Diary Using the following scale to measure how relaxed you feel before you started the breathing and relaxation exercises and again at the end not at slightly moderately very completely Day Breathing / relaxation exercise Level of relaxation before exercise Level of relaxation after exercise Example Monday Listening to the CD and having a go at relaxation therapy 2 5 Tuesday Wednesday Thursday Friday Saturday Sunday 13

14 Breathing Mindfully Many people with COPD tend to find they mither about the past and worry about what the future will bring. Very often, you may find you ask questions that have no answers such as what will happen if I have another bout of extreme breathfulness. This style of thinking only results in frustration and low mood. In today's session, we have looked at the importance of living in the present. A very simple way to begin the process of living in the now is to learn a skill that we c mindful breathing. How mindfulness can help you The aim of learning to breathe mindfully is to help the person develop calm nonjudgemental awareness, which ows thoughts and feelings to come and to go without being caught in them. Becoming more mindful is a great way of finding a sense of inner peace. It takes time and effort to develop the skills of mindfulness. Look forward to doing the breathing exercise, it should never feel like a chore. For many people who have experienced long-term physical health problems, becoming more mindful has made a positive change in their life. The link below is for a video on your computer, it is Jon Kabat-Zinn talking about mindfulness. Jon is known across the world for his work as a scientist, writer and teaching mindfulness in medical profession and society. This is a long video and you may need to watch it over two or three stages. Do make time to watch it because it will inspire you to become more at peace through being more mindful. 14

15 Coping better when living with COPD affects the way you see yourself Nobody likes feeling scared and many people feel scared when they think about times when they have panicked due to feeling helpless. When you think back to times when problems associated with your COPD have led to a hospital admission or you have experienced panic, or feelings of helplessness. Does remembering leave you feeling scared or troubled? If it does, share your concerns as you are not alone with these thoughts. The role of fear Many people who have had horrid will say it is scary that you are unable to manage things that were not previously a problem. Unfortunately, the brains response to fear is to prepare the body to behave vigorously. However, this is unhelpful if you have had problems with breathlessness. If we spend a few minutes thinking about people who regularly work in fearful situations, fire fighters, pilots, or surgeons, we can perhaps see that they have one thing in common, despite the presence of fear, they have to maintain calm to deal with situations safely. 15

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17 Part Two Psychological strategies that can help you manage your condition with more confidence and compassion Developing a Shared Understanding about Living with Breathlessness When we are experiencing distress we tend to experience three stages How we feel in our bodies Our thoughts What we do These stages were first recognised by a psychologist ced Lang in the 1960 s. Stage 1 Physical Feelings - this is when we notice a physical response in our body to the stressful situation or worrying thoughts. The physical responses are often a pounding or racing heart, sweating and changes to their normal breathing pattern. Stage 2 Unhelpful Thoughts these are the thoughts that follow the physical responses. Examples of unhelpful thoughts can be, catastrophic - I m going to die or self-critical I am not worth bothering with because I can t Stage 3 Unhelpful Behaviours these are they ways we respond to the unhelpful thoughts and physical feelings. Examples of unhelpful behaviours include avoiding physical exertion, not taking medication or getting drunk. An example of this in a person with COPD Your heart starts pounding; you become hot and sweaty and start to breathe more quickly (stage 1 physical feelings). You start to believe you are going to collapse or die because you can t breathe (stage 2 unhelpful thoughts). You cut down the amount of exercise you do and avoid going out of the house on your own (stage 3 unhelpful behaviour/avoidance). Activity We are going to work together to develop your individual shared understanding. This will help us to look at how your physical illness and reactions, thoughts and behaviours affect each other. We can use this information to work together to plan how we can improve your physical and psychological health, see the example below. Read about John s experience on the next page 17

18 John s Story John is 59 years old and becomes distressed because of his breathlessness. He is ashamed that he is unable to go out and enjoy a meal because he fears that people will be critical about his coughing and heavy breathing. An hour or so before he is due to go out for dinner; he starts to feel hot and sweaty. He is worried about what other people will think of him if they see and hear him coughing and spluttering. John then notices that his heart is pounding and he starts to feel dizzy. He tries to ignore these feelings but the physical feelings just keep getting worse. John s thoughts change he starts to think that he is having a heart attack so he rings his friends to tell them he is not coming. A few minutes later, having avoided going out, he notices that the sweating has stopped and his heart is back to normal. His thoughts change again. He now feels very down, annoyed with himself and cs himself a wimp. The physical feelings change again now he feels flat and tired. How often have your fears about letting yourself down because of your COPD led to you avoiding taking part in activities that you used to enjoy? It may feel as if, like John, you are living within a vicious circle. Do you sometimes find that the strength of your physical response to stress feels awful? Are these feelings are worse because of worrying and (probably) critical thoughts? As a result, do you find you are avoiding doing things that give you pleasure? You can see this illustrated on the diagram below Vicious Circle Feeling Stuck 18

19 Exercise Understanding your Reactions and How you can Change Can you think of a time when you avoided doing things because you were feeling anxious or worried? Write down what happened to you. Situation e.g. where you were, who you were with Your physical response to the fear e.g. heart racing, sweating, nausea Your self-critical thoughts at the time e.g. I am going to show myself up by fainting What you avoided e.g. going out with friends, leaving the house 19

20 Exercise Understanding your Reactions and How you can Change Now spend some time thinking about what you could change to help you in this situation. Could you keep calm? Could you be less critical? Could you try out some different ways of reacting to the thoughts and physical feelings? Write down some of your thoughts below 20

21 Becoming more compassionate with yourself Very often many people with long term physical conditions become very critical and over hard with themselves. This section of the workbook helps you to get more in touch with what we c your Compassionate Friend. Step One Spend some time doing a breathing exercise and perhaps the body scan this is in order to feel calm. Step Two Now look at the list of the qualities that a compassionate friend would need to have in order to help you through difficult times Read them out to yourself and as you do this see whether any faces or images of people you have watched on TV, seen in Films, read about or even just know of pop into your consciousness. Kind Firm Compassionate Wise Understanding Generous Humorous Non judgemental Patient Reliable Use the space below to draw a picture, write the name of or stick a photograph of your compassionate friend Step Three Now close your eyes and try and build your image of your compassionate friend. It may help to use of your senses. 21

22 Think about how they look, what they are wearing, what their voice sounds like and even how they smell. Step Four Are you comfortable with who you have chosen? If so try checking with them about some of your worrying or self critical thoughts. Are the answers you get wise? Compassionate Non blaming Kind Firm Understanding of you? If so this is probably someone that you can access and use to help you make the right judgements and the best decisions for you. Well done you have a compassionate friend! How do I use my compassionate friend? There will be times when you feel uncertain about the way you are thinking about things, about the decisions you need to make. At other times you will find yourself being over hard on yourself or others. At these times you may find it useful to close your eyes and use your visualisation skills to bring up your compassionate friend and spend some time with them. Ask them questions or simply spend time with someone who truly has your interests at heart. 22

23 How Doing More Can Help you to Feel Better and Less Tired! When we are unwell, we tend to rest and genery do less, as you are living with physical symptoms every day it may seem beneficial to avoid or do less physical activity to avoid more severe or new symptoms such as breathlessness, pain, and tiredness. However, doing less can make you feel worse Patient Story Jane Jane is 69 years old and used to work as a librarian. She woke up one morning feeling breathless, was admitted into hospital and diagnosed with COPD. Jane was treated and discharged. Two days later Jane attempted to go out for a gentle walk, but quickly became breathless, feeling as if she could not breathe. This panicked Jane and in response, she stopped many activities she used to enjoy including dog walking, dancing, and yoga. Three months later, Jane didn t feel any better, she had put on weight and was unhappy with how she looked and was becoming breathless quickly. She was unable to do the activities she had previously enjoyed as she was embarrassed by how she looked and was worried that the breathlessness may be due to a problem with her heart. An ECG did not show anything abnormal, but this still did not reassure Jane enough to take her dog out for even just a short walk. Jane s family noticed she was slowed down and becoming upset easily. Jane made an appointment to see her GP who told her she was depressed. Jane understood that depression can be helped by increasing helpful activities. She reviewed her life and decided she would start taking the dog out for a short walk so she didn t become too breathless. Having succeeded with the walking, Jane became more active by reengaging in other activities as well. At first, Jane felt tired and her muscles ached but by graduy increasing how far she walked and the number of activities she did in a day, Jane realised that by doing more her mood lifted, she started to feel better and the breathlessness improved. As you have seen in Jane s example, doing less can lead to becoming breathless more quickly even in activities she was previously able to do. However she also discovered that some activities and behaviours can help to improve physical symptoms, well being and overcome depression. Key Point: whenever anyone (with or without a physical condition) does an activity that they are not used to or haven t done for a while, e.g. running up the stairs instead of taking the lift, they will become breathless. 23

24 Increasing helpful activities Behavioural Activation Increasing helpful activities can help to improve physical symptoms and overcome depression. To gain benefits from increasing activity levels we are going to work together to plan how you can graduy change your day-to-day activity levels; this is ced Behavioural Activation (BA). When using BA to increase helpful activities it is important to start graduy and aim for a balance of activities that give you a sense of achievement, pleasure and are necessary. Planning your activities There are examples below, the sheets for you to complete are at the end of this section. 1. On BA Worksheet 1 write down three activities you used to do in each category but no longer do or do not do as often now, see the example below Behavioural Activation Worksheet 1 Activities that give you a sense of achievement Get dressed every day Make lunch for me and my husband Tidy the bookshelf Activities that give you a sense of pleasure Walk the dog Coffee with my friend Sudoku puzzles Necessary activities Make an appointment at the doctors to review my tablets Phone my cousin Look at better deals for electricity 24

25 2. On BA Worksheet 2 one section at a time, choose an activity and decide how easy or difficult it would be for you to start doing that activity again. For example, in the section activities that give you a sense of achievement tidy the bookshelf is the hardest for you to start again; walk the dog is medium difficulty and make lunch for me and my husband the easiest. Now do the same for the other two sections. Behavioural Activation Worksheet 2 Hardest Tidy the bookshelf Coffee with my friend Look at better deals for electricity Medium Difficulty Walk the dog Get dressed every day Phone my cousin Easiest Make an appointment at the doctors to review my tablets Make lunch for me and my husband Sudoku puzzles 3. Using your BA Diary Sheet, plan the day and time that you want to do the activities from your easiest box and write them on your diary. Begin by planning activities for 2 or 3 days each week. 25

26 Mon Tues Wed Thur Fri Sat Sun Morning Afternoon Evening Phone to make GP appointment Sudoku puzzles Make lunch for me and my husband BA Diary Sheet Example Start slowly, plan to do something for 1-2 hours a day at first and then graduy increase your activities over a number of weeks Avoid planning too much at first so you don t feel overwhelmed, get overtired or disappointed if you are unable to complete of the activities Keep your diaries in an easily reached place so that you can monitor your progress If you find it too tiring or you are feeling particularly unwell, try to do something else or ocate the activity you are unable to do to another day or time Treat each activity as if it was an appointment, you do it unless something significant happens to prevent you 26

27 Behavioural Activation Worksheets Behavioural Activation Worksheet 1 Activities that give you a sense of achievement Activities that give you a sense of pleasure Necessary activities 27

28 Behavioural Activation Worksheet 2 Most Difficult Medium Difficulty Easiest 28

29 Monday Tuesday Wednesday Thursday Friday Saturday Sunday Morning Afternoon Evening

30 Exercise We know that if we did not keep our car topped up with fuel, serviced and cared for it would not work well, yet we expect our bodies to work properly without paying attention to things, like exercise, that give us the best chance of staying well. We know that exercise helps us to keep well physicy, psychologicy and improve our well-being (Department of Health, 2009). Information and booklets have been produced by The British Lung Foundation ( and The Mental Health Foundation ( to highlight the benefits of exercise in helping people with a long-term health condition and may also feel low or depressed, to feel better and stay well. Some of the benefits of exercise include reduced breathlessness, improved energy levels, and fewer days spent in hospital. Exercise also releases feel-good chemicals into your brain ced endorphins and provide a distraction from depressing or worrying thoughts. It can help you to feel more confident and if done with others, gain pleasure from social contact. Exercise can be off-putting if it makes you think you have to join a gym or run around the block, but can be anything from a short walk to gardening, dancing or standing with support for a while. Here are some useful tips to help you exercise to stay well Chose something you used to enjoy before your COPD, you are more likely to continue Tai-Chi, Yoga and Pilates are particularly helpful Find out about exercise classes in your area from your local library, notice boards in shops or GP surgery Work towards going some gentle exercise for about minutes, three to five times a week, make it part of your weekly routine, you may find it helpful to plan it in your BA Diary Make it gentle! The pace that is right for you will leave you slightly out of breath. Consider the time of day you exercise too late in the evening can affect your sleep as you will be more energised, however exercising in the morning can help to improve your sleep Exercise is good for you and forms part of a healthy lifestyle. Exercise doesn t have to be expensive; it may be a cliché, but a brisk walk rey won t cost you anything

31 Think about What s in you can do at home or in your local area Country Park Sports Centre Golf Course Swimming Chair-aerobics Aqua-aerobics Walking group Walk down your garden Gardening Dancing Walking up stairs Bowling Golf Tai-Chi Yoga Pilates 31

32 In Control of your Worries - Looking for Rational Answers Please remember before trying to think rationy you do need to stop and create enough calm to be able to work well. When you recognise that you are calm and collected enough to work have a go at the exercise below. Activity We often worry or imagine negative things about ourselves or our situation, by working through the following questions you can learn to look at these worries or thoughts in a more realistic way. 1. What worrying thought or picture that you get? Write it down as clearly as you can. How strongly do you believe it? Rate your belief on the scale below by circling the number that fits how much you believe the worrying thought or picture, where 0 is I don t believe it and 10 is I completely believe it You will rate this thought again at the end of this exercise. 2. Is there any evidence or real proof to support the fact that this worrying thought or picture might be true? What would your compassionate Friend tell you? 3. Is there a reason or any proof that this thought may not be 100% true? Again check this out with your Compassionate Friend 32

33 4. If your friend was in the same situation as you and had the same thoughts what would you say to them? 5. Does thinking in this way help you? Can you change how you look at the worries or images and be able to see them in a more positive and accurate way? How is Thinking in this way Unhelpful? 1. Am I thinking in or nothing terms? Am I focusing on my weaknesses and forgetting my strengths? Am I expecting myself to be perfect?

34 5. Am I only focusing on the negatives? Am I over estimating the chances of disaster? Am I predicting the future instead of experimenting with it? What do I need to do to move forward and chenge this thought or change this situation? How strongly do you believe the thought now? What is a more rational way of thinking about the situation or fear now?

35 Week 1 Complete before the next group session 1. Patient Health Questionnaire (PHQ) Over the past week how often have you been bothered by any of the following? Write the first answer that comes to mind without thinking about it too much. PHQ-9 Several days More than half the days 1 Little interest or pleasure in doing things 2 Feeling down, depressed or hopeless 3 Trouble fing asleep or staying asleep or sleeping too much Nearly every day 4 Feeling tired or having little energy 5 Poor appetite or overeating Feeling bad about yourself, or that you are a failure or have let yourself or your family down Trouble concentrating on things, such as reading the newspaper or watching television Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you have been moving around a lot more than usual Thoughts that you would be better off dead or of hurting yourself in some way Total score 2. Generalised Anxiety Disorder Assessment (GAD) Over the past week how often have you been bothered by any of the following? Write the first answer that comes to mind without thinking about it too much. GAD-7 Several days More than half the days 1 Feeling nervous, anxious or on edge 2 Not being able to stop or control worrying 3 Worrying too much about different things 4 Trouble relaxing 5 Being so restless that it is hard to sit still 6 Becoming easily annoyed or irritable 7 Feeling afraid as if something awful might happen Total score Nearly every day 3. Clinical Global Impression Scale Over, how much do you feel you health has changed since the start of your therapy? Very much better (1) Much better (2) A little better (3) No change (4) A little worse (5) Much worse (6) Very much worse (7) 35

36 4. Avoidance scales Read each question then choose a number from the scale below that shows how much you are avoiding each of the situations or objects. Write the number in the box at the end of the question would not avoid it slightly definitely markedly always Social situations due to a fear of being embarrassed or making a fool of myself Certain situations because of a fear of having a panic attack or other distressing symptoms such as loss of bladder control, vomiting or dizziness Certain situations because of a fear of particular objects or activities such as animals, heights, seeing blood, being in confined spaces, driving or flying 5. Work and Social Adjustment Scale (W&SAS) Read each question and circle the number that describes how much your problem impairs your ability to carry out the activity. If you are retired, on maternity leave or choose not to have a job for reasons unrelated to your problem, please tick here You do not need to answer question 1. Work Your ability to function in your current work role Markedly 7 8 Very severely I cannot work Home management cleaning, tidying, shopping, cooking, looking after home/children, paying bills etc Markedly Very severely Social leisure activities with other people, e.g. parties, pubs, outings, entertaining etc Markedly 7 8 Very severely Private leisure activities done alone, e.g. reading, gardening, sewing, hobbies, walking etc Markedly 7 8 Very severely Family and relationships form and maintain close relationships with others including the people I live with Markedly Very severely 36

37 Week 2 Complete before the next group session 1. Patient Health Questionnaire (PHQ) Over the past week how often have you been bothered by any of the following? Write the first answer that comes to mind without thinking about it too much. PHQ-9 Several days More than half the days 1 Little interest or pleasure in doing things 2 Feeling down, depressed or hopeless 3 Trouble fing asleep or staying asleep or sleeping too much Nearly every day 4 Feeling tired or having little energy 5 Poor appetite or overeating Feeling bad about yourself, or that you are a failure or have let yourself or your family down Trouble concentrating on things, such as reading the newspaper or watching television Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you have been moving around a lot more than usual Thoughts that you would be better off dead or of hurting yourself in some way Total score 2. Generalised Anxiety Disorder Assessment (GAD) Over the past week how often have you been bothered by any of the following? Write the first answer that comes to mind without thinking about it too much. GAD-7 Several days More than half the days 1 Feeling nervous, anxious or on edge 2 Not being able to stop or control worrying 3 Worrying too much about different things 4 Trouble relaxing 5 Being so restless that it is hard to sit still 6 Becoming easily annoyed or irritable 7 Feeling afraid as if something awful might happen Total score Nearly every day 3. Clinical Global Impression Scale Over, how much do you feel you health has changed since the start of your therapy? Very much better (1) Much better (2) A little better (3) No change (4) A little worse (5) Much worse (6) Very much worse (7) 37

38 4. Avoidance scales Read each question then choose a number from the scale below that shows how much you are avoiding each of the situations or objects. Write the number in the box at the end of the question would not avoid it slightly definitely markedly always Social situations due to a fear of being embarrassed or making a fool of myself Certain situations because of a fear of having a panic attack or other distressing symptoms such as loss of bladder control, vomiting or dizziness Certain situations because of a fear of particular objects or activities such as animals, heights, seeing blood, being in confined spaces, driving or flying 5. Work and Social Adjustment Scale (W&SAS) Read each question and circle the number that describes how much your problem impairs your ability to carry out the activity. If you are retired, on maternity leave or choose not to have a job for reasons unrelated to your problem, please tick here You do not need to answer question 1. Work Your ability to function in your current work role Markedly 7 8 Very severely I cannot work Home management cleaning, tidying, shopping, cooking, looking after home/children, paying bills etc Markedly Very severely Social leisure activities with other people, e.g. parties, pubs, outings, entertaining etc Markedly 7 8 Very severely Private leisure activities done alone, e.g. reading, gardening, sewing, hobbies, walking etc Markedly 7 8 Very severely Family and relationships form and maintain close relationships with others including the people I live with Markedly Very severely 38

39 Week 3 Complete before the next group session 1. Patient Health Questionnaire (PHQ) Over the past week how often have you been bothered by any of the following? Write the first answer that comes to mind without thinking about it too much. PHQ-9 Several days More than half the days 1 Little interest or pleasure in doing things 2 Feeling down, depressed or hopeless 3 Trouble fing asleep or staying asleep or sleeping too much Nearly every day 4 Feeling tired or having little energy 5 Poor appetite or overeating Feeling bad about yourself, or that you are a failure or have let yourself or your family down Trouble concentrating on things, such as reading the newspaper or watching television Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you have been moving around a lot more than usual Thoughts that you would be better off dead or of hurting yourself in some way Total score 2. Generalised Anxiety Disorder Assessment (GAD) Over the past week how often have you been bothered by any of the following? Write the first answer that comes to mind without thinking about it too much. GAD-7 Several days More than half the days 1 Feeling nervous, anxious or on edge 2 Not being able to stop or control worrying 3 Worrying too much about different things 4 Trouble relaxing 5 Being so restless that it is hard to sit still 6 Becoming easily annoyed or irritable 7 Feeling afraid as if something awful might happen Total score Nearly every day 3. Clinical Global Impression Scale Over, how much do you feel you health has changed since the start of your therapy? Very much better (1) Much better (2) A little better (3) No change (4) A little worse (5) Much worse (6) Very much worse (7) 39

40 4. Avoidance scales Read each question then choose a number from the scale below that shows how much you are avoiding each of the situations or objects. Write the number in the box at the end of the question would not avoid it slightly definitely markedly always Social situations due to a fear of being embarrassed or making a fool of myself Certain situations because of a fear of having a panic attack or other distressing symptoms such as loss of bladder control, vomiting or dizziness Certain situations because of a fear of particular objects or activities such as animals, heights, seeing blood, being in confined spaces, driving or flying 5. Work and Social Adjustment Scale (W&SAS) Read each question and circle the number that describes how much your problem impairs your ability to carry out the activity. If you are retired, on maternity leave or choose not to have a job for reasons unrelated to your problem, please tick here You do not need to answer question 1. Work Your ability to function in your current work role Markedly 7 8 Very severely I cannot work Home management cleaning, tidying, shopping, cooking, looking after home/children, paying bills etc Markedly Very severely Social leisure activities with other people, e.g. parties, pubs, outings, entertaining etc Markedly 7 8 Very severely Private leisure activities done alone, e.g. reading, gardening, sewing, hobbies, walking etc Markedly 7 8 Very severely Family and relationships form and maintain close relationships with others including the people I live with Markedly Very severely 40

41 Week 4 Complete before the next group session 1. Patient Health Questionnaire (PHQ) Over the past week how often have you been bothered by any of the following? Write the first answer that comes to mind without thinking about it too much. PHQ-9 Several days More than half the days 1 Little interest or pleasure in doing things 2 Feeling down, depressed or hopeless 3 Trouble fing asleep or staying asleep or sleeping too much Nearly every day 4 Feeling tired or having little energy 5 Poor appetite or overeating Feeling bad about yourself, or that you are a failure or have let yourself or your family down Trouble concentrating on things, such as reading the newspaper or watching television Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you have been moving around a lot more than usual Thoughts that you would be better off dead or of hurting yourself in some way Total score 2. Generalised Anxiety Disorder Assessment (GAD) Over the past week how often have you been bothered by any of the following? Write the first answer that comes to mind without thinking about it too much. GAD-7 Several days More than half the days 1 Feeling nervous, anxious or on edge 2 Not being able to stop or control worrying 3 Worrying too much about different things 4 Trouble relaxing 5 Being so restless that it is hard to sit still 6 Becoming easily annoyed or irritable 7 Feeling afraid as if something awful might happen Total score Nearly every day 3. Clinical Global Impression Scale Over, how much do you feel you health has changed since the start of your therapy? Very much better (1) Much better (2) A little better (3) No change (4) A little worse (5) Much worse (6) Very much worse (7) 41

42 4. Avoidance scales Read each question then choose a number from the scale below that shows how much you are avoiding each of the situations or objects. Write the number in the box at the end of the question would not avoid it slightly definitely markedly always Social situations due to a fear of being embarrassed or making a fool of myself Certain situations because of a fear of having a panic attack or other distressing symptoms such as loss of bladder control, vomiting or dizziness Certain situations because of a fear of particular objects or activities such as animals, heights, seeing blood, being in confined spaces, driving or flying 5. Work and Social Adjustment Scale (W&SAS) Read each question and circle the number that describes how much your problem impairs your ability to carry out the activity. If you are retired, on maternity leave or choose not to have a job for reasons unrelated to your problem, please tick here You do not need to answer question 1. Work Your ability to function in your current work role Markedly 7 8 Very severely I cannot work Home management cleaning, tidying, shopping, cooking, looking after home/children, paying bills etc Markedly Very severely Social leisure activities with other people, e.g. parties, pubs, outings, entertaining etc Markedly 7 8 Very severely Private leisure activities done alone, e.g. reading, gardening, sewing, hobbies, walking etc Markedly 7 8 Very severely Family and relationships form and maintain close relationships with others including the people I live with Markedly Very severely 42

43 Week 5 Complete before the next group session 1. Patient Health Questionnaire (PHQ) Over the past week how often have you been bothered by any of the following? Write the first answer that comes to mind without thinking about it too much. PHQ-9 Several days More than half the days 1 Little interest or pleasure in doing things 2 Feeling down, depressed or hopeless 3 Trouble fing asleep or staying asleep or sleeping too much Nearly every day 4 Feeling tired or having little energy 5 Poor appetite or overeating Feeling bad about yourself, or that you are a failure or have let yourself or your family down Trouble concentrating on things, such as reading the newspaper or watching television Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you have been moving around a lot more than usual Thoughts that you would be better off dead or of hurting yourself in some way Total score 2. Generalised Anxiety Disorder Assessment (GAD) Over the past week how often have you been bothered by any of the following? Write the first answer that comes to mind without thinking about it too much. GAD-7 Several days More than half the days 1 Feeling nervous, anxious or on edge 2 Not being able to stop or control worrying 3 Worrying too much about different things 4 Trouble relaxing 5 Being so restless that it is hard to sit still 6 Becoming easily annoyed or irritable 7 Feeling afraid as if something awful might happen Total score Nearly every day 3. Clinical Global Impression Scale Over, how much do you feel you health has changed since the start of your therapy? Very much better (1) Much better (2) A little better (3) No change (4) A little worse (5) Much worse (6) Very much worse (7) 43