Wednesday, 30 April 2014

Stress and mood management

Back in March I attended a "stress and mood management" course for a day. This is a precis of my notes.

We started with an overview of the basis of Cognitive Behavioural Therapy (CBT). 

People have thoughts, and as a result of those thoughts they have behaviours, and this works the other way round as well, particular behaviours can affect thoughts. As a result of the interaction of thoughts and behaviours there are emotions and physical feelings. In a nutshell, often it is not possible to change the situation that you are in, but you can change the way you think about it. If you change the way you think about things then you can change the emotions and physical feelings. The aim is to actively do things differently.

We then moved onto anxiety - and looked at the physical feelings associated with anxiety. These feelings themselves are not harmful. They can include:

  • Headaches
  • Tense muscles
  • Itchy skin
  • Tiredness
  • Aches
  • Numbness
  • Hot or cold flushes
  • Sweat or clammy-ness
  • Pins and needles
  • Dizziness
  • Stomach churn
  • A need to go to the toilet
  • Poor decision making
  • Shallow breath
  • Blurred vision
  • Dry mouth
  • Blisters
  • Eczema
These are all associated with the body's natural reaction to a stressful situation - the release of adrenalin and preparation for the fight or flight response (for example, poor decision making arises from blood draining from the frontal lobe of the brain, and blurred vision is a focus on directly in front of you - i.e. tunnel vision). Some of those in the list are the body getting ready for this, and others are results of the adrenalin wearing off. This means that you can associate these physical feelings with anxiety and be aware of why they are happening.

The next thing to look at was the panic/anxiety cycle:
  1. There is something wrong
  2. This causes adrenaline to be released
  3. There are physical symptoms associated with this
  4. These sensations are detected by the brain, which enhances the feeling that something is wrong.
The release of adrenaline is a natural effect, and nothing can be done about this, but CBT aims to intervene where things can be changed.

With (1) you can appraise if there is something really wrong, and change your thoughts
With (2) adrenaline needs oxygen, so you can change your breathing pattern to minimise the effects of this
With (4) when you detect the symptoms you can be aware of these and change your thoughts.

We talked about breathing exercises - rectangular breathing - short breaths in and long breaths out - think of breathing along the sides of a door (or other rectangle in vision) - If in doubt, breath out. This rectangular breathing is a little like Pilates breathing where we breath in through our nose and out through pursed lips.

We then moved onto the natural course of anxiety:

There is a limit to your anxiety level, which means that once you reach this limit the level plateaus out. It will drop over time. The CBT aim is to confront the situation and then spot the levels of anxiety dropping off. 

Example: A bear walks into the room you're in. This is stressful and your anxiety levels go up. What do you do? - If you make the decision to leave the room quickly then you get relief and anxiety levels drop quickly. But, the body perceives this as a  reward and encourages you to do this again. Effectively the next time the bear walks into the room your anxiety level rise quicker and you get into a worse situation. By staying in the room a little longer, in the peak of your anxiety level you get the chance to appraise the situation and perhaps feel that it is not necessarily as bad as you initially make out. (note - I do not actually advocate staying in rooms with bears....)

You may have a range of safety behaviours - for example needing particular company when you do something. Sitting right next to the door when you are somewhere. You should consider trying the activity without the safety behaviour as this can limit your activities if your safety behaviour is not available.

The final point on anxiety is that caffeine causes the release of adrenaline, so if you're a regular coffee drinker then you may be artificially putting your body into fight or flight mode - i.e. artificially raising your stress levels. Worth also noting that alcohol does the opposite - it is a depressant - and with sufficient intake you can end up with anxious, depressed or angry feelings.

We then moved onto low mood (i.e. depression), and the low mood cycle:
  1.  You think there is no point. 
  2. This reduces your level of activity.
  3. You have fewer positive experiences
  4. This lowers your mood - eventually you think "what is the point in anything....".
Like the panic cycle CBT inputs where things can be changed, and there is some overlap. 
With (1) you can change the way you think about things
With (2) you can force yourself to do something.

We noted that activities can be divided into three areas, those that are "fun", those that are "routine" and those that are "necessary". Often it is the fun things which go first.

Motivation comes after action (e.g. you feel better about doing somethign after you have finished it) - so you can improve the situation by working backwards - i,e, increasing your level activity will reverse the situation.

It is important to note that if you are quite sad then the feelings associated with doing something may not, at first, make you feel better or make you feel like you used to. But, each activity will raise your level of happiness a little, and after several activities you should pass the threshold where you begin to feel OK - and its upwards from there.

You should look at the present moment to work out the way forward - it is not necessary to understand how you got to this place, and such reasoning can be unhelpful. The thing that will be remembered is what helped us to get out the situation.

The stress beaker

In life people have big stressors and little stressors. Some level of stress is natural and expected. Each person has a "stress beaker" within which they work fine. The problem arises when there are too many things in the beaker. 

Big stressors may be work, family, grief, health or money. Little stressors may be people, transport, tiredness or housework. One option is to try and prevent things getting into the stress beaker, but that is not always easy. The other way is to try and reduce stress by doing things which act like a "tap" at the bottom of the beaker. These include:
  • Exercise
  • Hobbies
  • Music
  • Being with other people
  • Reading
  • Eating well
So, doing some of these activities can help reduce stress levels, thereby allowing room for more things to come in the stress beaker (if that is your aim)

Thoughts and Feelings

Something happens, we think about it, we have a feeling.

Sometimes people have negative automatic thoughts (NATs) These thoughts can be always there, or you can have them every now and again, or not even be aware that you are having them.  NATs are distorted, plausible, involuntary and unhelpful. If you are depressed or anxious then you can have more of these NATs, they are influenced by mood.

Each person has set up various "rules for living" - i.e we use these rules to justify why we do things. Around these can be a range of unhelpful thinking patterns which result in NATs. The aim is to influence your rules for life to result in a change in NATs. There are 7 different thought patterns of interest here:
  1. All or Nothing - there is no grey area between two extremes
  2. Over-generalisation - this limits options for change
  3. Personalisation - this can attribute blame unfairly
  4. Jumping to conclusions - the tendency is to automatically jump to he negative conclusions
  5. Catastrophising - this invents a mountain where one doesnt really exist
  6. Disqualify the positive - would you rather be right or be happy?
  7. Should/ought/must - these fixed rules prevent options for change
There are four steps to challenging unhelpful thoughts:
  1. When you have an unhelpful thought you should see if you can identify which category it falls into - this can distance yourself from the immediate emotion. 
  2. You should consider the facts/evidence in front of you to prove/disprove the thoughts
  3. Think about is this thought helpful
  4. Think what you would say to a friend if they asked you about being in this situation.
Rules for living

These rules come from a range of sources, including friends, parents, school, society, religion, peers, experts, work (etc.). The rules are important because order in society is present and it helps us get along with each other - they are a framework to live in.

If your rules are too strict then they may be curtailing your behaviour, especially if you feel that you cannoy live up to your own rules. You can try to turn some of your won rules for life into guidelines.

Rules are rigid and compulsory - they include words like "must" or "should".
Guidelines are advisory and flexible - they include words like "could", "maybe", "sometimes" or "try" - a guideline cannot be broken.

For example the rule "I should always do my best" could become the guideline "I will try my best but I have a limit" - and this means that it may be more straightforward to on with life.

Other tools available include prioritising things and providing compensation for things.

It is important to note that whilst you can change your own rules (which others who know you may be surprised about) you cannot change anyone else's rules - the best you can hope for is that your rule changes can influence others to make their own decision about rule changes.

Communication

If you are angry you can have the same physical symptoms as anxiety. There are three outcomes for anger:
  • Let it out (shouting, physical behaviour) - this affects others who see you doing this
  • Bottle it up (becoming quiet or withdrawn) - this affects you only
  • Anger management
There are a number of communication styles which can help manage anger. If you speak "passively" then you phrase things as though THEY are in control of the situation. If you speak "aggressively" then you phrase things as though WE are in control. A passive/aggressive style starts passive and then turns aggressive.

The best approach is to be assertive - to do things positively: Look at the facts, work out how they make you feel, work out what you want. Try not to sound like a broken record "I dont want to...."

Problem Solving

The last part of the day was looking at problem solving with the "5 P's".

Position - if you find you worry a lot, you should set aside some "worry time" - this might only be 15 mins a day. If you keep postponing things to think about then they will keep coming back to you. If you know you will dedicate some time to thinking about them then your mind will change the way that it thinks about these. You need to manage this worry time.

Problem - Things that we think about are either problems (which are within our control) or worries (which are outside of our control - they may be in the past/future. Negative ones of these should be challenged. Dividing the thoughts into these two areas can help focus on those that we can change.

Possibilities - For any problem list all the options that you can take to solve it, and then choose one of those options to action. Simply working out a number of solutions can help the situation. This possibility listing doesn't have to be within the "worry time" - in fact you could set aside "problem solving time" for this and the next P stage.

Planning - Once you have chosen your option this needs to be planned. The option needs to be divided into steps and targets set for each one. Remember that plans should be SMART (specific, measurable, achievable,  realistic and time-limited)

Postpone - you always have the option of carrying over any problem into the next worry time if it too much to deal with at the time.

Summary
We covered a lot of things in the day. I'm still working out which of these are most useful to me. I found it very useful to get the differentiation between anxiety and depression, but also to spot that there are a lot of overlaps between the two and similar thought patterns can help either.

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