Mindfulness and Living Well with a Long Term Condition

Transcription

1 Mindfulness and Living Well with a Long Term Condition A Patient Workbook Developed by Clinical Health Psychology Services Aintree University Hospital NHS Foundation Trust Dr Mark Griffiths, November 2017

2 Contents Section Page number Introduction 1 Section one An introduction to mindfulness 2 Mindfulness exercise 1- Mindful breathing 5-6 Mindfulness exercise 2- Mindful eating 7-8 Section two Thoughts, feelings & behaviours 10 Mindfulness exercise 3- Body scan Section three Stress and difficult emotions 19 Mindfulness exercise 4- Three minute breathing space 24 Section four Compassion and defusion 25 Mindfulness exercise 5- Visualisation (leaves on a stream) Section five Taking care of myself 30 Section Six The impact of a long term condition 33 Section Seven Barriers and Valued Action 41 Appendix: 46 Mindfulness pillars Future goals (1) Reference list

3 Introduction This booklet has been designed to give you some information about mindfulness, and how you can adopt the principles and exercises of mindfulness to help you to cope with a long term condition or illness, such as the after effects of a stroke, diabetes, an amputation, renal difficulties, respiratory problems etc. Your clinician has recommended this booklet to help you live well, and cope as best you can, with your condition or physical health problem. This booklet is designed to encourage you to practice mindfulness skills and positive strategies for managing the emotional and psychological challenges of living with a long-term condition or illness. The workbook is intended for you to work through at your own pace, with support from a friend or family member if needed. The aim is to identify current problem areas, as well as strategies to help you move forward in a positive and proactive way. 1

4 Section one: An Introduction to Mindfulness Section one - Key points: This workbook is designed to help you learn about and adopt mindfulness strategies in order to think differently and cope with your long term condition. Mindfulness means paying attention in the present moment, without judgment. Often we go through life on autopilot, and are not always aware of the things that we do or the effect our thoughts and emotions can have upon our behaviour and actions. To do whilst reading this booklet It is important to attempt to practice mindfulness at least twice a day. You may find it useful to use the daily practice worksheets in the appendix (page 44) to keep track of your mindful progress. 2

5 Section one: An Introduction to Mindfulness What is mindfulness? Mindfulness means paying attention in the present moment, without judgment. Often we go through life on autopilot, and are not always aware of the things that we do or the effect our thoughts and emotions can have upon our behaviour and actions. We rarely think about the action we are taking and therefore aren t always living in the present moment. We can also find that our mind focuses on one specific area of our experience at any one time good or bad; when there is much more that might be paid attention to at any given moment. Mindfulness isn t a relaxation technique as such; it is a way of seeking a heightened state of broader awareness of the present moment, by paying them attention in a purposeful and non-judgmental. Using this strategy defends us against runaway thinking that can unintentionally lead us to moments of distress or unhappiness. However, although not the main intention, a common result in practising mindfulness is a feeling of relaxation or increased calmness of mind and body. Maintaining this calmness increases our emotional resources and helps us to deal with the stresses of day to day life; then helping us to get on with our lives as we would like to. Who uses it? Mindfulness has proved helpful to lots of different people, but is especially helpful to those struggling with anxiety, depression, or stress, as well as people living with chronic health conditions. Many schools and businesses use mindfulness as a way of helping employees become more mindful of themselves and others; helping reduce stress, improving levels of job satisfaction and improving work output. When to use it Mindfulness helps more, the more it is practiced. Most people find that if they give themselves space and time to practice once or twice a day over a number of weeks, it becomes easier to use the skills when they are feeling particularly stressed, worried, or low. Daily practice is key (both on good and bad days) to become familiar with the techniques that you can then apply and use to help yourself. 3

6 The Seven Pillars of Mindfulness Acceptance Accept yourself as you are (and remember that this doesn't mean you can't change) Letting go Recognise thoughts as thoughts, and letting them pass rather than holding onto them Non-judging Trying not to judge ourselves or others Non-striving Once we stop demanding results from ourselves, they become more likely to happen Mindfulness Patience Notice when you are feeling impatient, not letting this control us, and cultivating patience in ourselves Trust Respect your own experiences, no one can tell you how you are feeling or how you should feel Beginner's mind Seeing things for the first time as if revisit familiar places with an open mind Mindfulness is made up of seven pillars. At the back of this booklet each pillar is explored in turn. 4

7 Mindfulness exercise 1: Mindful breathing The point of this exercise: to be aware of something simple and every day, to pay attention in a new way, allowing thoughts and feelings to come and go without getting caught up in them. Note: You may have access to audio scripts. If so please listen to the mindful breathing track when practicing this exercise. Sit comfortably, with your eyes closed and your spine reasonably straight. Bring your attention to your breathing. Imagine that you have a balloon in your tummy. Every time you breathe in, the balloon inflates. Each time you breathe out, the balloon deflates. Notice the sensations in your abdomen as the balloon inflates and deflates. Your abdomen rising with the in-breath, and falling with the out-breath. Thoughts will come into your mind, and that s okay, because that s just what the human mind does. Simply notice those thoughts, then bring your attention back to your breathing. Likewise, you can notice sounds, physical feelings, and emotions, and again, just bring your attention back to your breathing. You don t have to follow those thoughts or feelings, don t judge yourself for having them, or analyse them in any way. It s okay for the thoughts to be there. Just notice those thoughts, and let them drift on by, bringing your attention back to your breathing. Whenever you notice that your attention has drifted off and is becoming caught up in thoughts or feelings, simply note that the attention has drifted, and then gently bring the attention back to your breathing. It's okay and natural for thoughts to enter into your awareness, and for your attention to follow them. No matter how many times this happens, just keep bringing your attention back to your breathing. 5

8 Thinking points: following mindful exercise 1 (mindful breathing) 1) Were you able to focus your attention on your breathing? 2) Did you notice any thoughts entering your mind? 3) How did you feel differently (before, during and after the exercise)? What is automatic pilot? In a car we can sometimes drive for miles on automatic pilot. We get to where we needed to be without really being aware of what we are doing. In the same way, we may not be really present moment-by-moment, for much of our lives; we can often be miles away without knowing it. This is our natural default as human beings. For all of us. This means that on autopilot, we can be influenced by our thoughts, feelings, and bodily sensations, without being fully aware of this, which can then trigger old habits of thinking which can be unhelpful, and contribute to feelings of worry, anxiety, low mood or anger. Self-critical thoughts are also very common when in autopilot mode. Becoming more aware of our thoughts, feelings and body sensations (in the moment) can help us to respond to situations with choice and increased awareness, rather than automatically; and reactively. 6

9 Mindfulness exercise 2: Mindful eating- a raisin The point of this exercise: to be aware of something simple and every day, to pay attention in a new way. Note: requires use of raisins; other types of foods can be substituted such as other fruit, popcorn, peanuts. Please be mindful of allergies. Do not attempt if an allergy is known. 1.) Find a comfortable seated position. 2.) Pick up the raisin. Notice if you have an urge to pop it in your mouth right away. 3.) Start looking at it, feel it between your fingers, the feel of it touching your skin. Really give it close attention. 4.) Exploring the folds, the texture, the shape, weight, colour. You may want to close your eyes while doing this. Does it have a top, a bottom, front or back? 4.) Whatever is going on in your mind whilst you do this, you might be thinking oh what the hell am I doing, this is stupid. Don t worry, just notice what s going on. 5.) And then, you might want to bring it up to your nose, experiencing the smell of the raisin, and as you smell it, what does that evoke for you, what happens, does it bring back any memories or feelings? 8.) Does the raisin have a sound? If you crinkle it near your ear, do you hear anything? 9.) And then, if you re happy to, placing it against your lips, without biting into it. Experiencing the raisin against your lips, and then, if you re ok with this, you don t have to, placing it in your mouth. 10.) And starting to roll it around your mouth, without biting into it. Feeling the raisin against your cheeks, tongue, against your teeth. Noticing what sort of tastes come, what happens in your mouth? 11.) And then if you d like to, you can bite into it, and taking your time with that, perhaps noticing which teeth get involved. And how that is, as you bite into it and the tastes get released. 12.) And then just pausing, and experiencing how it is, if you swallow it, following its journey down your throat, into your body. 13.) And then just sitting with the experience of having eaten a raisin, and knowing that you are now one raisin heavier. 7

10 Thinking points: following mindful exercise 2 (mindful eating) 1) How did it feel to be asked to pay attention to something in that way? 2) What did you notice about your thoughts and feelings towards the raisin? 3) Did paying attention in that way bring about any positive or negative memories? 4) What does paying attention like that say about how we pay attention to things day to day? What was the purpose of that exercise? Noting the contrast between mindful awareness and autopilot How paying attention in detail can reveal things that we hadn t noticed before Noticing that our minds wander as normal Daily practice of mindfulness skills As we have demonstrated above, we can adopt a mindful approach to many simple tasks, such as breathing and eating and mindfulness can therefore be applied to everyday chores and experiences. It is important to attempt to practice mindfulness at least twice. Many people find it helpful to attempt a mindfulness exercise in the morning to start the day, and in the evening before bed, to end the day. However there are lots of everyday activities which can be completed mindfully. An example, of completing a normal everyday activity mindfully, would be washing the dishes, or brushing your teeth (or similar). Something you currently do, each and every day, without thought (on autopilot). 8

11 Washing the dishes on autopilot Blitzing through the dishes, thinking about what I m going to make for tea tomorrow, worrying about that appointment I have tomorrow, what will come of it, will I get there on time, and will it be bad news? Before I know it, the dishes are done, but I feel no more relaxed or accomplished than I did 10 minutes ago, before I started the dishes. Mindfully washing the dishes I notice the temperature of the water and how it feels on my skin, the texture of the bubbles on my skin; I can hear the bubbles as they softly pop. I listen to the sounds of the water as I take out and put dishes into the water. I am aware of the smoothness of the plates, and the texture of the sponge. I watch the bubbles move around the sink, the light catching them and changing their colour. I am noticing things that I might not normally notice. A thought pops into my head, what will come of that appointment tomorrow? Instead of turning to that thought and trying to answer an impossible questions (the appointment is in the future, I don t know whether it will be good news or bad, and I can t do anything about it now), I turn back to noticing the bubbles in the sink, the texture of the sponge, the sound of the water splashing against the sides It is normal for thoughts to intrude our mindful exercises. The aim of the mindful activity is continually bringing our attention and awareness back to the activity, the here and now, rather than paying those intrusive thoughts so much attention. Other examples of everyday activities that could be completed mindfully: Going for a walk (paying attention to how your body feels, looking up and down, side to side, instead of directly in front, noticing sights, sounds, smells, and sensations. What do your feet feel like as they touch the ground?) Eating breakfast (noticing your experience of the food; taste, texture, temperature. Notice the movements your body makes as you eat) A bus journey (noticing the sounds of the bus, the chatter of others, the changing sensations, smells, and sights, look out of the window more, what do you see?) Putting the kids to bed (noticing the feel of the duvet as you tuck your child into bed, listening to the rustle of the covers, noticing the facial expressions of your child, the placement of their hair and hands as they settle into bed, the smoothness of the book you have picked to read them ) 9

12 Section Two: Thoughts, Feelings, Behaviours Section two - Key points: Mindfulness encourages us to observe the thoughts we have, rather than react to them. Often we can run away with our thoughts, give them too much attention, and treat them as factual and accurate representations of both us and the world around us. Sometimes we do not stop to think about where those thoughts came from, or why we might be thinking that way (good or bad). Being more aware can offer us the chance to take a more balanced view of our thoughts; not responding to our thoughts as truths within any given moment; helping our emotional responses; and our emotional and behavioural management. Thoughts are not facts. They are simply thoughts; not truths about you or others or about life (the past, now or the future). The more we can train ourselves to see thoughts as what they are; passing ideas, subjective and not necessarily factual or accurate, we can begin to prevent ourselves from running away with our thoughts. The way we automatically think in any given situation, can at times make the situation far more difficult to cope with and live through. By blocking and sinking, we are REACTING to our experiences; getting caught up in our immediate emotional responses to automatic thoughts. Instead, mindfulness teaches us to NOTICE & RESPOND to our experiences allowing mental space for REFLECTIVE THOUGHT. 10

13 Section two: Thoughts, feeling and behaviours Runaway Thinking To become more mindful we must train our awareness. Being aware of the thoughts we have can help us to pull back and reflect upon why we might be thinking this way, and whether this is a true reflection of our situation. Helping us to not get caught up in the thought train (i.e. runaway thinking). Such a reflective thinking approach can help us to establish a more detached and observing relationship to our thoughts; helping our ability to avoid our emotions getting carried away by our thoughts (which can otherwise sometimes take us to emotions, behaviours and outcomes that we wouldn t choose or want). Being more aware can offer us the chance to take a more balanced view of our thoughts; not responding to our thoughts as truths within any given moment; helping our emotional responses; and our emotional and behavioural management The more we can pull back and observe our thoughts, the more accepting we can be of our experiences; and the less reactive we can learn to be in response of the variety of thoughts (good and bad) that can pop in our head, often randomly and without choice. Observing our thoughts Mindfulness encourages us to observe the thoughts we have, rather than react to them. We do not need to judge ourselves for having these thoughts, but instead, simply seek to observe the thoughts we notice. Learn to notice and observe whatever thoughts pop into mind, (whether, negative / critical/ worrisome or more positive) and remind yourself that thoughts of all kinds will be present and pass through our minds at all times. This is a usual and normal part of human experience. Thoughts are thoughts not facts. They are simply thoughts; not truths about you or others or about life (the past, now or the future). As we train ourselves to see thoughts as what they are; passing ideas, subjective and not necessarily factual or accurate, we can begin to prevent ourselves from running away with our thoughts. In this way we protect ourselves from the negative emotional states that runaway thoughts can trigger. Thinking point: Think of a time when your thoughts ran away with you, when you didn t feel in control of your thoughts or your behaviour. 11

14 What happens when we react to our thoughts? The more attention we give our thoughts, the more we become fused with them. This means that our thoughts can drive our feelings and our actions, with little space to stop to consider what is happening to us (back in autopilot). Mindfulness can help correct this imbalance. We know that life is filled with stress, and events and situations which challenge us and make us feel bad. A long term condition such as diabetes, the after effects of a stroke, renal problems, chronic pain etc, can often be stressful (worrying, aggravating etc) and hard to manage. As we have discussed above, we tend to go through our lives on autopilot, subconsciously using our thoughts (and the judgements we then make in relation to these), to direct our un-checked or mindless behaviours. Our behaviours are often led by worry or fear; sometimes by the rules we impose on ourselves without realising (e.g. I have to ; I should etc.). Our runaway thoughts thereby make our decisions about things and inform our actions. This way of being leads to frequent patterns of negatively-led behaviour. This is not always helpful, and can mean that we struggle to find peace by failing to live in the moment. We are therefore unable to enjoy the moment, due to being cognitively and emotionally entangled, in actions from the recent past or the impending future. Such patterns fuel anxious and agitated living rather than self-acceptance, contentment and happiness. What this means, is that we allow our automatic thoughts to determine and lead how we feel and then act, this can at times make the situation far more difficult to cope with and live through. An example of this is as follows: Building blocks metaphor I can t cope with my pain, I feel depressed and anxious about what will happen in the future, it is overwhelming I hate my pain, I just want it to go away, no one understands or wants to help This pain is ruining my life, it s not fair Your own thoughts I can t do what I want because of the pain Chronic Pain The problem itself 12

15 Think of the example as a series of building blocks; each heavier than the last. The chronic pain is the original building block, and can be difficult enough to cope with and adjust to on its own. The thoughts that naturally come to mind when we are in pain make it even harder to cope with. The thoughts above demonstrate the idea of piling on negativity. It is normal to have negative thoughts, however the more they pile up and the more attention we give them, the more difficult it is to cope with the first building block; the pain itself. If we took those other building blocks away, you would still have the pain, but would it feel any less daunting or more manageable? Thinking point: Can you think of your own building blocks example? Your own thoughts The problem itself 13

16 How can we help with the building blocks? Going through life on autopilot, means that our runaway thinking can draw us into unhelpful patterns, of distress. In contrast being more aware of our thoughts (such as those in the example above) can help to defend against such patterns of unhappiness. The principles of Acceptance and Commitment Therapy (ACT) helps demonstrate how this can be achieved. We need to move away: We can achieve this by: Fusion with our thoughts Evaluation of experience Avoidance of our experience Reason giving for our behaviour Accepting our reactions and be present Choosing a valued direction Taking action The principles of ACT Accept our reactions and be present: Trying to rid ourselves of pain and distress is a natural impulse, but often ends up increasing our pain and distress. The alternative is to accept each experience, as it is happens, even those that painful or distressing. This doesn't mean giving up or being defeated by your pain or distress. Acceptance is an acknowledgement of, and a willingness to allow these experiences. Choose a valued direction What do you value in your life, what is most important to you in your life? Where do you want to be in life; how do you want others to see you and know you? Consider the bigger picture, what are your ultimate goals? How can you build positives and enjoyment back into your life? Take action Be proactive. Identify your runaway thoughts and begin practicing ways to change your relationship with them. These principles can be achieved through mindfulness. Becoming aware, being in the moment, and taking a non-judgemental but inquisitive stance towards your thoughts, can help you to accept your experience and to not become fused with your thoughts. Once we can observe our thought processes more clearly, we can begin to take action and consider our values, which will in turn lead to desirable outcomes. 14

17 Mindfulness exercise 3: The body scan Please use the audio for this exercise if you have one. The purpose of this exercise: to be aware of the different physical sensations in your body, to use your body as an anchor in order to be present and aware of your experiences. 1. Make yourself comfortable, lying on your back or sitting on a supportive chair, in a place where you will be warm and undisturbed. Let your eyes close gently. 2. Take a few moments to get in touch with the movement of your breath. Now bring awareness to the physical sensations in your body, especially the sensations of touch or pressure where your body contacts the mat, bed or chair. On each out-breath, let go, allow yourself to sink deeper into the mat, bed or chair. 3. Remind yourself of the intention of this practice. Its aim is not to feel any different, relaxed, or calm; this may happen or it may not. Instead, the intention of the practice is, as best you can, to bring awareness to any sensations you detect, as you focus your attention on each part of the body in turn. 4. Now bring your awareness to the physical sensations in the lower abdomen, becoming aware of the changing patterns of sensation in the abdominal wall as you breathe. Take a few minutes to feel the sensations as you breathe in and as you breathe out. 5. Having connected with the sensations in the abdomen, bring the focus or spotlight of your awareness down the left leg, into the left foot, then to the toes of the left foot. Focus on each toe of the left foot in turn, bringing a gentle curiosity to investigate the quality of the sensations you find, perhaps noticing the sense of contact between the toes, a sense of tingling, warmth, or no particular sensation. 6. Next, on an in-breath, imagine the breath filling the lungs, then passing down into the abdomen, into the left leg, the left foot, and out to the left toes. Then, on the out-breath, imagine the breath coming all the way back up out of the foot, into the leg, up through the abdomen, chest, and out through the nose. Continue this for a few breaths, breathing down into the toes, and back out from the toes. It may be hard to get the hang of just practice this breathing into as best you can, approaching it playfully. 7. Now, when you are ready, on an out-breath, let go of awareness of the toes, and bring your awareness to the sensations on the bottom of your left foot bringing a gentle, investigative awareness to the sole of the foot, the instep, the heel (noticing, for example, the sensations where the heel makes contact with the mat, bed or floor). Experiment with breathing with the sensations being aware of the breath in the background, as, in the foreground, you explore the sensations of the lower foot. 8. Now allow the awareness to expand into the rest of the foot to the ankle, the top of the foot, and right into the bones and joints. Then, taking a slightly deeper breath, directing it down into the whole of the left foot, and, as the breath lets go on the out-breath, let go of the left foot completely, allowing the focus of awareness to move into the lower left leg the calf, shin, knee in turn. 15

18 Mindfulness exercise 3: The body scan continued 9. Continue to bring awareness, and a gentle curiosity, to the physical sensations in each part of the rest of the body in turn to the upper left leg, across the pelvis, down the right thigh, right knee, right lower leg, right ankle, right foot, the right toes, back up again, to the right foot, right leg, up to the pelvic area, back, abdomen, chest, then through to your fingers, hands, arms, shoulders, neck, head and face. In each area, as best you can, bring the same detailed level of awareness and gentle curiosity to what you can feel in your body. As you leave each major area, breathe in to it on the in-breath, and let go of that region on the out-breath. 10. When you become aware of tension, or of other intense sensations in a part of the body, you can breathe in to them using the in-breath to gently bring awareness right into the sensations, and, as best you can, have a sense of their letting go, or releasing, on the out-breath. 11. The mind will wander away from the breath and the body from time to time. That is entirely normal. It is what minds do. When you notice it, gently acknowledge it, noticing where the mind has gone off to, and then gently return your attention to the part of the body you intended to focus on. 12. After you have scanned the whole body this way, spend a few minutes feeling the body as a whole, and the breath flowing freely in and out of the body. 13. If you keep falling asleep, open your eyes, or sit up rather than lie down. Tips for the body scan Regardless of what happens, 'just try it'. It doesn t matter if you fall asleep, lose concentration, keep thinking of other things, keep noticing the wrong part of the body etc. These are your experiences in this moment. See if it is possible to be aware of them all, just as they are. If your mind is wandering a lot, simply note the thoughts (as passing events) and then bring the mind gently back to the body scan. Let go of ideas of "success", "failure", "doing it really well", or "trying to purify the body". This is not a competition. It is not a skill for which you need to strive. The only discipline involved is regular and frequent practice. Just do it with an attitude of openness and curiosity, then allow the rest to take care of itself. Let go of any expectations about what the Body Scan will do for you: Imagine it as a seed you have planted. The more you poke around and interfere, the less it will be able to develop. So, with the Body Scan, just give it the right conditions - peace and quiet, regular and frequent practice. That is all. The more you try to influence what it will do for you, the less it will do. Try approaching your experience in each moment, with the attitude: "OK, that's just the way things are right now". If you try to fight off unpleasant thoughts, feelings, or body sensations, the upsetting feelings will only distract you from doing anything else. Be aware, be non-striving, be in the moment, accept things as they are. Adapted from Mindfulness-based Cognitive Therapy for Depression (2013). 16

19 Thinking point: 1) How did it feel to be asked to connect with and be aware of the physical sensations in your body? 2) The body scan can help us to focus and sustain attention, why do you think this ability is helpful and important? Note: Allowing your body to be as it is, is sometimes a difficult and uncomfortable thing for people to do, especially if they have physical long term conditions i.e. being asked to pay attention to your arm, when your arm has become weak and numb due to a stroke. Being asked to pay attention to your thigh, when your thigh regularly feels painful due to diabetic nephropathy. This is an important skill within mindfulness, as it teaches us to let an experience be, instead of fighting against it or pushing it away. Like we said before, the less we fight and avoid, the more likely we are to cope with the experience we are having. How we cope with challenge: blocking and sinking When people are struggling with pain or distress, it tends to be because they are REACTING to things rather than RESPONDING to things. We tend to find that those having difficulty coping with long term conditions or challenging life events, other challenges in life cope in either one of two ways: Blocking It is common to resist and avoid something that is causing us upset or pain. For example after having a stroke it would be common for a person to avoid thinking about the changes to their body after the stroke such as muscle weakness, in the hope that it will get better eventually. By avoiding the problem (or thoughts and emotions about it) we never truly acknowledge it, and therefore cannot move forward in life (for example, through rehabilitation and adaptation). In addition, people may find themselves using strategies such as alcohol, drugs, cigarettes, shopping or eating to temporarily blocks out bad thoughts or feelings. This can soon become an unhelpful means of avoiding the problem, which brings about its own, further problems. 17

20 Sinking Clinical Health Psychology Services In contrast to blocking, sinking describes the tendency to obsess about the thing that is causing pain or upset. For example trying to meticulously plan our meals, routine or life around our condition, dwelling upon how we might cope with it in the future, and how we are coping with it currently. We might also find ourselves feeling generally overwhelmed by our condition; feeling as if this is the only thing in our experience nothing else. By blocking and sinking, we are REACTING to our experiences; getting caught up in our immediate emotional responses to automatic and instinctive thoughts and letting them dictate how we are and what we feel. Instead, mindfulness teaches us to NOTICE & RESPOND to our experiences allowing mental space for REFLECTIVE THOUGHT and constructive observation. Not judging the thoughts, or yourself; but simply having a space to mentally consider: are these thoughts helping me now? ; what will be helpful for me to do now? This observing approach towards our thoughts therefore leads to: Awareness of our thoughts Awareness of our feelings Awareness of our body, muscle tension and breathing Awareness of the full content of our experiences Awareness of what might be the most helpful cause of action; being able to live in and through the rather than be pulled in by your immediate runaway thoughts and feelings, that would otherwise lead to a less helpful experience. 18

21 Section Three: Stress and Difficult Emotions Section three - Key points: Mindfulness can be used to help with feelings of stress. Stress is a normal part of life, and an automatic response in our body. We cannot stop challenging life events and stress from happening- but we can change how we respond to the stressors, and thoughts and feelings they provoke. We can respond differently, by responding mindfully. Following logical thoughts (automatic pilot thoughts) is not always helpful. The more CONSIDERED and CALM we can be, when presented with a problem, the better we may cope with the problem. The less we fight and avoid, the more likely we are to cope with the experience we are having. 19

22 Section three: Stress and difficult emotions This section is going to look at stress and the impact of this upon our thoughts, feelings, and behaviour, in more detail. We will also look at how practicing mindfulness can affect our body as well as our minds. Stress A very common human experience is the idea of feeling stressed. Stress is a normal emotional and physiological response to events that make us feel threatened, unwell or upset. When we feel threatened (physically or emotionally) our body s defense mechanism kicks into high gear in a rapid and automatic process known as fight or flight or the stress response. Our body s stress response When we perceive something to be a threat, our nervous system responds by releasing a flood of stress hormones (including adrenaline and cortisol). These rouse the body for emergency action. Our heart begins to beat faster, breathing becomes shallow, blood pressure rises, and our muscles tense. Our body cannot distinguish between physical, cognitive or emotional threats. This means that when we are stressed about a mounting bill, an argument with a loved one, our health or an upcoming operation, our body responds in the same way as if we were facing a physical threat. Therefore we need to recognize this response and respond differently. How we cope with stress Our usual attempts at coping with stress can involve attempting to either block out the stressful situation or feelings, or attempt to control and solve the feelings (which usually ends up with us feeling overwhelmed). Instead of trying to come up with more ways to struggle against the stresses and strains of living with a long-term condition or illness, one of the aims of adopting mindfulness in everyday life, is to help you move away from this struggle altogether. 20

23 The quick sand metaphor Our experience with our thoughts, and with negative experiences such as stress, is quite similar to being trapped in quick sand. When we are caught in quick sand, our initial instinct is fight as hard as we can to get out. What we know about quicksand is, the more we fight and move, the more trapped we become. The more trapped we become, the harder we struggle. Even though it makes sense to us to fight against it, our way of trying to solve the situation can actually trap us more. The most effective method in saving yourself from quicksand is to attempt to stop moving, and slowly lay backwards, so that the back of our head begins to touch the quick sand. This stops us from sinking and enables us to float instead. This goes against all our instincts, but it s exactly what we need to do. The same can sometimes be said for negative thoughts; fighting against the thoughts we have is a natural, logical (and instinctive) response (just as our reaction to quick sand), however, that does not mean that it is helpful to respond in this way, and can sometimes make the situation worse. 21

24 Responding to stress and difficult emotions We cannot stop challenging life events from happening- but we can change how we respond to stressors through planning and preparation. This is where learning mindfulness skills is beneficial. Instead of attempting to fight against stress and challenging thoughts / situations through blocking and sinking, mindfulness helps to cultivate the following, alternative way of coping: Stop Take a breath Observe Proceed (differently) RECOGNISE & RESPOND TO OUR EXPERIENCE, MOMENT BY MOMENT RESPONDING to our experiences leads to: Increased awareness of our thoughts Increased awareness of our feelings Increased awareness of our body, muscle tension and breathing Increased awareness of the full content of our experiences Adopting a mindful approach means taking a non- judging stance towards ourselves and our thoughts. It means not getting too tangled up with worrying thoughts, which are a normal part of human experience. This can be achieved by introducing the STOP mantra into everyday life: 22

25 Stop bring yourself into the present moment by asking- what is my experience right now? Thoughts (What are you saying to yourself, are you being rational, negative, positive etc) Feelings (Upset, sad, mad, angry, numb etc) Sensations (Physical sensations, tightness, lightness, tenseness etc) Acknowledge your experience, even if it is unconformable Take a breath direct your awareness towards your breathing. Your breath is an anchor to the present moment. Direct your attention to your breathing, to each in-breath and outbreath, one after another. Count to ten in your head whilst you are doing this. Your breath helps you to anchor yourself to the present and stay in tune with your awareness. Observe - expand your awareness outwards Expand the field of your awareness outwards away from your breath, so that it includes a sense of the body as a whole, your posture, facial expression, and then further out to what is happening around you; sights, smells, sounds etc. Proceed differently continuing without expectation Let your attention move with the world around you, instead of it being solely in your head. Sense how things are right now, in the present. Be open, curious, to new possibilities and experiences. 23

26 Mindfulness exercise 4: Three minute breathing space Please use the audio when completing this exercise. 1) Become aware of your experience - your thoughts and feelings in the here and now - Noting what thoughts, feelings, and body sensations are present for you right now - 2) Gather your attention towards a single object - the breath 3) Expand your awareness to include a sense of your body as a whole, and the next moments of the day The three minute breathing space- to use when unpleasant thoughts and feelings arise 4) Become aware of your experience - your thoughts and feelings in the here and now - Noting what thoughts, feelings, and body sensations are present for you right now - DESCRIBE, ACKNOWLEDGE AND IDENTIFY the experience. For example I am having a self-critical thought right now 5) Gather your attention towards a single object- the breath 6) Expand your awareness to include a sense of your body as a whole, and the next moments of the day Thinking point: 1) How was it, trying to observe the unpleasant sensations or thoughts, rather than react to them? 2) How do you think your posture and facial expression was during that exercise? 24

27 Section Four: Compassion and Defusion Section four - Key points: Adopting a different stance towards ourselves. Being more in the present means that we can see our own thoughts for what they really are; thoughts (not truths). Thoughts are not facts (they are based upon our automatic judgments and beliefs). We are often fused with our thoughts. Training ourselves, through mindfulness and other techniques, to take a step back from thoughts can help us to move forward in a more positive or proactive way. There are numerous defusion techniques, not all of which are listed here, but most work under the premise of identifying thoughts as thoughts. 25

28 Session four- Compassion and Defusion Self-compassion and self-kindness Throughout this booklet we have discussed how mindfulness can help us cope with life s challenges, through adopting a different stance towards our own thoughts, feelings, and current situations. Adopting a different stance towards ourselves. Being more in the present means that we can see our own thoughts for what they really are; thoughts (not truths). Thoughts are not facts (they are based upon our automatic judgements and beliefs). Mindfulness teaches us to watch our thoughts pass by us with a gentle interest and curiosity. Adopting this different way of being with and understanding our thoughts, brings the opportunity to be more compassionate and kinder towards ourselves. The more understanding we are, the calmer and more at peace we can often feel. It s just a thought! Cognitive defusion At times of upset and distress, we are often fused with our thoughts. This happens when we are running on autopilot, treating thoughts as facts, and not fully aware of the effects of this upon our behaviour, feelings and emotions. When we are stuck to our thoughts, it is almost as though we cannot separate ourselves from them. We are often so stuck that we cannot create any distance between our self and our thoughts. Cognitive fusion means that our experience is completely dominated by our thoughts. 26

29 Defusion involves learning to step back and detach you from these thoughts. By consciously choosing to disentangle yourself from your internal dialogue, you are practicing mindfulness. Mindfully observing the internal processes that you have, noticing them, but not passing judgment upon them, letting them pass. The following are a list of defusion techniques: 1) Using the STOP mantra (Section 3) is one method for defusing thoughts. Stop Take Observe a breath Other defusion techniques include: Proceed (differently) 2) Label your thoughts more specifically. E.g. is my thought a prediction, an insult, an evaluation, a memory, an unhelpful thinking habit such as mindreading, am I assuming I know what someone else is thinking? 3) Practice and use mindfulness daily, so that you are more aware of when you are in your own head as opposed to being in the present moment. 4) Use visualisation techniques to separate and observe your thoughts. 5) Mental appreciation- thank your mind for that passing comment. Thank you for telling me that. 6) Label your thoughts as thoughts. I am having the thought that 27

30 Mindfulness exercise 5: Leaves on a stream (visualisation) Please use the audio CD when completing this exercise. Find a comfortable seating position and close your eyes. Focus your attention on your breathing breathing in, and then breathing out. Be aware of your breathing and of the feeling of calmness and relaxation you can feel begin to wash over you, as you breathe in.and out, in..and out. Find a breathing rhythm that feels comfortable to you. Imagine there is a balloon in your stomach, with the balloon inflating as you breathe in..and deflating as you breathe out..the balloon getting larger as you breathe in.and smaller as you breathe out. You ll notice thoughts pop into your mind as you breathe just be aware of them, notice them but don t pay them too much attention. Be aware of them, and bring your mind back to your breathing, and the feeling of increasing calmness on each out breath. Notice sounds around you that you would not normally be aware of both inside and outside of the room. Just be aware of these don t pay any one thing too much thought. Notice.. and then continue to bring your attention back to your breathing. Notice different feelings in different areas of your body..some parts may feel warmer or colder than others; some muscles may feel tighter and some looser than others; some areas of your body may feel more comfortable than others. Just be aware of these differences that you can notice..and then bring your attention back to your breathing. Now imagine you are sat at the side of a stream, which is calmly flowing down a hill, on a warm sunny day. There is a tree next to the stream and its leaves are falling, one by one, into the stream, as the wind gently blows. Picture this in your mind. Take each thought that pops in your mind and place each one on one of the leaves, drifting down the stream. Watch each thought drift away, gently, as the stream runs gently down the hill. For every thought that pops in your mind, place it on a new leaf and watch it drift down the stream calmly and gently. Bring your attention back to your breath, feeling calmer with every out breath. When you are ready, bring your attention back to the room and open your eyes Mindfulness Script (M, Griffiths, 1/ 2014) 28

31 Thinking points: 1) What was it like being asked to visualise something, as opposed to being asked to just paying attention to different aspects of experience? 2) Did you struggle to visualise the river? Did you feel able to put your thoughts onto the leaves and let them float by, as opposed to holding them, reacting to them, judging them? 3) How does this tie in with the idea of cognitive defusion? 29

32 Section Five: Using mindfulness to continue to take care of your self Section five key points The more we practice mindfulness, the more helpful it can be in coping with challenging life events. The point of mindfulness isn t to try and avoid challenges in life or to avoid the thoughts that we have. Instead it is about changing our relationship with our thoughts, and how we react to them. 30

33 Section Five: Using mindfulness to continue to take care of your self Mindfulness helps more, the more it is practiced. The more that the seven pillars of mindfulness are incorporated into everyday life, the greater the potential benefit to your wellbeing. Daily practice, both formal and informal is key to becoming familiar with the techniques. Acceptance Accept yourself as you are (and remember that this doesn't mean you can't change) Letting go Recognise thoughts as thoughts, and letting them pass rather than holding onto them Non-judging Trying not to judge ourselves or others Non-striving Once we stop demanding results from ourselves, they become more likely to happen Mindfulness Patience Notice when you are feeling impatient, not letting this control us, and cultivating patience in ourselves Trust Respect your own experiences, no one can tell you how you are feeling or how you should feel Beginner's mind Seeing things for the first time as if revisit familiar places with an open mind 31

34 How else can we apply the principles of mindfulness? By doing things that make us happy; things that offer us a sense of fulfillment By doing something which gives us a sense of achievement By doing things that are personally meaningful or valuable. By doing something which provides calm enjoyment for example, bird watching, Pilates, Tai Chi, painting, jigsaws, gaining enjoyment from simply being with family etc. Take pleasure from moments in life that may be unexpectedly enjoyable or which we may seek to engineer. For your final exercise Write a letter to yourself, about your goals, aspirations, feelings and behaviour, in order to reflect upon this after some time. This is a powerful exercise to consider how you might put these mindfulness skills into practice over the next 6-12 months. What to include in the letter: A. Who are you today? What makes you happy? What gives you a sense of purpose? What are your goals? What makes you hurt? What are some of the things you are struggling with? What makes you sad? What are the wonderful and happy things in your life? - Family, friends, hobbies, pets, nature, surrounding etc. B. Then include the following answers to these questions in your letter: 6-12 months from now who will you be? What will be your goals? What will you have accomplished? What makes you happy? What are the things you used to feel stressed about, but don t any longer? Then reflect on this letter to yourself and focus your thinking on 3 things: 1. How are you going to get to your future self (as described in part B)? 2. What are the small steps you need to take to get there? 3. What might mindfulness offer you in reaching this destination? 32

35 Section Six: Using mindfulness to live well with your long term condition 33

36 In the earlier sections we have looked into our thoughts in detail; how to notice our thoughts and the impact they can have on how we feel and act. The aim of becoming more aware of our thoughts is not to try to change or stop them, but to take a step back from them and create the opportunity to react differently; not being automatically drawn into responding in the same old way. So often these automatic responses (which may once have been a useful strategy) bring about unintended, negative consequences in the long-term. For example, getting stuck in a struggle with our thoughts, trying to control them, through avoidance usually ends up getting in the way, narrowing and limiting our positive experiences and opportunities in life. Acceptance Rather than getting tangled up in this struggle, consider the idea of acceptance of our thoughts and feelings about our long-term condition, illness or situation. Remember that acceptance is not throwing in the towel but learning to live well alongside your condition, without trying to struggle against it, which we know results in greater problems in the long term. Learning to live well with a long-term condition or illness can be extremely difficult and challenging. People often feel they are expected to merely get on with it, or accept it. When it comes to dealing with illness or a long-term condition, acceptance is a positive way of addressing an unchangeable situation. It is not the same as defeat, helplessness, quitting, or resigning to a life of unhappiness, struggle, or misery. Acceptance can be defined as, the mental attitude that something is believable and true. Accepting that you have a long-term condition is different than giving up all hope. Acceptance means taking action in a valued direction despite experiencing the difficult and challenging aspects of your condition. 34

37 Values Clinical Health Psychology Services If we know that struggling (sinking or blocking) against our difficult thoughts and feelings doesn t work (and even makes things worse) then acceptance is a means of freeing yourself from this struggle to focus on other, more valued aspects of life. Thinking point: What do YOU want your life to be about? Perhaps you have found that your plans, goals, hopes and ambitions have been blocked by your long-term condition or illness. It is common to feel unsure about your values; what you want your life to stand for. So often we use our physical health to measure success with life (i.e., is my longterm condition solved or cured and removed from my life?) but if our condition cannot be cured or reversed, how long might you wait around to get rid of your health problems before moving on with life? Values are your desires for how you want to behave as a human being. Values are not about what you want to get or achieve; they are about how you want to behave or act on an on-going basis. Keep in mind there are no such things as right values or wrong values ; only those which are meaningful to you. Values are about how you want to behave towards your friends, your family, yourself, your environment, your work, etc. Values are not the same as goals. Goals can be achieved or crossed off, whereas values are on-going. For example, if you want to be a loving, caring partner, that is a value: it involves on-going action. In contrast, if you want to get married, that s a goal - it can be crossed off or achieved. If you want a better job, that s a goal. Once you ve got it - goal achieved. But if you want to fully apply yourself at work, contribute your best, and engage fully in what you re doing, that s a value: it involves on-going action. Thinking about what is truly important to you in life may help you to highlight goals that will give your life most meaning and consider what you might do right now to meet these values. 35

38 . Clinical Health Psychology Services Thinking points: 1) Deep down inside, what is important to you? 2) What do you want your life to stand for? 3) What sort of qualities do you want as a person? 4) How do you want to be in your relationships with others? 36

39 37

40 For each of these domains write a quick summary of your values, for example to live a healthy life and take care of my body (physical wellbeing), or to be a good friend to people who need me, and to enjoy my time with the people I love (friendships). Rate each domain for how important it is to you from 0-10 (0=not important) 38

41 Once you have completed this worksheet, please consider the following: Let s take this opportunity to consider which of the values you identified are most important to you. Becoming aware of your own values and the life direction to work towards will highlight goals that will give your life more meaning. Thinking points: Take an honest assessment of how closely you have been living your life according to these values. 1) Have you been engaged in activities that are consistent with your stated values? 2) Are you doing things that are important priorities for you? If so, how are you able to do this? If not, what is getting in the way for you to accomplish things that are important? 39

42 Section six - Key points: Clinical Health Psychology Services When we move away from the struggle with our thoughts, feelings, situation or physical health condition, we create the opportunity to try responding differently. Considering our personal values helps to identify targets for valued action, that is, actions you can take, right now, to give life more meaning. Accepting our physical health problem or situation means taking such action despite experiencing the difficult and challenging aspects of your condition. Acceptance is a positive way of addressing an unchangeable situation. Acceptance is not the same as defeat, helplessness, quitting, or resigning to a life of unhappiness, struggle, or misery. To do before moving onto the next section Complete all thinking points in this section Complete the values worksheet before moving onto the next section 40

43 Section Seven: Overcoming barriers to valued action 41