Relaxation & Stress Management Workbook Name:... SDSO 1
Every effort has been made to ensure that the information contained within this booklet was accurate at the time of print. Any feedback or suggestions would be gratefully accepted, please email j.sayers@bham.ac.uk. Any updates and supplementary materials can be found on intramed. All views and opinions expressed within this book, or in the Relaxation Sessions are not representative views of the College of Medical and Dentals Sciences or the University of Birmingham. Version: 1.3 Date of Origin: November 2009 Created in partnership between Duncan Shrewsbury, and the Student Development and Support Office, College of Medical and Dental Sciences. SDSO 2
CONTENTS: o Introduction o How to Use this Workbook o Stress What is it? Is it really that bad? Stress diary o Relaxation What is it? Effective Relaxation Techniques o Mindfulness What is it? What it involves Commitment o How to be Mindful Approaching Mindfulness Positive Experience Diary Negative Experience Diary o Exercises: Breath Enquiry Body Scan Mindfulness of Breathing 3 Minute Breathing Space o References o Further Information SDSO 3
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INTRODUCTION: WELCOME! By reading this you are already working on fundamental principals of stress reduction. By taking time out to do an activity designed to help yourself, and by being calm and still enough to read, you are beginning to relax. An important part of this process is to take the needs of yourself and your body seriously, and set a commitment to continuing relaxationbased practice. WHAT THIS IS This is a workbook designed to guide you through some simple exercises intended to help you relax and improve your mental and physical wellbeing. Whilst some of the techniques and exercises described may sound odd, everything within this workbook is evidence based and highly recommended. RATIONALE It is recognised that the demands of early clinical exposure, high academic pressures and responsibilities associated with studying medicine are enough to cause a great deal of stress to Medical Students. Moreover, we develop our coping strategies and behavioural patterns during the early stages of our exposure to such stimuli. Therefore, by showing you how to recognise and deal with stress in your life, it is hoped that you will be better able to respond to situations, without reacting with stress, and to effectively deal with lifestressors in your future career. RELAXATION AND TAKING TIME OUT TO RELAX Relaxing is often not as easy as it seems. The definition of relaxation is broad, covering the release of muscle tension and recovery of the system (body) from a disturbed state, to a feeling of tranquillity and an absence of worry. Clearly, if we cannot easily define what it is that we are trying to achieve, the mere attainment of a relaxed state must be complex... Wrong! Humans are great at over complicating things. Finding what works for you, resulting in a decent stress busting state of relaxation can be simple. We shall explore and discuss your stress and how to develop your coping and relaxation strategies in this workbook. SDSO 5
HOW TO USE THIS WORKBOOK This workbook is designed to follow and complement the Relaxation Sessions that operate within the Medical School. However, we know that is often not easy travel to the Medical School to attend these sessions. That is why we have also developed some Podcasts to accompany both the sessions and this workbook. Look out for the podcast symbol in the workbook for accompanying audio guidance. Simply log onto intramed and follow the links to Relaxation. Take your body s need for time to recuperate and relax seriously. Dedicate some time to read through this workbook and work through some of the exercises. It is usually best to aim for at least 3 times a week, perhaps only 30 to 40 minutes each time. By committing to go through these exercises it is also important to commit to continuing them after this course, as the techniques contained within will serve you well throughout life. Furthermore, evidence shows that maximum benefit is gained after regular practice Kabat Zinn, 1990). This workbook is designed to complement the introduction of Mindfulness based techniques. More comprehensive explanations and demonstrations can be found in the resources listed at the end. We would like to remind you that if you need advice about emotional/psychological difficulties you can contact the University Student Counselling and Guidance Service (www.as.bham.ac.uk/study/support/counsell/; 0121 414 5130) or you can make an appointment to see your Year Tutor in the Student Development and Support Office in the Medical School (0121 414 7830; c.maitland@bham.ac.uk ). SDSO 6
STRESS WHAT IS IT? The physiology behind the human stress response is a little complicated to explain here. Nevertheless, it is a complex process whereby the body automatically releases a combination of hormones and neurotransmitters to prepare the body to go into the fight or flight mode. This serves a protective function. However, humans have become particularly good at reacting to potentially inert events with this stress response. In order to survive, mechanisms which enhance the body s ability to deal with potential dangers (such as lions and tigers) and threats (such as infections) have evolved. Situations that are stressful such as a traffic jam are clearly neither a danger nor a threat, an inconvenience at most. Becoming stressed under such circumstances is a result of a learned response. We have been conditioned to respond to a myriad of situations with unwarranted stress. Stress can also be a product of past events and future possibilities. The anger and frustration of past events that we are unable to let go of can have constant repercussions in the present. Anxiety and apprehension generated over possible future occurrences also project back into the present experience, such as staying up all night worrying about an exam or job interview in the morning. WHY IS STRESS BAD FOR YOU? A little bit isn t! Many people function well, especially in terms of producing something for a deadline, under a little stress. However, long term exposure to low levels, or just shortterm exposure to high levels of stress can really take its toll on the body. It is widely accepted that stress exacerbates a great many medical conditions, and it is argued that it may in fact be the direct cause in many others too. Stress is a fact of life, and it would be impractical to avoid everything that caused you the slightest amount of stress. It is important to note how you respond to it. Some stressors, such as a presentation may elicit behaviour such as biting your nails. Whilst this is self destructive, it is not going to cause you any long term harm. However, if your response is SDSO 7
to tend towards violence or panic then the longer term implications are not so good. Therefore, stress in itself may not be particularly bad for you, but the way in which you react to it may be. By being aware of this and that our mind is worrying away unnecessarily, we have the potential to control the way in which we manage feelings from the past and apprehension of the future in order to achieve a better control of our stress levels. Having a level of control over stress has numerous benefits to our physical and mental health, which highlights the importance of cultivating an awareness of how our mind creates stress. Top Tip: Keeping a Stress Diary can help you to get to grips with the common causes of Short Term stress in your life as well as provide insight into how you react to and cope with them. By writing the details of these events down, you can analyse the feelings associated with the event and manage them. This is an important stage in learning to respond differently to similar events or to avoid them all together. There is a Stress Diary template on the next page, try filling it in over the next week or two. SDSO 8
RELAXATION SDSO 9
Many things can help us relax. Listening to music, hobbies, light exercise or just a good long soak in the bath are all great starts. Relaxing is important, but it is often overlooked in our daily routine. By taking time out to relax, you are giving your mind and body time to recover. This has obvious effects on stress and anxiety, but has been shown to increase your life expectancy too (Patel, et al., 1985). The Life Balance Pyramid is designed to guide you in creating a recipe for developing overall balance and wellbeing. In principle, if you have a good foundation of daily activities and a positive outlook on life, you can build on this with emotional, physical and social supporting activities. Toping this up with more emergency coping skills will help us to deal with all of the things that life has to throw at us in a more balanced manner that is less harmful to our own mind and body. By practicing relaxation strategies, such as the ones mentioned in this section, or Mindfulness, you are developing skills that will benefit you at every level of the pyramid. SDSO 10
EFFECTIVE RELAXATION TECHNIQUES: O PROGRESSIVE MUSCLE RELAXATION (PMR) This technique is very simple and does not require much time. PMR was developed in 1938 by Edmund Jacobson, an American doctor, who noticed that anxiety induced muscle tension and spasms. Jacobson used the principle of the physiology of the body having the capacity to alter the affect of the mind. By controlling the tension in the muscles, and then relaxing them he noticed that patients became less anxious. He successfully used his techniques to treat people with long standing insomnia. Try it Out: Once you are warm, calm and undisturbed, systematically tense groups of muscles, without straining, for up to 10 seconds. Focus on the sensation generated by that tension. Relax that muscle group, and rest for 20 seconds, enjoying the feeling of that muscle group being limp. Often, releasing the tension on an out breath feels really great. Move on to another group next, following the same pattern. Do this for about 15 minutes, or until you fall asleep! Don t worry about where you start and finish, developing your own routine and finding what works for you is best, although some people start with their eyelids and end with their feet. O 7 11 BREATHING This technique is a simple manipulation of the timing of our breaths. It is particularly useful in acute panic attacks, and was developed to help control hyperventilation. Try it Out: Take a nice deep breath in over a period of 7 seconds. Hold that breath for a while and then let it out over a period of 11 seconds. It is a simple as that. Many find it helpful to visualise certain things when breathing, such as breathing in calmness and love and breathing out anger and tension. Others visualise with colours, such as breathing in blue, and breathing out black. O YOGA There are many different disciplines of Yoga to follow, such as Ashtanga or Hatha. There are many books and other, interactive, resources available on this subject. However, yoga should only be practised within the safe and normal limits of your body s capabilities. It is advisable to be introduced under the guidance of an experienced instructor. Top Tip: Try some of these relaxation techniques, keeping a note of how you get on with them in the space provide on the next page. Record what you did, where and when you did it, and the feelings associated with the experience and what you felt afterward. Relaxing is about finding something that works for you so do not worry if you don t get on with them. SDSO 11
These are activities that can be included into your day to a variable degree, however, Mindfulness Based Stress Reduction (MBSR), is a program designed to incorporate certain behaviours as a way of life, a way of living mindfully. Use this space to record how effective you found the relaxation techniques: What activities do you already do that help you to relax? How could you fit regular relaxing activities into your daily life? SDSO 12
MINDFULNESS Mindfulness is a concept derived from ancient Buddhist practices. Put simply, it is the cultivation of awareness. We are often unaware of what our mind is actually doing. Whilst we may be doing one thing, our mind is busying away, worrying about another. As we focus our attention and develop an awareness of this, we are able to control how we emotionally respond to situations as well as control how our mind generates anxiety, fear, frustration and stress. MINDFULNESS BASED STRESS REDUCTION (MBSR) MBSR is a model of therapy that was pioneered and developed by Jon Kabat Zinn. In Massachusetts a clinic for stress reduction has been using MBSR, and another model MBCT (Mindfulness Based Cognitive Therapy) for several decades to treat effectively victims of stress. There is a mounting body of evidence, including some robust randomised controlled trials, to support the claims of the efficacy of MBSR in a wide demographic. KEY PRINCIPLES: In order to gain a greater awareness of what is happening to you in the present and therefore what your mind and body are experiencing you are encouraged to exercise your ability to focus your attention. Mindfulness can be easily described as Paying attention in a certain way with: Purpose, in the present moment with a non judgmental attitude (Kabat Zinn, 1990). By meditating, following specific techniques, you exercise your mind s ability to have an awareness of the present experiences, thoughts and feelings. The aim is to develop a means of breaking the learned reactions that we have to certain situations, such as getting stressed or angry. In being aware of what our mind and body are doing in the present, MBSR enables us to generate space around emotions and step back from the situation to chose a response as opposed to falling back on a reflex reaction. This gives us the means of actively reducing the number of stimuli that cause us stress, but also helps our minds and bodies to deal with stress in a much more peaceful and effective way. WHAT IS IT? Essentially, MBSR is a series of exercises that develop your focus and attention. Many of the meditations use the breath as a starting point. By focusing on what your body is currently experiencing, through it s five senses, you can focus your mind on the present moment. This subsequently enables you to gain an insight into what your mind and body SDSO 13
are a) truly experiencing in the present, and b) what they are doing and what responses they choose. COMMITMENT Your mental and physical wellbeing are your responsibility. Regardless of other commitments, you ought to take your body s needs seriously. This extends to your need to devote time to ensuring that you achieve a good balance and overall state of wellbeing. This needn t mean following the practices within this workbook every day. Spending you time can involve any number of activities. However, committing to developing your stress management and coping skills by occasionally practising the exercises in this book will prove to be very beneficial. The more you practise them, the easier they will become and you will start to notice that you respond to situations in a way that is much healthier to your mind and body. Use this space to explore how you might fit a relaxation routine into your daily life: SDSO 14
HOW TO BE MINDFUL APPROACHING MINDFULNESS When approaching the mindfulness based techniques discussed later, it is important to have the right attitude and to be kind to yourself. In order to create a positive and constructive attitude, there are some fundamental principals to adopt. You may notice how interconnected they are: o NON JUDGING Hold no judgements in your mind. Do not look for or ascribe value to feelings, thoughts or emotions. Pain is just pain. It simply is. When completing a breath inquiry, do not judge how you are breathing. Notice how you are breathing, acknowledge it, and allow it to just be. o BEGINNER S MIND This principle asks you to approach things with an almost childish and blissful naivety. When you make an effort not to attach your behavioural (and emotional) reactions and values to specific situations, you are able to just experience them in their purity. For example, waking up on a dark winter morning. You hear the rain outside and immediately feel glum and lethargic at the thought of having to get out of bed in the cold weather. However, if you break that reactive thought and experience the situation for what it is, you will appreciate how fantastic the bed feels, and how safe and cosy your house feels for sheltering you from the elements and ultimately how grateful you are to the dark and rainy morning for affording you this realisation. o PATIENCE Patience is a virtue! Buddhists describe patience as a form of wisdom. Being patient and understanding that sometimes things will only happen in their own time requires a level of acceptance. The wisdom comes in the acceptance that rushing things may not help matters. Patience comes when you allow things to happen without you rushing them along. o TRUST Trust yourself and your instincts. If your body is telling you that you are uncomfortable, then trust it and change your posture. This is something that is harder for us to recognise and do for our mind. If we are emotionally uncomfortable, we often ignore it, which does not show the trust in yourself that you deserve. SDSO 15
o NON STRIVING Working, or striving, towards a goal is what drives the majority of our activities. This can become a source of stress in itself, causing anxiety and frustration about performance and deadlines. If you adopt a non striving attitude, especially during meditation, you will simply be able to enjoy the present moment. As John Kabat Zinn puts it, non striving is about trying less and being more. o ACCEPTANCE Accepting things for what they truly are enables you to experience them for what they truly are. If you go back to the previous example discussed under Beginner s Mind you will see that by accepting the pure nature of an experience, without that being tainted by your beliefs and values, you can find greater richness and benefit in the experience. o LETTING GO Throughout our lives we experience pleasant and unpleasant things. We tend to hold onto the pleasant experiences, drawing them out. With most of the unpleasant experiences we automatically avoid them in one way or another. With other unpleasant experiences, however, we ruminate and dwell on them. During your meditation practice, let go of all experiences, allowing them to come and go at their own pace without applying any value judgements to them. By adopting these attitudinal foundations, and following the meditation practice, you will be able to start to develop a sense of awareness of your moment by moment experience. Through this, you can become more aware of your body and your mind. Once you have a greater awareness of your thoughts, you can start to deal with the challenging and unpleasant aspects of your life without pushing them away. You will also be able to start being kind to yourself and, by extension, others too. All of this will enable you, giving you choice. You can choose to respond rather than react to situation. This is important in preventing yourself from becoming stressed by the situations you find yourself in. MBSR DEVELOPMENT PATHWAY SDSO 16
POSITIVE EXPERIENCE DIARY In becoming mindful about your thoughts and feelings, you will start to deal and face unpleasant and potentially challenging aspects of your life. This can lead to a great deal of liberation and happiness in the long term, but can occasionally be a little unpleasant in itself. Therefore it is important to take stock of all the good things that you experience. In doing this, you may realise that you can derive pleasure from the most simple of experiences. On the next page there is a grid that you can fill out. Over a week, record details of the experiences that you find pleasant. NEGATIVE EXPERIENCE DIARY In order to deal with the unpleasant, you firstly need to identify it. On a following page, there is a grid to fill in with your unpleasant experiences. Over a week record the details of the events that you find unpleasant. By doing this we cannot only identify what it is that we find unpleasant, but how and why we find them unpleasant, evaluating our behavioural and emotional responses to them too. SDSO 17
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EXERCISES: The following techniques are described in a general way so that you can, and indeed should, adapt to them to an order, method and duration that suit you, your needs and your lifestyle. When you decide to spend some time going through one, or more, of these techniques, make sure that: You will be undisturbed o Turn off / silence mobile phones o Let others in your house / environment know you wish to not be disturbed Find a space to sit or lie down. Firm and comfortable, but not so comfortable you are likely to fall asleep. Ensure that you have a blanket or cover ready as your body temperature may drop. Some people get on better doing these exercises alone. However, there are podcasts available to guide you through them should you wish. These can be found on the Student intramed. Simply log in and follow the links to the Relaxation Programme. Some people do not find these exercises easy, and commonly find that their mind wanders a lot. This is not a bad thing at all. In fact, whenever you are noticing that your mind has wandered, that is in itself a moment of awareness. Just acknowledge it and bring your awareness back to your body. Sometimes people feel very restless during meditation too. This is normal and requires patience and perseverance. Your mind and body take time to settle into the exercise. However, sometimes your resistance may be due to an overwhelming anxiety to get back to work or some other competing activity. In this instance, perhaps leave the exercise for the moment and re schedule for a more appropriate time. Falling asleep is something else that happens quite commonly. This could just be your body telling you that it is tired and needs rest. Do not judge this as a failure to complete the exercise. Use this as a source of feedback, altering the way or the time you do the exercise to optimise your mind and body s ability to fall awake instead. BREATH ENQUIRY Lying flat on your back, allow your mind to become aware of your entire body in this moment. Focus your awareness on your breath, resting your hands, palmdown, one over your chest with the other over your abdomen. Take a few breath cycles to focus your awareness on the sensations associated with SDSO 20
breathing. Bring your awareness to the movement of your chest wall, your abdomen and how this moves your hands resting on your body. Without judging, notice the pattern of movement and what that tells you about the way you are breathing. Is your chest rising before your belly, or your belly before your chest? How deep is your breathing? How fast? Don t try to alter it, don t decide whether it is right or wrong, too this or too that... just notice your breathing and allow it to just be. Use this space to record how effective you found the Breath Enquiry, detailing your experiences: SDSO 21
BODY SCAN This meditation takes your awareness on a focused journey through your body. By concentrating your awareness on a particular part of your body, the sensations, feelings and state and by adopting the attitudinal foundations of mindfulness, you can enhance the relationship that you have with your body. Lying flat on your back, allow your mind to become aware of your entire body in this moment. Focus your awareness on your breath, resting your hands, either by your side, on your hips, or resting on your body. Take a few breath cycles to focus your awareness on your body. Feeling it in its miraculous entirety. Noticing the sensations created between your body and the support beneath you. Allowing, with every out breath, your body to relax and relinquish any tension to the ground beneath. Next, systematically progress through your body, focusing your attention on the sensations and feeling in the present moment. If your mind wanders off, notice it and acknowledge that as a moment of awareness, before gently guiding your attention back to your body and the present. If you notice physical discomfort, do not judge it. Accept it and guide your breath towards that area of the body. With the breath, carry kindness, warmth and love. This may sound odd... but just imagine it and notice the difference! Take anywhere between 15 to 45 minutes to do this. When you are ready, broaden out your awareness to your whole body, then the room and the present moment. Opening your eyes and allowing yourself a few moments to gently come around, getting up slowly. Top Tip: Try the Body Scan, perhaps playing with the order in which you visit specific parts of your body, finding what suits you best. Remember the basic principles, and do not worry if you notice your mind wandering off... when you do notice, this is a moment of awareness and is a positive sign of development. SDSO 22
MINDFULNESS OF BREATHING This meditation focuses your awareness on your breathing and the associated sensations. As your awareness focuses on your body and the coming and going of each breath, you will become attuned to the rhythm and requirements of your body. There are four stages to this exercise. It can be quite challenging to focus your awareness and attention for such a long time, so try working your way up to the four stages by starting with just stage one and adding in the next stage after a week or whenever you feel ready. Posture is quite important for this, ensuring that your body is in a stable position so that it can relax, whilst support deep breathing and not falling asleep. Many find it easier to be sat upright for this meditation. As with the Body Scan, you need to be undisturbed for the duration of your meditation and you ought to have a cover or blanket nearby. Settle into your posture and bring your awareness to your body and start to focus it onto your breathing and the associated sensations. In the first stage of the Mindfulness of Breathing, we focus on each breath, watching it come and letting it go. After each breath, count silently. Do this up to ten and then start again. If your mind wanders or if you lose count, do not judge, just start from the beginning. Allow your mind and body to settle into this meditation and focus your awareness fully before moving onto the next stage. In the second stage of the Mindfulness of Breathing, you continue to focus your awareness on your breathing and the associated sensations. Continuing the same practice from the first stage, however, this time you count before each breath. Again, if your mind wanders or if you lose count, do not judge, just start from the beginning. Allow your mind and body to settle into this meditation and focus your awareness fully before moving onto the next stage. In the third stage of the Mindfulness of Breathing let go of the counting. During this part of the meditation, simply bring your awareness to the breath. Watching it come and go, and watching the spaces in between. Allow your mind and body to settle into this meditation and focus your awareness fully before moving onto the next stage. In the fourth stage of the Mindfulness of Breathing bring your awareness to a specific part of your breath. This may be the sensation of the air rushing through your nostrils or past your lips, or the feeling of the air in your throat. By focusing your awareness on a specific part of the breath, you are exercising your ability to focus and attune your attention and awareness. SDSO 23
Use this space to record how effective you found the Body Scan, detailing your experiences: Use this space to record how effective you found the Mindfulness of Breathing meditation, detailing your experiences: SDSO 24
3 MINUTE BREATHING SPACE This technique acts as a fantastic break. If you find yourself in a potentially challenging situation, take some time out (it doesn t have to be 3 minutes) and run through the protocol: Take yourself aside to a quiet corner where you are less likely to be disturbed. Sit down on a firm and supportive chair. Feel free to close your eyes Top Tip: Try incorporating this into your daily routine. If you manage to do this 3 times a day, 3 to 4 days out of 7, you will start to notice a very significant difference in how you feel. It may be challenging at first, but stick with it. MINDFULNESS OF DAILY ACTIVITIES Simply bring your awareness to your bodily sensations during a daily activity. This can be anything from making a cup of tea, to having a bath or shower. Focus your mind on your breath and particular sensations in your body. As with the other exercises, practise adopting the fundamental attitudes and notice if SDSO 25
and when your mind wanders off. This can be an easy and refreshing activity. At first it may prove challenging, but it does get much easier. Use this space to record how effective you found the 3 Minute Breathing Space, detailing your experiences: How & when will you integrate this into your daily life? Use this space to record how you get on with the Mindfulness of Daily Activities, detailing your experience: What activities did you chose and why? What others could you be mindful about too? SDSO 26
REFERENCES: Cannon W. 1932. Wisdom of the Body. W. W. Norton and Company. New York. Jacobson, E. 1938. Progressive relaxation. University of Chicago Press. Chicago. Kabat Zinn J. 1990. Full Catastrophe Living. Delta Trade Paperbacks. New York. Patel C, Marmot MG, Terry DJ, Carruthers M, Hunt B, and Patel M. Trial of relaxation in reducing coronary risk: four year follow up. BMJ 1985; 290:1103 6. Vedhara K and Irwin M. 2005. Human Psychoneuroimmunology. Oxford University Press. Oxford. Williams M, Teasdale J, Segal Z and Kabat Zinn J. 2007. The Mindful Way Through Depression. Guilford Press. New York. FURTHER INFORMATION Breath works is more of a community than a company. They are a very friendly and affordable means of exploring and developing your own mindfulness practice. http://breathworks mindfulness.org.uk/ The UCSF Oscher Centre for Integrated Medicine: www.oscher.ucsf.edu UMass Centre for Mindfulness: www.umassmed.edu/cfm/mbsr Bangor University Centre for Mindfulness Research and Practice: www.bangor.ac.uk/mindfulness Human Givens Institute: Unique approach to Mental Health aiming for emotional health and clear thinking: www.hgi.org.uk/ SDSO 27
Resources provided by the University of Birmingham: The Counseling and Guidance Service: Phone: 0121 414 5130 Opening hours: Monday Friday Term time Vacation 9.00am 5.00pm 9.00am 12.30pm and 1.30pm 5.00pm (Evening appointments are also available during term time) CalmYou: The University s on line CBT program. Access through: www.my.bham.ac.uk using your university login details. Go to Support then CalmYou. The Advice and Representation Centre (ARC): Phone: 0121 251 2400 WWW: bugs.bham.ac.uk/support/arc/ SDSO 28
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