The Wellbeing Course LESSON 4: DIY Guide The Wellbeing Course was written by Professor Nick Titov and Dr Blake Dear
Welcome to the Lesson 4 DIY Guide We hope you have had a chance to read through the Lesson 3 materials a couple of times. Lesson 3 discussed the management of strong Physical Symptoms. The aim of Lesson 4 is to teach you about the Behavioural Symptoms of anxiety and depression and to cover some practical skills for managing them Prof Nick Titov Dr Blake Dear Research shows that applying the skills in this lesson helps to reduce the symptoms of anxiety and depression. We also know that changing habits and routines is challenging. But the majority of people in our Courses tell us these skills are practical and helpful. We hope you find this DIY Guide helpful. Professor Nick Titov, Dr Blake Dear, and the MindSpot Clinic Team If you have any technical difficulties, please let us know. Email: contact@mindspot.org.au. Contents About Unhelpful Behaviours... 3 Why Do People Use Avoidance and Safety Behaviours?... 5 About Graded Exposure... 5 How Does Graded Exposure Work For Anxiety?... 6 How Does Graded Exposure Work For Depression?... 6 Developing an Exposure Stepladder... 7 Jo and Glenn s Examples of Graded Exposure... 7 More Ideas For Graded Exposure... 11 What People Have Told Us... 13 Summary... 14 This Week s DIY Tasks... 14 Worksheet 1: Graded Exposure... 15 2
About Unhelpful Behaviours Unhelpful behaviours are the things we do and don t do that keep the cycle of symptoms going. The main type of unhelpful behaviours that are important in both anxiety and depression are: Avoidance Behaviours: When we avoid doing things because of fear or low motivation. Safety Behaviours: These are things we do to help us cope with our fears or low motivation. Common Avoidance and Safety Behaviours Please refer to the tables below for some common examples of avoidance and safety behaviours experienced by people with anxiety and depression (check the box next to the behaviours that apply to you). Panic Symptoms Avoidance Behaviours Avoiding places that might trigger panic attacks (e.g., driving, shops, crowds, public transport etc.) Avoiding things that could trigger panic symptoms (e.g., caffeine, spicy food, exercise, etc.) Avoiding trying new things (e.g., new sports, meeting new people, going out to unfamiliar places, etc.) Avoiding challenging situations and challenging tasks (e.g., new jobs or tasks, confrontations etc.) Safety Behaviours Needing someone to go with you into certain situations or to be around the right people Only doing things under very specific conditions and if it is the right time Going to the doctor for repeated check-ups despite numerous negative tests Having a few alcoholic drinks before doing anything challenging to reduce anxiety Social Anxiety Avoidance Behaviours Avoiding public situations (e.g. parties, social gatherings, presentations, crowded places etc.) Avoiding eye contact or saying hello to people Avoiding speaking to people directly, making phone calls, asking questions, etc. when it is appropriate Avoiding eating in public, using public bathrooms and participating in group activities Avoiding going for jobs or promotions where social interaction is required Safety Behaviours Needing someone to go with you into certain situations or to be around the right people Carrying something with you into social situations, i.e. Water bottle or mobile phone Always preparing for the worst (e.g. staying near exits, over-preparing and rehearsing what you are going to say) Having a few alcoholic drinks before going to functions or parties to reduce anxiety 3
Excessive Worry Avoidance Behaviours Avoiding news, TV, shows and movies that remind you of worries regarding family, friends etc. Excessive planning and list making to make sure everything gets done and you are always prepared Never deviating from plans or going into unfamiliar or unplanned situations so as not to rock the boat Avoiding actively managing worries and relying on others for reassurance that things will be okay Avoiding challenging situations and new things which can lead to stress and worry Safety Behaviours Always checking on family and friends to make sure they are okay Always expecting and preparing for the worst-case scenario Always needing a mobile phone and following a routine in case of the worstcase scenario Getting others to do things for you or accompany you for reassurance and so you don t worry Using alcohol or drugs to reduce anxiety Low Mood and Depression Avoidance Behaviours Avoiding social situations and contact with people Avoiding regular exercise, hobbies, and things you usually enjoy Avoiding problem solving and things that help you to cope and feel better Avoid expressing your opinions on important things Avoiding dealing with responsibilities (e.g. paying bills). Safety Behaviours Making excuses for not going out with family or doing social activities Telling yourself you are too tired to do the things that everyone else does Eating excessively to cope with distressing thoughts and disappointment Procrastinating on important issues and putting other people s needs before your own wellbeing Please see our resource Managing PTSD for more information on experiencing symptoms as a result of a traumatic event. 4
Why Do People Use Avoidance and Safety Behaviours? People often use avoidance and safety behaviours because: - People imagine something bad will happen or will make their symptoms worse. People often over-estimate the chance of something bad happening and how bad things will be. - People doubt their ability to cope with their symptoms if something bad did happen. People often under-estimate their abilities to cope with difficult feelings and situations. The trouble with avoidance and safety behaviours is that, while they often make us feel better in the short-term, they keep the cycle of anxiety and depression going in the long-term. They stop us from learning that: 1. We can cope with uncomfortable feelings. 2. Things are often not as bad as we expect them to be. 3. Unpleasant feelings often reduce over time if we confront difficult situations, especially feelings of panic and low energy. 4. We need to do things every day to make us feel good about ourselves. About Graded Exposure Research tells us that graded exposure is one of the most powerful ways of reducing anxiety and depression. Graded exposure has been used since the 1950s. Results of 100s of research studies have found that graded exposure is a simple, but very helpful skill. Graded Exposure is very effective for overcoming fears, worries and doubts about managing all sorts of physical and other everyday activities, tasks and situations. For example, starting a new physical activity, starting work, asking for help, talking to others about difficult topics, being in public and interacting with people more, being alone or out of our normal environment. Essentially, we can use graded exposure for any activity, task or situation that triggers discomfort, stress and anxiety or we have fears, worries or doubts about. Because it is gradual, graded exposure helps us safely and systematically: Gradually confront the things that we have been avoiding, beginning with the things that are only slightly difficult to do. Over several days we can practice confronting a task until it becomes easy to do that is, it no longer triggers symptoms. We can then confront something that is slightly harder to do until the symptoms fade. By gradually confronting of exposing ourselves to the things we find difficult, we learn to cope with more and more difficult situations. Doing this builds confidence and competence, and helps us to resume activities we have been avoiding. It also teaches the body to reduce symptoms of panic and low energy. 5
How Does Graded Exposure Work For Anxiety? Clinical studies tell us that if you keep going into a situation that triggers anxiety (e.g. the Fight or Flight Response) the severity of your symptoms will reduce and won t last as long. Graded exposure helps by teaching your body not to trigger the Fight or Flight Reflex. And, at the same time, it gives you the opportunity to practice managing your symptoms in a gradual and controlled way. Over time this means your symptoms reduce and you learn effective strategies for managing the symptoms of anxiety without avoidance and safety behaviours. How Does Graded Exposure Work For Depression? Most people with low mood also avoid some situations or activities because of anxiety or fear. But, they may also avoid because they don t believe they have the energy to cope with the activity or that they won t enjoy the activity. Graded exposure helps to tackle these fears and feelings by allowing people to confront them in a gradual and consistent way. As we continue to gradually confront situations we avoid, our energy levels, motivation and confidence improves and our natural enjoyment increases (see graph below). 6
Developing an Exposure Stepladder To get the most out of Graded Exposure it is essential to create an Exposure Stepladder, which helps to guide us and measure our progress. Developing a Stepladder involves 3 steps: STEP 1: Think of something you would like to be able to do. This is your goal. It can be anything. But, make sure it is safe and realistic if unsure, check with your doctor. STEP 2: Think of lots of similar activities, tasks and situations, and rank them from easiest to hardest. Every activity, task and situation can be broken down into smaller bits. The goal is to come up with a range of similar activities and tasks without big jumps in between them. Be creative and brainstorm with others. STEP 3: Pick an easy task that you can do and do it until it becomes easy. Pick a task or activity that you know you can do now and do it until it becomes very easy. Then, pick the next thing you know you can do and work your way up over days, weeks and months - sometimes it can take a long time. The trick is to start very low and build up slow. Some key points to remember Pick a realistic and important goal. If it s not realistic, then it isn t possible and trying to achieve it may make things worse. If it isn t important, it will be hard to stay motivated and stick at it. Break goals down into steps by making a step ladder. Having a ladder is essential. So, identify lots of similar activities, tasks and situations to work on for your ladder so, there is always a next step that is possible. Start low and build up slow: Always start low and increase towards your goal in a very gradual way. Starting too high or increasing too fast can reduce your motivation and confidence. Some days will be tough: Building up our activity levels is hard work. Things won t always go as planned and there will be tough days. So, it is essential that we are realistic in your expectations and gentle with ourselves. Jo and Glenn s Examples of Graded Exposure Let s see how Glenn and Jo use graded exposure. 7
Step 1: Think of a goal and similar tasks - Think about how the goal, activity or situation can be made smaller or manageable. Be creative. Step 2: Rank these tasks If a particular task or situation is too hard think of something you can change to make it easier. Step 3: Pick an easy task and do it Pick an activity, task or situation that you know you can do now without too much difficulty. - Do that activity, task or go into that situation until it becomes easy. Then, work your way up. - The trick is to start low and build up slowly. My Goal: To go for a 60 minute walk, 3 times a week Similar tasks include: - 10 min walk with mate 3 times a week - 20 min walk with a neighbour 5 times a week - 10 min jog, 3 times a week - 30 minute walk, 4 times a week - Doing stretches for 5 mins, 3 times a week - Walking by myself for 5 mins, 3 times a week Stepladder Goal: Walking 3 days a week for 60 minutes 1... Very hard: 10 minute jog, 3 times a week 2 Hard: 30 minute walk, 4 times a week 3 Medium: 10 minute walk with neighbour, 5 times a week 4 Medium: 5 min walk alone, 5 times a week 5 Easy: 10 minute walk with a mate, 3 times a week 6 Easy: Stretches for 5 mins 3 times a week 7 Easy: Walking by myself for 5 mins, 3 times a week 8 Glenn decides to begin with the easiest task from his list. He also decides to increase his motivation by inviting his neighbour and a mate to join him. As his fitness and energy need to improve, he starts to feel more confident and that he is sleeping better. The first two weeks were the hardest, but Glenn used his phone to remind him to exercise more. He also bought himself a new music download as a reward after doing this for a month. It took Glenn 2 months to reach his goal. 8
Step 1: Think of a goal and similar tasks - Think about how the goal, activity or situation can be made smaller or manageable. Be creative. Step 2: Rank these tasks If a particular task or situation is too hard think of something you can change to make it easier. Step 3: Pick an easy task and do it Pick an activity, task or situation that you know you can do now without too much difficulty. - Do that activity, task or go into that situation until it becomes easy. Then, work your way up. - The trick is to start low and build up slowly. Goal: To go back to the scene of the accident Similar tasks include: - Reading the work report about the accident - Writing down what happened at the accident - Look at images of accidents on the internet - Going to harder call-outs at work - Park at the place where the accident occurred - Talk to my friends about the accident Stepladder Goal:.Going back to the place where the big accident occurred. Very hard: Standing for 20 mins in the field where the car and truck landed after colliding 1 Hard: Parking next to the place where the accident happened 2 Hard: Going to a harder call-out at work 3 Hard: Reading the work report about the accident 4 Easy: Talking to my friends about the accident 5 Easy: looking at images of car accidents on the internet 6 After looking at images on the internet and talking to two friends and his wife about the accident, Glenn felt more able to read the work report about the accident. This was difficult for Glenn and he needed to practise some of the skills like controlled breathing and grounding and thought challenging. Re-reading helped him feel less anxious about it After two weeks he went and parked at the place where the accident happened. It wasn t easy, but going through the ladder had prepared him. Glenn needed to do this 5 times before he was able to get out of the car and stand where the car and truck collided. At first he could only do this for 5 minutes but by going back every day for a week he was able to do it for 20 minutes. 9
Step 1: Think of a goal and similar tasks. - Think about how the goal, activity or situation can be made smaller or manageable. Be creative. Step 2: Rank these tasks If a particular task or situation is too hard think of something you can change to make it easier. Step 3: Pick an easy task and do it Pick an activity, task or situation that you know you can do now without too much difficulty. - Do that activity, task or go into that situation until it becomes easy. Then, work your way up. - The trick is to start low and build up slowly. Goal: Give speech at my sister s small wedding Similar tasks include: Talking with friends Giving a speech in front of friends Talking in front of my boss and team at work Talking in front of people I don t know Reading a speech out loud in front of a mirror Saying hello to a stranger Having a conversation with a stranger Stepladder Goal: Giving speech at the wedding...1 Very hard: Giving speech in front of boss at work 2 Hard: Talking in front of team and people I don t know 3 Hard: Talking with a large group of friends 4 Medium: Saying hello to a stranger on the street 5 Medium: Starting a conversation with a stranger 6 Easy: Talking with my family 7 Easiest: Write and read speech out to myself 8 Jo decides to prepare her short speech and practice on her own. Then she practices by talking more in front of her friends. She notices that as she moves up a level her anxiety increases but then reduces as she builds her confidence. She also makes an effort to drop her safety behaviours (speaking quickly, avoiding eye contact). She doesn t move to the next level until she feels relatively comfortable. Jo achieved her goal of giving a very brief speech at her sister s wedding in 1-2 weeks. 10
More Ideas For Graded Exposure Below are more ideas to help you to create your own Exposure Stepladder. Some of these ideas may seem bizarre, but the idea behind them is that they allow you to directly test your unhelpful beliefs, which is a very powerful way of tackling the Cycle of Symptoms. Panic Symptoms Breathe through a straw for 30 seconds, 1 minute, etc. Walk up and down stairs quickly for 1, 2, 5 minutes, etc. Put cotton pads or tissues in mouth while doing day-to-day activities (e.g. simulate dry mouth, etc.) Spin on the spot for 30 seconds or 1minutes, etc. Wear an extra layer of clothing or sit in a hot car for 5, 10 or 15 minutes, etc. (e.g. to simulate being hot, etc.) Breathe quick and shallow for 1, 2, 5 minutes, etc. (e.g. to simulate hyperventilation) Put your head in your lap for 1, 2 or 5 minutes, etc. (e.g., to simulate being light headed) Eat spicy food, drink caffeinated beverages, etc. Hold breath for 10, 20 and 30 seconds, etc. Shake your head from side to side (e.g., to simulate feeling dizzy) Assertiveness Saying no to a child, partner, colleague or friend Delay responding to requests rather than responding immediately (e.g., by saying I ll think about it ) Ask someone to stop a behaviour that is annoying you (e.g., a friend who keeps turning up late) Ask a store attendant for a price check or a refund Discuss your concerns and/or feelings with someone Politely ask for help with something Ask a sales person to describe a product to you in detail and ask questions Express an opinion or idea Decline a request at home or work Pay for something in very small change. Reassurance Seeking Travel to an unfamiliar place without company, a mobile phone, etc. Do not check the news or weather for 1, 2 or 5 days, etc. Do not check your body for physical symptoms for 1, 2 or 5 days, etc. Reduce checking of mobile phone for messages, phone calls, etc. Do not remind family members of anything for 1, 2 or 5 days, etc. Do not check in or ask family members about something you are worried about for 1, 2 or 5 days Go to the grocery store without a shopping list Leave mobile phone at home for 1, 2 or 5 days, etc. 11
Perfectionism Wear mismatching outfit for 1 day, etc. Do not wear makeup for 1, 2 or 5 days, etc. Deliberately mispronounce a word or make a mistake when talking to a friend Deliberately make a mistake or a typo in an email, report, etc. Do not use a mirror or check oneself for 1 day, etc. Do not clean house for 1, 2 or 5 days, etc. Deliberately make a social faux par by calling someone by the wrong name, etc. Miss exercise for 1, 2 or 5 days, etc. Leave dirty dishes in sink and invite friends over, etc. Send an email to a colleague or your boss with typos in it Low Energy and Fatigue Walk for 5, 10, 20 or 30 minutes, etc., once, twice, three times or more a week Jog for 5, 10, 20 or 30 minutes, etc., once, twice, three times or more a week Swim for 5, 10, 20 or 30 minutes, etc., once, twice, three times or more a week Do stretches 5, 10, 20 or 30 minutes, etc., once, twice, three times or more a week. Do 1, 2 or 3 pleasant activities, etc., each day Do 1,2 or 3 social things (e.g., call a friend, say hi to someone, meet up with a friend, etc.) each day Do 1, 2 or 3 small things you ve been putting off (e.g. household task, cleaning or chore) Social Anxieties Say hi to 1, 2 or 3 people you usually wouldn t talk to in a day (e.g. the bus driver) Strike up a conversation with a stranger or colleague Deliberately dial the wrong telephone number Ask a stranger the time or for directions Compliment a friend, colleague or stranger Speaking loud on the phone while in public (e.g. on the bus, on the train) Ask someone the time while wearing a watch / ask someone directions then walk in the opposite direction Go into a shop try on several items and then don t buy anything Buy something with lots of small change 12
What People Have Told Us Over the years we have worked with a lot of people with anxiety and depression and we have asked people to provide us with feedback about their experiences, and things they thought were important to keep in mind. In this section you will find some key messages from our previous participants Start with an easy task and progress gradually. People often tell us that starting on a step that is too high is too challenging, and reduces confidence. Remember to start on something that is less challenging and work your way up the ladder. Don t do anything too difficult too soon that s why it s called graded exposure! A good rule of thumb is to keep practicing the task and stay in the situation until it becomes boring. Make a good ladder. People say it helps to be flexible and to identify lots of potential tasks to work on for your ladder. We ve found that this helps participants to make quick progress and to improve their confidence in lots of areas of their life. Expect some anxiety. Most people tell us that graded exposure is hard work, but the good news is that it works! It is normal and necessary to experience some anxiety during graded exposure so that your body and mind have the opportunity to adapt to that level of anxiety and learn that nothing terrible is going happen. Use your other skills! People often tell us they have been confronting their fears and low motivation, but they still really struggle. We have learned that combining skills is essential for people to really tackle their fears or low motivation. So, it is essential to challenge unhelpful thoughts and your physical symptoms when doing graded exposure. Be determined. Some days will be tough. Remember that recovery involves ups and downs. Occasionally, things won t go as planned. But learn from your experiences and move on. 13
Summary We have covered a lot of important information. Let s review the key points: 1. Avoidance and safety behaviours are common behavioural symptoms of anxiety and depression. 2. They can be tackled with graded exposure which involves 3 steps: Think of a goal and similar situations and tasks Rank them from easiest to hardest on a ladder Start practising an easier task until it is no longer difficult. Then, carefully and gradually work your way up the ladder 3. Remember, graded exposure works by allowing us to practice our skills and improve mastery of different situations. Like the other skills in this course we firmly believe that graded exposure is one of the key skills all people need to learn. Congratulations on your progress so far. Lesson 5 contains helpful information about getting better and staying well. Please log back into www.mindspot.org.au again and review Lesson 4. Please revisit the website as often as you like to re-read any of the lessons and check when Lesson 5 becomes available. This Week s DIY Tasks Our experience tells us that those who benefit the most from the course do the following: Re-read the Lesson and DIY Guide for Lesson 4 at least twice this week. Complete and use the Graded Exposure worksheet at the end of this DIY Guide. Have a look at the Case Stories and Additional Resources. Copyright 2015 The MindSpot Clinic All rights reserved. You may use and/or copy this information for personal reference only. The MindSpot Clinic endeavours to ensure all information contained in this material is correct at the time of inclusion. However, the accuracy of the material cannot be guaranteed and people using the information do so entirely at their own risk. The information may not be reproduced or published in any other way or by any means without the prior written consent of The MindSpot Clinic. 14
Worksheet 1: Graded Exposure Step 1: Think of something you would like to be able to do - Think about how the goal, activity or situation can be made smaller or manageable. Make sure it is realistic and be creative. Step 2: Think of lots of similar activities and tasks, and rank them from easiest to hardest - Every activity, task or situation is made up of smaller or easier activities, tasks or situations. - The goal is to come up with a broad range of similar activities, tasks or situations without any big jumps between them. Be creative. Step 3: Figure out what you can comfortably and safely do now - Pick an activity, task or situation that you know you can do now without too much difficulty. - Do that activity, task or go into that situation until it becomes easy. Then, work your way up. - The trick is to start low and build up slowly. 15