Handouts, questionnaires and other leaflets

In my 'consulting room' I have two big magazine style racks on the wall (see below). Each rack has eleven compartments, and each compartment contains 10 to 20 different A4 sheets of questionnaires, information leaflets, Powerpoint miniatures, and other handouts (300 to 400 items in all). I've listed compartments on the left. Click on the different headings to gain access to compartment contents.  

I have also included background details for training courses that I run - see folders on the left.  One is "Autogenic relaxation training" which gives details, handouts & MP3 recordings of an eight session relaxation/meditation/mindfulness course.  I ran this course for many years.  It has now been incorporated into a longer, broader course - the twelve session "Life skills for stress, health & wellbeing".  Also of interest for a more purely mindfulness-focused training, see "Using Williams & Penman's book "Mindfulness: a practical guide" as a self-help resource - overview of 10 supporting blog posts".  The other regular course I facilitate myself is on "Interpersonal group work" and the link on the left gives handouts and a session by session description of a typical "Opening up" group.   


Introduction & monitoring

Here are a series of forms that I use almost every session with clients, or for screening and orientation at the start of therapy:

Summary sheet - at the end of virtually every session with a client I move my chair round to sit beside them and, using a clipboard to press on, I write out a summary sheet.  Under the sheet is a second "No carbon required" (NCR) sheet, so when I hand them the summary, I have a copy which I put into their notes.  It would probably be cheaper, but a little more fiddly, to use a sheet of carbon paper to make the copy.  Summary sheets seem to be useful in a whole series of ways.  They can emphasise key points and highlight ‘homework' assignments.  We refer to them early in the next session together, encouraging linking from appointment to appointment, and making it more likely that homework will be discussed.  The summary sheets also mean I don't have to keep many notes during the session itself (the sheet acts as the notes), so I can give more attention to the client.  A further benefit is if there is a subsequent muddle about the time of the next appointment, the date and time have been written at the top right of the summary sheet and it can be checked back to.  Finally, I typically give clients an A4 folder at the first or second session with me and suggest they keep all the handouts, summary sheets and reflection sheets in their folder.  I'm fairly regularly told by clients that they get a good deal of benefit going over these folders - even years later, when maybe they are facing another difficult time in their life.

Reflection on session - I usually hand one of these sheets to clients at the end of each session with me.  I ask them to fill it in and bring it back with them to the next session.  I tell them that they are probably going to get most benefit from this exercise if they fill in the sheet within a few hours after the end of the session.  At the start of the next session my usual sequence is to collect and score (and put onto their progress chart) any assessment questionnaires that we're using to monitor their anxiety or depression or other difficulties.  I then look at the summary sheet from the previous session - usually using their top sheet as it tends to be easier to read than my NCR sheet.  I then look at their reflection sheet(s).  This is only a typical sequence and sometimes (for example if they come in looking pretty distressed) I will use other sequences in how we start sessions.

Reflection on recording - if there were one thing I would change about my one-to-one work with clients over the last decade or so, high on the list would be to have started recording sessions sooner.  I've only been being doing this for a few years now and it seems very helpful.  As you can see, there's a question on the "reflection on tape" sheet asking (0 to 10) how useful they found it having a tape of the session.  Clients typically score the usefulness somewhere around 7, 8 or 9.  What I do is tape almost every session with clients (not usually the history-gathering first session) and hand them the tape at the end of the session with the request to listen to it at least once at some point before the next session and then fill in the ‘reflection on tape' sheet.  Where the session has involved quite powerful emotional work (e.g. with PTSD) I might encourage them to listen to the tape several times or even daily.  Occasionally they will let others (e.g. their partner) listen to part or all of their tape - to help the other person understand particular issues better.  Mostly they bring the tape to their next session and we simply recycle it by recording the next session over it.  I say that, if there are any sessions where they want to keep the tape indefinitely, they are welcome to do so.  With my summary sheet, the reflections sheets, the tapes, and other personal material, I suggest they take care that they store this material securely. 

We're at a somewhat difficult transition phase technologically.  I could record sessions on a digital voice recorder and then send the recording to the client later in the day via email.  This isn't really realistic for me.  I'm often hugely busy and sorting out attachments and emails like this at the end of every day with clients just doesn't make good sense.  Similarly actual session time is full enough as it is, without adding in time for transcribing digital recordings to CD's or other media.  I use a simple Sony tape recorder and a small microphone. This duo works well together.  I've tried small tieclip style microphones as well, but any added pick-up quality isn't worth the cost of impeded movement for me (I move my chair around during the session to be at an angle (usually), facing, or beside the client).  Most people can dig an old tape recorder out of their attic, or somewhere, to listen to the tapes.  I keep a few Sony Walkman personal tape players that I can lend out or sell to people who don't have a tape player at home.  Occasionally someone will prefer to bring in their own digital recording equipment instead.  If you are going to see a therapist who doesn't record sessions for you, I recommend you consider taking in your own recording equipment.  Nearly always any sense of artificiality about being recorded or nervousness about listening to one's own voice rapidly dissipates with a few minutes use.  Adding to these comments in 2012, I would point out that lots of clients now carry smart phones which have perfectly adequate voice recorder/voice memo modes and very reasonable built in microphones.  This is ideal because they can then listen to the recording - for example through headphones - in their own time.  I also now stock a few cheap digital dictaphones as well as a few analogue personal tape players, so I can lend out gadgets for either of these formats. 

Reflection on therapy overall - I probably don't use these overviewing reflections sheets as much as would be most helpful.  I do use them occasionally though - at the end of a sequence of therapy sessions or at other review times.

Reflection on reading - another sheet to encourage reflection.

Learning circle of experience - a Powerpoint slide handout that I occasionally use with clients when we're discussing the importance of both active engagement and reflection in the process of therapy.

Making therapy as helpful as possible for you - an important orientation handout that I give to nearly all new clients at the end our first session together.

M.I.N.I. screen and other questionnaires - I regularly use the M.I.N.I. screen, typically in the latter part of the first session with a new client.  The M.I.N.I. screen is an abbreviated version of the full Mini International Neuropsychiatric Interview (M.I.N.I.) - "the most widely used psychiatric structured diagnostic interview instrument in the world.  The M.I.N.I. has been translated into 43 languages and is used by mental health professionals and health organizations in more than 100 countries."  I find this very useful - for example in picking up significant comorbid problems that I've missed in the initial interview.  Unfortunately, in its most recent version 6.0, it is no longer free, but at a once off fee of less than $20 it ain't bad!  See the Medical Outcome Systems website.

Attitudes to therapy scale - I use this to monitor confidence and empathy.  Both are crucially important for effective therapy.

Expectancy & credibility scale - downloadable as both a PDF file and as a Word doc.

Progress charts - I use these charts to monitor clients' progress.  Usually at the first or second session together we will have come up with one, two, possibly three, rarely four, assessment questionnaires that seem particularly relevant for tracking progress with difficulties that are important to the client.  Examples are questionnaires assessing anxiety and depression levels, more specific assessments of PTSD, OCD, panic, etc, severity, measures of functioning & disability, measures of wellbeing & happiness, and at times just "bog standard" measures using simple 0 to 10 scales to assess the severity of problems that are not easily covered by standard questionnaires.  I usually start using a week-to-a-square progress chart and, when therapy sessions become more widely spaced, I may move on to fortnight-to-a-square, month-to-a-square, or even two-month-to-a-square charts.  I find this charting hugely useful.  I typically keep questionnaires that clients fill in at the start of therapy (partly to refer back to later on to highlight changes), but with all subsequent questionnaires I usually transfer relevant scores to the chart and destroy the questionnaire (it helps to reduce endless paper storage).  The visual picture presented by the chart seems much more helpful than scores that are presented just as a series of numbers.  If we're making good progress, this shows clearly on the chart and tends to boost a client's optimism and commitment to the work we're doing.  If we're not making adequate progress, this too shows on the chart and helps to underline the importance of adding additional therapy components (e.g. medication to psychotherapy or vice-versa) or other changes.  We can also put other information onto the charts such as changes of job or other life circumstance.

Depression information

Here are a few handouts that I've put together over the years to provide background information about depression.  The development/maintenance diagram is probably the handout here that I use most - both to explain issues about depression and also for many other psychological disorders as well. 

Development & maintenance of distressed states - I use this Powerpoint diagram - also available as a PDF - a lot when discussing with people why they are in a distressed state.  The diagram applies to depression but it also applies to nearly all other distressed psychological states as well.  It can be helpful in highlighting the importance of maintaining, precipitating and vulnerability factors.  I also point out that therapeutic gains can be made working with all three of these general sets of factors - for example, emotional processing work for past experience (both precipitating and vulnerability factors) and more standard cognitive-behavioural approaches for maintaining factors. 

Why do we get depressed & what can we do to get better? - I print out this pair of Powerpoint slides as a two-slides-to-a-page handout.  It combines the development/maintenance diagram (see above) with an introduction to an evolutionary psychology view of depression.  This latter can help to destigmatise the depressive state and make further sense of it. 

Diagnosing depression - this two-sided handout gives diagnostic criteria for DSM-IV diagnoses of depression, dysthymia, mania & hypomania.  It also gives a diagram illustrating different kinds of depression.

Depression, background information - I put this four page handout together quite a few years ago now.  It seems to have withstood the passage of time pretty well, with most of the facts and figures still accurate.

"Vicious circles" model & other ways of feeling/responding - two Powerpoint slides I typically print out as full A4 handout sheets.  They illustrate how behaviours, relationships, body states & thoughts/images can all combine as vicious circles maintaining depression or as methods that combine to encourage recovery.

Antidepressants, timing of response - traditionally people tend to be told that they will have to wait for three or four weeks before they may get much benefit after starting antidepressants.  This isn't correct and these research abstracts highlight that response typically occurs in days not weeks.

 

 

Depression assessment

Depression assessment scales come in two basic forms - interviewer/clinician rated and sufferer/patient rated.  As stated in the background information on the IDS/QIDS questionnaires (see below) "There are several accepted clinician rated and patient self report measures of depressive symptoms. The most commonly used clinician rated scales are the 17, 21, 24, 28, and 31 item versions of the Hamilton Rating Scale for Depression (HRSD) (Hamilton 1960, 1967), and the 10-item Montgomery-Asberg Scale (Montgomery and Asberg 1979). The most frequently used self-reports include the 13, and 21 item version of the Beck Depression Inventory (BDI) (Beck et al. 1961), the BDI-II (Beck et al. 1996), the Zung Depression Rating Scale (Zung 1965), the Carroll Rating Scale (CRS) (Carroll et al. 1981), and the Patient Health Questionnaire - 9 (PHQ-9) (Kroenke et al. 2001)."  There are problems with many of the older scales - either because the scales themselves are flawed - like the Hamilton - or because they are expensive - like the Hospital Anxiety and Depression Scale (HADS) and the Beck Depression Inventory - or both.  Happily there are several good, free, quick scales currently available to choose from.  Unfortunately different scales may not agree as much as one would want on, for example, the severity of someone's depression.  Good clinical judgement is also required.

Combined PHQ-9, GAD-7 & phobia measures - the UK Increasing Access to Psychological Therapies (IAPT) initiative recommends routine use of a combination of questionnaires, the PHQ-9 for depression, GAD-7 for anxiety, and three IAPT phobia scales (social, agoraphobia, and specific phobia).  Here is a downloadable version of this combined measure.  Click for a 7 page PDF giving more background information about the PHQ-9 and GAD-7, including helpful scoring information.  If one only wants to measure depression, or if one is using a specific anxiety measure (e.g. the SPIN, IES-R, etc) and so don't need the more general GAD-7, here is the PHQ-9 downloadable on its own as a Word doc and as a PDF file

Two Question Screening for Depresson - this is a two question primary care screen - with a possible further four questions for to clarify likely diagnosis further.

Inventory of Depressive Symptomatology (IDS) and Quick Inventory of Depressive Symptomatology (QIDS) - the IDS is a 30 item scale while the QIDS contains 16 items.  Both are available in both clinician-rated and patient-rated forms (e.g. QIDS-SR16 & background) .  They are also available in, at least, a couple of dozen languages.  These are very well researched and widely used scales - for example in the huge US STAR*D research studies.

Clinically Useful Depression Outcome Scale (CUDOS) - this is an 18 item patient rated scale.  In some ways it is easier/quicker to score than the QIDS (but less researched & less widely used).  The CUDOS also contains questions on function & life quality.  It is free to use in its paper version or can be linked to a subscription when patients can score it via the internet and the clinician can access these scores - with a chart showing change in scores across time, and a linked patient appointment reminder system.  The website provides scoring information and the related Clinically Useful Anxiety Outcome Scale (CUXOS).

Depression Happiness Scale, full 25 item scale (DHS) & shortened 6 item scale (SDHS) - these scales - both long and short forms -are of particular interest in allowing assessment of movement into happiness & wellbeing (as well as monitoring of depression). 

Geriatric Depression Scale, full 15 item scale & shortened 5 item scale - a number of research studies have documented the value of these simple questionnaires - both the fuller version & the shorter version - for detecting and monitoring depression in the elderly. 

Mood Disorder Questionnaire (MDQ) - a good screening scale for detecting bipolar spectrum disorders (mania & hypomania) that can improve patient care in primary care, psychiatric service and possibly too general community settings.  I sometimes use an unvalidated weekly adaptation to monitor progress. 

Dysfunctional Thoughts Record - here's a classic thought monitoring record.  The success of simple behavioural activation in comparative trials with the fuller cognitive behavioural package means that I now rarely use this type of record sheet.  This is further reinforced by the way mindfulness based cognitive therapy and ACT teach taking a different stance to the process of thinking itself rather than disputing the content of thought.

Rumination Record - here's a simple 4 question rumination scale assessing frequency, interference caused, sense of uncontrollability, and associated distress.  Rumination is a major problem in depression, so it can be helpful to target it.

Intrusive Memories Record - distressing memories may be clinically important in the onset/maintenance of depression - see for example encouraging initial research - so appropriate methods of tracking such memories make good sense.

Self-Discrepancies Questionnaire - mismatches between "actual self" and "ideal self" judgements are associated with increased depression risk.  There has been considerable research in this area and it can suggest possible therapeutic intervention targets. 

Depressive Beliefs Questionnaire - a "home grown" questionnaire to highlight beliefs that might be used, for example, as targets for behavioural experiments. 

 

 

Problem solving & behavioural activation

Here are a series of forms, questionnaires and handouts that I use regularly in my work.  The problem solving diagram is a recurring theme - both at the start of therapy and as a sheet to return to when reviewing and considering additional therapeutic options.  Other sheets are classic variants on the tools used by many cognitive behavioural therapists - with occasional alternatives and additions, that I've come up with over the years, thrown in as well.

Problem solving diagrams - here are half a dozen Powerpoint slides providing different options for the Problem solving diagram I use with nearly all clients who come to see me.  My typical routine at a first session is to gather information.  If the case is relatively straightforward, towards the end of this first session (when I've gathered most of the information I need) I will give them some initial screening and assessment questionnaires to fill in.  While they are doing this, I transfer information that I have been jotting down as they told me their story, onto a problem solving diagram.  I usually use the diagram making up the fifth of the six slides you can download here, but sometimes (with anxiety problems) I will use the sixth slide diagram.  Slides one to four are simpler versions of the same approach.  If I'm pushed for time, I may only fill in the top two thirds of the problem solving diagram at this stage - detailing "problems & wellbeing" and their "evolving wishes & worst symptoms".  If I get the chance though, I will also brainstorm the best supported therapeutic options that they have.  With more complex cases, all this may have to wait until the second session.  I then show them the diagram, make changes if they have further comments, and then photocopy it for them to take away and revise/add to if they want before our next session.  Typically - although I am simply organizing and feeding back the information they have given me - clients usually seem very grateful for this "making sense of" their symptoms and "giving hope" that there are options that can help them.

Rumination assessment - a simple four question way of assessing initial severity and monitoring progress in reducing rumination. 

Rumination, from TRAP to TRAC - classic behavioural activation model of the shift from ruminative Trigger-Response-Avoidance-Pattern TRAP to getting back onto the problem solving Trigger-Response-Alternative-Coping TRAC.  This handout also contains plenty of research back-up for the notion that rumination is largely bad news.

Checklist of potential problem areas - this is a list of a dozen potential problem areas that it can be helpful to show clients to jog their memories for any important issues that they have failed to mention in the initial interview.

Hassles scale - this is the classic 117 items hassles assessment scale.  More minor hassles of everyday living can be as important as major problems in wearing people down.

Psychological & physical difficulties are so common that they're normal - the facts & figures on this sheet are now somewhat dated.  The intention however is clear - to try to reduce a sense of stigma/shame about having difficulties by highlighting how common it is to sometimes struggle with psychological and physical symptoms. 

Problem solving therapy - a three page handout I put together describing an approach to effective problem solving.

Initial person-centred outcome measures - assessment measures adapted from the MYMOPS - Measure Yourself Medical Outcome Profile - inititiative. 

Follow-up person-centred outcome measures - adapted MYMOPS follow-up assessment measure.

Disability assessment, 3 areas - this is the classic Sheehan three item disability questionnaire using 0 - 10 scales to assess difficulties with work (including housework), family relationships, and recreational & social functioning.  This type of simple scale can be very helpful for assessment, clarifying appropriate activity challenges, and monitoring progress.  

Disability assessment, 4 areas - this is the Sheehan scale (see above) slightly extended to separate out couple/marriage issues from other family difficulties. 

Disability assessment, 5 areas - the NHS Increasing Access to Psychological Therapies (IAPT) initiative has extended this disability measurement still further, using 0 - 8 scales to assess work, home management, social/leisure activities with others, social/leisure activities on one's own, and family & other relationship activities.  This "Work & social adjustment scale (W&SAS)" is downloadable as a Word doc and as a PDF file - see too the associated scoring advice

Disability assessment, 8 areas - and the last of these disability scale options is an eight item questionnaire, where the items are typically more narrowly focused and are chosen by client & therapist to focus on issues that are specifically relevant for the client involved. 

Pittsburgh enjoyable activities test (PEAT) - (also available as a PDF file) this useful 10 item questionnaire looks broadly at both individual and social forms of enjoyable activity.  It has been shown to correlate with a whole series of both physical and psychological positive measures.  Good both for broadening one's mind about the variety of enjoyable activities to consider and for producing a score showing how the frequency of one's involvement with such activities compares with a general population.  Writing more about this questionnaire, I've posted Assessing and encouraging enjoyable activities.

Behavioural activation strategies - a handout detailing the kinds of activation strategies to be used in a Jacobson style approach to depression treatment. 

Nourishment, adversity & suffering - a handout giving a simple fairly behavioural view of the development & treatment of depression.

Activity schedule 1 & instructions - slightly adapted classic CBT one page weekly activities record sheet with a second page giving instructions on its use.

Activity schedule 2A and schedule 2B & instructions - here are a couple of slightly more adapted activities record sheets with instructions.  These record sheets are designed to take into account more recent research suggesting that increasing pleasant emotional experiences of various kinds and decreasing unpleasant experiences of various kinds may provide additive benefits for depression and other disorders.

 

Depression, CBASP & neuroscience

Here is a mixed bag of handouts and questionnaires.  Most are spin-offs from CBASP (pronounced 'seebasp') - the awkwardly named cognitive behavioral analysis system of psychotherapy.  There are also a few handouts which are adapted downloads from the neurosciences site "The brain from top to bottom".   When in 2000, Keller et al reported on the very impressive results obtained by treating chronic depression with a mixture of CBASP and antidepressants, it seemed likely that a big step forward had been taken in improving the lot of chronic depression sufferers.  The "CBASP research results" handout (below) gives the abstracts for 14 research papers that are both relevant to CBASP and also highlight other important related themes like the value of the therapeutic alliance in both psychotherapy and pharmacotherapy, and the way that a traumatic childhood history suggests that someone would be much more likely to benefit from psychotherapy than medication.  I wrote more on CBASP in autumn 2008.  I have also lectured on CBASP and a copy of the Powerpoint slides is included below.  The current state of play (December 2009) is that a major attempt to replicate and extend the initial encouraging results has yielded disappointing outcomes.  It's unclear why this has happened - possibly because the patient population involved in this second major study tended to be more disabled than in the first study (e.g. worse socioeconomic and literacy problems).  Happily a third study is now under way in Holland and a fourth in Germany (personal communication from Elisabeth Schramm) to check further on the promise of this interesting approach to tackling the sense of powerlessness and interpersonal difficulties of many people suffering from long-term depression.  Professor James McCullough, the originator of CBASP, has a website that gives more detail of relevant books, research papers & training opportunities. 

At the bottom of the list of handouts and questionnaires (below) are three from the great Canadian Institute of Neurosciences website "The brain from top to bottom: an interactive website on human brain and behavior".  I've written before about this web resource and now attach three adapted downloads on fight/flight, pleasure/pain, and memes/memory.   

Lecture on CBASP - these are the Powerpoint slides from a talk I gave on CBASP to a group of psychologists back in early 2006.  Though I say so myself, it's a pretty good presentation!  As I've explained, CBASP received a bit of a set-back with results from an attempted US replication study.  Results from a current Dutch replication will help to clarify how helpful CBASP really is.

CBASP research results - Here are 14 research studies relevant to the cognitive behavioral analysis system of psychotherapy (CBASP).  The outstanding paper is the Keller et al report in 2000 highlighting how the combination of CBASP and antidepressant medication could produce very encouraging outcomes for people suffering from chronic forms of depression.  There were then a series of further papers on different aspects of this potentially landmark research including the Klein et al (2003) report on the importance of the therapeutic alliance for both psychotherapy and pharmacotherapy results, the Nemeroff et al (2003) report on chronic depression sufferers with a history of childhood trauma doing much better with psychotherapy than pharmacotherapy, and the Klein et al (2004) report demonstrating the value of monthly CBASP sessions as a way of maintaining initially successful outcomes.  Results from a first replication study were disappointing (personal communication) - possibly because of the severity/complexity of the cases selected for the trial (e.g. problems with literacy, etc).  Happily Wiersma et al (2008) describe a fresh attempt at replication which should help considerably in clarifying the value of CBASP in the treatment of chronic depression.

Coping survey questionnaires, classic interpersonal, adapted interpersonal, and adapted other - at the heart of CBASP is "situational analysis" training which maybe produces many of its benefits by helping combat the overgeneralization and sense of powerlessness very characteristic of persistent depression.  It also aims to help those using the method to become more goal focused, to realize their own interpersonal behaviours encourage or hinder achieving their goals, to recognize the main problem behaviours that hinder them getting what they want, and to help them learn new interpersonal skills to remedy these problems.  The "classic interpersonal" sheet is the standard CBASP form used for this exercise, while in the "adapted interpersonal" sheet I have reshuffled the exercise to be a little more in line with ideas from - for example - ACT, implementation intentions, and self determination theory.  Although the interpersonal focus of both these forms is probably entirely appropriate, I've also produced the "adapted other" form which looks at taking charge and acting from values in non-interpersonal situations as well.  It's important to emphasise that CBASP's focus is on teaching clients to learn these more self-empowering attitudes and self-correct themselves.

Feelings of choice scale - this is a simple questionnaire I put together to help clients attend to and track their feelings of powerlessness and autonomy.

IIP-48 questionnaire & score sheet - I use these questionnaires about characteristic interpersonal style a lot - in many more situations than when I'm working with a CBASP-influenced approach.  To paraphrase Alice Miller and others "The walls we build to protect ourselves, become the prisons in which we live."  This assessment tool highlights and helps track changes in our interpersonal "prison walls."

Significant others list - this CBASP exercise is usually completed in the second therapy session.  It begins the work of clarifying how clients have been affected by significant others earlier in their lives and how these effects may now negatively affect their current relationships.

Significant others grid - the significant others list is now used as a springboard to predict problems (and potential learning experiences) that are likely to emerge in the therapeutic relationship.  It lays the groundwork for the therapeutic relationship itself to become an environment for helpful "behavioural experiments".

Significant others work, suggestions - suggestions for using the significant others approach.

Significant others, therapy relationship suggestions - after the core "situational analysis" method, working within the therapeutic relationship is the other obvious CBASP "technique".  Here are further thoughts about making this focus helpful.

Life review charts - CBASP also works with a "time line" that helps client and therapist see how mood has varied over the years.  I adapted these ideas a little and produced six related life review charts.  Again I use these much more widely than just in CBASP-related interventions.  To see, and maybe download, go to the handout section "Life review, traumatic memories & therapeutic writing".

Thoughts after completing a 3 day CBASP training with Prof Jim McCullough - in April '07 I completed a three day training course with Jim McCullough.  As can be seen from the '06 Powerpoint lecture handout (above), I had already done a fair amount of studying, trying out, and thinking about CBASP before doing this course.  Here are a collection of post-course thoughts. 

Fight, flight & freeze circuits - this is a great adapted Canadian Institute of Neurosciences download on the well-known fight/flight/freeze reaction giving a bit more detail than most people will be familiar with. 

Pleasure, pain & inhibition - this neurosciences download makes a powerful scientific argument for activation rather than the chronic withdrawal seen in so many anxiety and depression syndromes.  

Memes & collective memory - at times quirky & opinionated, this download introduces ideas about memes - units of information transmitted from brain to brain - and scientific paradigms.  Much psychotherapy could be seen as working to propagate healthier meme structures. 

 

GAD and health anxiety

Here are a series of assessment questionnaires and handouts for Generalized Anxiety Disorder and Health Anxiety Disorder.  Note that the 2010 Increasing Access to Psychological Therapies "IAPT Data Handbook" recommends using the GAD-7 to monitor progress in Generalized Anxiety Disorder and the short 18-item version of the Health Anxiety Questionnaire to monitor Health Anxiety progress. 

GAD, 2 question screen - answering "yes" to either of the two screening questions on this sheet suggests it's worth checking for a diagnosis of full Generalized Anxiety Disorder (GAD) - for example by using the GADQ (see below).

GAD, questionnaire (GADQ) - a simple questionnaire for making a full diagnosis of GAD.

GAD-7 plus - here is the IAPT recommended GAD-7 plus the other basic IAPT measures, the PH-9 and phobia scales.

GAD, assessment (GADSS) and scoring - the GAD Severity Scale.  Useful, and pays more attention to GAD's associated physical symptoms than the more purely worry-focussed scales that are often used.

GAD, metacognitions (Wells) - GAD assessment scale developed by Wells.  Includes measures of safety behaviours and metacognitions.

GAD, brief measure of worry (BMWS) - a PDF of an interesting worry questionnaire developed by the Australian Black Dog Institute.

GAD, assessment (PSWQ) - the Penn State Worry Questionnaire (PSWQ) is possibly the most widely used measures for GAD.  Here is a copy with some scoring information on the third page. 

GAD, weekly assessment (PSWQ-PW) - you may find an adapted "weekly" version of the PSWQ is easier to use when monitoring therapeutic progress.  Here is the PSWQ-PW, again with some scoring information on the third page of the download. 

GAD, worry record (Borkovec) - Tom Borkovec and colleagues reported that about 85% of worries/fears that a GAD sufferer experienced never happened.  For the 10-15% that did happen, they routinely found that the difficulty was coped with much better than the sufferer feared.  This Worry Record encourages people to check this out for themselves - a good behavioural experiment.

GAD, worry tree and reducing worry tendencies - the Worry Tree is a helpful two slide Powerpoint handout for dealing with immediate worries.  The Reducing Worry Tendencies is similar but looks more at the medium term.  Tom Borkovec's hopes for the value of emotional/interpersonal additional work still needs to be validated before being taken as routinely relevant.

GAD, Powerpoint miniatures (Borkovec) - in the autumn of 2004, I spent a week with Tom Borkovec at Penn State University in the US.  This 12 slide Powerpoint presentation is a short talk I subsequently gave about the experience and about GAD. 

Health anxiety questionnaire (HAQ) - this 21 item health anxiety questionnaire yields four subscales, which can make it easier therapeutically to target specific behaviours like reassurance seeking.  The third page of the download gives some idea of likely scores in different disorders.

Health anxiety inventory (HAI) - the 18 item (short form) HAI is the disorder specific scale recommended by the NHS Improving Access to Psychological Therapies (IAPT) initiative.  The third page of the download gives typical scores for a Health Anxiety group, a more general anxiety group, a control group, and so on.  The Centre for Anxiety Disorders and Trauma website also provides freely downloadable copies of the short form of the HAI scored for a week or a month and the long form of the HAI also scored for these two different time frames.      

Health anxiety rating scale (Wells) - this health anxiety assessment questionnaire developed by Adrian Wells can be useful, particularly with a CBT approach, when tackling and quantifying safety behaviours like checking and reassurance seeking.

Health anxiety thoughts record - this is a fairly classic cognitive therapy thoughts record adapted for health anxiety.

 

Social anxiety information & assessment

In May 2013, the National Institute for Health and Clinical Excellence (NICE) published a new evidence-based clinical guideline on "Social anxiety disorder: recognition, assessment and treatment".  They state: "This clinical guideline offers evidence-based advice on the recognition, assessment and treatment of social anxiety disorder in children and young people (from school age to 17 years) and adults (aged 18 years and older). It includes a recommendation on the treatment of specific phobias that updates and replaces the section of NICE technology appraisal guidance 97 that deals with phobia."   I discuss the guideline and provide a series of useful links in the blog post "New NICE guidance on the recognition, assessment and treatment of social anxiety disorder".

On this page there are a collection of relevant information sheets, handouts and questionnaires.  As I write in the "Diagnosis & background facts" sheet below - "About 7% of the population qualify for a full formal diagnosis of social anxiety disorder in any one year, but even those who suffer from what qualifies as only a partial syndrome can have their lives significantly affected.  Social anxiety disorder makes sufferers more vulnerable to subsequent depression and, when comorbid, the depression tends to be more severe and more resistant to treatment.  There may well also be comorbidity with other anxiety disorders.  Social anxiety disorder is frequently not diagnosed even though it is disabling and well worth treating."

Diagnosis & background facts - this handout gives the criteria for a DSM-IV diagnosis of social phobia/ social anxiety disorder.  It also gives the abstracts of four research studies illustrating how common and troublesome social anxiety can be.

I went to a workshop on the treatment of social anxiety disorder with David Clark in July 2013.  It was very helpful.  I've listed assessment & monitoring questionnaires that he recommended below:

As a general measure to assess and track changes in social anxiety severity, the freely available Social Phobia Inventory (SPIN) is the questionnaire recommended by the England & Wales NHS Improving Access to Psychological Therapies (IAPT) "outcomes toolkit".  Interestingly David seems to prefer the Liebowitz Social Anxiety Scale (LSAS) probably because it makes a pretty full job of assessing both anxiety and avoidance.  

Social Phobia Inventory - SPIN - (PDF file and Word doc): a widely used, freely available 17 item questionnaire for assessing social anxiety disorder.  On the second sheet of the download, I give suggestions about what the different levels of score mean.

Liebowitz Social Anxiety Scale - LSAS - (PDF file and Word doc): this 24 item questionnaire assesses both social anxiety and avoidance.  It's good and is widely used in clinical trials.  On the second sheet of the download, I give scoring suggestions and some information about improvement. 

Participants on David's July workshop were subsequently sent copies of four further questionnaires he recommends using.  These measures were emailed as a Word doc attachment in Arial font printing out as "letter" sized handouts.  They are available to download in this format here.  I have also rewritten them in my preferred Tahoma font printing out as A4 sized documents and have listed them individually below: 

Social Phobia Weekly Summary Scale (PDF file and Word doc): this 6 item questionnaire uses 0 to 8 numerical rating scales to assess disturbance/disablement, avoidance, other-focused/self-focused attention in general & in difficult social situations, pre-event anticipatory worry, and post-event subsequent rumination.  

Social Cognitions Questionnaire (PDF file and Word doc): this questionnaire assesses the frequency and degree of belief in 22 thoughts that may go through people's minds when they feel socially frightened or anxious.  There is additional space for writing down and rating less common, more personalized "catastrophic" social concerns. 

Attitudes Questionnaire (PDF file and Word doc): an extensive 50 item assessment form.  The instructions state - "This questionnaire lists different attitudes or beliefs which people sometimes hold.  Read each statement carefully and decide how much you agree or disagree with each one ... Because people are different, there is no right or wrong answer to these statements.  To decide whether a given attitude is typical of your way of looking at things, simply keep in mind what you are like most of the time."

Behaviours Questionnaire (PDF file and Word doc): this questionnaire assesses the frequency of 28 "safety behaviours" that people suffering from social anxiety may perform.  It is suggested that these behaviours often seem like they help the anxiety in the short term, but in the longer term there is a real danger that they maintain the problem.

David also gave us a book chapter handout entitled "The assessment interview and getting started".  Interestingly in the table on "Standardized questionnaires that are useful for collecting information in advance of the Clinical Interview" he mentions the LSAS, Cognitions, Attitudes, and Behaviours Questionnaires (all listed above).  This group of four questionnaires seems to be the standard assessment bundle (plus the Weekly Summary Scale).  They can be partly concentrated down to the Social Anxiety Overall Summary sheet (see below) and then individualized still further when completing the Social Anxiety Flow Chart (below). 

However in the chapter table, the assessment list also includes the Beck Depression Inventory and the 1998 Mattick & Clarke Social Phobia Scale and Social Interaction Anxiety Scale.  Many therapists will have alternative assessment instruments for depression other than the relatively expensive copyrighted Beck Inventory - for example IAPT recommends the PHQ-9.  At the risk of gilding the lily, here are the two Mattick & Clarke questionnaires, which can in some situations provide additional useful assessment, monitoring & treatment planning details:

Social Phobia Scale (PDF file and Word doc) and the Social Interaction Anxiety Scale (PDF file and Word doc): these two 20 item scales assess social situations and aspects of social situations that are anxiety provoking. 

Even if one only uses some of the above questionnaires, there is now a lot of information that has been recorded.  In the book chapter handout we were given, it is suggested that it may be helpful to summarize much of what is most important from this extensive initial assessment on the following sheet:

Social Anxiety Overall Summary (PDF file and Word doc): this form provides a place to summarize information from the various questionnaires under the four general headings - feared situations, avoided situations, negative thoughts (worst fears), and safety behaviours.

Now as a cooperative effort with the social anxiety sufferer, it is recommended that one draws out a "flow chart" of what happens when they become particularly self-conscious & embarrassed.  Many cognitive therapists will do this using a wall mounted whiteboard.  There are advantages to developing the flow chart this way - for example in externalizing the problem and side-stepping what might feel, to the client, an over-intense eye-to-eye interview.  My preference is to sit beside the client and draw out the flow chart on a piece of paper (see below) held on a clipboard.  Using this format one has a sheet that can be photocopied and handed to the client to take away, think about and potentially add to.  Producing the social anxiety flow chart together may well take 40 minutes or so to do well.  At this stage, it is a process of description and "finding out" together rather than an explanation.  Try not to rush the process - when it's done well it can lead to the sufferer feeling very understood.  It is recommended that one select a specific example of a socially embarrassing situation that the client has experienced and can remember fairly easily (a recent event is often good to focus on here).  One starts with a brief description of the situation (top of flow chart).  Moving on to the physical anxiety symptoms that were experienced may well be a good next step (interestingly the Beck Anxiety Inventory may be useful here too).  Then one can enquire and fill in details of thoughts (about perceived social dangers) and sense of self-consciousness (quite possibly linked with an image and/or felt-sense about how one is coming across to others).   One might then move on to producing quite an extensive list of safety behaviours that were involved.  One can add further information from other social anxiety events they have experienced and it may well be useful to give them the sheet to take home and add to after they have been through new socially challenging experiences.   

Social Anxiety Flow Chart (PDF file and Word doc): this is an alternative to the widely used white board diagram. 

Also likely to be useful is a sheet that can be used for recording behavioural experiments - a core component of this highly successful cognitive therapy treatment for social anxiety disorder:

Behavioural Experiments Record Sheet (PDF file and Word doc): this type of homework recording form is likely to be used quite extensively during CBT treatment. 

And lastly in this list, is a copy of the Cognitive Therapy Competence Scale for Social Phobia (CTCS-SP).  To measure therapist skill in treating social anxiety, Clark & colleagues have impressively developed a specific assessment scale - see "Assessing therapeutic competence in cognitive therapy for social phobia: Psychometric properties of the cognitive therapy competence scale for social phobia (CTCS-SP)."  Then, crucially, they have shown that skill measured in this way is predictive of patient outcomes - see "Treatment specific competence predicts outcome in cognitive therapy for social anxiety disorder."  As the authors of the "Treatment competence" paper comment " ... informal use of the cognitive therapy rating scale by students themselves is likely to be helpful. Certainly, we have found that many therapists who are learning CT for social anxiety learn a great deal about how particular procedures should be implemented by studying the particular items on the CTCS-SP and rating their own sessions according to the scale."

Here is the Cognitive Therapy Competence Scale (CTCS-SP) (PDF file and Word doc): a useful way to assess one's own practice. 

Besides this core series of questionnaires, here are a further few odds & ends:

The Mini-SPIN is a three item Social Phobia screening questionnaire.  Here are downloadable Word doc and PDF file versions.  I tend not to use the Mini-SPIN much.  Possible social anxiety disorder is typically picked out when I give new clients the much more inclusive and general MINI screening questionnaire and talk to them about their symptoms.  I may be wrong.  Possibly I should use the Mini-SPIN more often.

10 tips for public speaking & other ideas - see the international Toastmasters website.  Much more helpful than their suggestions sheets is the opportunity Toastmasters provides for real life practice and desensitization.  I have encouraged and seen many social anxiety sufferers benefit from going to their local branch of Toastmasters.  See the site for links to local groups in many different countries.

Blushing information - here are five research studies providing reinforcing evidence for a CBT conceptualization of blushing and social anxiety.  This handout can be helpful for people who struggle with concerns about blushing.

Social avoidance scale - I can't actually remember where this scale comes from.  I suspect that I put it together as an adaption of Ost's Agoraphobia Scale.  This scale has obvious applications both for initial assessment, for monitoring progress, for desensitization/exposure work, and for behavioural experiments.

SPRS - I often use this questionnaire, developed by Adrian Wells - particularly to help clarify people's catastrophic fears and "safety behaviours".

You may well find further useful ideas & suggestions by clicking this website's tag on "social anxiety" and Gillian Butler's books are a helpful self-help (or better still - guided self-help) resource.

 

Panic, OCD & depersonalization information & assessment

Here are many of the handouts and questionnaires I use currently (autumn '09) when working with people suffering from panic disorder, agoraphobia, OCD or depersonalization/derealization disorder. 

Panic disorder severity scale - self report (PDSS-SR) - this is the main scale I use to assess initial panic severity and track progress.  It's the self-report form of the PDSS, which has been shown to be comparable to the interview version.  The PDSS is copyrighted to Dr Katherine Shear who has given permission for the scale to be used by clinicians in their practice and researchers in non-industry settings.  For other uses of the scale Katherine Shear should be contacted.   Scores for the PDSS are interpreted somewhat differently depending on whether there is also agoraphobia present or not.  See Scoring the PDSS

Diagnosing panic attacks, etc - I will sometimes sit down beside the person I'm working with, show them these diagnostic criteria and clarify which symptoms they suffer from and which they don't ... and then come to a diagnosis.

Vicious circle & maintaining factors - I often print this Powerpoint handout out (2 slides to a page) to use as a handout and also to clarify why and what we're doing in therapy.

Interoceptive symptom induction tests - again, I use this to remind myself of standard 'interoceptive' challenges.  Can be helpful when fear of catastrophized internal sensations (e.g. feeling faint/might have stroke; heart palpitations/might have heart attack, etc) seems an important part of the symptom picture.  These tests can then be used to clarify anxiety pathways and also as desensitization/exposure/behavioural experiments. 

Panic attack diary page 1 - this diary format (both pages) can be useful for gathering lots of relevant information about symptoms, triggers, avoidance and so on. 

Panic attack diary page 2 

Paired word exercise - a classic test.  If reading through these paired words induces anxiety/panic in a sufferer it can be very useful in helping them see how their catastrophic interpretations are a key part of the problem.

Catastrophic beliefs questionnaire - again can be useful in assessment and monitoring when using a CBT approach for panic disorder.

Panic rating scale (PRS) - I tend to use this scale particularly to clarify safety seeking behaviours and catastrophic thoughts. 

Agoraphobia assessment and scoring, Ost - a scale I use a lot as an initial assessment, to guide desensitization/exposure/behavioural experiments and monitor progress.

See too the Centre for Anxiety Disorders and Trauma website for other freely downloadable panic-relevant questionnaires. 

Normal intrusions - a list of 52 "normal intrusive thoughts" with the percentage of 293 students (none of whom had been diagnosed with a mental health problem) who reported that they had experienced this thought.  I often hand out this leaflet to help people realize that experiencing occasional disturbing intrusive thoughts is totally normal.

OCD diagnosis & prevalence - leaflet giving DSM-IV diagnostic criteria for obsessive-compulsive disorder and some details of prevalence rates.

Obsessive-compulsive inventory (OCI) - this is designed as a questionnaire to be completed by people suffering from OCD.  It is recommended for use by the NHS Increasing Access to Psychological Therapies (IAPT) initiative.  Here is a Word version with each question 'tagged' to indicate which subscale it refers to (the hoarding subscale is probably the least helpful).  The UK Institute of Psychiatry website provides a PDF version of the scale and see too pages 22-23 of their booklet for more details on OCI scoring, including typical scores for OCD sufferers and a 'normal' control group.  It is suggested too that a total score of 40 or more suggests probable "caseness".  Note both versions of the OCI given above just assess distress, not frequency, of symptoms.  Note that the excellent Centre for Anxiety Disorders and Trauma website provides a series of other helpful OCD questionnaires. OCD flow chart (Menzies) - an interesting & informative flow chart developed by Menzies and colleagues in Australia.

More recently still, I have moved to using the shortened 18-item OCI-R - for more details see the blog post A better way to assess & monitor progress with OCD.

OCD flow chart & explanation (Wells) - this flow chart developed by Adrian Wells is particularly helpful in guiding cognitive behavioural therapy for OCD.  The behavioural exposure & response prevention approach is at the heart of treatment, but other cognitive targets can usefully be included in therapy.  The explanatory background sheet gives helpful instructions on using the flow chart that are relevant for both sufferer and therapist.

Dysfunctional thoughts record - a classic cognitive therapy thought record sheet adapted for use in OCD.

Assessing rituals - simple listing, general diary & timed diary - forms for assessing what rituals are being used.

Assessing obsessions - simple listing of obsessions, often used with the rituals diaries (see above)

Target symptoms list (long term goals) - this sheet & the one below are used in conjunction with Lee Baer's fine self-help OCD book "Getting control" - often useful to use with therapist help.

Rating progress (practice goals) - used with Lee Baer's book on OCD (see above).

Exposure practice record - a simple exposure & response prevention exercise record sheet for OCD exposure (real life) practice.

Imagery practice record - a simple exposure & response prevention exercise record sheet for OCD exposure (in imagery) practice.

Depersonalization scale, scoring and background - good for assessment and monitoring progress. 

 

PTSD assessment, images, memories & information

Here are a whole series of handouts and questionnaires on intrusive memories, imagery, trauma and PTSD.  They overlap with handouts listed in the "Life review, traumatic memories & therapeutic writing" section of this website.  The "tag cloud" provides links to further relevant information - for example by clicking on tags like "PTSD""trauma" or "imagery".  Also of specific relevance are three posts about Marylene Cloitre's treatment developments for complex PTSD, a post on Emily Holmes's work with imagery, a post on a PTSD lecture by Anke Ehlers, and seven posts on Nick Grey's workshop "Memory-focused approaches in CBT for adults with PTSD".

Flowcharts 1 & 2 (Ehlers & Clark) - here are a couple of Powerpoint slides that - although in colour - print out well in black & white.  I particularly use the second of these slides as a handout when working to process traumatic memories.  I use it to explain the why, what and how of the therapeutic approach we'll use.  I think this orientation is especially important when working with traumatic memories, so that the client understands why they're being asked to re-connect to painful experiences they may well have been trying hard - and in Type I trauma, unsuccessfully - to forget.

The Ehlers & Clark model for cognitive therapy treatment of PTSD involves particular focus on the trauma memory itself and on trauma-associated beliefs. Work on the trauma memory typically involves four methods - imaginal "reliving" or "revisiting", a written account, a "site visit", and discriminating triggers. See April 2012 blog posts for more on this. There is a detailed blog post on reliving/revisiting, a handout making suggestions on how to complete the written account downloadable both as a Word doc and as a PDF file, and more detailed descriptions of site visits & discrimination training.

Written exposure therapy - there are a couple of blog posts about this exciting development in writing treatment for PTSD - "One of the most exciting therapeutic writing studies for years" and "Written exposure therapy: how do you do it?". A handout giving background and describing how to use this form of expressive writing is available both as a PDF file and as a Word doc. I tend to use this handout in conjunction with the excellent one derived from the Ehlers & Clark model (see above). Fascinatingly, this approach is likely to be relevant for work with difficult memories associated with other disorders than formal PTSD e.g. may well be useful for depression, social anxiety disorder, etc.

PTSD diagnostic criteria page 1 & page 2 - these two handouts can be printed out as 2 slides to the page Powerpoint sheets.  They give the full DSM-IV diagnostic criteria.  They can be looked at with a client, if it seems appropriate, to discuss whether they are suffering from full or subsyndromal PTSD.

PTSD assessment & treatment - a useful aide-memoire to guide the therapy sequence for PTSD - put together from a seminar given by Ann Hackmann.

Processing traumatic memories: the factory metaphor - this is a simple one-page handout that can help orientate people when beginning to work on trauma processing.  It is downloadable both as a Word doc and as a PDF file.

Understanding our reactions: self monitoring - this is an assessment form that can be used to self-monitor or to complete within a therapeutic session.  It looks at experiences of strong emotional reactions and asks a series of questions that can clarify the source of the emotion (leading to ideas about appropriate responses). 

Standard questionnaire and Shortened questionnaire for Smucker-style imagery rescripting.  This more therapist-active style of trauma memory"rescripting"intervention may be particularly appropriate when the associated feelings involve emotions like shame, guilt or anger rather than just fear.

Memory, catharsis & health - I gave this 36 slide Powerpoint presentation back in 2004.  It still has much that's currently relevant to these subjects (including some information on therapeutic writing). 

Trauma memories in anxiety & depression - this is a 30 slide Powerpoint presentation I gave in late 2005.  It can still be helpful in highlighting the commoness and probable therapeutic importance of trauma memories in many other conditions besides formal PTSD.  Examples mentioned in the talk include depression, social anxiety disorder, agoraphobia & panic disorder, psychosis, OCD & BDD, and eating disorders.  There is also some data on Smucker's work as well as the key contributions of Ehlers & Clark.  

Smucker's work on trauma processing - here are a couple of slides illustrating points made by Mervyn Smucker at a conference in 2004 about the possible importance of more active rescripting of trauma memories associated with non-fear responses like anger, shame, guilt or mental defeat.  I think the jury is still out on how necessary this active rescripting is, but it does make a welcome therapeutic change sometimes from the straightforward 'reliving' work.

Trauma & PTSD are very common page 1 & page 2 - here are four Powerpoint slides, that I usually print out as a double-sided handout with 2 slides per page.  The slides highlight the commoness of PTSD - to an extent "normalizing" a client's experience. 

IES and scoring details - this is the classic 1979 Horowitz Impact of Event Scale that has been widely used in subsequent research.  A major problem with the scale is that it assesses only Intrusions and Avoidance and does not consider Hyperarousal symptoms.

IES-R - the revised Impact of Event Scale adds in a Hyperarousal assessment to the original IES.  This is the questionnaire recommended by the IAPT initiative.  You can download the scale & scoring information in both PDF and Word formats: IES-R.pdf, IES-R.doc, IES-R.scoring.pdf and IES-R.scoring.doc.  

The Posttraumatic Cognitions Inventory is probably the most widely used trauma beliefs assessment questionnaire.  It is detailed at the end of Foa et al's 1999 paper, which is downloadable in free full text from the Oxford Cognitive Therapy Centre at www.octc.co.uk/files/pdfs/PTCI.pdf.  Here is the questionnaire itself both as a Word doc and as a PDF file.  Another trauma cognitions questionnaire it's worth considering is given in Buck, Kindt, Arntz et al's 2008 paper "Psychometric properties of the Trauma Relevant Assumptions Scale".

PTSD with Pain screen - this is a quick screening questionnaire to help detect PTSD in people suffering with chronic pain disorders.

Intrusive memories assessment - this is a quick intrusive memories assessment scale developed by Professor Chris Brewin.

Posttraumatic growth inventory - this interesting scale was developed by Tedeschi & Calhoun.  They write that they are happy for the scale to be employed for research purposes as long as financial gain does not occur from its use.  See their website at UNC Charlotte for more information & freely downloadable research papers.  You can download the scale itself as either a Word doc or a PDF file.  See too a blog post I have written - "Writing (& speaking) for resilience & wellbeing 3: personal growth" .  The PTGI scale assesses areas where there may have been helpful learning & growth after trauma - for example, new possibilities, deepening of relationships, increased sense of personal strength, appreciation of being alive, and existential or spiritual change.  Clearly it is important to employ this measure sensitively and only when it seems it might be indicated e.g. if the client themself seems open to looking at possible posttraumatic growth.  When I use this scale, it is sometimes as much for its "educational function" in alerting the person to these issues.

Increasing access to psychological therapies (IAPT) outcomes toolkit

The "Improving Access to Psychological Therapies" (IAPT) initiative is very ambitious and exciting.  It states its principal aim is to support English Primary Care Trusts in implementing "National Institute for Health and Clinical Excellence" (NICE) guidelines for people suffering from depression and anxiety disorders.  It comments "The Improving Access to Psychological Therapies (IAPT) programme began in 2008 and has transformed treatment of adult anxiety disorders and depression in England. Over 900,000 people now access IAPT services each year, and the 'five year forward view for mental health' committed to expanding services further, alongside improving quality."  

One aspect of this carefully planned initiative is strong encouragement to assess and monitor the progress of those who are getting help.  The emphasis is on good assessment measures that are free to use.  See below:

 

Clarification of use of anxiety disorder specific measures - this is a helpful 2 page PDF clarifying how it is recommended specific anxiety disorder measures are used.

Depression, anxiety & phobia measures - IAPT recommends routine use of a combination of questionnaires, the PHQ-9 for depression, GAD-7 for anxiety, and three IAPT phobia scales (social, agoraphobia, and specific phobia (the IAPT Data Handbook suggests a score of 4 or above on any of these phobia scales be classified as 'clinical caseness').  These questionnaires appear on page 65 of the "toolkit" (see above).  I've produced a downloadable handout of this depression/anxiety/phobia measure that may allow easier further adaptation and printing out.  Click here for a 7 page PDF giving more background information about the PHQ-9 and GAD-7 - including helpful scoring information. 

Work & social adjustment scale (W&SAS) - this is another IAPT measure that's recommended for regular use.  It assesses problems in functioning with work, home management, social leisure activities, private leisure activities, and family & relationships (all on 0 to 8 scales).  The measure (along with other details) appears on page 66 of the "toolkit".  Again I've produced a downloadable handout as a Word doc & as a PDF file with associated scoring suggestions, again as a Word doc or a PDF file

IAPT recommends that, when appropriate, a disorder-specific assessment questionnaire is also used.  They specifically mention:

Social Phobia - the Social Phobia Inventory (SPIN).  Here is a two page handout of the SPIN with some scoring information. 

Obsessive-compulsive inventory (OCI) - here is a Word version with each question 'tagged' to indicate which subscale it refers to (the hoarding subscale is probably the least helpful).  The UK Institute of Psychiatry website provides a PDF version of the scale and see too pages 22-23 of their booklet for more details on OCI scoring, including typical scores for OCD sufferers and a 'normal' control group.  It is suggested too that a total score of 40 or more suggests probable "caseness".  Note both versions of the OCI given above just assess distress, not frequency, of symptoms.  

Post-traumatic Stress Disorder - the Impact of Event Scale - revised (IES-R) - the 1995 Revised Impact of Event Scale adds in a Hyperarousal assessment to the original IES.  Unfortunately there is currently less data on typical scores for normal subjects and for those suffering from PTSD.  The UK Institute of Psychiatry provides some useful information on pages 28-29 of their booklet.

Health anxiety inventory (HAI) - this is the 18 item (short form) HAI.  The third page of the download gives typical scores for a Health Anxiety group, a more general anxiety group, a control group, and so on.  The Centre for Anxiety Disorders and Trauma website also provides freely downloadable copies of the short form of the HAI scored for a week or a month and the long form of the HAI also scored for these two different time frames.  

Panic/Agoraphobia, the Mobility Inventory - this version of the Chambless mobility inventory from the UK Institute of Psychiatry's Centre for Anxiety Disorders and Trauma site is scored on the basis of total ratings for being alone and being with other people.  I think IAPT are making a mistake only recommending the Mobility Inventory as a disorder-specific measure for Panic/Agoraphobia.  The Inventory just assesses agoraphobia.  People can be tortured by panic attacks with little agoraphobia.  See my post Handouts & questionnaires for improved assessment & monitoring of panic disorder for suggestions on how this situation can be improved.

Phobia, the Fear Questionnaire - advice on accessing this questionnaire is given on page 12 of the IAPT downloadable PDF which mentions the article by Cox, B.J., Parker, J.D., Swinson R.P. Confirmatory factor analysis of the Fear Questionnaire with social phobia patients. The British Journal of Psychiatry (1996) 168: 497-499.  In fact the Fear Questionnaire is detailed in a still earlier article: Marks, I.M. and Matthews, A.M. Brief standard self-rating for phobic patients.  Behavior Research and Therapy (1979) 17: 263-267. [Abstract/Full Text]

Anger - IAPT could identify no free measure.  They recommend using the PHQ/GAD in conjunction with general measure of severity, frequency duration and impairment.  I find this two question Anger Assessment Questionnaire helpful (scoring information on the second page). 

Generalised Anxiety Disorder - the Penn State Worry Questionnaire (PSWQ).  Here is a copy of the PSWQ with some scoring information on the third page.  You may find an adapted "weekly" version of the PSWQ is easier to use when monitoring therapeutic progress.  Here is the PSWQ-PW again with some scoring information on the third page of the download. 

 

Wellbeing, time management, self-control & self-determination

This is a bit of a ragbag section.  It contains a mixture of handouts on wellbeing, time management and related topics.  A lot of my work involves helping people face fear and anxiety.  The "Determination training" and more straightforward monthly "Practice record" are often helpful here.  The "Respected figures exercise" is one of the most frequent forms that I ask people to fill in - it clarifies values and so highlights how one wants to act.  The handout on Kohlberg's work is relevant to values too, especially at times when the focus is on fairness and assertiveness.  I often move from the "Respected figues exercise" to the five "Goals for roles" handouts.  They build from clarifying "Role areas" and using this for the "Funeral speeches" or "80th birthday party exercise" up through a possible "Brainstorm" exercise to "Visions, challenges, responses" and then "5 year, 1 year & 3 months" planning sheets.  See the series of four posts on meaning & values starting with "Purpose in life: reduces dementia risk, increases life expectancy, treats depression and builds wellbeing" for more on this.  Many of these values/time management ideas are more fully explained in Stephen Covey's fine book "The 7 habits of highly effective people".  The "Day & week projects record" is a form I use on a daily basis to keep my own time management sharp and realistic.  The "Goals - ACT WISeST" sheet I put together from some research on what kinds of goals promote both effectiveness and also wellbeing.  The whole area of "self-control" is covered much more fully in a series of blog posts starting with "Self-control, conscientiousness, grit, emotion regulation, willpower - whatever word you use, it's sure important to have it".  This is a hugely important area - do try to make time to read these self-control posts (if you find it hard to make the time, they are even more importantly for you!).  There are then handouts on "Mental contrasting" and "Implementation intentions" - relevant for pretty much everyone, especially therapists.  I have also put together a blog sequence on character strengths - going to "Strengths of character: head, heart & gut" will link you on to the full blog sequence with a whole bunch of associated downloadable handouts.  Towards the bottom of this page, there are a series of handouts on Self-determination theory (SDT).  I'm a big fan and I frequently use these handouts to introduce these ideas to people.  I think SDT is great - see the blog I posted on "Self-determination theory" for a bit more detail on this.  

Determination training - record sheet and suggestions for use that can be particularly helpful when encouraging people to tackle challenging tasks (for example with exposure/desensitisation work).

Practice record - this is a sheet that I get people to record on when keeping tags on work they're doing over a month.  This might be forms of physical exercise, relaxation, socialising or other areas that they are targetting.

Goals, values, meaning - this is a handout I put together a long time ago.  It still has some value for orientation in this area.

Respected figures exercise (as a Word doc & as a PDF file) - I use this sheet a lot for helping people clarify their values.  I suggest to them that they are unlikely to feel good about their lives unless they are trying to live the values that they particularly respect.

Life highlights exercise - this exercise was pointed out to me by a friend.  I haven't used it much, but it looks good!

Alternative lives exercise - I invented this exercise when I was thinking about my own life.  It aims to get people to think out what else they might have liked to have done and then realize that they can get at least some of this within the life they already have.

Kohlberg's stages - interesting ideas for challenging people to think about and live their values.

Vaillant's stages - helpful handout when talking to people about the differing challenges they may face at different stages in their lives. 

Diaries (respected figures) - 2 qualities & 3 qualities - these are monitoring forms that I would typically use when encouraging people to live values that have emerged from the "Respected Figures" exercise.

Goals for roles - role areas; 80th birthday party (as a Word doc & as a PDF file) and funeral speeches (as a Word doc & as a PDF file) - I often use "Goals for roles" sheets after having done the "Respected figures exercise".  The "Role areas" form helps clarify different aspects of one's life and it can be used to provide some structure to the "80th birthday party" exercise.  The "Funeral speeches" exercise may, at times, be even more potent.  One can probably get a fairly good snapshot of overall wellbeing by simply seeing how well the different roles in one's life are currently going - see the self-assessment exercise (as a Word doc & as a PDF file).

Goals for roles - brainstorm; visions, challenges & responses (as a Word doc & as a PDF file); 5 year, 1 year & 3 months (as a Word doc & as a PDF file) - forms I typically use after the "80th birthday party" or "Funeral speeches" exercise to get to the nitty gritty of specific goal targets.

Goals for roles - these values & goals ideas are explained much more fully in the series of four blog posts - "Purpose in life: reduces dementia risk, increases life expectancy, treats depression and builds wellbeing", "Purpose in life: how do you score on the questionnaire & why does it matter?" (these two blog posts are combined into a handout that can be downloaded as a Word doc and as a PDF file), "Purpose in life: reconnecting to meaning & values" and "Purpose in life: clarifying future goals & the challenges we will face in achieving them (for individuals, couples & groups)" (these two posts as well are combined into a further handout downloadable as a Word doc and as a PDF file).

Weekly worksheet - here is a weekly activity planning/monitoring form adapted from Stephen Covey's writings (see above)

Day & week projects record - I use this form myself on a daily basis.  It helps me clarify and keep to targets for the day.

Importance of attitude - the science behind this handout is rather dated now, but it still makes useful points about control, challenge & commitment

Goals - ACT WISeST (as a Word doc & as a PDF file) - I'm rather chuffed with this handout.  I was feeling impatient with the quite widely used acronym SMART (specific, measurable, etc) when goal setting.  ACT WISeST seems a more evidence based acronym to me and I enjoyed putting it together!

Self-control is a crucially important area - see the series of blog posts beginning with "Self-control, conscientiousness, grit, emotion regulation, willpower - whatever word you use, it's sure important to have it".  There are currently six handouts & two questionnaires that I use in this area.  See both Word doc and PDF files available from the relevant blog posts - "Self-control ... it's sure important to have it", "Self-control ... more on the many benefits""Building willpower: it's like strengthening & nourishing a muscle", "Self-control ... possible adverse effects", "Self-control, conscientiousness, grit, emotion regulation, willpower - the importance of training""Building willpower: the eight pillars""Commitment contracts: another good way of helping us reach our goals" and "Self-control ... how do you measure it?".

Also linked to self-control is the series of three posts (and three associated handouts) on "Commitment contracts" - an interesting and potentially helpful way of boosting our effectiveness at reaching difficult goals.  The posts are "Commitment contracts: another good way of helping us reach our goals", "Commitment contracts: orientation, practicalities & use as therapeutic tools" and "Commitment contracts: a personal example".

Mental contrasting - a simple way of boosting energy & commitment for goals that are important to us.  Mental contrasting is often used in research as a technique that is linked with implementation intentions (see below). 

Implementation intentions, background (as a Word doc & a PDF file) and instructions (as a Word doc & a PDF file) - implementation intentions help us achieve goal intentions.  They are a well-researched and well-validated way of making goal intentions more effective over a whole series of important areas including changing health behaviours and achieving personal goals.  This is significant stuff ...

I have also put together a blog sequence on character strengths - going to "Strengths of character: head, heart & gut" will link you on to the full blog sequence with a whole bunch of associated downloadable handouts. 

Psychological needs & wellbeing 1, Psychological needs & wellbeing 2 (SDT) - I use this handout a lot at the moment (2008) to introduce discussions on wellbeing and the importance of responding to our key basic psychological needs for Autonomy, Competence & Relatedness.  Try printing them out as a two-slides-to-a-page Powerpoint handout. 

Goals & wellbeing 1, Goals & wellbeing 2 (SDT) - building on a discussion of needs (see above), this SDT approach to goals looks particularly at how well pursuing different types of goals leads (or doesn't lead) to key need satisfaction.  Try printing them out as a two-slides-to-a-page Powerpoint handout. 

Motivation, effectiveness & wellbeing 1, Motivation, effectiveness & wellbeing 2 (SDT) - these two handouts build on the Needs and Goals SDT handouts above.  Good for discussion of autonomous and controlled motivations.  Try printing them out as a two-slides-to-a-page Powerpoint handout. 

Motivation questions (SDT) - autonomous, rather than controlled, motivations tend to lead better outcomes (see Motivation, effectiveness & wellbeing handouts above).  These four questions can be helpful in teasing out the mixed motivations that we often bring to goal decisions.  Can be very helpful in looking at whether goals we choose are likely to be 'healthy' or not.

Goals, motivations & wellbeing (SDT) - puts the SDT goal and motivation ideas (see above) onto a useful grid when printed as a single Powerpoint slide. 

Subjective vitality scale & background (SDT) - clicking on this vitality scale links through to a download from the great Self-Determination Theory (SDT) website with it's hundreds of article PDF's and other useful material.

Balanced measure of psychological needs - this 18-item scale published in 2012 is now my favourite questionnaire for assessing S-DT need satisfaction.

Basic need satisfaction scale - this 21-item scale assesses how well the three basic psychological needs for autonomy, competence & relatedness are being met.  With this scale - and the Work need satisfaction & Relationship need satisfaction scales below - it's good for averaged scores to be in the 5 to 7 range. 

Basic need satisfaction background - this is a handout giving some useful background to self-determination theory and the need satisfaction scale.

Work need satisfaction scale - a further 21-item scale adapting the basic need scale to the work environment.

Relationship need satisfaction scale - a 9-item scale assessing satisfaction of autonomy, competence & relatedness needs in a chosen relationship such as with a partner, friend, parent, or child.  The scale can also be used for assessing one's relationship network in general.

Relationship need satisfaction background - a handout giving background to self-determination theory and the relationship need satisfaction scale. 

Alcohol & food

Here are a series of information and assessment handouts on alcohol and food.  "We are what we eat" is bit over-simplified, but only a bit.  It's amazing how important what we eat and drink is for our psychological and physical health.  This site's blog posts  "New research shows diet's importance for preventing depression" and "Preventing cancer through life style choices" make this point well and also provide links with many other sources of information.  Searching the tag cloud brings up much recent relevant research and advice.  Try clicking, for example, on diet or the more specific fats, fruit and vegetables.  For additional information, note that the blog has a whole series of posts on the crucial importance of lifestyle choices, including how we use or abuse alcohol.

I'm a big fan of the Harvard School of Public Health "Nutrition source" website.  I think their "Healthy eating plate" and "Healthy eating pyramid" downloadable PDF pictures are great.  As handouts, I add some key points from the Nutrition source site to the back of the Healthy eating plate picture.  Similarly I add a somewhat longer set of Nutrition sources comments to the back of the Healthy eating pyramid picture when handing this out.  See the two blog posts "Emerging research on diet suggests it's startingly important in the prevention of anxiety & depression" and "So what dietary advice should we be following - for psychological as well as physical health?" for more about all this.

To hammer in the key issue of diet's effects on the development of anxiety and depression, I use the "Diet, anxiety & depression" Powerpoint slides that I've produced as a six-slides-to-a-page handout.  See to the blog post "Zinc and depression"

There are a wealth of freely downloadable handouts about food available on the internet.  I like the series of over 50 leaflets produced by the British Dietetic Association including Healthy eating - getting the balance rightA healthy breakfast - the best start to your day; Fruit & vegetables - enjoy 5 a day!; Healthy packed lunches; Healthy snacks; Whole grains - the way to go; Fluid - why you need it and how to get enoughVegetarian diets - keeping a healthy balancePre-menstrual syndrome - can diet help?; Want to lose weight and keep it off ... ?Diet and depression; Food allergies and intolerances - what are they?; The truth about ... food allergy and food intolerance testing; Cholesterol facts; Fat - getting the balance right; Omega-3 fatty acids; Folic acid - but visit the BDA site for another thirty to forty options.

There is also good advice from the British Nutrition FoundationHealthy eating: a whole diet approach, ideas for Healthy packed lunches, and Healthy eating for school-age children.

The "Mediterranean Diet" is one of the best supported approaches to healthy - and very enjoyable - eating.  The Mayo Clinic provides some practical advice at "Mediterranean diet: Choose this heart-healthy diet option" and "Blog: The new Mediterranean Diet Pyramid", while over at Amazon UK see a bunch of yummy cookbooks by searching on "Mediterranean cooking".

Alcohol disorder assessment - two question screen - this is a useful two question screen for alcohol problems.  Other options include the well-known four question CAGE.

Alcohol disorder assessment - AUDIT and scoring - this is the Alcohol Use Disorders Identification Test (AUDIT) developed by the World Health Organization to help identify people whose alcohol consumption has become hazardous or harmful to their health.

Damage caused by alcohol - this one page handout highlights some of the worrying and significant damage caused by excessive alcohol use.

What is a unit of alcohol? - it is easy to be drinking more alcohol than one realizes.  This one page handout clarifies what a unit of alcohol is and how many units are likely to be in a number of commonly consumed drinks.

How to cut down on your drinking - this 6 page adapted World Health Organization guide to cutting down on drinking contains a whole series of useful suggestions.  For links to several other good alcohol-related sites click here.

Drinking diary - here is a simple one page, four week alcohol consumption diary form.

5 stages of change - this is a handout detailing Prochaska & Clemente's 5 stages of change (and 10 processes of change) model - useful as orientation when working to produce changes in health behaviours. 

Autogenic relaxation training

Autogenic Training (AT) is a method of producing deeply relaxed, peaceful states of mind and body.  AT can accurately be viewed as both a form of relaxation and a form of meditation - the "Four aspects of inner focus" chart illustrates mechanisms of action.  Autogenics is often taught as a method of stress management - a way of helping with a variety of "disorders of overactivation" that might manifest physically (e.g. headache, insomnia, gastrointestinal problems, etc) and/or psychologically (e.g. stress, anxiety, etc).  There are links to a session-by-session description of an Autogenic Training course - complete with relevant handouts & downloadable recordings - at the bottom of this page.  Interestingly AT may also, at times, help with treatment and relapse prevention for depression.  Probably because forms of meditative relaxation produce experiences of positive emotion and subsequent improved functioning, Autogenics can also be used to promote happiness and wellbeing.  The following background remarks give more detail of both my own exploration of AT and of how it can be learned and adapted to help in a wide variety of situations.  

I went up to university in 1968 and read philosophy for two years.  It was a time of student activism, LSD, the Beatles and Tim Leary's "Turn on, tune in, drop out".  I certainly turned on & tuned in and I thought about dropping out, but decided to switch to medicine instead.  In 1970 I enrolled as a medical student, and began practising yoga & meditation.  I took it all seriously.  I went through a phase of getting up at 4.00am to do yoga and meditate till 7.00am, when I'd get ready & go into medical school.  Besides yoga & pranayama practice, I explored all kinds of other approaches - Zen, Sufi, Vipassana, Dynamic, Tai Chi.  I went to a series of one to two week silent meditation retreats and twice travelled to India - the second time I wasn't clear that I would come back.  I did though.  I taught forms of meditation & yoga through medical school and over subsequent years.  As one of my main teachers put it - "If you're not really practising yourself, it's immoral to teach.  If you are really practising yourself, it's immoral not to"

In the late 70's I became interested in Autogenic Training (AT).  This was for a variety of reasons - AT adapted well to being taught in a time limited group format and there was research showing its value.  And, in the 70's, meditation was probably considered a bit more "way out" than it is now, relaxation could be dismissed as not being "powerful" enough, and self-hypnosis often came with fear of "loss of control" baggage.  I liked the way that most of my clients didn't know anything about Autogenic Training and so approached it with fairly open minds when considering skills it might be worthwhile learning.

I studied Autogenics with Wolfgang Luthe and Malcolm Carruthers.  It fitted easily into the breadth of "altered states of consciousness" experiences that I was already familiar with.  I began teaching classes in the early 1980's and I remember lecturing at a big international conference on Autogenics at around this time.  For a variety of reasons I was clear Autogenics was useful but not uniquely so.  In fact Manzoni et al's recent "Relaxation training for anxiety: a ten-years systematic review with meta-analysis" suggests that Autogenics as usually taught may not to be as effective as some other forms of relaxation/meditation for anxiety problems - but then this may also be true for Mindfulness-Based Cognitive Therapy too.  It is interesting to ask why this might be so for AT.  My suspicion is that the Autogenic establishment (of which I'm not a member) may have worked too hard to keep it "pure" and true to it's founder's teachings. 

Scientific knowledge moves forward.  I believe how we teach relaxation/meditation approaches should evolve as new evidence accumulates.  So for example, traditional Autogenic teachers typically won't give trainees tapes or CD's of the practice exercises.  As the Wikipedia article on Autogenics rightly points out, there are many parallels between AT and Progressive Muscular Relaxation (PMR).  In their review of 29 controlled trials of PMR - "Efficacy of abbreviated progressive muscle relaxation training: a quantitative review of behavioral medicine research" - Carlson & Hoyle found that providing training tapes was associated with better outcomes.  Similarly Lars-Goran Ost's careful teaching of relaxation application during everyday life was a step forward from relaxation exercises taught without application training.  And approaches like therapeutic writing are much better validated than traditional Autogenic methods of verbalised cathartic release.  There are a whole series of further ways that more recent research suggests we can improve how we teach inner focus methods and happily the field will continue to evolve.  I certainly found these adaptations were associated with good outcomes - for both anxiety & low mood - in a number of case series that I recorded with the AT classes I was teaching.  It was good too to know that - like the currently favoured MBCT - learning AT was associated with reductions in depressive relapse.  The chart "Four aspects of inner focusillustrates a way of looking at overlapping methods involved in these kinds of practices.  I've already posted on this blog more details about each of the four components of this chart - "Reducing negative states", "Nourishing positive states", "Encouraging mindfulness" and "Exploring & processing".   

To learn about more traditional approaches to Autogenics, you can read the relevant Wikipedia article, see psychologist Raymond Richmond's description of his approach to Autogenics, and visit the British Autogenic Society website.  The latter provide a list of accredited Autogenic teachers.  Below I give an outline of an eight session Autogenic Training course as I taught it in 2008/2009 (in future I intend to incorporate AT into a broader "Life Skills & Stress Management" training).  This AT outline includes downloadable MP3 practice sessions.  These are recordings of my own practice of Autogenics while speaking about how I focus as I go through the various exercises.  You will almost certainly gain more by attending a real life Autogenic class than by simply taking yourself through this "online training".  However there is very encouraging research highlighting that we can get very real benefits through online delivery of training materials.  If you want to try Autogenics to help with any particular psychological or physical problems, it would be sensible to talk to a health professional first to clarify diagnosis and recommended treatments.  People vary in how easily they learn this kind of skill - just as we vary, for example, in how easily we learn to play music, drive, or type.  However naturally gifted we are, learning a new skill takes considerable dedication and practice.  Initially becoming relaxed may seem so unusual that we can occasionally experience relaxation-induced anxiety - "Don't ask me to relax, it's only my tension that's holding me together!"  Like swallowing a mouthful of water when learning to swim, this is no big deal.  If you happen to be someone who initially sometimes experiences relaxation-induced anxiety, simply take your time.  As when we learn to swim, you may like to stay in "shallow water" for a while with shorter sessions, seated practice, and having your eyes open, until you gradually learn how wonderful it is to feel the profound "safety" of deeply peaceful states.  Most people however quickly take to the practice "like a duck to water"!   

The eight session Autogenic Training course outline that follows is intended for various different audiences.  Established teachers of meditation, relaxation & stress management classes may find aspects of this material interesting and useful for their work.  Clients who are currently seeing me personally may benefit from having access to this course outline.  Other readers may like to dip into these practices either as a skills learning experience in its own right, or to supplement and encourage additional exploration & learning.  Whether you're a member of one of these groups or simply curious - I hope you find something of interest in this material. 

 

Autogenic training, session 1

Here are handouts and Autogenic relaxation exercises from the first "lesson" of an eight session Autogenic Training (AT) class.  This first "class" concentrates on relaxation of the voluntary muscles of the arms & legs.  It is probably sensible to stay with this focus for at least a week or two before moving on to the next exercise in the sequence.  Subsequent lessons teach relaxation of several further body systems.  Please read the introductory post on Autogenics before starting any of these exercises.  If you're hoping to learn AT to help with physical or psychological symptoms, it may be sensible to talk to a health professional first to check on diagnosis and other treatment options.  While you're learning these skills, don't practise them if you're driving or operating other dangerous machinery.

When teaching these skills to groups, I routinely insist on having an initial one-to-one session with would-be participants to check whether learning Autogenic Training is likely to be appropriate for them.  If it is, I typically encourage them to assess where they're starting by completing some questionnaires that can then be repeated at the end of the course to see what progress they have made.  I ask what target symptoms or difficulties they most want help with and I encourage them to write a brief description on an initial target symptoms assessment sheet and estimate roughly how troublesome these symptoms/difficulties are for them.  Depending on how they are, I will probably also ask them to complete measures of depression, anxiety and possibly wellbeing.  There are many good standard questionnaires that can be used - see for example this website's pages on "Depression assessment"various forms of "Anxiety assessment", and options for assessing "Wellbeing and mindfulness".

Initially I encourage participants to focus on learning to induce a relaxation response, although I also mention some recent findings on the importance of Positive Emotional States (see below).  I say to them that the reduction in metabolic rate (how fast their "internal engine" is going) can be measured by their oxygen use.  As you can see from the relaxation response diagram, you should quite quickly be able to slip into a peaceful state where your metabolic rate is less than the state you'd achieve in a full good night's sleep!  This is one reason why I emphasise that practising Autogenics is not at all like "having a snooze".  It can be so much more helpful than that.

I teach the basic training positions (see "Basic remarks" sheet below) and highlight that the whole training is a skills-learning challenge & opportunity (see "What progress can you expect" below).  I take the trainees through the very first exercise (download and play the 11 minute Arm Heaviness MP3) and ask them to practise twice daily for a few days before moving onto the second exercise (download and play the 13 minute Arm & Leg Heaviness MP3). 

I explain that most people experience a relaxation response as involving increasing looseness and heaviness in the big voluntary muscles of their arms and legs.  Some people however may experience the relaxation as lightness or tingling or some other sensation.  I say that the particular subjective experience isn't important - simply treat my remarks about "heaviness" as a code word for whatever you personally experience as you allow a deepening relaxation response.  I ask people to keep a record of their practice (see sheet below) and to practise occasionally without using my recorded voice.  This learning to practise without my voice isn't crucial (some research studies have relied entirely on relaxation practice just listening to recordings), but it does make it easier to develop applied practice during everyday activities further into the course.

Unsurpisingly, you'll get out of this practice just about what you put into it.  By this I mean that learning a new whole-body skill is much more than simply developing intellectual understanding.  Knowing rationally how to play a piano and actually being able to play it are very different things.  While you're learning, try to practise at least twice daily - the first time before you get started with your day's work, and the second time at some stage during the late afternoon or evening.  Interestingly, you should to be wide awake to practise.  AT sessions in bed don't count towards your daily couple of training exercises - this is because it will be too easy to lose focus.  So by all means practise to help you get to sleep, but at this learning stage try as well to get in two formal practices during the day. 

This takes determination - a reason why it may be easier if you're learning with a teacher or in a group.  Consider though - time is one of the most democratic things there is.  We all get exactly the same number of hours and minutes in our day.  "Not having time to practice" isn't a valid explanation - what is true is that we may not have put learning AT high enough on our list of priorities.  Think about this.  Do you really want to explore this kind of practice?  Do you think it could help you in worthwhile ways?  If so, please work at it - at least for several weeks.  You'll then have a much better idea of whether or not to make it part of your long term everyday routine. 

At this early learning stage, it may be better to practise at times when you are already feeling pretty relaxed.  See the "What progress can you expect" sheet.   When we learn to drive, we start in a quiet side street.  Later of course we drive in busy rush hours - and, when we're skilled, we'll use Autogenics to help in times of high stress.  Step by step.  Be determined.  Enjoy it! 

Autogenics slides 1-6 - first 6 Powerpoint slides as 6-slides-to-a-page 'miniatures' handout.  During classes, I typically project these and subsequent slides onto the wall to illustrate points I'm making during the two hour training session.

Autogenics slides 7-14 - Powerpoint slides 7 to 14.

Target symptoms initial severity sheet - I often ask people starting the Autogenic Training what they most hope learning these methods will help them with.  I encourage them to keep to one or two key target symptoms/difficulties, describe them briefly on this sheet, and make a rough assessment of how typically troublesome they are.  At the end of the course it is good to repeat this questionnaire.

Autogenics, basic remarks - gives details of body practice positions and other simple initial advice.

Autogenics, what progress can you expect? - this orientation leaflet emphasises a skills-learning view of the Autogenic Training course and draws parallels with other skills-learning activities like learning to drive or to type.

Autogenics, the relaxation response - at this first Autogenics class I introduce people to the way we can slow right down, reducing our metabolic rate in a few minutes by a greater percentage than we're likely to achieve in a whole night's sleep. 

Autogenics 1a: Heaviness, Arms, 11 minutes - 3.8Mb MP3 file.  Clicking on this (and subsequent) Autogenic Training exercises opens a browser window linking you to the chosen recording.  

Autogenics 1b: Heaviness, Arms & Legs, 13 minutes - 4.4Mb MP3 file. 

Positive emotions 1 - the first couple of four slides on positive emotions presented as a two-slides-to-a-page handout.

Positive emotions 2 - and the second pair of slides on positive emotions.

Practice record, first week - it's likely to be helpful if you keep a record of your practice.

Autogenic training, session 2

I usually encourage people to practise the first Autogenic Limb Heaviness exercises twice daily for at least a week before getting them to consider moving on to this Neck & Shoulders exercise.  There are several important points that I try to get across in this second lesson.  One is that better stress management and life skills are abilities that pretty much everyone would benefit from.  The handout "Psychological & physical difficulties are so common that they are normal" highlights two important facts - "The first is that if you are having difficulties you are not alone - the majority of us have health problems of one kind or another.  The second is that there is a huge need to do something about this situation.  The challenge we face is in how we choose to respond to our predicament.  Probably the single most important thing that we, as individuals, can do is to start living healthier lifestyles".  Some of the Powerpoint slides that I show at this second session then emphasise the gains achievable through appropriate use of calming skills.

Other points of importance at this second session are being clear about the Neck & Shoulders Autogenic exercise itself - one can use either of the two downloadable MP3's (see below).  The 12 minute and 19 minute exercises are simply shorter and longer variants of the same Neck & Shoulders focus.  The other key issue that I emphasise particularly at this session is the challenge of focus and mindfulness during the practice.  The longer 19 minute exercise explores this issue in fuller detail than the 12 minute exercise, so it's important to sometimes listen to the longer exercise. 

The handout "Dealing with mental chatter" is one way of approaching the focus during Autogenic (or other meditation/relaxation) practice.  The slides on "Attention & mind-wandering" illustrate that one is likely to quieten the mind more easily at the start of a practice session by making some (relaxed!) effort to focus.  With Autogenics this typically involves really attending to the detail of what your muscles and body in general feels like as it releases.  Giving the "busy mind" a challenge like this to "get its teeth into" helps the attention to become less dispersed.  Other ways of seeing this issue of mindfulness like "The bus driver metaphor" can also be helpful.  Notice what metaphors or images particularly help you.  Besides the "wise fish" and "bus driver" descriptions, one can think of focus as being like trying to get on with an activity in a room where a neighbour has a radio on (the busy mind) a bit loudly next door, or where the traffic outside is fairly noisy.  Another description is that working with an initially chattering mind in the practice is a bit like taking a loved, but rather naughty, child for a walk.  It requires gentle firmness and patience - at least at the start of the session - to keep on track.  What you'll usually find is that once the mind has quietened a fair amount, these "distractions" fade away, so as a good session progresses you may well not need to keep refocusing so "effortfully" to keep the attention on the practice. 

Please try to practise at least twice daily - sometimes on your own for at least 10 minutes - and sometimes using either of the two recorded exercises.  Of course occasionally you may not manage the twice daily sessions.  That's OK - it's human - simply get back to regular practice again as soon as possible.  There is a "Practice recordsheet that it's usually helpful to use, and a "Stress management reading list" that is a bit dated now but still includes several good books.  

Autogenics, dealing with mental chatter - the "wise fish" metaphor for focus during relaxation/meditation practice ... and everyday life.

Autogenics, slides: attention & mind-wandering - slides that can be printed out as a six-slides-to-a-page handout giving information about brain imaging studies during attention & mind-wandering.  This data has encouraged me - as a relaxation/meditation teacher - to encourage people to be a little firmer about the effort they put into maintaining focus, especially at the start of a relaxation/meditation exercise.

Autogenics, four aspects of inner focus - the model that I use to illustrate four overlapping aspects of inner focus.

Autogenics, problems are normal - see above for information about how I use this handout to "normalise" psychological & physical symptoms while simultaneously emphasising our ability to do something about this situation.

Autogenics, slides 1 to 8 - teaching slides used during this second Autogenic Training lesson.

Autogenics, slides 9 to 19 - further teaching slides.

Autogenics 2a: Neck & Shoulders, 12 minutes - 4.1Mb MP3 file.  I encourage people to use either this 12 minute or the similar 19 minute Neck & Shoulders exercise (see below).  They are the same sequence, it is just that the 19 minute exercise gives a bit more detail about maintaining focus/mindfulness. 

Autogenics 2b: Neck & Shoulders, 19 minutes - 5.3Mb MP3 file

Practice record 2 - often helpful to keep a record of your practice to see how you do across the days.

Reading list, stress management - somewhat dated, but still contains details of several good books.

 

Autogenic training, session 3

Here are materials for the third session of the Autogenic Training classes that I've taught for many years.  Please read the introductory remarks and take time to work through the first and second Autogenic Training exercises before starting on this third Limb Warmth focus.  Once working with the Warmth exercises, use "Autogenics 3a: Warmth, Arms, 13 minutes" for several days before moving on to "Autogenics 3b: Warmth, Arms & Legs, 12 minutes" for a few more days.  While learning, I encourage people to practise twice daily and, at times, to practise on their own without the recording.  It is not crucial to do the latter, but it is likely to help in "making the practice your own" and in later application during everyday activities.  Keep a record of your practice on the downloadable sheet

All handouts and MP3 exercises are listed and downloadable from further down this page.  Have a look at the initial session 3 slides (1-10).  They make the point that how we pay attention and what we pay attention to has a huge effect on our lives.  As Mihaly Csikszentmihalyi, originator of the influential concept of flow, has put it: "Attention shapes the self and is in turn shaped by it".  This is a good time to explore the well-known "mindful raisin eating exercise" (you're welcome to try this with alternative simple foodstuffs if you'd prefer).  There are lots of minor variants on this exercise, see for example the Full Circle Foundation's or Robert Zettle's approach.  Further into the third Autogenic teaching session I go on to discuss the very encouraging results achieved with mindfulness-based cognitive therapy in reducing depressive relapse - see slides 11-17.

I also introduce an additional exercise for the next week on appreciation and gratitude.  I really like this exercise which has been well researched by positive psychology scientists.  Have a look at the explanatory slides and read through the suggestions sheet before using this exercise on a daily basis for a week. 

Finally, I encourage people to complete the early reflections sheet to review their practice and consider what it's important for them to continue with or focus on particularly.  When learnng something new, it's usually helpful to combine experiential work with time to reflect as well.

Autogenics slides 1-10 - here are an initial 10 Powerpoint slides that I typically show course participants.  They illustrate that we have a lot of choice about what & how we pay attention to things, and that this hugely affects our lives.  I introduce the savouring, mindfulness & flow distinction and link this both to the "eating a raisin" exercise and to homework for the week on a savouring & gratitude exercise (see individual slide on savouring/mindfulness/flow and the gratitude & appreciation handouts below). 

Autogenic slides 11-17 - these slides illustrate findings from the key study on mindfulness-based cognitive therapy and reduction in depressive relapse that has been so important in getting mindfulness taken much more seriously by scientists worldwide.

Savouring, mindfulness & flow - this slide illustrates these three overlapping forms of attention.

Gratitude & appreciation slides 1-7 - here is background to the gratitude/appreciation exercise showing both that increasing standards of living have not obviously been associated with much improvement in happiness, and that deliberately paying attention to things we appreciate has beneficial effects in a number of helpful ways. 

Gratitude & appreciation exercise suggestions - here are suggestions on using this week's gratitude/appreciation exercise.

Gratitude & appreciation record sheet - and here is a sheet for recording a week's gratitude/appreciation exercise.

Autogenics 3a: Warmth, Arms, 13 minutes - 4.5Mb MP3 file.  Clicking on this (and subsequent) Autogenic Training exercises opens a browser window linking you to the chosen recording.  You can then either listen to the Autogenic exercise immediately by clicking on the right-pointing triangle in the green music player diagram, or you can download the recording to be played later from your computer or MP3 player.  

Autogenics 3b: Warmth, Arms & Legs, 12 minutes - 4.3Mb MP3 file.  Here is the second of these Warmth exercises.  You can move onto using this exercise when you have had a chance to practise the first Warmth exercise for several days.

Early reflections sheet - I usually give course participants this sheet to fill in and then get them to pair up to discuss what they've written with another participant.  We then have a general group discussion about the issues that have emerged.  If you're exploring these exercises on your own, it makes even more sense to give yourself a chance to reflect on the work you're putting in and the new ideas you're encountering.

Practice record 3 - it's likely to be helpful to keep a record of your practice, especially when you are initially learning these methods.

 

Autogenic training, session 4

For the fourth Autogenic Training class, I introduce a number of new practices and ideas.  These include the next stage in the basic Autogenic Training sequence (pulse & general calmness), beginning to work on application during daily life (1st differential exercise), and a focus on the "Nourishing positive states" aspect of inner focus exercises.  For this latter, I discuss ideas about the importance of our attitudes, process visualisation, and implementation intentions.  Please read the introductory remarks and work through the first three Autogenic Training exercises before starting on this fourth Autogenic stage.

As I've said before, in these initial weeks of learning the Autogenics, do your best to practice at least twice daily - sometimes using the recordings and sometimes simply taking yourself through the exercise on your own.  This fourth standard exercise introduces the phrase "Pulse steady and calm".  It's certainly possible to focus on the sensation of the pulse (at wrist, chest, or throat, etc) during this stage.  I personally, and in my classes, teach a focus here on a more general sense of relaxation and calmness.  I say that we are currently a bit like a "starfish" - we've specifically relaxed all four limbs and the neck & shoulders - here's a chance to encourage the relaxation to spread deeply right through our whole system.  I point out that the blood nourishes every living cell in the body.  Now, in a similar way, let the relaxation nourish every corner of the body.  You're welcome to use either the shorter 12 minute Pulse exercise or the longer 22 minute exercise or practice without a recording (for 10 to 20 minutes) depending on the time you've made available.  The shorter and longer exercises cover the same ground - the longer simply goes into it more deeply.  If it's helpful, and it usually is, continue to keep a record of your practice.  

I would eventually like you to be able to practise Autogenics - or at least to settle, relax and quieten - when you're walking down the street, or in a meeting, or stressed or pretty much anywhere else.  While you're learning, don't try this when you're using dangerous machinery or driving.  However - as when learning almost any new skill - gradually increase the challenges you set yourself.  If you're to walk down the street while being very relaxed, you'll need to keep some parts of your body active (e.g. the legs) while relaxing other parts (e.g. the arms, shoulders, face, etc).  This first differential exercise begins to help you explore this.  Please try to practise the 11 minute first differential exercise (with the recording and sometimes on your own) once daily for at least a week.  It counts as one of your twice daily Autogenic exercises - so at minimum try to do one pulse/calmness and one differential exercise pretty much every day. 

Glance through the slides 1-6 and 7-12 (see below).  They highlight the crucial importance of the attitudes we approach our lives with.  It's good to set ourselves goals that are chosen aligned with our personal values.  See the goals - ACT WISeSt handout for more on skilful goal setting and the process visualisation slides (see below) to suggest interesting and helpful ways to increase the chances of achieving these goals.  Implentation intentions, background updates these ideas further and implementation intentions, instructions suggests specific powerful methods of visualisation that you can use in the quiet at the end of Autogenic practice to set up key intentions for the rest of the day.  Finally the reflection on intentions sheet encourages you to review what you've found most personally useful about these insights and what you want to continue to explore.  It's an added bonus learning how to use implementation intentions.  It's not crucial to developing skill in Autogenics, but it highlights one of the ways that inner focus and visualisation can more effectively move out into the rest of our lives. 

Autogenic slides 1-6 - these first six slides, for the fourth Autogenic lesson, introduce new practices (pulse & 1st differential) and ideas/research on the importance of our attitudes.  The focus is particularly on realizing at a deep level that outcomes in our lives are strongly affected by our beliefs & behaviours ... and that having a sense of "control"/choice/freedom is of great importance.  Practising calming skills can nourish this sense of control/choice/freedom in a series of overlapping ways. 

Autogenic slides 7-12 - this second set of six slides highlights this "nourishing positive states" use of inner focus.  Slide 3 of this set illustrates varous types of "positive state" that can be encouraged in this way.  The slides also introduce process visualisation exercises.

The importance of attitude - this handout is quite dated.  It focuses on Suzanne Kobasa's work on "Hardiness" - one way of exploring the value of control/choice/freedom.  The points it makes still have value.

Goals - ACT WISeST - ACT WISeST is an acronym to help with skilful goal setting.

Process visualisation slides 1-2 and slides 3-4 - highlights ways of using visualisation to achieve goals - in the way you act and/or in what you achieve - more effectively.

Implementation intentions, background - I wrote a blog post on the background to implementation intentions which gives links to a good deal of the relevant research.

Implementation intentions, instructions - and there's a further blog post on more practical suggestions on using this very helpful tool. 

Reflection on intentions - it's usually good to reflect on what you've been learning.  It often helps you "digest" the ideas better and make them more your own.  The questions on this reflection sheet are designed to encourage this process.

Autogenics 4a: Pulse, Shorter, 12 minutes - 4.0Mb MP3 file.  As described above, my focus in teaching the Pulse exercise is particularly on encouraging deep relaxation and calmness to spread throughout the body (and mind) now.

Autogenics 4b: Pulse, Longer, 22 minutes - 6.3Mb MP3 file.  It's fine to practice the shorter Pulse exercise, but good to use this longer form sometimes instead.

Autogenics 4c: First Differential, 11 minutes - 3.6Mb MP3 file.  The first of the differential exercises developed by Ost to facilitate application of skills during everyday life. 

Practice record 4 - it's usually helpful to keep some kind of record of your practice while you're in this initial learning phase with the Autogenics.  It allows you to note how well you're keeping the practice going, how deeply you're able to go, any patterns around missed or "messy" practices, and so on.

 

Autogenic training, session 5

Here are the handouts and other materials for the fifth Autogenic training session.  Start this exercise once you have worked through the first four lessons.  Take your time.  If you have conscientiously worked your way through to this fifth session, you're doing really well.  Congratulations.  Don't feel you have to finish each new exercise in a week.  Take longer if you want to - these are skills that can last a lifetime, so enjoy developing them really thoroughly.  Session five introduces focussing on the breath, extending our ability to apply these skills during other activities, better understanding of emotions, and the use of therapeutic writing.

The next step in the standard Autogenic Training sequence is to add a focus on the breath.  The aim is simply to attend to and follow the movement of the breathing.  One isn't trying to control the breathing.  Changes in the breath however are likely to occur.  I often liken this stage to the earlier "Neck & shoulders are heavy" exercise.  I say that before getting to "Neck & shoulders are heavy" one isn't deliberately holding any tension in the neck & shoulder area.  However usually when getting to this focus, one finds that there is tightness that one hadn't been aware of, and one notices the shoulders dropping a bit as they relax.  I say that, in a similar way, one isn't typically aware that one is holding or tightening around the breathing.  However as one silently repeats the words "Breath breathes me", relaxes more fully, and simply observes the rise and fall of the chest & abdomen, nearly always the breath starts to slow and deepen.  Eventually, as one becomes progressively more peaceful, one's need for much oxygen decreases, and the breath may well become quite gentle and shallow.  The 11 minute and 18 minute Breath exercises cover the same set of instructions - use whichever you have time for.  Do make sure that you sometimes try the longer exercise as there is a bit more detail included. 

The other new component of the actual Autogenic practice involves moving another step forward in developing the ability to apply these skills during everyday life.  One aspect of this is in learning to cope better with "distractions" such as a noisy environment.  I talk to trainees about this, saying that they probably have all already had the experience of starting an Autogenic practice session while there is some fairly troublesome outside noise.  If the session then goes well, they may have noticed that - on opening their eyes at the end - they find the noise is still going on as before, but that during much of the session it simply wasn't an issue.  The noise just went right by without being a source of any significant disturbance - "water off a duck's back"!  I say that it's likely to be useful to learn to further develop this ability to practise calmness even when the outer (or inner) environment isn't particularly peaceful.  I suggest that "simply letting the noise go by" is a useful strategy here.  I comment that if one is tightening physically or psychologically against the noise, it is exactly these areas and these attitudes that maybe one needs to let go of.  The noise is a teacher in highlighting physical areas and mental assumptions that it may be helpful to release.  Sometimes one may want to concentrate a bit more firmly on the actual Autogenic sequence so one isn't so easily knocked off focus by the distractions.  Sometimes, particularly as the exercise deepens, letting the noise (or other distractions) go past is easy and straightforward.  I have a radio - typically tuned to be distractingly just off station - turned on as we go through the Autogenic exercise.  This gives good practice in developing this ability.  I say that if anybody finds this exercise particularly difficult, it is probably worth practising it further on their own - possibly initially with the sound turned down more to make it easier to start with (it is usually also easier to work with distracting music rather than distracting voices).  I also point out that dealing with unwanted noise is not that different from dealing with other "unwanted distractions" during the practice (or during everyday life).  These distractions may be external such as noise, cold, light, movement and rain - or internal such as pain, tiredness, anxiety, anger and depression.  All these distractions provide opportunities for "mindfulness" practice - and external distractions may be easier to deliberately set up than internal distractions. 

Another aspect of this application training is introduction of the 15 minute second differential exercise, which shifts from the very simple body movements of the first differential exercise to slowed fragments of real life activities.  On the recording these are drinking, writing, and standing.  Particularly in the first days of practising the second differential, do the movements in slow motion (and possibly just repeatedly write the same word!).  Gradually, you can learn to maintain a good, peaceful state in the rest of the body, as you bring the speed of the movements up to a more routine, everyday pace.  If you find practising standing feels too unsteady initially, start by practising close into a corner of a room.  If you wobble, you have the walls just behind you and on either side.  Over the days, as you gain confidence in practising standing up, you can then move to practising a little in front of a flat wall (no longer needing a corner), and then to practising away from any supports.  Many people however, will feel fine about practising standing away from any supports straight away.  Try to use this second differential exercise every day.  When you move to sometimes not using the recording, feel free to take on different challenges - try maintaining a peaceful, relaxed state as you go through other simple everyday activities like eating something, cleaning your teeth, washing, walking, and so on.  Notice how this differential exercise both teaches applied relaxation during activities, and also "de-automatises" the activity so you can become aware of it - the subtle muscle & other sensory details - in a way that one usually never notices.  These exercises are about coming into the present as much as about relaxation - "Lose your head, and come to your senses".  As before, aim to practise the differential at least once daily, and the breath exercise at least once daily.   

In addition to these developments in the Autogenic Training practice, I typically introduce ideas about emotions and therapeutic writing at this fifth session.  Look at the Powerpoint slides (see below) to understand this evolutionary, adaptive view of emotions.  Developing better understanding can help hugely in making our emotional reactions less confusing and less stressful.  We have emotions because, when appropriate, they can help us function better and respond more constructively to our environments.  The Good Knowledge page on this website entitled "Emotions, feelings & personality" gives more extended information and handouts about this area, as too does clicking on Emotions in the "Tag cloud".  Finally I discuss Therapeutic writing.  In classical, traditional Autogenic Training, one is taught to practise a rather surprising set of exercises involving emotional discharge.  There has been virtually no decent research showing that these exercises add anything useful to the Autogenic relaxation exercises.  Therapeutic writing, in contrast, has been extensively researched with approaching two hundred studies showing its benefits.  The "Power of words" slides and three handouts on therapeutic writing (see below) give much more detail - as too does clicking on Writing in the "Tag cloud".  I encourage Autogenic "trainees" to explore this information and try out therapeutic writing.  Initially you can always explore the more gentle exercises described in "Therapeutic writing for health & wellbeing", but do become familiar as well with the more "cathartic" focus on difficult experiences described in the other writing handouts.

At the bottom of this page, you will find downloadable reflection and practice record sheets - both are usually worth using to continue to explore and personalise the value you get from this training. 

Autogenics 5a: Breath, Shorter, 11 minutes - 10.3Mb MP3 file.  This 11 minute and the longer 18 minute exercise (below) cover the same ground.  Use whichever you have time for. 

Autogenics 5b: Breath, Longer, 18 minutes - 5.5 Mb MP3 file.  Good to use this longer exercise occasionally as it has a chance to go into the practice in a bit more detail.

Autogenics 5c: Second Differential, 15 minutes - 5.3 Mb MP3 file.  An extension of Ost's application training. 

Autogenic slides 1-7 - these first seven slides, for the fifth Autogenic lesson, introduce the overall structure of the class, especially the focus on understanding our emotions better.  I would leave out slide 3 (participants are already familiar with it) when producing a six-slides-to-a-page handout.

Autogenics slides 8-14 - this second set of a further seven slides continues to explore aspects of emotions.  I would typically not include the cartoon in producing a six-slide handout.

Power of words 1 - this sequence of 6 Powerpoint slides can be printed out as a (6 miniatures to a page) handout introducing some background to therapeutic writing.  This and the next half dozen slides (below) are from a talk I gave back in 2003.  Subsequent research further backs up the potential value of this approach.  See too the handouts on Therapeutic writing (below).

Power of words 2 - a further 6 slides that can also be printed out as a (6 miniatures to a page) handout.  

Therapeutic writing, Jamie Pennebaker download - a download (some while ago) from Jamie P's website.  Pennebaker is the "grandfather" of therapeutic writing research.  Good stuff.  

Therapeutic writing, written by me - as it says 'on the tin'!

Therapeutic writing & speaking: inspiration from values - this post explains how one can benefit from writing about other topics - such as life goals or intensely positive experiences - as well as one can by writing about trauma and life upheavals.

Reflection on emotions - a sheet to help you think about and personalise what you're learning about emotions.  In a group training, this would usually be an individual exercise that would then lead to discussion in a pairs and, finally, discussion as a group.

Practice record 5 - here's another sheet on which to record your practice.  This is often helpful to do, especially in this initial learning phase. 

 

Autogenic training, session 6

Here are the handouts, recordings, and reflection/record sheets for the sixth Autogenic training session.  There are four overlapping themes to this 'lesson'.  Obviously a key issue is the next Autogenic Training step - the focus on the abdominal area.  I usually initially get trainees to put a hand or both hands on their abdomen when they are learning this exercise.  The hand(s) are positioned a little below the belly button, unless the trainee has specific abdominal symptoms - when positioning the hand(s) over the troublesome area may be more appropriate.  The hand(s) don't have to be in direct contact with the skin.  A sense of gentle, warm contact through clothing is fine.  This typically helps one focus on the abdominal area and the hand contact also merges easily with the feeling of belly relaxation and warmth that one begins to allow. 

The phrase I use here is "Belly warm and radiates warmth".  The relaxation response is associated with blood flow partly shunting away from the big, voluntary muscles (that could be used for fight or flight) to potential areas of self-healing & recharging like the skin and digestion.  Belly warming is probably a real phenomenon, but it is likely to be subtle and I suggest you simply imagine the sense of increasing warmth.  It is the deepening experience of relaxation and peace that matters.  When I learned Zen meditation many years ago, my Japanese teacher used to encourage us to focus our attention on the abdomen.  He would say "Belly centre of the universe.  Sit like mountain!"  This area - the body's centre of gravity - is known in the East as the Dan Tien or Hara and has long been an important focal point for internal meditative techniques.  Pretty quickly you're likely to find you can focus here without needing to make contact with your hands.  Allow a deepening sense of centred relaxation and warmth to grow and to spread calmness out through the body "like the rays of the sun".  After all this is also the site of the solar plexus - the complex network of nerves located behind the stomach. 

There are two downloadable Autogenic exercises that can be used - see lower down this page.  They are each about 13 minutes long and one uses the standard emphasis on deepening relaxation that we have become familiar with already in earlier Autogenic exercise recordings.  The other explores aspects of mindfulness more.  In this latter exercise, you are asked to note how much you remain with your basic focus on the Autogenic relaxation sequence.  It's fine and to be expected that various "distracting" thoughts, images & sensations - the fishhooks - will go through your mind.  Simply letting these distractions float by doesn't count as being "off focus".  If however you find yourself spending time "on a fishhook", mindlessly thinking about these distractions, you are now "off focus".  For the purpose of this training, this "off focus" time is what you're noticing quickly and allowing yourself to unhook from.  In the mindfulness recording, you are asked to make a series of estimates of roughly what percentage of the exercise you are managing to stay "on focus", with the Autogenic sequence, allowing any distractions simply to float past.  Become familiar with both the Belly relaxation and Belly mindfulness exercises.  Sometimes use the recordings and sometimes practise without them.

The second of four themes, in this sixth Autogenic Training session, is a further step in application practice.  You should have used the first and second Differential exercises (described in the fourth & fifth Autogenic Training sessions) regularly before moving to this next stage of application.  When I'm teaching someone this exercise personally, I would now hand them about a dozen small adhesive coloured dots.  You can buy them in many stationery shops.  Tongue in cheek, I say that ideally at this stage I would employ an assistant to follow the trainee around for a week or so.  Every now and then the assistant would tap the trainee on the shoulder to get them to check on how relaxed and present they are - a kind of gentle "How are you doing?" moment.  I say however that this could be rather intrusive and expensive, so we'll use the reminder dots instead.  It should be possible for you to construct an alternative to these dots if you don't have easy access to them - for example by using very small fragments of paper attached with little sections of sellotape or blu-tack. 

Think about the sequence of one of your typical days - getting up and dressed, hopefully eating some breakfast, maybe travelling to work or getting on with things at home, and so on.  As you imagine your way through a typical day, think about places that you could stick reminder dots.  I don't want you to have any long sections of the day when you won't "bump into a dot".  If appropriate - because you're using public areas - the dots can be mostly hidden so that only a little fragment of it is visible to you.  It's the fact of being reminded "How are you doing?  Can you relax a bit more?  Can you be present a bit more?" that matters.  So locations many people use include mirrors, tooth brush handles, on cups or mugs, beside kettles and kitchen sinks, on fridges and clocks, key rings and watch straps, on telephones and purses/wallets, inside desk drawers, on computer mice, files, pens, car dashboards, near TV's, and so on.  As you go through your day, it would be good if fairly regulary you came across a reminder dot - maybe 30 or 40 times daily.  Probably best if it's not continuously in your line of sight for long periods of time e.g. not on or too close to a computer screen.  The aim is for the dot to remind you and if it's constantly there it tends to lose its reminding function - you simply adapt to it and forget about it.

When you notice a dot, you don't have to stop what you're doing.  In fact, my preference would be that, if anybody was observing you, they wouldn't notice that you are doing anything special or different.  At mimimum, please would you take two or three slightly longer, slower breaths.  While you're doing this - as you continue to get on with whatever else you're doing - drop your shoulders, relax your face and body, let go of unnecessary tension.  We tend to go through life tightened up a notch or two more than we need to be.  Here's a reminder not to make all this unnecessary effort.  At the same time as relaxing a little, also come into the present a bit more.  The two - relaxing and coming into the present - are often linked.  To relax and let go a bit I need to stop planning/worrying/fantasising about the future.  I need to let go of memories and mulling over the past.  To relax and settle, I'm likely to come into the present - to be here now.  It's fine too to let the reminder move you into a more extended application of relaxation/being in the present.  I sometimes describe this exercise as being like an accordion or concertina - it can be contracted down to just a few breaths or it can expand out to some minutes in length.  So, for example, if my eye catches a dot when I'm eating or when I get out my wallet/purse to pay for a bus ticket, or while I'm doing the washing up - then I can get on with the activity at the same time as savouring the present time experience of what I'm doing, relaxing, appreciating, really being in the feel of the present moment in my life for minutes on end.  Human beings adapt quickly to situations, so reminder dots will tend to lose their signal value after a while.  That's fine.  It would be great if a fairly intense use of these dots for a few weeks means that you start to have checking into the present and releasing/softening as a default mind-body space you move into often during gaps and at different times during your day.  You can always unpeel all the dots after a while and possibly reintroduce them occasionally over subsequent months.

As part of the application training, I also introduce a "Coming to our senses" exercise.  I explain that it is now perfectly possible to go for a walk and work through a full Autogenic practice as you stroll along.  In fact I would encourage you to experiment with this.  It can be fun, peaceful, and good training.  When doing this the attention is quite largely focused inside.  An alternative exercise is to come to your senses.  See the "Coming to our senses" slide for more on this Observing, Sensing, Hearing practice, where the attention focuses more on the outer world.  In both cases - Autogenics during activity and Coming to our senses - there is a softening/loosening/relaxing and a coming into the present.  These exercises are probably best done when you're moving through the world - walking, cycling, running, or on a train, bus, plane, or as a car passenger.  I written several blog posts about this kind of process - for example while walking in the Sahara earlier this year, or in the Scottish hills

The third theme I look at in this sixth Autogenic Training lesson is covered in the slides.  I discuss Csikszentmihalyi's ideas and research on flow - see slides 1-6, slides 7-12 and the flow channel diagram.  The slide Savouring, mindfulness & flow illustrates straightforward overlaps and distinctions between flow and mindfulness, while Attention, focus & time extends this mapping of what & how we pay attention a bit further.  Attention skills developed during Autogenics allow us to have more choice now over how and where we focus our attention.

The fourth and last theme in this sixth session is illustrated by the presentation Responses to suffering slides 1-6 and slides 7-12.  Since the Autogenic classes I teach are only a couple of hours long, there isn't usually much time to go into this Responses to suffering area deeply.  I bring it in at this stage largely because of Professor Whorwell's work on hypnotherapy, irritable bowel syndrome (IBS) and other disorders.  The hypnotherapy here involves deep relaxation and healing imagery and Autogenics can be easily adapted to include these ideas.  This links into the whole area of healing visualisations - see, for example, slide 11 of the Responses to sufferering sequence. 

I may well also give course participants the Reflection on flow sheet to encourage them to think a bit more deeply about 'flow'.  I also give them a Practice record sheet. 

Autogenics 6a: Belly, Relaxation, 13 minutes - 4.5 Mb MP3 file.  This adds in the Belly focus (see above for description) linked with allowing deeper relaxation & peacefulness - as we have been doing developing the Autogenic Training sequence over the weeks so far. 

Autogenics 6b: Belly, Mindfulness, 13 minutes - 4.5 Mb MP3 file.  This exercise gives a different slant.  It focuses more on mindfulness and attention (see above for a fuller explanation). 

Autogenic slides 1-6 - these slides particularly focus on introducing ideas about "flow" .

Autogenic slides 7-12 - further slides in, largely with focus on flow.

The flow channel - a useful model illustrating the interaction between flow, challenge and skills.

Coming to our senses - an attention exercise that can be seen as applied relaxation, but probably is better conceptualised as a form of mindfulness training.

Responses to suffering slides 1-6 - a broad overview on applying problem solving for troublesome symptoms.

Responses to suffering slides 7-12 - these further slides also begin to introduce potential ways of using helpful imagery.

Reflection on flow - a set of three questions to encourage personal reflection on 'flow'.  In a group training this would probably used as a springboard into pair and then full group discussion.

Practice record 6 - again this record sheet is a way of encouraging making the practice more personalised and reflective.

 

Autogenic training, session 7

Here are handouts and recordings for the seventh Autogenic Training session.  The initial "Autogenic relaxation training" page gives introductory details of this method.  In the face-to-face trainings that I run, I would typically start the two hour class by practising last time's Autogenic Training exercise together - in this case it would be the sixth session's belly focus.  I would then collect the trainees' record sheets and go round the group looking at how each individual's practice had been going and trouble shooting/sharing experiences.  This group discussion time can be very valuable.  It brings up all kinds of interesting points, encourages people to interact and help each other, and reinforces the sense that we are all on this learning/exploring journey together.

At this seventh training session, I focus on two main themes.  The first is to complete the full standard Autogenic Training sequence by adding in a focus on the forehead.  The phrase I teach is "Forehead cool and clear".  I usually get trainees to observe me smoothing out my own forehead.  I draw my fingers slowly and firmly from the midline of the forehead out and back over the temples on each side.  I then ask them to close their eyes and repeat this slow, firm smoothing out movement for themselves.  Typically it's experienced as a pleasant, cool, soothing sensation.  I ask them to "take an internal photograph" of what this feels like and I say that it can be helpful to remember & recontact this sensation when they are at the "Forehead cool and clear" stage of their Autogenic Training practice.  I mention that, objectively, it is probably not so much the forehead that cools as that much of the rest of the face warms slightly.  It's interesting though that we have phrases like "Keeping a cool head in a crisis". 

I comment that for me there are at least two useful aspects to the forehead focus.  One is that relaxing the forehead and eyes seems a particularly potent way of quietening the brain.  The other is that letting the face go feels to me like a metaphor for letting go of personality and all the strivings & struggles associated with our egos.  Per-sona, that through which the sound comes.  Letting all that go.  As a special yoga teacher, who taught me, used to put it "Nothing to do, nowhere to go, no one to be".  I sometimes mention my experience many years ago of teaching a relaxation sequence to a large hall filled with over a hundred people.  They were all lying on their backs on the floor and I was taking them through the relaxation from the raised stage.  As they went through the sequence, I still remember the fascinating impression I had that they were all getting so much younger.  As their faces cleared of tension and worry, smoothing out, calming, they seemed to shed years in age.  Precious.  A kind of innocence.  So "Forehead cool and clear" is, in a sense, letting all the striving go.

The second major theme I focus on in this seventh session is the importance of balancing present-focused flow & appreciation with value-directed goals.  There is a link here to the "Bus driver metaphor" that I've written about in a previous blog posting.  The Powerpoint slides for this session explore these issues in more detail (see below).  The third slide, for example, uses the yin-yang sign to underline the key challenge of balancing longer term structure, plans & goals with moment-to-moment awareness & appreciation.  I highlight that we can be very productive and get lots done, but if we're not connected to our values, to what we're about, then all this activity can just be a dust storm hiding the emptiness of our lives.

I ask people to consider their values by completing the "Respected figures exercise".  I underline that one doesn't have to respect everything about the people who one writes down - but there should be important ways that one deeply respects some of how they have lead their lives.  It is these qualities that are key.  For many people this exercise is helpful in clarifying key qualities that they feel are deeply important in leading a worthwhile, good life. 

I talk too about keeping a broad balance in our lives.  One effective way of doing this is to think of our lives as involving a series of overlapping roles.  Examples might be husband/wife, son/daughter, father/mother, friend, worker (this might involve more than one role), general administrator (covers the practical/financial/paperwork side of things), possibly a role involving hobbies/interests, and (non negotiable) a role or roles covering self-care (exercise, food, sleep, addictive substances, spirituality, etc).  The "Role areas" sheet is a way of jotting down the roles that fit for your life.  There isn't a right or wrong way of doing this, but I suggest you keep the number of roles to 8 or less, and try to make sure that pretty much every waking minute is covered by one role or another.

This "Respected figures" and "Role areas" explorations now lead easily into the "80th birthday party" exercise.  This is a good way of getting an overview of how you want to be and what you want to become.  So I ask participants to imagine that it is their 80th birthday party.  A series of guests get up to make short speeches.  Each speech is a celebration of how you've lived each of the roles in your life.  So a friend would stand up and talk about what a precious, special, marvellous friend you have been.  We're allowing time travel here, so one of your parents would miraculously appear to praise how you have been as a daughter/son.  If you've been in a couple, your partner would celebrate how fantastic it's been to live with you.  You imagine too that people who know how well you've done in the general administration and self-care roles talk with great admiration about how you've been in these areas of your life.  As you can see from the "80th birthday party" exercise sheet, I suggest that you keep all these comments brief and inspirational.  This is not about self-aggrandisement.  This is not about how you are at the moment.  This is about how you'd love things to turn out if your life went absolutely as you would want it to develop - and if you were able to live the values that are most important to you and be the person that you would most want to be.  The "Best possible selves" is another good way of exploring this territory.

We now get down to the more nitty-gritty issues involved in turning these ideals and dreams into shorter term goals.  I ask people to complete the "5 year, 1 year & 3 months" sheet.  Particularly as we get to 1 year and 3 month intentions, our dreams now need to crystallise down into firmer, more specific intentions.  The "Brainstorm" sheet can help us stretch ourselves, but we want to get a balance between stretching and realism.  The "Goals - ACT WISeST" advice can be helpful here.  It's unlikely that participants will complete all these exercises in the two hour class, but I encourage them to finish the exercises on their own.

I ask them too to continue to record their Autogenic practice.  Since the next class is the last in the 8 session series, I suggest they experiment with briefer recording using the monthly practice record sheet (see below). 

Autogenics 7a: Forehead, Relaxation, 11 minutes - 3.8 Mb MP3 file.

Autogenics 7b: Forehead, Mindfulness, 12 minutes - 4.1 Mb MP3 file.

Autogenic slides 1-9 - slides for this seventh Autogenic Training session.

Autogenic slides 10-15 - further slides for this seventh Autogenic Training session.

Goals, values, meaning - this is a handout I put together a long time ago.  It still has some value for orientation in this area.

Respected figures exercise - I use this sheet a lot for helping people clarify their values.  I suggest to them that they are unlikely to feel good about their lives unless they are trying to live the values that they particularly respect.

Goals for roles - role areas & 80th birthday party - I often use goals-for-roles sheets after having done the "Respected figures exercise".  The "Role areas" form helps clarify different aspects of one's life and it can be used to provide some structure to the "80th birthday party" exercise.

Goals for roles - brainstorm, 5 year, 1 year & 3 months - forms I typically use after the "80th birthday party" exercise to get to the nitty gritty of specific goal targets.

Practice record month - this monthly practice record form allows people to begin to experiment with still recording their practice, but in less detail.

 

 

Autogenic training, session 8

Here are the handouts and recordings for the eighth and final session of this basic Autogenic Training course.  The initial "Autogenic relaxation training" page introduces the method and gives access to the previous seven lessons in the training sequence. 

There are two main themes for this last session.  One is to encourage course participants to review what they have learned over the previous weeks of the training, and to become clearer what feels right for them to do now.  The second theme is to introduce some ideas about the importance of relationships and how this can overlap into Autogenic Training.

Often I will have asked course participants to track their progress using assessment questionnaires like the "Target symptoms sheet" and other more general depression, anxiety, wellbeing and mindfulness measures (see more on this in the "Autogenic training, session 1" description).  I will take time now to get trainees to complete these questionnaires again to help clarify what progress has been made.     

The key tool I use to encourage personal review of what has been learned is the "End of course reflection sheet".  Initially I get participants to spend some time responding to the two questions on the first side of the sheet: 1.) Looking back over the Autogenic course, what for you personally have been the best things about it?  In what ways has your life improved?  What new skills or abilities have you developed?  Have you had any insights or new ways of seeing things that feel valuable?  Are there other positive things you have experienced doing the course?  2.) Looking back over the course, what for you personally have been the main difficulties that you have experienced? Are there useful lessons you can learn from these problems? Are there any implications that are important for you to remember? Is there anything further you want to do about these difficulties now or in the future?  I give them a fair amount of time to think and write about these questions.  Good learning tends to involve reflection as well as taking in new knowledge and experience.  I'll then get them to discuss what they have been writing, first in pairs or small groups and then bring it back to an open forum in the full group.

We talk as well in the full group about "where from here" issues.  I've taught Autogenic Training for well over two decades and, over the years, I've experimented with various ways of building "follow-up" into the course.  I say that course "graduates" probably fall into one of three categories.  Some (hopefully only a few) feel that the course was interesting and introduced useful ideas and practices, but now it's time to move on without actively continuing to do much with all this information.  A largish group will practise sporadically, but mainly the methods taught will become a kind of psychological first aid kit.  They are "put on the shelf" and left to gather dust until life becomes particularly choppy and the techniques are brought back and restarted.  This is fine, but I am particularly interested in supporting people who want to continue to practise fairly regularly.  In my experience, Autogenics is a very good method to learn and use. 

I suspect this 16 hour training course is full of riches, support and good new experiences for many participants - possibly even richer and more digestible than many meditation trainings.  Where Autogenics can fall down - in contrast to an ongoing supportive meditation practice group - is that there isn't likely to be a local practice community that meets regularly over the long term.  It's hard to keep going through all the highs and lows of a personal practice without forms of support.  I know.  I've practised methods of inner focus/relaxation/meditation most days of the week since first learning about these approaches in 1970 - now nearly four decades.  Human beings are great at adapting - practice can lose its freshness.  See the blog post on "Goal renewal boosts wellbeing" for more on this.  It may be worth exploring other related approaches to Autogenics.  I, for example, often combine Autogenics with Mindfulness practice.  There are likely to be Buddhist groups that meet fairly locally to many locations around the world.  Some such groups will be doctrinaire and invasive, but many will be spacious and provide support for individuals to practise in their own ways.  Retreats too can be a blessing - maybe in Buddhist environments, but many Christian retreat centres allow and encourage visitors to find their own ways to peace and quiet.

Books too can be a fine resource - I provide a short reading list - and the internet as well is full of good (and also toxic) things.  I say that if you're inspired by a particular book or writer, it can often be helpful to just dip in and out - for example, reading a couple of pages or so most evenings.  Personal support is very precious too when it's available.  I sit quietly before breakfast most mornings with my wife.  She's a yoga teacher and we do different silent practices, but the support and quiet and connection is very special and anchors our lives.  I also meet with a dear friend - a meditation teacher - every three months or so for a day, and we review our lives and look ahead to clarify our intentions for the next three months.  These intentions certainly include issues like meditation practice.    

After all this I ask the course participants to look at the second side of the "End of course reflection sheet" and respond to the third question: 3.) Remembering both the good things that have come from this course and any difficulties that you have faced, what do you feel it would be most helpful for you to do now?  What kind of Autogenic practice do you want to keep up?  Are there other issues that you would really like to do something about?  Also on the second side of the reflection sheet are suggestions on how to construct more effective intentions - as there are as well on last week's handout "Goals - ACT WISeST".  To give them a flavour of how mutual support can continue to help, I suggest that once they have written down their intentions they write a brief second copy.  They then pair up with another member of the group.  I ask them to exchange phone numbers or email addresses and copies of their intentions.  They explain their intentions more fully and agree to check in with each other after another month or so to talk about how it's been going.  This pair support is optional, but I encourage everyone to seriously consider trying it.  Sometimes small groups or two, three or four people may continue to meet up face-to-face. 

Over the years, I've experimented too with providing an occasional "course graduates" half day review.  More successfully still, I've run a number of "Autogenic support groups" that are advertised in the following way: The Autogenic Training support group is a five session monthly follow-up for those who have, at some stage in the past, already completed an initial Autogenic Training course.  James writes: "I feel the standard eight session Autogenic Training course is a great way of learning calming skills, developing mindfulness, and reviewing more general aspects of stress management.  A weakness of the standard course is the lack of follow-up.  It's often hard to keep  up regular practice on one's own.  Even when one does keep going pretty well, the quality of the practice can become less satisfying and less helpful.  The monthly Autogenic Training support group aims to counteract this tendency."  Most recently I am beginning to explore designing and teaching a longer "Lifeskills & Stress Management for Health & Wellbeing" course that both incorporates Autogenics into a wider training and also aims to more formally build a supportive self-help community into the follow-up.

Rich ... supportive ... by now the group feels like a band of caring, known, good, fellow travellers.  We've been on quite a journey together.  Although it isn't presented as an obvious key component of the Autogenic course, the participants have learned a lot from each other as well as learning from what I have offered.

I talk a bit about community and relationships at this last session.  I've written a lot about these issues on this website.  See, for example, the eighth session Powerpoint slides (below), the handouts on aspects of relationships (below) and website pages on "Relationships general" and "Relationships, families, couples & psychosexual"

I give participants a final couple of Autogenic practice recordings (see below).  They are both variants on the full standard Autogenic sequence taught at the seventh session.  However one is a - typically morning - "Energising" practice, and the other a long - typically in bed at night - "Quieting" practice.  I also introduce them to the possibility of linking compassion practice to the standard Autogenic Training sequence (something I go into more fully on the follow-up "Autogenic support group").  There are a further 12 practice recordings as well as explanatory information on the "Compassion & criticism" webpage.  Plenty to be going on with.  I encourage people to vary which recordings they use - and to continue to practise often (or maybe always) without recordings.  I very much hope all this information and sharing has been useful to you.  The "Four aspects of helpful inner focus" are a treasure trove for relieving suffering and enhancing wellbeing and joy in living.  If you find these approaches feel right for you, do explore them.  They can become lifelong friends - in the good times and the bad.

Autogenics 8a: Forehead, Energising, 12 minutes - 4.0 Mb MP3 file.

Autogenics 8b: Forehead, Quieting, 28 minutes - 8.1 Mb MP3 file.

Autogenic slides 1-6 - Powerpoint slides for this eighth session of the course.

Autogenic slides 7-13 - further slides.

Target symptoms final severity sheet - this simple 0-10 assessment questionnaire checks back to the symptoms/difficulties that a course participant initially hoped learning Autogenic Training would help with - and asks what change in symptom/difficulty troublesomeness has occurred over the course.

Reflection sheet, end of course - a key worksheet we work with at this final course session.

Relationships are important for our health - I wrote this information leaflet a longish time ago, but it still makes very relevant points.  Clicking on the relationships tag or other similar tags in this website's tag cloud will bring up a wealth of more recent relevant material.  See for example the blog post "Social integration and a midsummer potluck lunch".   

Communication scales - a handout from Carkhuff & Berenson's adaption of the classic Rogerian person-centred triad highlighting key interpersonal qualities in close relationships

Personal community map questions - I ask people to answer these questions as they fill in, and after they've filled in, their personal community map (see below).  Their answers help to clarify what they probably need to do to continue building personal relationships that promote health, stress resilience, and wellbeing.  

Personal community map instructions - these instructions go with the 'personal community map' (below), explaining how to fill the chart in, and giving background information. 

Personal community map - this chart is a helpful way of encouraging people to begin describing their relationships.

IIP-48 questionnaire & score sheet - I use these questionnaires about characteristic interpersonal style a lot.  I look out for high score spikes on the score sheet and/or answers in the "3's" and "4's" on the questionnaire.  It's then worth exploring whether these responses are linked with relationship difficulties in the subject's life.  To paraphrase Alice Miller and others "The walls we build to protect ourselves, become the prisons in which we live."  This assessment tool highlights and helps track changes in our interpersonal "prison walls."

 

Compassion & criticism

Be kind whenever possible.  It is always possible.     Dalai Lama 

This section lists a series of loosely linked handouts and questionnaires about compassion, self-criticism, hostility, self-esteem and related subjects.  Compassion is an area that is being actively researched at the moment from a series of overlapping angles.  Here in the UK, Paul Gilbert's work is probably the best known.  His focus has partly been on the damaging effects of excessive self-criticism (for example in vulnerability to depression) and the potential benefits of promoting self-compassion.  In the States, Kristin Neff has been a leading researcher on self-compassion - see for example her Self-compassion website and list of freely downloadable publications.  I think both these authors would argue that self-compassion may often be a preferable way to relate to oneself rather than focusing too much on boosting self-esteem.  Other research - for example, by Mark Leary & colleagues - has further supported this view.  From different traditions, more emotion-focused investigators have looked at self-criticism using approaches such as internal dialogue exploration - see the Emotions, feelings & personality handouts webpage. 

Other research teams have come at compassion from varying viewpoints.  Barbara Fredrickson looked at how loving-kindness meditation boosts positive emotions, leading to better functioning and increased life satisfaction.  James Carson explored possible benefits for people suffering from chronic pain.  From a rather different angle, Jennifer Crocker at Michigan's Self & Social Motivation laboratory has explored how compassion impacts on relationships with others as well as oneself.  Also relevant here are the posts "Cooperative behaviour cascades in social networks" and "Be the change you want to see in the world".  See too interesting work on implications of research on intercessory prayer.  More in the public domain, Buddhist teachers like Sharon Salzberg have published quite extensively on loving-kindness meditation, and there are further groups like the Random Acts of Kindness Foundation.  All in all, although the field cries out for more research (and possibly more over-arching theory), we seem to have reached a stage where one can say there are real benefits for people who develop both greater self-compassion and greater compassion for others.  

Self-compassion scale - long form (Neff) with scoring and research - Kristin Neff's self-compassion scale can be helpful in assessing various aspects of self-compassion.  It can be a little time consuming to score, so may be best to work with just occasionally during therapy - or use the short form (below).

Self-compassion scale - short form (Raes, Neff, et al) - downloadable both as a Word doc and as a PDF file.  I find this 12-item short form of the self-compassion scale very convenient.  It's quicker & easier to complete & score than the long form, making it much more likely that one will use it to monitor treatment effectively.  The total score of the short form correlates very well with the total score for the long form.  It's probably better to use the long form if one wants to focus on sub-scale scores.  See Kristin Neff's list of freely downloadable publications on the web for more information about these scales and her work generally.

4 item scale, self-criticism & self-compassion - I find the Neff self-compassion scale a bit too long and slow to score for week by week use.  This simple self-constructed 4 item scale can be helpful in keeping an eye on how things are going session by session, while the fuller Neff scale is only being used occasionally.  Here is the scale as a PDF too. 

Toxicity of self-criticism abstracts - a chronic self-critical, self-attacking attitude is toxic to our wellbeing.  Sometimes this damaging attitude  to ourselves seems to be associated with difficulties in childhood, including poor care from our parents (possibly due to their own depression) and bullying from other children.  This handout gives research abstracts that illustrate these points.  

Toxicity of hostility abstracts - persistent anger, hostility & cynicism are damaging - not only to those at the receiving end but also to those who repeatedly feel these emotions.  This handout details some research studies highlighting these connections.

Undoing the brainwashing, slides 1 & 2 and slides 3 & 4 - here are 4 slides (usually printed out as 2 slides to a page handouts) that illustrate ideas from Paul Gilbert's compassionate mind training.  Slides 3 & 4 particulary are from Paul's work on how the way one is treated by external harsh critics (e.g. parents, etc) can be 'ingested' and become a way that one views and treats oneself.

Moods affect us quickly & powerfully - here is a nice two slides to a page handout illustrating the rapid effects of hostility and of compassion on mind and body.

Assessment of self-critic (or self-scarer) dialogue work - this is a questionnaire I put together to encourage client reflection after they have worked with forms of two-chair dialogue involving their internal self-critic (or self-scarer for anxiety disorders).

Post-imagery rescripting questionnaire - and this form is similar to the one above, but used more after work on specific memories (rather than after dialogue work) - for example using Mervyn Smucker style rescripting.

Compassionate/self-image goals scale and background - this is a scale from Crocker's fascinating work on compassionate and self-image goals.  See too the "Self and social motivation laboratory" website at http://rcgd.isr.umich.edu/crockerlab

Contingencies of self-worth scale - this is another questionnaire from the Crocker lab (see above).  Interesting way of probing what people's self-worth is based on ... and what the subsequent effects then are.

Rosenberg self-esteem scale - 9 point version and 4 point version - two versions of this classic scale.  I personally prefer the greater spread of scores provided by the 9 point version.

Nourishing self-esteem background - people who are low in self-esteem are often in the paradoxical position of really wanting to feel appreciated & validated by others, but finding it hard to believe that compliments genuinely mean that they are valued in any lasting way.  This handout gives background to an exercise that teaches people with low self-esteem ways of allowing appreciation to touch and help them more.  

Nourishing self-esteem exercise - here are more details of the exercise that encourages people with low self-esteem to allow compliments and appreciation to help them.

Boosting self-compassion & self-encouragement by strengthening attachment security: twelve practical suggestions - these two blog posts and the associated downloadable handout does "what it says on the tin" in providing some practical exercises that can be used to nourish our self-compassion.

5 stages of change & associated processes - this is the trans-theoretical stages of change model of Prochaska, DiClemente & Norcross.  It can be used to explain step-by-step change in many different behaviours.  It can useful when encouraging people to move from a habit of self-criticism to one on self-encouragement.

Development of caring in health professionals - here are a couple of research abstracts on caring in nurses linking this central quality with the nurses' experience of caring from their parents and from their nursing school.  The latter was particularly important, raising a series of questions about the knock-on effects of less caring institutions that train health professionals.

3 facet mindfulness questionnaire and discussion - this is a three component, cut-down version of the 5 facet questionnaire (see below).  I like this scale partly because it highlights the importance of reducing internal self-judgement in mindfulness. 

5 facet mindfulness questionnaire, scoring and background - see discussion also on the 3 facet questionnaire (see above).

There are a dozen MP3 recordings listed below.  It would be possible to use these tracks as a "compassionate mind training" sequence, although I've listed them more to illustrate the kind of approach that it's probably sensible to use.  The twelve recordings make up a four exercise training.  Each exercise includes a brief (1 to 3 minute) introductory track and then a medium length (15 to 18 minute) and longer (24 to 28 minute) meditation.  If you want to follow this sequence, please read the Suggestions for goodwill practice handout (below) first. 

There are a number of caveats.  I initially made these home recordings for people who had already completed the 8 x 2 hour Autogenic Training courses that I run.  Autogenic Training is a form of deep relaxation training.  It makes good sense to relax and quieten before moving on to the Goodwill exercises - hence the Autogenic exercise that precedes the Goodwill section on each of the meditations.  If you haven't already trained in Autogenics, the approach may seem a little strange at first.  It basically consists of moving one's attention through the different body systems - limbs, circulation, breathing, digestion, etc - settling them down.  The way I teach is somewhat unusual.  I have been practising forms of meditation most days of the week since 1970, so I have a fair amount of experience.  The recordings consist of me sitting quietly going through the meditation practice myself and sharing what I am focusing on as I do this.  The quality of the recordings isn't great, partly because they are simply made at home, and partly because I have reduced the size of the files by a factor of about six to allow them to be downloaded more easily and quickly.

For various partly evidence-based reasons, I encourage the Goodwill focus to be quite "emotional" rather than "cerebral".  I also encourage longer practice sessions where possible, although each meditation is also given as a somewhat shorter "medium length" practice.  Many people find that allowing compassion for themselves is particularly tricky - hence the sequence beginning with someone it feels relatively easy to feel love for, then moving on to family & friends in the second exercise, before reaching a focus on oneself too in the third exercise.  The fourth exercise then moves to include "all living beings".  Typically I encourage people to use each exercise over at least a week or two, before moving on to the next exercise in the sequence.  Particularly for people with high levels of self-criticism, I might suggest that they keep returning to the third exercise's compassion for oneself focus, rather than always using the fourth exercise.

It is worth noting that there are a whole series of ways to nourish a greater sense of compassion for others, and for oneself.  Much of the recent research has explored how to encourage self-compassion to combat the self-criticism that is a significant risk factor for depression.  Goodwill, loving kindness and compassionate mind meditation interventions are one approach that can be useful.  Psychotherapeutic two chair dialogue work (with the self-critic), challenging "brainwashing" from traumatic childhood experiences, building wellbeing through increasing competence & relatedness, experiencing real care in a good therapeutic relationship, and other approaches can all also be helpful in changing chronic patterns of self-criticism and hostility.

A final technical point.  It's a little difficult to make MP3 files available for download on the internet due to understandable concerns about illegal distribution of potentially copyrighted material.  I've got round this by joining MySpace as a band!  This allows me to upload MP3 files to a site where they can be a source for subsequent downloads.  I'm sure there are more elegant ways of getting round this, but I'm tickled to present myself as a rock band (frustrated ambitions of youth!).  When you click on one of the meditation track links, it will hopefully take you to the site where - by clicking on the named file - you can either open and play the file directly or save it to listen to later. 

Suggestions for goodwill practice - this is a three page handout that I give clients who are learning goodwill/loving kindness/compassionate mind training with me.  It contains references to various aspects of my work that probably aren't relevant to the situation with other teachers.  However the vast majority of the handout is either directly relevant to, or easily adapted to, goodwill meditation trainings provided by other trainers.

Goodwill practice record - this is a simple weekly practice record for goodwill/loving kindness/compassionate mind training.  It should be pretty easy to adapt this for the particular formats used by other trainers.

Goodwill & Autogenics 1: introduction - this is a brief 3 minute MP3 file introducing the initial practice.  There are fuller details in the written Suggestions handout (see above). 

Goodwill & Autogenics 1: 16 minutes - this initial exercise begins with an Autogenic Training relaxation and moves on to a Goodwill practice focusing on somebody that one feels particularly caring for.

Goodwill & Autogenics 1: 28 minutes - a longer version of the meditation exercise given above.  There is some evidence suggesting that longer practices are more helpful, but there needs to be more research before one could make firm recommendations about this issue of duration.

Goodwill & Autogenics 2: introduction - briefly introduces the second exercise.

Goodwill & Autogenics 2: 17 minutes - again an initial Autogenic relaxation is followed by a Goodwill practice, now extending from somebody one feels particular caring for to also include friends and family.

Goodwill & Autogenics 2: 24 minutes - a longer version of the meditation given above.

Goodwill & Autogenics 3: introduction - briefly introduces the third exercise.

Goodwill & Autogenics 3: 15 minutes - an initial Autogenic Training exercise followed by a Goodwill practice that adds a focus on oneself to the mix.  This is probably especially relevant for people who suffer from excessive self-criticism and vulnerability to depression.  Interestingly there may also be relevance - as self-soothing - for people who struggle with anxiety.

Goodwill & Autogenics 3: 24 minutes - a longer version of the meditation given above.

Goodwill & Autogenics 4: introduction - briefly introduces the fourth exercise.

Goodwill & Autogenics 4: 18 minutes - Autogenic relaxation followed by a Goodwill practice that moves through the sequence from somebody one especially cares for, to friends & family, to oneself, and out from there to "living beings everywhere".

Goodwill & Autogenics 4: 24 minutes - a longer version of the meditation given above.

 

Emotions, feelings & personality

This section contains handouts and questionnaires about emotions, feelings & personality.  It seems helpful to understand emotions through an evolutionary perspective - we have emotions, to a large extent, because they had (and have) survival value.  We are the descendants of people with adaptive emotional systems that helped them stay alive and function well.  Typically unwelcome feelings that seem maladaptive are due to emotions that are firing off inappropriately.  As a rule of thumb, if an emotion is an appropriate reaction to a situation it can help us respond successfully.  If the emotion is inappropriate then it's likely to be more useful to work to change the emotional response - through therapy or other approaches. 

There are handouts and questionnaires too on Fredrickson's work on positive emotions, and questionnaires on assessing the emotions we experience.  There's a link to Grossman's "Emotion regulation questionnaire" and further handouts about managing emotion including important work on reappraisal.

Also included are a series of handouts on feelings, schema and personality.  The "Our life stories: needs, beliefs & behaviours" is a model I put together to help guide work on the longer term dysfunctional personality patterns that we probably all experience to some extent.  The "big five" is a very widely used way of assessing personality, and this "ten aspects" version I find particularly interesting.  There are then a series of handouts from Arnoud Arntz's fine work on understanding and treatment of borderline personality disorder.  I have found that Arntz's ideas seem more broadly helpful than just with borderline (which anyway is a poor descriptor for this emotional regulation disorder).  There are also some sheets derived from Young's associated work on schema. 

Emotions are like a ‘radar system' - this pair of Powerpoint slides, that I print out as a two-slides-to-a-page handout, introduces the idea of emotions as an evolutionarily adaptive system.  I use the metaphor of emotions as a 'radar & rapid response system' - normalising emotions and conceptualising emotional problems as inappropriate levels of activation in a basically adaptive system.   

Emotions, ‘arriving' & ‘leaving' - this pair of Powerpoint slides handout introduces a simple model of 'arriving' (understanding what one is feeling) and 'leaving' (acting from or processing the feelings).  The ideas are based on the work of Les Greenberg, Robert Elliott and others. 

Emotions, awareness & regulation - again a pair of Powerpoint slides based largely on the work of Greenberg and colleagues.  The handout both looks at aspects of emotions and introduces a metaphor of wading into a river as a way of considering over- and under-regulated emotions.

Emotions as different rooms in a house, page 1 & page 2 - here are four Powerpoint slides that I usually print out as a handout with two slides per page.  Page 1, with ideas from Antonio Damasio, looks at the changes emotions produce in body and brain.  Page 2, partly inspired by John Teasdale, suggests that different emotions produce such different mind-body states that it may sometimes be helpful to view humans as possessing a series of different "minds" rather than just one.  I then introduce the metaphor of humans as "houses" with a collection of different mind-body "rooms" that we move between.  

"Positive" emotions, page 1 & page 2 - again this is a four Powerpoint slide handout usually printed as two slides per page.  It looks at the work of Isen and Fredrickson on the function of positive emotions, including the broaden-and-build theory.  The handout also briefly considers how positive emotions can be encouraged and the value of acting from them.

Fredrickson's positive:negative emotional ratio - this questionnaire assesses the ratio of positive to negative emotions.  It - and variations of it - have been used in Fredrickson's research.  Research suggests that, for healthy functioning, one needs a ratio of between 3:1 to 11:1.  This applies whether one is studying individuals, couples or work teams.  See Fredrickson's Positivity Ratio website to access free online tools to assess and track positivity ratio.

"Positive" emotions: optimal ratio, page 1 & page 2 - another four Powerpoint slide handout (typically printed as two slides per page) that complements the "Positive" emotions and emotional ratio handout and questionnaire (see above).  These slides give further background on the importance of a 3:1 to 11:1 ratio, benefits of positive emotions, types of positive emotion, and how positive emotions can be encouraged. 

Emotions & feelings - this six Powerpoint slides to a page handout discusses definitions, components, types and functions of emotions. 

Understanding our reactions: self monitoring - this is an assessment form that can be used to self-monitor or to complete within a therapeutic session.  It looks at experiences of strong emotional reactions and asks a series of questions that can clarify the source of the emotion (leading to ideas about appropriate responses). 

Understanding upsetting feelings, one weektwo week forms, and suggestions - the 'Understanding our reactions' form (above) is used to note specific obvious examples of strong emotional reactions.  These two 'Understanding upsetting feelings' forms are a little different.  They encourage regular daily self-observation.  Sometimes getting people to do this routinely for a while produces better information - possibly because it helps them keep the daily monitoring task in mind, rather than forgetting to do it.  The 'Suggestions' sheet provides some background advice on keeping the forms.

Experiencing scale - this scale assesses seven levels of emotional and cognitive involvement with one's ongoing (internal) experience.  Primarily tested in person-centered therapy - but also for other therapies such as group therapy and CBT - it has been found that being more emotionally engaged with therapy tends to be associated with better subsequent outcomes. 

Emotion regulation questionnaire - and also a handout giving scoring & background details about the questionnaire.  See as well a couple of posts I've written about this area - "Oregon university research on emotional regulation, interpersonal perception & personality" and "Stanford psychophysiology lab research on emotion regulation".

Beliefs about emotions questionnaire - this two page questionnaire & scoring/background handout is based on work at Oregon university (see blog post link above).

Getting a better perspective - this important handout is one that I use a lot.  Effective use of reappraisal in our emotional & interpersonal life is crucially important, mature & helpful in a whole series of ways.  The blog post "Reappraising reappraisal" is the handout with added background and links.

Our life stories: needs, beliefs & behaviours, page 1 & page 2 - here is a two page handout (printed out at 2 Powerpoint slides to a page) that I use a lot, especially when working with long term personality patterns.  The ideas aren't at all original, although this particular way of presenting them is my own.  I point out that a triangle of frustrated needs, dysfunctional beliefs, and outdated unhelpful behaviours probably made sense and may even have served them well, when the pattern developed in childhood/adolescence (e.g. in relation to "past people", slide 4), but that the triangle may well not be serving them well now (in relation to "current people" in their lives, and possibly with "therapist or group" too - providing learning opportunities in-session).  I tend to encourage work at all corners of the triangle - clarifying healthy needs, challenging dysfunctional beliefs, and exploring more functional behaviours.  There is a bit more information on this "Our life stories: needs, beliefs, behaviours" model in a series of four brief blog posts put onto this site in September 2010

Triangle of emotions, assessment & treatment - these two handouts are usually printed out as 1 slide to a page.  They give suggestions for ways to assess and treat/help each corner of the triangle.  

Personality assessment, big five aspects & domains - I like the way the "Big Five" (Neuroticism, Agreeableness, Conscientiousness, Extraversion & Openness to Experience) approach to personality assessment is applicable to all of us, not just those who are said to suffer from "personality disorders".  I even more like this DeYoung et al's 10 aspects approach.  Here is his 100 item questionnaire as a Word doc & as a PDF and here are some background comments as a Word doc & as a PDF.

Arntz/Young emotional regulation disorder mode diagrams - here are a pair of Powerpoint slides that I print out as a two-slides-to-a-page handout.  The diagrams are at the heart of Arntz's very successful treatment for borderline personality disorder.

Arntz/Young emotional regulation disorder mode template - this "template" taken from the mode diagrams (above) makes it easier to write on the client's own descriptors for the the different modes e.g. "healthy George" or "toxic mother" or "frightened little Jane" etc.  Using their own words to describe their different "modes" is likely to be useful therapeutically. 

Arntz/Young transforming inner conflicts mode diagrams - interestingly this Arntz mode diagram is useful more broadly than simply for people suffering from borderline personality disorder.  In fact most of us can probably see ourselves, to some extent, in these diagrams.  I use this slightly adapted version of the original handout (see above) when working in these less borderline-focused instances.

Arntz/Young transforming inner conflicts mode template - again, this is an adaption of the Arntz work that I use in less borderline-focused instances of personality work (see above)

Overview of therapeutic methods (adapted parent/adult/child model), page 1 & page 2 - (print these out as 2 Powerpoint slides to a page handouts) after surprising myself with how useful I found the adapted Arntz diagrams (see above), I thought it might be fun to expand the ideas back to a version of the old Transactional Analysis parent/adult/child model.  This makes it easier to include Gilbert/Neff style self-compassion work ("self nourisher" on slide 3) and Fredrickson style work on encouraging positive emotions ("happy child" on slide 4).

Emotional regulation disorder/borderline: checklist & scoring - this checklist and the severity scale (below) are both from Arnoud Arntz's fine work on treating borderline personality disorder.

Emotional regulation disorder/borderline: severity index & scoring - the borderline personality disorder severity index (bpdsi iv) used in Arnoud Arntz's work.

Emotional regulation disorder/borderline: diagnosis & background - diagnostic criteria for borderline personality disorder and research abstracts about this surprisingly common condition.

Young, early maladaptive schemas - due to lack of good research I didn't take Young's work seriously until Arntz's results with borderline were published.  Here is some information about Young's maladaptive schemas with a possible simple scoring system that I get clients to fill in.

Young, schema modes - and here is some details of Young's schema modes.  These ideas were at the core of Arntz's work.

 

Exercise & light

This section links to resources for exercise and for using light therapy.  Exercise is an absolutely key component of what this website is primarily about - achieving improvements in our stress, health and wellbeing.  Try, for example, clicking on this exercise tag to see a series of relevant blog posts.  The gains from exercising more are so huge that they have major implications for government health budgets - unfit populations get sicker and cost much more to look after.  It's no surprise then to find that there are many excellent, nationally developed, internet sites giving high quality exercise information.   

Exercise, readiness - the vast majority of people can exercise perfectly safely, and the overall physical and psychological gains achievable are much greater than any likely costs.  However, especially if one hasn't been exercising for some time, the Physical Activity Readiness Questionnaire (PAR-Q) is a useful brief 7 item screen available from the Canadian Society for Exercise Physiology.  They write: "If you are planning to become much more physically active than you are now, start by answering the seven questions ... If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor."  The short, associated, general Physical Activity Readiness Medical Examination (PARmed-X) and more specific Physical Activity Readiness Medical Examination for Pregnancy (PARmed-X for Pregnancy) provide helpful advice for health professionals assessing patients' exercise readiness, and the downloads may also be interesting for general readers.  See too the blog post "Exercise 1: checking it's safe to start"

Exercise, how much - the Department of Health for England & Wales have published the GPPAQ, a quick screening assessment.  The General Practice Physical Activity Questionnaire (GPPAQ) takes less than a minute to complete, is well researched, and has clear recommendations on its use.  It classifies adults into four categories of physical activity - Inactive, Moderately Inactive, Moderately Active, and Active.  You can download the full 22 page GPPAQ booklet (updated in May 2009) which contains GPPAQ details (on page 13) and also gives background information and advice about appropriate health professional response to the answers elicited by the questionnaire.  See my post "UK Department of Health, resources of assessment and advice" for more on this. 

Actually overlapping and, for me, even more generally useful are the 2008 "Physical activity guidelines for Americans" - see my post "US Department of Health & Human Services, resources for assessment and advice".   Also the American College of Sports Medicine (ACSM) - the ACSM has listed a series of "position stands", academic reviews, on a variety of useful topics including "Appropriate Physical Activity Intervention Strategies for Weight Loss and Prevention of Weight Regain for Adults", "Progression Models in Resistance Training for Healthy Adults" and "Exercise and Physical Activity for Older Adults".

We tend to underestimate the importance of resistance/strength training.  It's not just for muscle-builders.  Strength training seems important for improved life expectancy (over and above the effects of aerobic fitness) as well as improved function.  See my blog post "The recommendation to do strengthening exericises" .

Here in Scotland, the government's Take Life On website has a good section on Being Active.  Another excellent Scottish resource is the Active Scotland site which allows one to search for local exercise groups and facilities anywhere in the country.  I'm also a fan of Paths to Health and the way one can search there for a local walking group.  All these websites have good links to networks of other useful exercise-related resources - for example Cycling Scotland, JogScotland, the Physical Activity & Health Alliance and the more broadly geographically focused Swim4Fitness and Green Gyms.

For the UK as a whole there is a rich set of resources & links on exercise & health at the "British Heart Foundation".  "Green Gyms", "British Swimming"  - the even more broadly geographically focused "Swim4Fitness" - the "Bike List", the "Ramblers", and more locally to England, the "Walking for Health" initiative (with its local walk finder).   

And extending further afield, the many resources include - in Europe, the "European heart network" and the "European network for the promotion of physical activity"; in Australia, the "Healthy and active Australia" campaign and the "Australian sports commission"; in Canada there's "Health Canada" and the "Canadian physical activity guides"; in the USA, "National coalition for promoting physical activity" and the "2008 physical activity guidelines"; there's the "Asia Pacific physical activity network", the researchers' "International physical activity & the environment network", and the World Health Organization's "Global strategy on diet, physical activity and health".

Pedometers - the Paths to Health site has a useful section on pedometers (little gadgets for counting the number of steps you take).  See my post "Pedometers can help us walk more".  Good research shows that pedometers are successful at encouraging people to exercise more and that they are one of the most cost-effective strategies for doing this.

Exercise for depression research - here's a four page article I wrote on this subject back in 2005.

Exercise, four week record sheet -

Exercise, resources for depression -

Light therapy, background information -

Light therapy, self-assessment mood scale -

Light therapy, diary form -

Interpersonal group work

Here are a set of handouts and questionnaires that I often use when I'm running interpersonal process groups.  Also on the left of this page you'll find links to a session-by-session description of one such group.  As the "Group therapy, background information" leaflet (see below) comments: "Group therapy simply means that therapeutic work is done in groups rather than one-to-one. Many different types of therapy have been tried in group format. Rather than construct a long list of such therapies, it may be more helpful to divide the many types of therapy group into two general categories - structured groups and process groups. Structured group therapy often involves the transfer of skills and knowledge. It may feel a bit like a classroom situation. Frequently, structured groups are used as a cost-effective way of delivering similar forms of therapy to individual one-to-one work. Process groups, however, use groups not just for cost effectiveness but also to focus on forms of learning that are specific to the group format itself. Process groups acknowledge that the developing relationships between group members are also a major therapeutic resource."  In actual practice this structured-group/process-group distinction isn't so cut and dried.  See the post on "Training in group facilitation" for more on this.  Many participants in, for example, structured stress management groups will comment how they have benefited from listening to the experiences and comments of other group members.  Similarly, facilitators of structured groups will knowingly or unknowingly have interpersonal group processes contributing to the effectiveness or ineffectiveness of the groups they run.  However the handouts listed below are those I am more likely to use in groups that acknowledge interpersonal process as a major learning resource.  It's likely that most people would benefit from participation in groups of one type or another e.g. group education, group activities, group support, group therapy, and so on.  This variety is illustrated by the blog post "Different kinds of group, different kinds of friendship".  These interpersonal groups however, that focus on how we relate with others, are primarily for those who are robust enough and psychologically minded enough to engage with this fascinating and rich opportunity to share, learn, and develop deeper, more open, more compassionate ways of being with other people. 

Group therapy, background information - this brief overview of group therapy aims to provide some initial orientation for would-be participants.

Course publicity leaflet - the kinds of interpersonal process groups I run have evolved over the years.  This publicity leaflet illustrates the current "Opening Up" (relationships & emotional intelligence) format that I'm working with.  Everyone who joins these groups will have also had some individual one-to-one sessions with me.  Facilitators no doubt vary a lot in how they use the mix of group and one-to-one therapy.  There are advantages and disadvantages to running them side by side.  I personally find it very useful to at least see group participants for one-to-one orientating and reviewing sessions.

Confidentiality agreement - people coming to these interpersonal groups are likely to be challenged by the degree of honesty and self-disclosure involved.  It's important to minimise reasons why participants might feel inhibited about opening up.  I make it explicit verbally in initial one-to-one orientation, at the first session of the group, and via this "Confidentiality agreement" that any personal information shared by members of the group is to be treated as confidential and is not to be discussed with non-group members.  

Inventory of interpersonal problems (IIP-48) - there are many before-and-after assessment measures that are potentially relevant to the kind of work focused on in these interpersonal process groups.  I routinely ask participants to fill in this 48 item version of the "Inventory of Interpersonal Problems".  Scores on the six subscales can be added up and noted on the "IIP-48 Scoring Chart".  I then typically join these six subscale points to make what is likely to be an irregular star shape.  The more the spikes of the star are distant from the "no-problem" centre, the more difficulty the person is likely to be experiencing in interpersonal relationships.  I both pay particular attention to any large spikes on the scoring chart and also any "3" or "4" answers on the IIP questionnaire itself.  I chart change both by adding further - hopefully reduced in size - stars to the person's diagram as they later retake the IIP-48, and also by simply monitoring reduction in the IIP-48 total score which is simply the sum of the six subscale scores.

Personal community map - this is another assessment exercise that I ask would-be course participants to complete when considering whether to come to the group.  It is a helpful way of encouraging people to begin describing their relationships.  It may take an hour or so to fill in properly, but it can then provide a major focus for subsequent therapy.  When handing out this chart, I also give the instructions and questions sheets (see below) 

Personal community map instructions - these instructions go with the "Personal community map" (above), explaining how to fill the chart in, and giving background information. 

Personal community map questions - I ask people to answer these questions as they fill in, and after they've filled in, their personal community map (see above).  Their answers help to clarify what they probably need to do to continue building personal relationships that promote health, stress resilience, and wellbeing.  Sheldon Cohen's work, for example, highlights the value of building high scores on intimacy (question 2) and integration (question 4), while maintaining low scores on - at least chronic - conflict (question 5).  There will almost certainly be times in our lives when scores on these questions won't be good, but an awareness of this gives us challenges to work on - for example, deepening our relationships with some people on the map so they come in closer to the centre, developing a cluster of close relationships so we don't have "too many eggs in one basket", having a wide variety of acquaintances/less close friends so our personal community map is more "mountain shaped" (cluster of close relationships at the top/in the centre, broad range of acquaintances/less-close friends further down the mountain/further away from the centre) rather than "pole shaped" (some close relationships at the top/centre but only a smallish number of acquaintances/less-close friends further down/further out).  "Pole shaped" personal communities seem too vulnerable to illnesses, friends/family moving away, changes in job, and so on.  It seems important too, to maintain the ability to make new friends over our lives, so as we age we don't simply see a progressive attrition and shrinkage of our early life personal community.  Healthy gardens have a mix of plants in them!

Maladaptive schema assessment - this is a fairly quick/straightforward way, from Young's work, of getting a sense of internal beliefs/feeling structures that may sabotage making good, close relationships.  These "schema" are likely themselves to be largely caused by experiences in relationships earlier in our lives. 

I tend to pretty routinely use these three questionnaires - the "IIP-48", the "Personal Community Map" and the "Maladaptive Schema Assessment" - for all group participants.  I ask them to answer the questionnaires for the last month or some other time period that represents how they usually function.  We may well use a model like the one described in the blog post "Our life stories: needs, beliefs & behaviours" to help organise emerging patterns.  Depending on what is most important for each individual, we may also use other questionnaires from those listed on the "Relationships in general""Relationships, families, couples & psychosexual""Wellbeing, time management & self-determination" and other pages.

Initial difficulties severity scale - this scale attempts to distil the picture that has emerged from the other assessment questionnaires and from one-to-one discussion to give a key area(s) that each participant currently wants to work on in the interpersonal group. 

It's usually time very well spent, orientating would-be participants to what the group is likely to involve.  This both speeds up the time it takes new group members to start engaging helpfully in group interactions, and reduces drop-out rates.  Participants who know roughly what the group is going to be like, why the experience is relevant to what they want to change in their lives, and how they can best engage with the group to gain most benefit, are likely to be participants who get most from the group experience.  I've listed various handouts that can be relevant in this orientation process.

Our life stories: needs, beliefs & behaviours, page 1 & page 2 - here is a two page handout (printed out at 2 Powerpoint slides to a page) that I use a lot, especially when working with long term personality patterns.  The blog post "Our life stories: needs, beliefs & behaviours" gives a fuller explanation.  Although a bit "complicated", this "map" can be helpful in clarifying, for would-be group participants, where it might be most helpful for them to focus when working in the group.  The ideas aren't at all original, although this particular way of presenting them is my own.  I point out that a triangle of frustrated needs, dysfunctional beliefs, and outdated unhelpful behaviours probably made sense and may even have served them well, when the pattern developed in childhood/adolescence (e.g. in relation to "past people", slide 4), but that the triangle may well not be serving them well now (in relation to "current people" in their lives, and possibly with "therapist or group" too).  I tend to encourage work at all corners of the triangle - clarifying healthy needs, challenging dysfunctional beliefs, and exploring more functional behaviours.

What it's usually helpful to talk about in the group - research shows that explaining to would-be group participants what the group focuses on, how it works, and why it's relevant for them, reduces subsequent drop-out rates and helps participants engage in the group more quickly and more productively.  The already described assessment questionnaires are useful here.  This "What it's usually helpful to talk about in the group" leaflet is a further step in this orientation process. 

Therapeutic factors - here are the 12 therapeutic factor categories that Irvin Yalom describes in his seminal book "The theory and practice of group psychotherapy".  Typically interpersonal factors, catharsis and group cohesiveness are rated very highly.  There is considerable variation though - with the type of group studied, with how long  the group has been meeting for, and with the participant's level of functioning and personality style. 

Group facilitator style & outcome - Lieberman, Yalom & Miles's major early group research profoundly affects the way I facilitate groups and the way I teach group facilitation.  Key facts are illustrated by this six-slides-to-a-page Powerpoint handout - also available as a PDF handout.  These slides highlight particularly the importance of "caring" and of "meaning attribution" in how one facilitates groups.  The slides also remind us that group therapy is not "neutral" - some facilitators were found to run groups where almost all participants benefited and none seemed to experience a negative outcome.  With other facilitators, participants were lucky if they managed to leave the group unscathed psychologically.

Self-acceptance & other comments on the value of group work - here is a 25 slide Powerpoint presentation that I gave at a big cognitive therapy conference in Edinburgh in 2008.  The talk makes a number of points about the importance of the therapeutic alliance including the potential value of experiential group work for health professionals themselves.

Communication scales - a handout from Carkhuff & Berenson's adaption of the classic Rogerian person-centred triad highlighting key interpersonal qualities in close relationships.

Honesty, transparency & confrontation - this interesting 3 page handout describes the emotion-focused therapist Les Greenberg's comments on honesty/authenticity in therapeutic relationships.  His remarks however are also very relevant to other close relationships that are basically supportive but sometimes run into difficulties e.g. couples, families, and friendships. 

Self-concealment scale & related references - this is an interesting questionnaire I use occasionally to highlight the health risks of being to "self-concealing" and "private".  It links in with the overall benefits of intimacy and interpersonal trust.  It links too with the importance of clients feeling they can be really open in the therapeutic relationship.

Experiencing scale - this scale assesses seven levels of emotional and cognitive involvement with one's ongoing (internal) experience.  Primarily tested in person-centered therapy - but also for other therapies such as group therapy and CBT - it has been found that being more emotionally engaged with therapy tends to be associated with better subsequent outcomes.

Although I currently call the interpersonal process groups I run here in Edinburgh "Opening Up", they used to have the rather clunky title "Relationships & emotional intelligence".  This is still a pretty good description of what the groups focus on, and below are half a dozen handouts more specifically on emotions and emotional intelligence.

Emotions & feelings - this six Powerpoint slides to a page handout discusses definitions, components, types and functions of emotions.

Emotions are like a ‘radar system' - this pair of Powerpoint slides, that I print out as a two-slides-to-a-page handout, introduces the idea of emotions as an evolutionarily adaptive system.  I use the metaphor of emotions as a 'radar & rapid response system' - normalising emotions and conceptualising emotional problems as inappropriate levels of activation in a basically adaptive system.   

Emotions, ‘arriving' & ‘leaving' - this pair of Powerpoint slides handout introduces a simple model of 'arriving' (understanding what one is feeling) and 'leaving' (acting from or processing the feelings).  The ideas are based on the work of Les Greenberg, Robert Elliott and others. 

Emotions, awareness & regulation - again a pair of Powerpoint slides based largely on the work of Greenberg and colleagues.  The handout both looks at aspects of emotions and introduces a metaphor of wading into a river as a way of considering over- and under-regulated emotions.

Emotions as different rooms in a house, page 1 & page 2 - here are four Powerpoint slides that I usually print out as a handout with two slides per page.  Page 1, with ideas from Antonio Damasio, looks at the changes emotions produce in body and brain.  Page 2, partly inspired by John Teasdale, suggests that different emotions produce such different mind-body states that it may sometimes be helpful to view humans as possessing a series of different "minds" rather than just one.  I then introduce the metaphor of humans as "houses" with a collection of different mind-body "rooms" that we move between. 

Understanding our reactions: self monitoring - this is an assessment form that can be used to self-monitor or to complete within a therapeutic session.  It looks at experiences of strong emotional reactions and asks a series of questions that can clarify the source of the emotion (leading to ideas about appropriate responses).

And finally here are a couple of handouts, below, used to encourage group participants to reflect on what they're experiencing.  "Meaning attribution" has been highlighted as a key process that group facilitators should focus on by the Lieberman, Yalom & Miles research mentioned earlier.

Reflection sheet & Session rating scale and background - I ask all group participants - including myself as facilitator - to fill in a reflection sheet & session rating scale in the last 10 minutes or so of each session.  I then copy or scan the reflection sheets (and chart the session ratings), and all participants get copies of all sheets in time to look through before the next meeting.  This can enrich the group and the learning process in all kinds of interesting ways.

The eight session "Opening up group" course outline that follows is intended for various different audiences.  Other current and would-be process group facilitators may find aspects of this material useful for their work.  Clients who are wondering whether to take part in this kind of group process may like to read through some or all of this description before deciding whether or not to enrol on a course.  Other readers may like to dip into these postings for their relevance to relationships more generally.  Whatever your particular focus, I hope you find something of interest here. 

 

Opening up group, session 1

For many years I have run two kinds of "training group" for clients.  One teaches what can loosely be thought of as "stress management skills".  The latest version of this is the "Life skills for stress, health & wellbeing" course that I have been describing at some length in blog posts over the last three months.  The other kind of group that I regularly facilitate focuses on relationships.  As this group has evolved over the years it has been given various titles.  For quite some time I called it the "Relationships & emotional intelligence" group.  It was an accurate description of what we focused on, but it was kind of clunky as a label.  I've now reverted to simply calling the course "Opening up".  The publicity leaflet reads:

what is this course about?  This course is about relationships and emotional intelligence.  It involves working in a small group of 6 to 8 people (plus the facilitator Dr James Hawkins) over seven evenings and a full day session.  We will be looking at relationships in three areas - in the group itself, in our lives generally, and in our pasts.  The aim is to help us understand better and improve how we relate with others.    

why take time to look at relationships?  It's worth taking the time because relationships are such a huge part of our lives.  Past relationships deeply affect how we feel about ourselves and how we interact with others.  Current relationships can be a great source of joy, warmth and support, or of loneliness, frustration and unhappiness.  Human beings are social animals.  In many ways we are the sum of our relationships.  As adults, we don't have to just accept how we learned to relate when we were younger.  We can look at our interpersonal style and how we connect with our emotions.  We can get feedback from others.  We can decide what patterns we are happy with and what we'd like to improve on.  The group gives us the opportunity to do this and a chance to practise new ways of being with others.  We can change how  we are in relationships.  In doing so we change ourselves, our worlds, and the way we affect those around us.

how does working in the group help?  There are specific personal characteristics that are crucially important in allowing us to develop really nourishing relationships.  Our upbringing, education and society in general often actively inhibit this emotional intelligence.  With care, hard work and the right situation, these qualities can be encouraged to develop.  One of the mechanisms for this is by opening up.  The diagram below illustrates how feedback and self-disclosure can allow us to share more deeply, opening the ‘window', and providing us with a chance to learn and change.

Johari window

The so-called "Johari Window" illustrates the way that being more genuine allows others to get to know us better, while feedback helps us to learn how we actually affect those around us - in Burns' words "O wad some power the giftie gie us to see oursels as ithers see us!  It wad frae monie a blunder free us, an' foolish notion."  The Johari diagram was developed by Jo Lufts and Harry Ingham many years ago and is a nice illustration of "opening up" (if you want a copy of the diagram, here are downloadable PDF and Powerpoint versions)

So yesterday was the first evening of the current "Opening up" course.  I went to my first interpersonal group - a weekend "Encounter group" - back in 1972.  It blew me away.  I just hadn't realized people could be so open and honest with each other.  I'd been brought up in a traditional, caring, good British family.  I kind of felt the world would fall apart, and the walls smeared with blood, if one allowed such open expression of feeling.  Not true!  I dived into this group therapy world and have a pretty huge experience of many different types accumulated over nearly forty years.  I can be a fairly questioning cerebral animal, and I've certainly done a good deal of reading and thinking about group processes.  I've run many groups and I train other therapists in these approaches as well - see for example the five day course scheduled to run for the University of Strathclyde and Caledonian University next March (pages 15 & 16 of their "Psychological therapies knowledge exchange programme").

What I'd like to do over the eight sessions of this "Opening up" group is jot down some thoughts and reflections triggered by the different meetings.  It's crucial that group participants feel as safe as possible in sharing personal material.  I get everyone to sign a "Confidentiality agreement" on joining the course and I'm certainly not going to use this blog post to share anything about the work of individual participants.  However reflection on the group is typically very useful, so I hope this series of general reflections will be helpful both for participants and would-be participants in "Opening up" groups - and for others who are interested in this format for therapy and personal growth.

The first session of a group can be quite challenging.  Preparation of participants before they even walk through the door is important - why is coming to this group personally relevant for them, in what way might the group be helpful, what is the group interaction likely to involve?  The American Group Psychotherapy Association website is a useful resource.  It has a publicly orientated "About group psychotherapy" section, and a more therapist orientated set of "Practice guidelines for group psychotherapy" with pieces on a series of topics including "Creating successful therapy groups" and "Preparation and pre-group training".  I wouldn't accept anybody onto an "Opening up" group if I hadn't already seen them one-to-one.  I have also sent out a set of handouts which include a couple I've particulary asked them to read before the first meeting - "Group therapy, background information" and "What it's usually helpful to talk about in the group".  Other handouts and pre-/post-assessment measures are listed in two previous blog posts - "Interpersonal groupwork 1" and "Interpersonal groupwork 2".

So we started with welcomes and gentle ice-breaking - an exercise in pairs "How did you feel coming to the group this evening?" with possible extensions into what this says about me more generally and the kinds of patterns I have relating with others.  I've been in a lot of groups where we all sat around in more or less frozen silence for quite a while before anybody said anything.  They have their value, but here in the "Opening up" group I'm strongly influenced by the early, and still relevant, findings on the kind of group facilitator style associated with better outcomes.  Key facts are illustrated by this six-slides-to-a-page Powerpoint handout - also available as a PDF handout.  These slides highlight particularly the importance of "caring" and of "meaning attribution" in how one facilitates groups.

A little later we moved on to a pair exercise exploring what each of us personally most want to achieve, or change, or learn more about in this group.  This was then distilled down into one or two key sentences and I wrote each person's intentions up onto A1 flipcharts which will remain visible throughout all future sessions of the group.  Participants may adapt or change their key intentions over the course of the group, but it can be very helpful continuing to relate what happens in the group to what each member particularly wants to be working on for themselves.  Plenty of friendly, opening discussion.  I sometimes see the early part of the group as constructing a safe enough, caring enough, strong enough "cooking pot" that will be able to contain the future group process as it heats up emotionally.  And finally in the last ten or fifteen minutes I ask everyone - including myself - to fill in a "Reflection sheet" (see too the related "Background" description).  This filling-in-of-reflection-sheets is scheduled at the end of every meeting.  Later in the week I will copy or scan the reflection sheets, and all participants get copies of all sheets in time to look through before the next meeting.  This can enrich the group and the learning process in all kinds of interesting ways.   A good first session ... the boat is leaving harbour ... 

See next week's post "Opening up group, second session" for more on how the group develops.

 

Opening up group, session 2

I posted last week on the first meeting of this "Opening up" group.  The reflection sheets everyone had filled in after the initial meeting had been copied and sent to all participants, so we already had more material to work with as we started this second session.  I've experimented with different ways of beginning interpersonal group meetings over the years.  In peer groups I usually bid to start with a few minutes of silence.  I find it seems to help people "arrive" and then to engage more deeply, more quickly - it certainly does this for me.

Often then there would be agreement that everyone who wants to "checks in".  I usually start interpersonal groups I'm leading with this round of check ins too.  I suggest that if bigger issues start to emerge, the person involved considers flagging the issue as something to return to once everyone has had an opportunity to briefly say how they're doing.  Strong emotion however typically "trumps" other structures so - if someone is pretty charged up - I would usually make space for them to work straight away.  This is both about going with the general guideline that strong emotion usually highlights that an issue is worth looking at, and about going right ahead to focus on "emotional elephants in the corner of the room" rather than have them distract everyone from other less charged work.

So we checked in.  Good.  Then issues were picked up both from the reflection sheets and from what had been said as people checked in.  We're working on three relationship domains in these groups - relationships in our pasts & how they've affected us, our current relationship networks & what's going right & wrong with them, and relationships in the here-and-now of the group.  Good discussions.  People raised important issues in their lives.  Others responded with their experience, insights, and feedback.  Caring and open; increasingly so.  Learning to trust.  Feeling accepted.  Seeing others take risks in self-disclosure and taking risks oneself - and finding out it's OK.  Important, especially at this stage of the group.  The handout on "Therapeutic factors in groups" highlights that the benefits of group therapy come in a whole series of ways.  Typically interpersonal factors (both expression & feedback), catharsis and especially group cohesiveness are rated particularly highly - but it varies with the stage of the group and with the psychological robustness & emotional intelligence of the participants.

The here-and-now relationships in the group are a particularly rich potential source of learning - partly because we've all witnessed the development of these "group relationships" and can give each other well-informed, eye-witness feedback.  I now asked people to pair up (there was one group of three) to talk more about this in-the-group relationship domain.  I introduced the "Needs, beliefs & behaviours" model that highlights how our past experience of relationships can so strongly colour our current relationships out "in the world", and also our here-and-now relationships in this group.  It's a model I've described more fully in a series of blog posts - "Our life stories ... part one, needs", "Our life stories ... part two, beliefs", "Our life stories ... part three, behaviours" and "Our life stories ... part four, relationships"So the pair exercise was to talk with one's partner about how experience in past relationships (especially early in our lives) is affecting how we're relating here with others in this group - and to talk to about what each of us wants to change in our "interpersonal styles".  Paraphrasing Alice Miller "The walls we build to protect ourselves become the prisons in which we live".  This is jailbreak time! 

See "Opening up, third session" for a description of next week's meeting.

 

Opening up group, session 3

We had the third session of this "Opening up" group last night.  I wrote last week about the second session.  There are seven of us in this group - six other participants and myself.  My impression over many years of group work done in different time chunks (evenings, single days, weekends, residentials lasting several days) and in different group sizes (approximately four to forty participants) is that the larger the time chunk, the larger the group size that it's realistic to work with.  I'm talking here about interactive interpersonal groups.  Obviously if one is teaching skills to a structured group (especially if one limits sharing by group members), one can work effectively with much bigger numbers than this.  There are also psychodynamic interpersonal groups that "work" with over a hundred participants.  Somewhat different kinds of issues seem to come up in different sizes of group - there are different lessons to be learned.  Three people hardly even qualify as a group.  Four to maybe mid-teens (higher numbers here preferably put into bigger time chunks) seem quite "family", while above mid-teens pushes towards "village".  I've written previously in some detail about my experience of working in a four day peer group of 37 people.    

Well yesterday our group of seven was further diminished as one member was abroad for the week and another was ambushed by a baby sitting crisis.  Only five of us.  Maybe it was no accident that in this smaller group a couple of people used the evening to share more deeply - than we've reached so far in the group - about what has been going on in their lives over the last months and years.  To me it really does feel a privilege and a gift to be trusted like this - to have a person talk so openly about their life and the struggles they have been going through.  As the song goes "To know you is to love you".  I can feel my heart open and, as facilitator particularly, I'm at times also trying to sense "Is this person getting their needs met?  How does this relate to how they might open up to friends or family in their larger social network?  Are there any patterns here to help with?  Are there new experiences/learnings to acknowledge?"  It's not dramatically different from working as a one-to-one therapist, but the pool is bigger to swim in.  There's more going on. 

Many group therapists like to work with a co-therapist.  This is an issue well explored in Irvin Yalom's great book "The theory and practice of group psychotherapy".  I personally much prefer to work as a solo therapist for a bunch of reasons - organizational, personal & therapeutic - but I can see many benefits of working with a colleague, especially in one's early years in groups.  Important too not to be stupidly arrogant here.  Often the most helpful interventions aren't made by the "therapist" anyway.  It's one of the many joys of groups - the way that we can all help each other.  In some situations, caring and challenging between group members can be more powerful than anything the therapist can offer.  And a group member who finds that what they're saying is valued by those listening - this then loops back to validate & nourish the speaker as well.  I'm reminded of O'Laoire's "An experimental study of the effects of distant, intercessory prayer" where those doing the praying seemed to benefit at least as much as those being prayed for.  A more recent example is Barbara Fredrickson's fine study showing that regular practice of loving kindness meditation (with its focus mainly on wishing others well) produces very worthwhile wellbeing benefits for those practising the meditation.  As the Dalai Lama has been quoted as saying "If you want others to be happy, practise compassion.  If you want to be happy, practise compassion".

Sharing more deeply: the group bonding more strongly.  A couple of apparent paradoxes I've regularly come across in groups.  One is that participants often fear sharing much about themselves because they're concerned they'll be judged and rejected.  In fact the opposite is usually the case - the more one vulnerably, bravely, honestly shares about oneself, the more one is typically accepted and cared about by others in the group.  Another paradox is that the more one plunges down into deep, personal, emotional experiences - the more these experiences can transform (in almost Shakespearean terms) into archetypal challenges that others can more easily resonate with.       

See "Opening up, fourth session" for a description of next week's group. 

 

Opening up group, session 4

I wrote last week about the third session of this "Opening up" group.  Yesterday evening was the fourth session.  The "cooking pot" of the group (a metaphor I used at the end of the post about our first group session) is getting stronger.  Group members seem to be feeling more trusting, more ready to share deeply.  And this produces a "virtuous circle" of taking more interpersonal risks, developing more care for each other, so feeling safer to be vulnerable, and then still more understanding and kindness.  Being part of this gives me hope for us as human beings.  We're surely capable of so much cruelty & ignorance, but we're also so capable of sensitive, gentle caring for each other.  I've participated in many "spiritual/meditation" retreats as well as many of these "interpersonal/emotional" groups.  I've more often plunged to deeper feelings of connection and love in the interpersonal groups than I have in the spiritual/meditation groups.  "To know you is to love you"

So precious to be able to take this kind of vulnerable, caring, openness into our families and close friendships.  Not, of course, all the time ... but able to visit this kind of gentle "looking after".  Familiar and trusting of these emotional/interpersonal states in varying levels of depth.  Able to "colour" our relationships.  So valuable to develop these wider "palettes".  It reminds me of the recent research study "Eavesdropping on happiness" that used digital audio recorders to unobtrusively track real world behaviours.  The authors reported clearly that " ... the present findings demonstrate that the happy life is social rather than solitary, and conversationally deep rather than superficial".  Highly relevant for happiness & wellbeing (see too the self-determination study "Daily well-being: the role of autonomy, competence, and relatedness") and for stress resilience, and even more bluntly for survival itself.  For more on this "hard end point", see the recent post "Strong relationships improve survival as much as quitting smoking".  In the journal editorial commenting on this major meta-analysis, the authors stated "Quite remarkably, the degree of mortality risk associated with lack of social relationships is similar to that which exists for more widely publicized risk factors, such as smoking.  Arguably, such a level of risk deserves attention at the highest possible level in determination of health policy."  Nice to think these interpersonal groups could dovetail into " ... the highest possible level in ... health policy".  I joke, but I'm also absolutely serious.  Working in interpersonal groups to learn to improve my relationships has been of immense value to me.  It has also contributed deeply to the precious levels of wellbeing I feel in so many of my close relationships ... with my wife, my children, my friends ... and it has clearly helped me become a better therapist. 

As an aside, a while ago I thought it would be fascinating to find out whether health professionals who had been to the peer interpersonal groups I've been involved with for many years felt that what they had experienced had been useful for their work helping others.  I sent out a simple survey to 46 people who had been to these groups, asking "Please give a number somewhere between 0 and 10 to indicate approximately how helpful you feel these groups have been for you as a health professional, where 0 stands for ‘not helpful at all' right up to 10 which stands for ‘very helpful indeed'."  I had 45 responses.  They gave an average score of 8.4 out of 10, suggesting that this mix of doctors, psychologists, counsellors, nurses and other health workers found the experience very useful for their work with others.  For more on this see the last ten slides of the presentation "The alliance is crucial. What are the implications?   

So after the check in, again people shared more.  One brave soul especially talked so openly about pain in a key relationship in their life.  Touching, so much so.  And the domino effect.  One person's brave sharing makes it easier for others ... even others who may have done very little opening up like this before in their lives ... even others whose childhoods had taught them the hard, hard lesson that showing vulnerability is likely just to lead to more pain.  Very special to begin seeing, experiencing that it doesn't have to be this way.  In one-to-one therapy, I can explain this.  They can begin opening up to me.  There's something so powerful though, such a big addition to see opening up by others in real time.  To experience, to feel, to witness that it can be OK, that it can be much more than OK.  Tremendous.  This can be real healing.  And I feel a little tearful just remembering it.

One of the handouts everyone in the group has had is the well known "Experiencing scale" with its emphasis on the value of allowing real emotional experiencing to help therapeutic change.  I mentioned in the group that three powerful ways I recognise of deepening emotional involvement in interpersonal groups are what we have been doing these last two evenings (sharing very openly and honestly about strongly felt experiences in our past or current lives), and secondly risking exploring how we are relating with each other here in the group, and thirdly coming down into the here-and-now of feelings in our bodies - our hearts & guts.  The next group meeting (the fifth one) is a full day session.  I like to do this, to have a full day together.  It's not typically as rich as a residential weekend (which I've scheduled into some groups I've run), but it's easier to arrange and a good compromise solution in the attempt to make a bigger "pool" for us to swim in.

Like "real life", the group river is likely to flow deeply and shallowly, fast and slow, smoothly and turbulently.  "New weather always unfolding out of the same sky".  Part of becoming a competent group facilitator or group member is learning this, beginning to develop "faith in this process".  Faith - and also the courage and knowledge to help the deepening and connecting processes.  Who knows what will happen in the next meeting?  Nobody.  Can we navigate the river to make it more likely that we benefit?  Certainly!

I'll write soon about the next - full day - session.

 

Opening up group, session 5

I wrote just a few days ago about the fourth session of this "Opening up" group.  This fifth session was a full day meeting.  Good to have a whole day together.  A bigger pool to swim in, more time to explore.  Nice too to share food together - we all brought contributions for lunch.

We began the group a bit differently today.  I suggested we took 10 minutes while we all wrote starting with the words "If I pushed myself a bit harder in the group, I ... ".  I asked them to write deeply and honestly and spontaneously.  I said that they wouldn't be expected to read out what they wrote.  The important thing was for us all to really dig down and explore how we could open and use the group more fully.  We then paired up to share what had emerged.  People were welcome simply to talk about the general sense of what they'd written, or they were free to read it to their partner if they wanted to.  I asked as well that they discuss how they could help each other work with the possibilities that had come up in their writing, as we went through the day.  There are quite a few blog posts about therapeutic writing on this website, and it's a useful ingredient to introduce into groups every now and again.  Fascinating how, even in groups where participants are very honest with each other, still material emerges with writing that doesn't emerge in the same way with just talking.  We didn't do this today, but a precious thing to try is for everyone to write on some theme for say 10 minutes, then go round sharing (talking about what emerged, or in groups that are OK with this openness - simply reading it out), then (without any further discussion) everyone writes again for another 10 minutes, and then we go round to read again.  Typically people's first time round explorations trigger thoughts/feelings in others that then enrich the group's second round of writing.  

Jamie Pennebaker, the "godfather" of expressive writing, has said that it can be a bad idea to read what you've written to others.  Quite rightly he points out that expressive writing isn't meant to be balanced or careful, and that reading it out may give the listener an unbalanced picture which they may well react to unhelpfully.  Alternatively, if the writer knows that they will be expected to read out what they've written, they are likely to start inhibiting how spontaneously and freely they write.  I think Jamie is generally correct about this, but I also know that in groups which "know what they're doing" and which already have a culture of considerable openness, simply reading out what one has written can be fine and helpful.

So we then came back to the full group, shared a bit about what had emerged from the writing exercise and pair discussion, and went on to check in more generally.  We were the full group today (7 of us).  We made time to discuss how the people were who had shared particularly deep personal material in the previous couple of groups.  Someone who had been feeling dubious about the whole group process also had the opportunity to share this, to be heard and valued, to realise that others too - at times - shared similar feelings.  So important in these interpersonal groups to watch out for people becoming peripheralised.  So important to care for and make space for the inevitable doubts and distancing that will sometimes emerge.  In one-to-one therapy, "micro-ruptures" occur regularly in the therapeutic process/alliance.  Very important to keep one's eyes open for this and try to work through such difficulties.  The same is true in group work.  Honouring and validating individual's points of view.  Being inclusive not exclusive. 

And eventually to lunch.  Yummy!  Good food.  Good company.  And a chance to walk for a little in the autumn sunshine.  And back in the group for the afternoon, reminding them of the point I made in the blog post about last session - "One of the handouts everyone in the group has had is the well known "Experiencing scale" with its emphasis on the value of allowing real emotional experiencing to help therapeutic change.  I mentioned in the group that three powerful ways I recognise of deepening emotional involvement in interpersonal groups are what we have been doing these last two evenings (sharing very openly and honestly about strongly felt experiences in our past or current lives), and secondly risking exploring how we are relating with each other here in the group, and thirdly coming down into the here-and-now of feelings in our bodies - our hearts & guts".  And later in the afternoon I set up a couple of exercises that more involved our current in-group relationships and helped to focus us on how we were feeling in the here-and-now.  The first I call "The gaze exercise".  I can't remember where I got it from - I've been using it for years.  The way I work with it is to get people to pair up.  It can also be done in threes, but on the whole it probably fits more easily as a pair exercise.  Usually easiest if each pair positions themselves so they're pretty much at the same eye level.  Distance is negotiable.  "Not too far apart" is quite a good instruction.  The exercise involves 4 minutes of silence.  The first 2 minutes one simply looks at the other person.  This isn't an eyes-locked-together kind of exercise.  One is given full permission to "look them up and down".  Yes, look at their eyes, and also their face, their hands, their clothes, hair, bodies.  It's an awareness exercise.  How do I feel as I look at them and they look at me?  How do I hold my body?  What happens to my breathing ... to my expression?  What thoughts come up about them, about myself, about the situation?  What are my emotions?  Do they stay the same or change?  What do I observe?  What do I remember?  What associations do I have?  What do I fantasise?  2 minutes can be a long time.  Then the 3rd minute, everybody closes their eyes.  What happens?  The request is to notice how one now feels, senses, thinks - with eyes closed.  Then the 4th minute is a repeat of the first 2 minutes - eyes open again, looking at the other person.  So this is a real time, awareness/relationship exercise.  After the 4 minutes, the request is to share with your partner what has come up.

People vary a lot in how easy or difficult they find it to do this exercise.  It's an awareness meditation - helping us realise how much is potentially going on as we're relating with another person.  It's also a challenge noticing what emerges, and having the courage and emotional intelligence to put words to the experience in an authentic, possibly challenging, but constructive way.  Again it comes back to the person centered, I-Thou, three legged stool of genuineness, empathy, and caring.  If one or other leg of the stool is short, it wobbles.  The close relationship typically lacks something of importance.  I've done this exercise many times - in groups and also with friends.  Rich.  I love it.  It's like savouring fine wine, really taking time to taste relating to another person.  Quite a few people hate it.  Too close.  Too challenging.  Too intimate.  Too artificial.  For someone who wants to explore close relationships, how to relate more truly, how to develop this intelligence - this can be a good exercise to try.  So people took quite a while to share their experience in their pairs, and then we came back to talk a bit about it in the full group. 

I commented that it can be very interesting to go right on to do "The gaze exercise" with another person.  It helps one see what about one's experience one transfers across in a similar way from one of these exercises to another exercise, and what seems more particular to the specific person one happens to be doing the exercise with.  Am I more in touch with thoughts, or sensations, or feelings?  Am I more aware of the other person or more aware of myself?  What difference does it make if there a man or a woman?  Am I able to stay present with what's going on?  As with pretty much all "real life" relationships too, it can be helpful to consider three overlapping domains that are involved.  One domain is myself.  What is this exercise demonstrating about me - maybe my self-consciousness, or vanity, or dominance, or carefulness, or sexuality, or kindness, or past life experience.  Another domain is the other person.  What feedback can I give this other about their face, their expressions, their posture, their hands, their body, thoughts about them, intuitions, memories, images, associations.  And the third overlapping domain is our relationship.  How do I feel with this person?  Is this how I expected to feel?  Maybe it's as expected, or quite possibly it's richer and more complex than I expected.  So much in 4 minutes!  And of course then the huge question about what I remember, what I'm prepared to share, how vulnerably and honestly and constructively I share it.  Maybe find a friend and try this exercise!  Preferably when you're both clear-headed and not misted by, for example, alcohol.   

A lot of discussion can come out of this 4 minute experience.  Maybe allow 20 minutes to discuss in pairs.  Once we had talked about the experience in the full group, I queried whether people would like to go straight on to trying it again with another partner.  There wasn't a clear majority wanting to repeat it straight away.  I suggested we try a related but somewhat different sequence - "The space between us exercise".  This one most people probably find a bit easier than the "Gaze exercise".  It's also simpler to introduce it into conversations with those we're close to.  It's just a somewhat formal way of asking questions like "How are we doing together?", "How do we feel about each other just now?", "How's our relationship going right now?".  This interesting way of asking this kind of question comes from Irvin Yalom's book "The gift of therapy" (see too Yalom's website).  He suggests one simply asks "How do I (and how do you) feel about the space between us right now?"  The form of words can feel a bit awkward & artificial to me, but I also find it helpful.  It helps me to focus both on what's going on within me ... "How do I feel ... ?"  Emotions are physical things.  What am I feeling in my heart, my gut, my face, my posture ... what am I feeling here being with you?  And how is that intertwined with how we're relating right now ... and how we've related in the past?  Not just "How do I feel?" but "How do I feel about the space between us right now?"  My experience is that it's easier to hide in words with this exercise than in the silence of the "Gaze exercise", but it's also, in some ways, more useful, more practical.  I've probably used this exercise, this focus, suggested it with many of my closer friends.  It's easily transferable ... in a café, a bus, walking.  Fun to use.  Fascinating to use.  Yalom talks about using the exercise often in therapy with clients.  He is a different style of therapist from me.  However, particularly in longer term work, I will sometimes suggest trying this exercise.  See the blog post "Needs, beliefs & behaviours - part 4, relationships" for more on why this can be useful.  I will pretty much always offer to speak first and, pretty much always, my client will accept my offer.  Now here's a challenge.  The point of therapy ... what it all rests on ... is to focus on what is likely to be helpful for the client.  And this exercise can be very helpful.  And it demands of the therapist a good deal of "real time", emotional intelligence.  Often I can very honestly express my fondness and respect for the client.  Especially if we've been working together over some time, this can be so important.  I know with my own son, how important it has been to express not only my love for him, but also my respect for how he is leading his life.  I may think that he would know this, not need it spelled out in so many words ... but spelling it out in so many words can be immensely precious.  Sometimes, of course, there are not just "positive" feelings around to be expressed.  But difficult feelings can often be even more helpful to speak through than "positive" ones.  It's how they're expressed.  Les Greenberg has written interestingly about this - see the handout "Honesty, transparency & confrontation".

Enough!  Time to draw this rather long blog post to a close.  And the full day meeting also came to a close.  As usual we finished by writing reflection sheets.  It seemed to me that it had been a good, helpful day.  I was slightly uneasy about how "prescriptive" I'd been offering three structured exercises across the day.  Quite a lot of structure.  But it seemed to have worked well.  Blessings.

For a description of our next meeting, see "Opening up group, sixth session".

 

Opening up group, session 6

Yesterday evening was the sixth session of the "Opening up" group.  It had been a longer gap than usual - ten days since our full day meeting at the fifth session.  As we often do, we began with a round of "checking in"; an opportunity for all of us to say briefly how we were feeling.  Like two or three others, I had been particulary busy in the preceding few days.  Great how present-time, honest interaction with a group of others brings me out of all that brain-busyness into being more here-and-now.

There was some untangling to do from last session.  I was concerned that I had upset someone with feedback I'd given them at the end of last time.  My experience in this kind of interpersonal group is that sometimes this kind of "upset" can be very helpful, but probably only if it's understood and digested.  Also, although I'm the facilitator of this group and have most experience in this kind of work, I'm also a group member.  My take on things may sometimes have value, but it's certainly not some kind of direct line to reality - other group members' impressions are so very important too.  Partly because the person I felt I'd upset had earlier said they were interested in getting more feedback from others in the group, this seemed a good time to encourage a "hot seat" exercise where they had the opportunity to get this.  It was also potentially a helpful way of putting anything that I had felt & said into a broader context.  They courageously agreed to go ahead with this and, in fact, expressed concern that people might be too "nice" in their feedback.  I suggested people tried phrasing their feedback as both something that they had particularly appreciated or celebrated about the person in the hot seat, and also something that they'd found a bit of difficulty with or wanted the person to think about or be aware of.  This "mixture of colours" way of giving feedback can sometimes make what's shared more valuable (although I think there's a danger that the person receiving the feedback may remember the "difficulties" and forget the "appreciations").  Maybe this "hot seat" exercise is something we could all try at the last session of our group in a couple of weeks' time?

As an aside to any group facilitators or potential group facilitators reading this post, I personally would consider it incompetent to encourage another group member to do this "hot seat" exercise without knowing what it might feel like through having experienced it myself.  I've probably been in the "hot seat" in this kind of way at least fifteen to twenty times over the years.  It ain't easy - rich, interesting, intense, but not easy.  And if at the last session we do go ahead to have everyone get a chance to be in the hot seat, I will certainly take my turn receiving others' feedback.  In this kind of interpersonal group, I deeply believe it's not OK to stand on the side of the swimming bath shouting suggestions to real swimmers.  As group facilitator I too need to be a "real swimmer".  See the recent post "A quiet rant to group facilitators & would-be group facilitators" for more on this.

And if we do focus on this hot seat exercise at the last session, I will encourage there to be someone scribbling a record of what's said to each person and will encourage people giving feedback to do it while holding a microphone.  This way everyone receives both a tape containing feedback from everyone else in the group and a written sheet noting the points that have been made.  I don't force this hot seat exercise onto groups but, if they're ready to go with it, it can be very precious. 

As I mentioned when describing the first group session, this is "Johari Window" territory (see below).  We're increasing the open area of the window.  When else do we get genuine, caring, face-to-face feedback from a range of other people who have similar experience of being with us and observing how we are interpersonally over many hours of interactions?  This group has now been together for six sessions (five evenings and a day) - 16 hours of uninterrupted, undistracted time relating with each other.  This is an immensely rare opportunity.  As Burns wrote "O wad some power the giftie gie us to see oursels as ithers see us!  It wad frae monie a blunder free us, an' foolish notion."  

The Johari window 

If you want a copy of this diagram, here are downloadable PDF and Powerpoint versions.

And the focus of the group moved on.  In earlier sessions people shared "back stories" and that can be very valuable.  In the last couple of meetings, we've moved to more present time interactions "in the room".  I've mentioned the importance of working at moderately high levels of emotional engagement.  If it's too emotionally intense people may not be able to take it in, if there's too little intensity there may not be much of importance to take in anyway.  However people in the group vary over what's "too much" or "too little" intensity for them.  Part of the group facilitator's challenge is, in group selection, to try to select people who have approximately equal ability at swimming in emotional waters.  However this ability isn't just about experience of groups.  It's about life experience more generally, about attachment security, about emotional/social intelligence, about commitment and courage, all kinds of things.  As "swimming instructor" part of my job is to notice if someone is either "swallowing too much water" at one end of the spectrum or isn't particularly stretching themselves as they "swim in the group pool" at the other end of the spectrum. 

There is much that can be involved in these "in the room" interactions.  A metaphor I described in the handout "What it's usually helpful to talk about in the group" suggests "We're like musicians - a ‘chamber orchestra' or ‘jazz group' - who have gathered to play music together.  The instrument each of us plays is ourself - allowing who we are and how we feel & think to sound out awarely and truthfully.  Sometimes we'll be very much in tune with others and feel that we're seen clearly, valued & strengthened in who and how we are.  Sometimes we're out of tune with others.  This can be particularly valuable.  By looking at these ‘out of tune' times - times when we feel irritated, misunderstood, suspicious, or upset - we can often learn a lot about how we're perceived and what we might benefit by being more aware of.  The handout "Honesty, transparency & confrontation" gives more details of how we can work constructively with ‘out of tune' times".

And this is what we continued to do.  One person in particular was able to feel and have the courage & skill to articulate a difficulty they were having with how another person often expressed themself in the group.  This is important territory that many people never visit much in interpersonal relationships - or if they do, it's so often with attack/defence, blame/denial, distancing/resentment.  It's what many people mean when they talk about confrontation, but it might be better seen as "self-disclosure" - not so much attacking as vulnerably & caringly opening up.  It can be so hugely useful to explore how to do this as well as one can.  And this led as well to looking a little at how one knows what one feels - at how one can talk a bit less from the head and a bit more from the heart and gut.  The handout on "Emotional awareness" addresses this issue, as too do Daniel Goleman's books on emotional & social intelligence, "Expressing emotion" by Kennedy-Moore & Watson, and many of Leslie Greenberg's books including "Emotion-focused therapy: coaching clients to work through their feelings".  These are important aspects of emotional & interpersonal competence! 

For a description of our next meeting, see "Opening up group, seventh session".

 

Opening up group, session 7

So this was the seventh - and penultimate - meeting of this "Opening up" group.  I wrote about the sixth session last week.  Sadly, because of family crises, a couple of people hadn't been able to get to this evening's meeting.  In fact, of the five of us at this session, one arrived late.  Rather than simply get going and possibly want to update the late arrival once they were with us, or wait for them rather than getting started, I used a method that often seems helpful when somebody is a little late.  So instead of starting with a verbal check-in, I suggested we all take ten minutes to write about how we were feeling now at the start of this evening, at the penultimate meeting of this group.  As usual I explained that I wanted them to write very freely and deeply about their emotions and thoughts, but that they would then be totally free to share as much or as little of what they'd written as they wanted to.

Happily the latecomer arrived half way through this process and was able to do some writing before we moved onto the sharing phase.  When we each took a bit of time to talk about what we'd written, various issues emerged.  One of the issues was someone's doubts and unease about being in the group.  One of my functions as group facilitator is to keep my eyes open for people becoming too isolated or sidelined.  This can happen in a whole series of ways and it's a risk factor for someone being "damaged" by the group experience rather than gaining from it.  I talked a bit about this in my post about the first session of this group when I explained what kind of facilitator style I would be using and why.  I have been heavily influenced by the findings from Yalom et al's research.  They commented, in a major trial monitoring the effects of 18 therapy groups, that "In some groups, almost every member underwent some positive change with no one suffering injury; in other groups, not a single member benefited, and one was fortunate to remain unchanged." 

As the researchers reported "All meetings were observed (and tape recorded) - trained raters analyzed and coded all leader behaviours & statements; participants also completed questionnaires about the leaders.  The therapeutic school that the leader represented (e.g. gestalt, psychodrama, transactional analysis, etc) had very little bearing on their behaviours/statements in the group.  Factor analysis of what the leaders said and did highlighted four important leadership functions which had clear and striking relationships to outcome - these are emotional activation, caring, meaning attribution & executive function."  Optimal outcomes were associated with leaders who were "middle of the road" for emotional activation and executive function, but very high on caring and meaning attribution.  These research findings are described more fully in the following Powerpoint and PDF handouts.  

I sometimes think of a good therapist as being like a good musician.  You need to have put in hours of work practising, reviewing, digesting the knowledge and skills involved.  This is a bit like the musician, the pianist, putting in thousands of hours of practice working on their fluidity and technique.  Then in the concert hall - when actually playing with others - all these skills are at the service of something much more heartful, emotional, connected.  It would be nice to think that sometimes I can work as a one-to-one or group therapist with a similar interconnection between head, heart & gut - and an underlying foundation of hours of background work, exploration & practice.  And it isn't entirely different for anyone else hoping to be "skilled" or sensitive or deeply able to connect & navigate through a series of different interpersonal situations.  It does take years to become an expert, but one needs caution.  Better therapists - and people who are more facilitative & nourishing for others more generally - are not always the most experienced.  If I interact badly, the fact I've done it this way many, many times may mean I've had a lot of experience - but the experience has been in becoming deeply entrenched in doing things the wrong way.  This is one of the many reasons why feedback from others - as in this type of group - can be so important. 

So we made space for the person who was having doubts about the group to share their thoughts and feelings.  Important to hear and honour their position.  Even though people's experience of the group may often mirror problems they struggle with and want to change in their everyday life, making this link isn't something to be done by a facilitator in a "one up" or defensive way.  And the person involved and the group connected, softened, moved forward encouragingly.  And a challenge for me - when group members are "swimming" in the group with quite varying degrees of ease & confidence - how to encourage everyone to "work" at a level that stretches them.  And it's a subtle, at times controversial, issue how much it's my "job" to "activate" and how much it's my job to sit back and let people find their own way.  My understanding is that my task is to steer a middle way here.  Good as well for me to understand my own personal character style.  I tend to push forwards, take risks in my own life.  This can be fine, but as facilitator, it's the group's wellbeing that I need to focus on.  Rich challenges.

So some people worked very authentically exploring their here-and-now relationship in the group, some talked about their cautious exploration into trusting the group & other people more and how they were succesfully experimenting with being more open in their outside relationships, and some linked their current group experience to difficulties & pain from early in childhood and looked at how that might change.  Precious.  So much, so many opportunities for helpful learning in the multiple interweaving interactions of groups.  A little like playing chess, I think the good facilitator needs to have general guidelines in the back of their head for what directions it's likely to be productive to steer in, and what kinds of situations should be given priority - while at the same time being present and responding to the never-before-experienced newness of what's emerging in the here-and-now.  It's not a surprise that recent work suggests that encouraging psychotherapists to practise forms of mindfulness meditation increases their helpfulness as therapists - see Grepmair et al's research "Promoting mindfulness in psychotherapists in training influences the treatment results of their patients: a randomized, double-blind, controlled study" and other more recent qualitative and quantitative studies.  It seems very probable that the same findings would apply more generally to non-therapists hoping that mindfulness practice would - amongst other benefits - help to nourish their interpersonal relationships.

 

Opening up group, session 8

We had the final meeting of this eight session "Opening up" group last night.  I wrote last week about the seventh session.  This last meeting ran a day later than usual because of a clash with a family birthday. 

Yesterday evening I wasn't feeling as buoyant as I usually do.  Partly tiredness, partly physical aches & pains, maybe other reasons it's harder to put my finger on.  Although - as usual - I meditated briefly before starting the group, I regretted not making a bit longer for this.  I think it would have "cleared my palate" more.  This is a rich issue - how important is my state of being as therapist/facilitator for doing good work?  Pretty important!  But not as straightforwardly as one might initially expect.  I certainly do not experience that the happier and more "up" I am, the better the work I do.  For me it's definitely not as simple as this.  There have been times when I've been struggling with a difficult issue in my own life, when I think I've worked very well indeed as a therapist.  It's been as if my own pain has helped me be more open, more sensitive, more caring for others.  And I've had buoyant times when I've been insensitive and out of touch with others who were finding life much harder than I was.  Overall though, being pretty buoyant as a therapist is probably a good thing.  We do sit with a lot of suffering.  We need to keep our heads above water.  I'm lucky.  I'm pretty naturally happy, and my life circumstances and how I look after myself nourishes a buoyant state too. 

But this evening I was swimming a little lower in the water than usual.  Facilitating a group seems to put me "more in the spotlight" than when I'm working one-to-one.  It somewhat changes how I "swim" - the therapeutic choices I consider.  So one way to go in this situation is for me to talk about my "out-of-sortness".  I almost certainly wouldn't do this working one-to-one or teaching a stress management skills group, except possibly with a throwaway line like "Sorry, I've got a bit of a sniffle today".  But I do consider this kind of self-disclosure much more in an "Opening up" style group.  After all, modelling effective personal disclosure is one of the facilitator's challenges.  Good to have choices though.  This was the final evening of the group.  Time was short as we were probably going to use much of the second half of the evening for a feedback exercise.  And on the initial check-in, it was clear there were other more pressing issues.  It felt better for me to keep swimming, to come out of myself more through opening my heart.

So how did it seem everyone had done in the group?  Mixed, as one would expect.  Some people clearly appear to have benefited a lot from the group experience, some a bit, and one or two were unclear how much or little they had learned.  Inclusion is so important in group therapy, so too honouring people's experience and personal paths - see, for example, Sheldon & Bettencourt's paper "Psychological need-satisfaction and subjective well-being within social groups".  Another issue we touched on again was the possiblity of contact with each other after the group had finished.  I had blind-copied the weekly group reflection sheets to everyone when I'd emailed them out.  Would some people, or maybe everyone, now like to share email addresses and/or phone numbers?  In some types of group this would be a no-no, and in others an assumed part of the process.  There's very little research evidence demonstrating that either contact or no-contact is therapeutically preferable.  I asked participants to feel through what they personally would like and let me know after the group had finished.  I could then post out contact details for those who wanted to be part of this process. 

And then after a good deal of reviewing & discussing, we returned again to a process we've explored on a whole series of occasions in this group - getting feedback and Burns's words "O wad some power the giftie gie us to see oursels as ithers see us!  It wad frae monie a blunder free us, an' foolish notion."     

Johari window

There was some discussion about how we might give & receive feedback more "formally" now on this last evening of the group.  I lean a bit towards a spoken & tape-recorded version of this process, but it would be a rare group (of the current, eight weekly session format) where everyone felt OK about going with this rather "public" & challenging exercise.  So, as is more usual, we used a written approach.  Initially we spent time individually thinking about & jotting down some initial ideas about what we would like to say to each of the other people in the group.  I suggested we split our feedback for each participant into two parts.  One part is a celebration, an appreciation, a bouquet for something we've particularly enjoyed & valued about the way the other person has been in the group.  And the second part, a request, a hope, a suggestion for something we'd like them to be aware of & to keep working on. 

The group is kind.  I upped the energy a bit, by pointing out that we might never see the person we're writing about again.  What gift can we give them?  What would we like them to know was particularly valued & appreciated about them if we were never going to have another chance to share this with them - and what would we especially want them to stay aware of & work on that we believe might help them to lead a happier, fuller life in the years to come?  This is such a very rare opportunity.  We've spent about 20 hours together over 8 weeks - 20 hours without distractions of other activities, 20 hours where the focus has been on our relationships with each other.  Now here's a chance to get feedback from 6 other people (and from ourselves) about how we've been experienced.  There may never be another opportunity like this in our lives. 

We now each took a sheet of A4 paper and wrote our name at the bottom of it.  At the top of the sheet we then gave ourselves feedback.  What have we particulary appreciated, what do we especially celebrate about how we ourselves have been in the group over the last two months?  We then switched to writing about what we had more difficulty with, what we would want to keep more aware of & try to work on over how we had related to others & ourselves in this group.  Then after 3 or 4 minutes writing, I asked everyone to fold over the top of their sheet and pass it to the left.  We each now had a feedback sheet for someone else - their name written at the bottom of the paper, but what had already been written hidden. 

Now the same process again, but for the person whose feedback sheet we were now holding.  Bouquets & brickbats.  Celebrations & challenges.  Again we took 3 or 4 minutes and passed once more to our left.  So after 7 episodes of writing, we ended up with our own sheet back in our hands.  Time to open them up and read what had been written about us by everyone in the group including ourselves.  I too, of course, as another group member went through the same process also receiving & giving feedback.

Rich.  Good to pay attention to.  And some discussion.  Clarification of people's handwriting!  And then slowly the evening came to a close.  I reiterated that for some people one 8 week "term" of this "Opening up" group was interesting and enough.  I said however, that for those who had found it pretty useful, it was likely they would benefit more by returning for further "terms".  How we relate with ourselves & others is so deeply part of who we are.  To change, to evolve, takes time.  Our experiences in the group spill out to & change "outside world" relationships, but this is a step by step process.  I usually run a couple of these groups a year - one in the spring and one in the autumn.  Some people will keep coming for several groups running over two or three years.  This can be life-changing.   

And partings, a group hug, good wishes.  Heart-warming, very precious to have spent this time together.

 

Life review, traumatic memories & therapeutic writing

This section includes charts to help clarify life history, traumatic events, childhood experiences, and therapeutic writing.  It overlaps with some of the handouts given in the linked "PTSD assessment, images, memories & information" section .  I use "therapeutic" writing as a general term covering all types of writing that have been shown to be helpful & "therapeutic".  When describing the form of therapeutic writing, developed by Jamie Pennebaker and other researchers, that focuses particularly on writing one's "deepest thoughts & feelings" about life traumas & difficulties, I tend to use the term "expressive" writing (to distinguish it, for example, from other forms of therapeutic writing focusing on diverse topics such as "best possible selves", "intensely positive experiences", "self-affirmation" and so on).  In general terms many of these handouts, charts and questionnaires can be helpful in exploring the way we are affected by our pasts. 

Chart, early years (0 to 13) - this is the first of six charts that I sometimes use to get an outline of the basic facts of a person's life history.  The charts take a good deal of time and effort to fill in.  I give them to the client I'm seeing as 'homework'.  I typically only use these charts when I'm involved in longer term work with someone.  They can be useful in many overlapping ways.  They can clarify the time pattern of chronic and recurrent disorders, they can highlight and order sections of a person's life that have been particularly traumatic, they can pinpoint particular events that may benefit from emotional processing (and by helping organize the memories, start the work of processing itself), and they can be useful sheets to refer back to when reminding oneself of previous work that has been done.  This 'early years' chart can helpfully be combined with the ACE questionnaire (see below).

Chart, adolescence & adulthood (14 to 34)

Chart, maturity (35 to 55)

Chart, getting older (56 to 76) - I don't have a further chart covering age 77 to 97, but you're welcome to adapt an existing sheet if you want to produce a 'getting even older' chart!

Chart, six year & three year details - these two sheet are used when it seems helpful to put a particulary important section of someone's life under more of a spotlight.  Particularly over times of trauma, memory can become disorganized and over-generalized.  Putting events into a narrative sequence can paradoxically sometimes be an important part of putting events 'behind you'.  An image for this is of a messy cupboard.  Painful memories have been shoved into the 'cupboard' in a messy, disorganized way - partly because the memories themselves are so upsetting.  Unfortunately they've been shoved into the cupboard so haphazardly that one can't properly shut the door.  Every so often the door of the memory cupboard swings open (probably triggered by some linked event occurring in one's current life).  Out spills the painful memories and one trips over them.  Part of the work of using these charts is to take the memories out of the cupboard and restack them in a more organized way, so that they don't keep falling out so often!

Self-concealment scale & background information - this is a questionnaire to measure "the tendency to conceal from others personal information that one perceives as distressing or negative".  Quoting the original research paper "Self-concealment significantly correlated with self-report measures of anxiety, depression, and bodily symptoms and accounted for a significant incremental percentage of the variance in physical and psychological symptoms even after controlling for occurrence of trauma, trauma distress, disclosure of the trauma, social support, social network, and self-disclosure."  The background information sheet gives further examples of research showing the problems associated with excessive self-concealment.

Monitoring & understanding our reactions - when people have excessive or inappropriate reactions to current experiences, this is often because their responses are being coloured by unhelpful learning from the past.  This questionnaire can help in understanding these links.

Note, I have written a series of blog posts on therapeutic writing (also downloadable as handouts) that begins with the post "Writing (& speaking) for resilience & wellbeing 1: introduction".

Power of words 1 - this sequence of 6 Powerpoint slides can be printed out as a (6 miniatures to a page) handout introducing some background to expressive writing as developed by Jamie Pennebaker.  This and the next half dozen slides (below) are from a talk I gave back in 2003.  Subsequent research further backs up the potential value of this approach.  See too the further handouts on Expressive writing (below). 

Power of words 2 - a further 6 slides that can also be printed out as a (6 miniatures to a page) handout.  

Expressive writing, Jamie Pennebaker download - a download (some while ago) from Jamie P's website.   

Expressive writing, written by me - as it says 'on the tin'!  This is a two page Word doc format "how to" handout on expressive writing about life traumas & difficulties as explored by Jamie Pennebaker and other researchers.  Here is a PDF file of the same material. 

Therapeutic writing & speaking: inspiration from values - this post explains how one can benefit from writing about other topics - such as life goals or intensely positive experiences - as well as one can by writing about trauma and life upheavals.

Therapeutic writing combining expression & reappraisal - see the post "An intriguing and encouraging development in therapeutic writing".

Importance of traumatic memories 1 - this sequence of 6 Powerpoint slides can be printed out as a (6 miniatures to a page) handout introducing the potential importance of working on traumatic memories in many cases of anxiety or depression - as well as with PTSD.  If you're using it as a handout, you can toggle Powerpoint to show the slides in black & white or in colour.

Importance of traumatic memories 2 - this second set of 6 slides gives further general explanation and details of research on trauma memories in depression and in social anxiety.

Importance of traumatic memories 3 - this third set of 6 slides extends the research details to cover agoraphobia, OCD, eating disorders, and other difficulties.  The sequence of 18 slides is taken from a lecture I gave in early 2006.  Subsequent research has added further weight to the probable value of emotional processing as a potential part of the treatment for many psychological difficulties.

Healing traumatic memories - these 2 slides can be printed out as a (2 miniatures to a page/full pages) handout explaining the nuts & bolts of the Ehlers & Clark cognitive model for processing trauma memories.

The Ehlers & Clark model for cognitive therapy treatment of PTSD involves particular focus on the trauma memory itself and on trauma-associated beliefs. Work on the trauma memory typically involves four methods - imaginal "reliving" or "revisiting", a written account, a "site visit", and discriminating triggers. See April 2012 blog posts for more on this. There is a detailed blog post on reliving/revisiting, a handout making suggestions on how to complete the written account downloadable both as a Word doc and as a PDF file, and more detailed descriptions of site visits & discrimination training.

Written exposure therapy - there are a couple of blog posts about this exciting development in writing treatment for PTSD - "One of the most exciting therapeutic writing studies for years" and "Written exposure therapy: how do you do it?".  A handout giving background and describing how to use this form of expressive writing is available both as a PDF file and as a Word doc.  I tend to use this handout in conjunction with the excellent one derived from the Ehlers & Clark model (see above).  Fascinatingly, this approach is likely to be relevant for work with difficult memories associated with other disorders than formal PTSD e.g. may well be useful for depression, social anxiety disorder, etc.

Adverse childhood experiences (ACE) questionnaire & background information - this questionnaire is adapted from the major Adverse Childhood Experiences Study (see www.cdc.gov/nccdphp/ace), one of the largest investigations ever conducted on the links between childhood maltreatment and later-life health and well-being.  Over 17,000 people have been followed since enrolment in the mid 1990's.  To date (2008), over 30 scientific articles have been published and over 100 conference and workshop presentations have been made about this work.  The ACE Study findings suggest that these experiences are major risk factors for the leading causes of illness and death as well as poor quality of life in the United States.  Progress in preventing and recovering from the nation's worst health and social problems is likely to benefit from the understanding that many of these problems arise as a consequence of adverse childhood experiences.

Life events, genetics & depression onset 1 - these 2 Powerpoint slides (and a further 2 below) can be printed out as a (2 miniatures to a page) handout explaining how genetic risk and difficult life events interact in precipitating depression.  The probably severity of different types of life event is also highlighted.  If you're producing a handout from these slides, you can toggle Powerpoint to show them in black & white or in colour.

Life events, genetics & depression onset 2 - see above.  These 2 slides extend the relevance of negative life events to triggering other psychological problems besides depression ... and discusses too issues about coping abilities.

Life events questionnaire - a classic life events questionnaire.

Life skills for stress, health & wellbeing

In the 1970's I taught yoga and several different types of meditation.  In the 1980's I began teaching courses in Autogenic Training, a form of deep relaxation/meditation.  I continued running Autogenic classes for about 25 years.  In addition to the relaxation/meditation exercises, the teaching also covered several other life skill/stress management techniques.  For a much fuller description of these eight session courses, visit the Autogenic Training section of this website.

Gradually the course became "too big" for the Autogenic label.  It had evolved into a broader stress management course that still had Autogenics at its core.  At the same time a number of other developments emerged.  These included exciting new research on the value of mindfulness training and also improved understanding of how physical healthy living practices - exercise, diet, alcohol moderation, smoking cessation - are actually of huge importance for psychological health too.  And to top it all there was now also a burgeoning research literature on ways of going beyond "good enough" to focusing on increasing happiness & wellbeing.  It was time to move forward.  In May of 2010 I wrote:   

On Monday of next week I'm due to run the first evening of a new twelve session course that I have been "cooking" for quite a while - see, for example, the post I wrote back in February "Developing a training course: life skills for stress, health & wellbeing".  I explained then that "I've known for some time that I wanted to "upgrade" the stress management/relaxation skills course that I've been teaching for many years.  I find the emerging research on mindfulness-based cognitive therapy (MBCT) exciting and encouraging, however the patient population I'm working with is much broader than just people with recurrent depression.  Although MBCT/MBSR have been used for people suffering from diverse disorders, it is the results achieved in reducing depressive relapse that I find particularly impressive.  I want to provide a training that is evidence-based and applicable to a wider group of people struggling with anxiety, depression, stress, relationship difficulties, poor health habits and general unhappiness (and wanting to build better health and greater wellbeing in their lives).  The emerging MBCT and MBSR literature is relevant here, but so too is a wealth of other research - for example the recent meta-analysis of relaxation therapies for anxiety disorders, the encouraging results being achieved teaching acceptance and values-based action for chronic pain patients, and the recent startling outcomes reported using mixed methods group interventions for both cancer patients and people with heart disease.

I've decided to bite the bullet and develop a group "life skills" training course for the patient population I see, from the ground up - using inspiration from a wide range of successful interventions - rather than simply take an already developed training course "off the shelf".  I went on to write "I feel excited about this.  I plan to run a new group course for this broader client population.  An important aspect of the course will be a relaxation & mindfulness exercise, but within a broader overview.  Probable ingredients for the course - besides the relaxation/mindfulness - will be work on improving health behaviours using implementation intentions, a focus on relationships & compassionate mind training, and exploring the relevance of values-based action, positive emotions, and self-determination." 

The publicity leaflet I subsequently put together reads:

what is it?  This course is ambitious.  It aims to help us live longer, healthier lives that are more energised, happy and fulfilling.  We will work to improve our knowledge and activities in three interconnected areas - stress management, healthy lifestyle, and overall wellbeing.  The recent Norfolk study  (Khaw et al, 2008) involving more than 200,000 UK adults showed that, over 11 years follow-up, those with the healthiest lifestyles (for smoking, exercise, alcohol & diet) died at only a quarter of the rate of those with the worst lifestyles.  Those living most healthily were - for mortality risk - biologically 14 years younger than those living poorly.  Yet most of us are not living well.  Two US studies  (Reeves et al, 2005; Stampfer et al, 2000) show only 3% of the population tick all boxes for basic healthy lifestyle practices (smoking, exercise, alcohol, diet, weight).

On this course we will look at how to build and fine tune healthy lifestyles.  Fascinatingly we now know that exercise and diet are also very important stress management tools.  Additionally we will develop skills in relaxation and meditation using Autogenic Training and goodwill practices.  These methods have been shown to reduce anxiety and vulnerability to depression, as well as increasing positive mood.  We'll review our relationship networks too and consider ways of improving this crucial resource for both stress management and wellbeing.  We'll check on how well we sleep.  We'll learn about goal setting, motivation, implementation intentions and forms of therapeutic writing.  And we will explore positive mood, engagement and meaning in life - three interweaving contributions to wellbeing and overall life satisfaction.

Potentially this course is life changing.  What it will definitely provide is a huge amount of support for participants to live much more healthily, more productively, and more happily.  Broad-based lifestyle and stress management courses like this can definitely have major impacts.  Two recent studies  (Andersen et al, 2008; Orth-Gomer et al, 2009) randomised people to standard care or to standard care plus a broad-focused lifestyle/stress management group.  In the cancer study, at 11 years follow-up, those randomised to the group intervention had halved their risk of death compared to those just on usual care.  In a similar type of randomised trial for heart disease, those given a broad based group intervention, over 7 years follow-up, reduced their chance of death by almost threefold.  And this course isn't only about life and death!  It is also centrally about living more relaxed, energised and happier lives.  Research now highlights clear pathways to do this.

who is the group for?  The group is for anyone who wants to work seriously at helping themselves be healthier, less stressed, and more fulfilled.  It will be hard work - and potentially life changing.  We will be 6 to 8 people (plus the facilitator, Dr James Hawkins).  James will provide the knowledge base and many years of experience with these methods.  We  as a group will work together over seven months to encourage and support each other on this "journey" of change.  It's one of the great strengths of group work that we can inspire, challenge, empathise, learn from, and help each other. 

So I plan to blog about the challenges, impressions, feedback, and outcomes that emerge running this first version of the "Life Skills" course.  Hopefully this will be useful in a whole series of ways.  Some of the ideas and comments may be helpful for other stress management/health behaviour/mindfulness training course facilitators.  Blogging about the course may also provide another useful layer of information for current and would-be course participants.  I hope too that the process of reflection will help me make this course as excellent as a I can.

And given below are detailed descriptions of the twelve "Life Skills" course training sessions. 

 

A: Life skills for stress, health & wellbeing, session 1

Yesterday we had the first evening of the Life Skills group.  I've written in the past about the background planning behind this group.  How did this first meeting go?  Well there were nine of us - eight participants and myself.  Rather demandingly I'm both running a new course and trying to get used to new technology at the same time.  For years, when running small group trainings here at our house, I've used an overhead projector to shine transparencies up onto the wall.  For a while I've wanted to upgrade to a laptop and data projector, and this evening I went ahead to put this into practice.

I had a series of 19 Powerpoint slides prepared for this 2 hour first session - rather too many even though the course participants just received handouts of 12 of them (first session, slides 1-6 and first session, slides 7-12).  After welcoming everybody, I explained my three priorities for the evening - 1.) to provide an overview of the whole twelve session course and help participants relate this to their own personal goals.  2.) to introduce an initial four areas: Autogenic Training, physical exercise, autonomous motivation & skilful goal setting.  3.) for everyone to be clear about the specific "home work" they wanted to focus on during the following week.

I explained that over the twelve sessions of the course I wanted to explore and help them develop more knowledge & competence in a.) "basic skills": exercise, diet, weight, alcohol, smoking & sleep. b.) "meditation": Autogenic Training, applied relaxation, visualisation, mindfulness & compassion.  c.) "wellbeing": positive emotions, self-determination & happiness.  d.) "relationships": emotional intelligence & social networks.  I said that this is a big buffet of options.  I didn't expect them to miraculously become experts and paragons of good practice in all these areas.  I did however want them to understand the importance of each area, what would be involved in developing competence in the area, and what they personally wanted to do about it.  I talked about Prochaska et al's stages of change model - highlighting that there were a series of worthwhile steps to take when developing new patterns of behaviour.

I handed out pieces of paper and asked everyone to write down briefly their own personal priorities for the course.  I got them to fold these papers and put them in a bowl, which was then passed round again so that everyone could now take out one of the papers.  Each person in turn went on to say their name and to read out what was on their paper.  Meanwhile I wrote the personal priorities they read out onto A1 flipchart sheets.  In this way everyone gets to say their name, and we all get an overview (anonymously) of what participants' priorities are, without - at this early stage of the group - everyone having to "bare their souls" over what they are most troubled by and most want help with.

I insist on seeing anyone wanting to enroll on this course for at least one initial one-to-one session with me beforehand - to understand what they hope to get from taking the course, to make sure this is appropriate and realistic, to orientate and prepare them for what the course involves, and to begin making a therapeutic relationship with them.  Even so, it is still helpful for me as well to see these personal hopes put up on the A1 sheets at this first evening.

I went on to highlight what we'll focus on over the first four sessions of the twelve session course.  These initial subject areas are going to be Autogenic Training, physical exercise, diet and weight.  I will also be exploring motivation, Self-Determination Theory, goal setting, and the behavioural stages of change model.  I introduced Autogenic Training further and we went on to an initial practice session.  I explained how I think there is a lot of sense in practising for 10 to 15 minutes a couple of times daily while learning Autogenics.  I talked too about what progress can you expect and asked everyone to keep a record of their practice - and a record of their physical exercise too.

I discussed checking it's safe to start exercising and the US guidelines on moderate & vigorous exercise.  I gave them each a copy of the 2 page US guideline handout "Be active your way: a fact sheet for adults"I asked them to begin charting their daily aerobic exercise using the guideline's "moderate activities" and "vigorous activities" distinction.  

I'd probably tried to push a bit too much into this first two hour session, but overall the evening seemed to have gone pretty well.  Content for this week has been starting to practice the Autogenic Training relaxation/meditation exercise and beginning to chart aerobic exercise.  Orientation has involved better understanding of what the course - as a whole - involves, what our focus will be in these first few sessions, and what participants particularly wanted to achieve through taking the course.  I also talked about motivation, highlighting the importance of each of us making decisions autonomously.  I said that they were more likely to be committed to lasting changes if the activities & "home work" they set themselves over the course made good sense to them and they wanted to do it.  I said that I didn't want them to go along with things just because of a sense of group pressure or other external motivation.  This will be something it will be worth revisiting over these first weeks of the course. 

I'll post again on how the course is going after next week's meeting .

 

B: Life skills for stress, health & wellbeing, session 2

So it was the second session of the group yesterday.  I blogged about the first session last week.  Sadly a couple of people couldn't get to this second meeting - due to a pre-planned holiday and to an unexpected crisis.  It's quite common for participants to miss one or two evenings across a twelve session course like this, but I want to be careful when people miss such an early meeting.  It's important that they don't lose their way and get left behind.  They will get copies of the handouts and the Autogenic CD, but I also make a note to contact them myself.   

As I've highlighted already, this course is broad.  We're going to be looking at health behaviours (exercise, diet, smoking, alcohol), relaxation/meditation skills (applied relaxation, mindfulness, visualisation, compassion), relationships (emotional intelligence, social networks), and wellbeing (positive emotions, self-determination, happiness).  Over the first four sessions, our focus is primarily on exercise, diet, and relaxation/mindfulness.

We started the session with the Autogenic Training practice they had working at over the previous few days. Everyone had kept a practice record for the last week.  I collected these records and we then went round giving everyone in turn a chance to say a bit about how their Autogenic practice had been going - and to troubleshoot any emerging difficulties.  As each person reported in, I had their weekly practice record in front of me.  This helps a lot in being able to respond helpfully.  Additionally they had kept a note of any physical exercise they had done during the week and had estimated how many "moderate activity" minutes of exercise had been involved.  See the basic 2 page "Be active your way: a fact sheet for adults" US guideline handout I gave them last week for more details on this.

I then went on to project the first half dozen Powerpoint slides for this week's session.  Participants also receive miniatures of these slides as one of their handout sheets.  I introduced them to the research behind my blog post "Would you like to be 14 years younger - it's largely a matter of choice!".  I highlighted that this research on mortality - showing a quartering of the death rate over 11 year follow-up in those with healthy rather than unhealthy lifestyles - is paralleled by similar research on psychological state.  So the post "New research shows diet's importance for preventing depression" links with a couple of papers published at the end of 2009, while more recently still Jacka et al have shown a diet-anxiety link too.  The associated, freely-viewable American Journal of Psychiatry editorial "Nutrition and psychiatry" discusses all these findings.  Exciting times!  And great that the health behaviour advice we should be following to optimise our physical health & mortality risk, is increasingly being shown to be the same advice we should be following for our psychological health as well.

A caution in running this "Life skills" course is not wanting to overwhelm people with too many behavioural change demands at once.  However some course participants will already be following most or all the health advice on exercise and diet - and I don't want these group members to get bored because they're not being asked to make any changes!  There's a challenge for me here as course facilitator.

Anyway, my compromise at the moment is to simply begin dietary change by starting to get us all to chart our daily fruit & vegetable intake this coming week.  Research suggests this is one of the more important areas of food-mood connection.  I handed out the British Dietetic Association's leaflet "Fruit & vegetables - enjoy 5 a day!".  Although I know a fair amount about healthy eating - and my own diet is good - I would be pushed to say just how much cucumber or cabbage or blackberries I would need to eat to qualify as having consumed a "portion".  It will be interesting to chart this.  And there are many helpful internet resources too; see for example a variety of websites that I have recommended

I also took a further step forward with our focus on exercise.  They had been simply charting "moderate activity" exercise minutes last week.  This week I'm asking them to begin setting themselves exercise targets.  At minimum, I would hope for everyone to be getting 150 "moderate activity" minutes over the week - pushing up towards 300 minutes.  Some participants are already easily achieving this, while others struggle to reach this level.  I talked about the value of making exercise flexible, accessible and enjoyable.  I warned against being totally committed to just one form of exercise e.g. just running, or just cycling, etc.  My concern is that it may make participants too vulnerable to injury.  Having a choice of more than one form of exercise means that even if, for example I can't run due to a strain, I may still be able to use a bicycle or swim.

For those who got a good deal of their weekly exercise through walking, I introduced the idea of walking intensity and pointed out that - to qualify for their overall weekly exercise total - they needed to walk in chunks of at least 10 minutes, at least at intensity 2 to 3 on the UK scale I handed out.  I also encouraged them to consider using pedometers.  See an earlier post on this site - "Exercise 4: pedometers can help us walk more".  I gave them details of this post in the handout on pedometers and, for those who wanted, lent them a pedometer to try out over the next week. 

I now asked them to reflect on the course so far and consider what they would like their priorities to be over the coming week. I gave them a form to fill in about all this - a "Reflection & intentions" sheet.  They then paired up to share what had emerged for them, and to explain their next week's intentions to their partner.  I explained that I would get them to get back in the same pairs next week to check in on how their intentions had gone.  I would very much like to encourage this kind of group support to become very helpful for them over these coming weeks.

Finally we looked at the next Autogenic Training exercise they would be moving to this week - see the second half dozen slides I showed them.  I talked about "Dealing with mental chatter".  Fuller details of what this involves, with handouts and downloadable recordings, are available on this site at "Autogenic Training, session two".

Good.  This session felt less potentially over-full of information than last week's to me.  Having this broad focus on three areas - relaxation/meditation, exercise, and diet - seems to be working OK.

See "Lifeskills ... session 3" for what we cover next week.

 

 

C: Life skills for stress, health & wellbeing, session 3

We had the third session of this twelve evening course yesterday.  I blogged a week ago about the second session.  The twelve Powerpoint slides for this third meeting give an overview of what we covered (slides 1-6 and slides 7-12).  As usual we began the evening with an Autogenic relaxation session - this time using the "Neck & shoulder" focus we had been working on last week.  I then asked the group members to pair up again with the person they had set up last week's personal intentions with.  Pretty much at every session I intend to ask course participants to pair up to review how they've done with their previous week's intentions (currently this involves Autogenics, exercise & diet intentions).  Later in the evening I get them to pair up again (with a new partner) to review what has been covered that evening and to make personal intentions for the following week.  In this way I hope to build group support, encourage personal reflection, and help people "take ownership" of the life style changes they are choosing to make.  This also gave me time to pair up with someone who had missed last week's session and check in with them on how they had been managing.  We then reconvened as the full group.  I collected their practice records from last week and we went round individually troubleshooting and discussing how last week's Autogenics, diet and exercise intentions had gone.

I then introduced the three continuing themes for this week.  We extended work on exercise for stamina and added the US exercise guidelines' recommendation to do strengthening exercises for all major muscle groups at least a couple of times a week.  We continued with the intention to eat 5-9 portions of fruit & veg each day, and extended dietary intentions into new areas too.  And we moved to the Autogenic "Warmth" exercise, began practising an additional very brief couple of short relaxation/mindfulness exercises during the day (as well as the longer practices in the morning and evening), and started learning about implementation intentions. 

The 2008 US exercise guidelines state that, in addition to stamina-focused aerobic exercise, "People are encouraged - on at least two days per week - to strengthen the major muscle groups involving legs, hips, back, chest, stomach and shoulders.  Exercises for each muscle group should be repeated for 8 to 12 repetitions per session."  I have blogged in more detail about the good sense behind this recommendation, and the course participants were given a handout of these comments about strengthening exercises.  I also demonstrated examples of exercises for the shoulders & chest (press-up variants), stomach (half sit-up variants), back (prone extensions), hips (extensions prone or on all fours), legs (using a chair, stairs, and jumps).  The strengthening exercise blog post and handout also give links to helpful books.  

We then went on to a simple Scottish NHS quiz about our diets.  This quiz has some gaps, but it is good for getting us to take a broader look at what we eat.  Participants were also given the British Dietetic Association's simple general handout on "Healthy eating - getting the balance right".  I then got the group to reflect individually on the course so far and particularly this new information on exercise and diet.  They filled in a "Reflections & intentions" sheet (after I had explained briefly about the new Autogenic application and visualisation exercises they would also be asked to try).  They then paired up to discuss what they had written and share their specific exercise & diet intentions for this next week.

I now moved back to the Autogenic exercises again.  I said that I would like them to explore three areas - application during daily life, implementation intentions, and the new "Warmth" exercise.  Slide 7 from their Powerpoint handout illustrates the way I gradually introduce application of relaxation/mindfulness into daily life during the course.  They were asked - in addition to probably trying to practise a fuller 10-15 minute sessioin twice daily - to take a minute or two a couple of times a day to do a brief relaxation/mindfulness exercise.  I also talked to them about implementation intentions.  I have blogged about this important area in the past and the blog posts also contain links to the two handouts I gave them - see "Implementation intentions & reaching our goals more successfully (first post)" and "Implementation intentions & reaching our goals more successfully (second post)".  We then ended the evening with the Autogenic "Warmth" exercise they would be due to practise for the first three or four days of this coming week.  For the second half of the week the aim is to move onto the second "Warmth" exercise.    

... and see "Life skills ... session 4" for next week's focus.

 

D: Life skills for stress, health & wellbeing, session 4

So yesterday we had the fourth evening of this twelve session course.  I posted on the third session last week.  What we covered is illustrated on the Powerpoint handouts I gave out as two six-slides-to-a-page handouts.  Click on slides 1-6, Powerpoint or slides 1-6, PDF and slides 7-12, Powerpoint or slides 7-12, PDF to see.

We began as usual with an Autogenic Training relaxation/meditation practice - this evening it was the "Pulse" exercise.  I often find that as the group develops, there seems a palpable feeling of increasing inner quietness week-on-week in how deep these shared practice sessions feel.  I realise that a big bit of this is that I become increasingly comfortable with the group, so my own personal practice with them deepens.  My guess is that it's also more than this - with me picking up an overall change in the group itself.  It shows itself too once we move to group discussion - more relaxed, open, sometimes jokey than in earlier sessons.  Good.

Everyone was here this evening - eight participants and myself.  I was speaking to a colleague at the weekend about a somewhat similar training course that they are running.  Their group seemed to be struggling a bit.  Part of this seemed to be the lack of initial one-to-one orientation at the start of the course.  It does seem so important that everyone sees clearly how doing this course - putting in the work - could be really helpful in areas that they individually particularly want to see improve. 

We split into three groups of three to talk about how last week's practice and intentions had gone.  I said that there were no failures, only potentially useful lessons.  I used the metaphor of climbing a mountain.  If anyone easily achieved their intentions for last week, maybe this coming week they could set themselves slightly more stretching targets - angling up the mountain more steeply.  If anyone failed to achieve all their intentions last week, maybe this was a lesson that they were pushing themselves too hard - angle up the mountain less steeply - set intentions for the coming week that are less difficult.  Good this small group work - it strengthens bonds, familiarity, affection within the group and gives people chances to learn from and help each other.

We came back to the full group.  I temporarily collected their practice records from last week and we went round checking in and troubleshooting.  Morale-boosting for the whole group to hear people talking about having more energy and feeling happier.  Reality-checking to talk about the difficulties of interacting with family members who might not be that positive about - for example - eating more fruit and veg.  I talked about how good or bad health behaviours can spread through social networks, as too can kindness or selfishness.  See for example the article "The company you keep really does matter" or "Cooperative behavior cascades in human social networks"

We then went to the slides.  I highlighted our goals for this evening - 1.) to take the Autogenic Training forward with the "Pulse" exercise, the "First differential" practice (see my posting on "Autogenic training, session 4" for more on this) and a new short 12-breath "Coming to our senses" practice.  This short exercise is downloadable both as in Powerpoint format and as a PDF.  2.) To continue with and potentially expand the quantity and variety of physical exercise.  3.) To continue to build a healthier diet - this week they received British Dietetic Association handouts on "Fish/Omega-3 fatty acids" and "Healthy snacks".  4.)  To review smoking, alcohol and weight.

I've blogged about alcohol several times.  See, for example"New NICE guidance on alcohol misuse".  I handed out several of leaflets from the "Alcohol & food" page of this website, including: 

Alcohol disorder assessment - "AUDIT and scoring" - this is the Alcohol Use Disorders Identification Test (AUDIT) developed by the World Health Organization to help identify people whose alcohol consumption has become hazardous or harmful to their health.

"Damage caused by alcohol" - this one page handout highlights some of the worrying and significant damage caused by excessive alcohol use.

"What is a unit of alcohol?" - it is easy to be drinking more alcohol than one realizes.  This one page handout clarifies what a unit of alcohol is and how many units are likely to be in a number of commonly consumed drinks.

So the overall challenges for this week included Autogenics (Pulse, 1st Differential, and 12 Breath Exercise), continuing to work with exercise & food, and to consider monitoring alcohol intake.  They had "Reflection & intentions" sheets as well as "Practice records" .

And next see "Life skills ... session 5" ...

 

E: Life skills for stress, health & wellbeing, session 5

Yesterday evening was the fifth session of this 12 evening training course.  I wrote about the fourth session last week.  As usual, this evening, the material we were due to cover was described in a dozen Powerpoint slides which the participants received as a handout.  See slides 1-6, Powerpoint or slides 1-6, PDF and slides 7-12, Powerpoint or slides 7-12, PDF.

We began with the main Autogenic Training relaxation/meditation which we'll be practising over this week - the "Breath" exercise.  The eight participants then paired up to talk about how their various intentions had gone over the last week.  We then reconvened as a full group and went round checking in on how things had been going.  Although I had hoped to get round this check-in fairly quickly as there was much material to cover in the evening, I also emphasised that if there were important issues that had come up during the previous week they would take precedence.  Balancing time given responding to "what comes up" with time given to pre-prepared course material is sometimes a challenge. 

And two or three quite important points did emerge.  One of them is the issue of what to do when a practice session is hard & upsetting - when one's mind is busy & distressed even though one is aiming to settle and hoping to find peace.  There isn't a single "correct" response here.  Three that are all perfectly reasonable are a.)  Simply see one's situation as similar to a learner driver finding the traffic too busy for their current level of skill.  It's fine at this stage of the training course to take a break and try the Autogenic practice again later when one is feeling a bit more settled.  b.)  A related response is to acknowledge that we're learning a cluster of methods in this "Life skills" course.  Sometimes an alternative technique may be better.  Problem-solving, taking physical exercise, talking with a friend, and practising therapeutic writing are all perfectly reasonable alternative strategies when one is feeling distressed.  It's good to have a cluster of methods one can use and to get more skilful at knowing what to use when.  c.)  A third possible response - which we discussed at some depth this evening (the fifth session of the course) - is to sit with the difficulty & distress.  I said that often relaxation/meditation practice is lovely, peaceful, quietening and joyful.  Sometimes it isn't.  I talked about my experience on meditation retreats with my knees giving me agony, or at the dentist choosing to work with difficult sensations rather than having an injection.  So often our reactions to challenging experiences - the "wrapping paper" of responses we put around the experience - these reactions can easily become as much or more of a problem than the initial experience itself.  "Mindfulness" may well involve "just being with what is", with openness and kindness, letting the feelings, thoughts, and sensations come into our consciousness and flow on out.  I explained that it is fine - at this stage of the training - to take a break from the occasional practice session that is this difficult, but it is likely to be helpful occasionally to practise "sitting with difficulties".  So, I said, I might be sitting and my ear starts to itch strongly.  It's fine simply to scratch it, but it is also interesting and helpful to realise that I don't have to scratch the itch.  I can simply accept the itch and be with it.  Good to have this choice.  Good to practise being with these experiences more without "running away", to develop a strength of being able to just be with difficulties without adding the "wrapping paper" of the "It shouldn't be this way, it's so awful, it will never get better" style responses.

Challenging.  I had given them the "Bus driver metaphor" handout this evening.  I've blogged too about my own use of these ideas in "Ways of coping: theory & personal experience".  I talked about David Barlow's work and the need to be cautious about forms of avoidance and give real thought to desensitising or confronting inappropriate avoidance at whatever level - behavioural, interpersonal, emotional, somatic and cognitive.  I talked too about some of the more recent application of these ideas for chronic pain sufferers - and the similarities to living with other types of difficult symptoms.  This will be material it's useful to revisit further into the course.  Next week, for example, I plan to run the first Autogenic practice with a radio turned on behind the group - challenging us all to relax/be mindful under more difficult circumstances.

This discussion on mindfulness and avoidance overlapped into a deeper discussion on worry & rumination.  I'd given them a six-miniatures-to-the-page Powerpoint handout on "Worry, anxiety & tension"  as well as "Rumination & worry scale" that they could use to track their tendency to worry and/or ruminate over the following week if they suspected that this is a problem for them.  

This lead on to looking at what we pay attention to - illustrated in slide 8 of the overall 12 slide Powerpoint handout for this evening.  I used the Garden of Eden story to illustrate this.  Human beings - more than other animals - are able to imagine and plan for multiple possible future circumstances.  We can also remember, think over, and learn from what happened in the past.  This ability to "time travel" and "possibility travel" in our minds is something that can be very helpful - and could certainly be something that promoted adaptation during our evolution.  However this "apple from the Tree of Knowledge" also comes at a price.  We can worry endlessly about the many things that might go wrong, or ruminate round & round about what happened in the past.  We may spend less & less time in the present - in coming to our senses, to our relationships, to being in this extraordinary, marvellous natural world, with this extraordinary, priceless gift of being alive.  Knowledge can come at this price, a kind of "being cast out of the Garden".  And it's fascinating that the story goes in Matthew's gospel "Verily I say unto you, Except ye be converted, and become as little children, ye shall not enter into the kingdom of heaven."  I personally am not a member of any religion, but there seems a deep truth here.  I know how easily I can go right through a day, very busily, very effectively, but it's as though I'm skating across the surface of life.  It's as though I'm in danger of getting to the end of my life and remembering that I've got a lot done, but forgotten the grace I've often illustrated through Mary Oliver's precious poem, "The summer day" with it's final lines:

I don't know exactly what a prayer is.
I do know how to pay attention, how to fall down
into the grass, how to kneel down in the grass,
how to be idle and blessed, how to stroll through the fields,
which is what I have been doing all day.
Tell me, what else should I have done?
Doesn't everything die at last, and too soon?
Tell me, what is it you plan to do
with your one wild and precious life? 

Several handouts from the "Wellbeing & calming skills" page of this website are relevant to these points - including "Attention, focus & time", "Savouring, mindfulness & flow", and the section on "Gratitude & appreciation": "Gratitude & appreciation record", "Suggestions" and "Miniatures" - this is a delightfully simple and potentially very helpful happiness-boosting intervention.  The miniatures can be printed out as a six slide to a page Powerpoint handout providing background information.  The suggestions sheet explains how to do the exercise, and the record sheet is filled in as one follows these instructions.  I believe humans (and many other animals) tend to take fairly static aspects of their environment for granted.  I suspect this has adaptive survival advantages in hunter-gatherer environments.  Part of the cost is the hedonic treadmill where we rapidly take for granted precious every day facts - our ability to function, our relationships, the beauty of nature, the taste of food, so many things.  As has been said "We tend to only notice the really important things in life when they're gone."  This gratitude noting exercise readjusts the thermostat of our appreciation.  It will probably then slide back and may benefit from being readjusted by doing this exercise for a week every month or some other regular reminder.  

Besides these explorations of "mind noise" and reminding ourselves to notice & appreciate more, we also touched on issues around sleep - see the handouts & points made on the "Sleep, ADHD & fatigue" page of this website.  And to keep a degree of focus on diet too, they received handouts on "A healthy breakfast - the best start to your day" and "Pack a healthy lunch".  As usual I highlighted that all of us can benefit from continuing to work with the Autogenics, exercise, and diet.  Other aspects like charting rumination & worry, or working more seriously on ideas around sleep, will be highly relevant for some course participants but not particularly important for others.  I asked everyone to look at what mix is likely to be a realistic and personally relevant challenge for this coming week.  They all had the usual "Reflection & intention sheets" and "Practice records" .

For next week's details, see "Life skills ... session 6".

 

F: Life skills for stress, health & wellbeing, session 6

Yesterday we had the sixth session of this twelve evening "Life skills" course.  I wrote last week about the fifth session.  A dozen slides covering material we explored are viewable/downloadable at slides 1-6, Powerpoint or slides 1-6, PDF and slides 7-12, Powerpoint or slides 7-12, PDF

I began by talking about having choices when we're facing aversive/difficult/unpleasant experiences.  Quite often we are simply able to remove the source of discomfort ... or remove ourselves from it.  This evening we were going to practise going through a relaxation/meditation session while there was a radio in the room blaring quite loudly, tuned just "off station" to make it even more unpleasant.  Obviously it would have been possible to have simply turned the radio off ... and often in life removing a source of discomfort is a sensible choice.  Sometimes though we will be faced by aversive experiences that it's not so easy to simply remove.  This might, for example, involve physical pain or discomfort, or emotional suffering, or interpersonal difficulty.  This links with the "Bus driver metaphor" we talked about in the session last week (with its notion of the driver learning to "accept/ignore" unhelpful interactions with "bus passenger" thoughts/feelings).  It links too with much material elsewhere on this website reachable via the "Tag cloud" and clicking on words like "Acceptance" and "Mindfulness". 

So if we're to practise simply being with difficult experiences "mindfully", it makes it easier to start with if we work with challenges that we can set up in progressively more confronting steps.  Using sound source distractions while practising meditation is a good example.  Working with experiences of cold (e.g. swimming or showering in cold water), or physical discomfort (e.g. while exercising intensely) are other options.  Being alert for opportunities to practise with other aversive experiences - emotional, behavioural, interpersonal - during everyday life can also be helpful.  This is not intended as an exercise in masochism or passivity.  It is however intended to give us more choice in our lives (to tolerate, to change, to problem solve, to discuss, etc), more sense that we can "keep our heads above water" even when the going gets tough.  So we went ahead to do the Autogenic session with the radio blaring in the background.  We then went round discussing how the experience had been.  This too can be such good learning - some found it pretty hard, some interesting & not too difficult, some even found that it helped them stay in the present & reduced "mind wandering".  I talked then about possible home practice of this kind of challenge.

We then paired up to talk about last week's practice, before convening as the full group to each have a turn to say how things had been going.  This gave me a chance to get a better sense of how individuals were doing and to troubleshoot where appropriate.  We also talked more about last week's gratitude/appreciations exercise, which most of us had enjoyed and valued a lot.  I explained that I think that - as "hunter gatherers" we're internally programmed to attend preferentially to sources of possible danger, rather than sources of possible pleasure.  It makes sense for survival.  However for most of us, in our current life situations, we would do better to adjust this "internal thermostat" and train ourselves to savour and appreciate and be more grateful for this extraordinary life and this extraordinary planet ... rather than being consumed by anxiety about endless "what-ifs".   

I then went on to project this evening's Powerpoint slides (see above).  I talked about the crucial importance of our relationships.  I showed data from a series of research studies demonstrating the increased mortality risk in having poor relationships - as or more significant than much better publicised risk factors like smoking or having high blood pressure.  I also talked about the central value of relationships in boosting our wellbeing.  Obviously relationships can be a huge source of pain and stress, but they can also be a major source of joy, warmth, and meaning in our lives.  I introduced the notion of Self-Determination Theory's (SDT's) three basic psychological needs for autonomy, competence & relatedness.  See the webpage "Wellbeing, time management & self-determination" for much more on this ... and I gave them the "Psychological needs & wellbeing 1" & "Psychological needs & wellbeing 2" SDT handouts.  I also mentioned Sheldon Cohen's work and his argument that to flourish we need high levels of interpersonal intimacy/closeness, high connection with a broader social network, and low levels of chronic interpersonal stress & conflict.  I gave everyone copies of the "Personal community map", the "Personal community map instructions" and the "Personal community map questions", and asked them to fill in the map and answer the questions over this next week.  

They also had a further dietary handout on "Wholegrains", a "Practice record", and a CD of the "Belly warmth" Autogenic exericise.  Clicking on  "Belly warmth" will also take you through to a description of another major focus for this week - the "reminder dots" exercise.  I had already got them to pair up to go through their day identifying where they could usefully position these dots.  So we finished with a brief further Autogenic relaxation/meditation session.  We'd run out of time and I asked them to complete the "Reflection & intentions" sheet soon, so that we could review it next week along with their practice record.

And see "Life skills ... session 7" for detail's of next week's meeting.

 

G: Life skills for stress, health & wellbeing, session 7

Yesterday was the seventh session of this "Life skills" group.  I discussed the sixth session last week.  As usual the participants had a handout of a dozen slide miniatures covering material we were to explore.  See slides 1-6, Powerpoint or slides 1-6, PDF and slides 7-12, Powerpoint or slides 7-12, PDF.  We began with an Autogenic relaxation/meditation session using the "Belly focus" that participants had already been working with.  We then split into pairs to discuss how last week's intentions had gone.  Then to the full group and our usual check-round.  This was followed by me introducing the main additional themes for this week.

In the early weeks of the course we have worked on "basic life skills" - exercise, diet, alcohol, smoking - as well as developing increasing experience with Autogenic Training, and looking at a cluster of other areas including sleep, goal setting & motivation.  We have now broadened the focus to begin looking at relationships.  I spoke last time about evidence showing the crucial importance of good relationships for our physical health as well as for our sense of wellbeing.  Participants had been given the "Personal community map instructions" and asked to fill out the "Community map" and answer the "Personal community map questions"

This often helpful bottom-upwards procedure was complemented this evening with a top-downwards values-roles-goals exercise.  Participants were given three handouts to fill in.  The "Respected figures exercise" is a good way to clarify our values.  It asks us to jot down three to five people who we have a lot of respect for.  They can be relatives, friends, others we've met in our lives, people we've read about, historical figures, famous people.  The key point is that there's something about the way they've lead their life that we really respect.  There may be other aspects of their lives that we don't like at all, but they do represent - at least in some areas - qualities that we are moved by.  In the second column of the form we write down what these qualities are that we genuinely admire.  Then in the third column there's space to note  - from the list in the second column - what qualities or clusters of qualities particularly stand out.  I suggest to people that if we don't try to live our lives honouring these qualities that we've chosen, it's unlikely that we'll feel good about ourselves and how we've lived.  In terms of the "Bus driver metaphor", that I've previously introduced, these qualities tell us about how the "bus driver" is trying to drive - what the compass bearing of our values is.  

The second of the three handouts I gave them was a "Role areas" sheet.  I suggested that we may well be in danger of leading lives that are somewhat out of balance.  The stereotype would be of a committed career-focused person who didn't give enough attention & energy to their important relationships, or a self-denying parent or partner who focused on supporting others without also paying attention to their own health and enthusiasms.  I encouraged the group to consider their lives as a series of roles - for example, "relative", "son/daughter", "partner", "parent", "friend", "worker" and so on.  I explained that there isn't a right and wrong about what labels and role areas we choose to use.  In my own life, the best way of dividing up my different life areas has evolved as my parents have died, kids left home, job developed, and so on.  All of us are likely to need a role that we might label something like "administrator" that covers a host of practical house-keeping, financial and other issues.  We all also need a role or roles that cover "self-care" including diet, exercise, sleep, and possibly also more psychological/spiritual aspects of our wellbeing as well.  We may also want a role to cover other enthusiasms, activities, and hobbies.  There isn't a right or wrong way of dividing up roles.  I do however say that pretty much every waking minute should be covered by one or other role description.

The third sheet they were given was a "Goals for roles" exercise.  Typically I use the "When they speak about me at my funeral" focus.  I think that the acknowledgement of our mortality helps to concentrate our minds on what really matters to us.  For some people though the rather less confronting "Eightieth birthday party speeches" sheet serves the same function.  I asked the group to fill in the speeches they would really like to hear, focusing on their main relationship roles.  As a way of reducing "writer's block" I often suggest that one just give oneself a couple of minutes per role to write out the outline of the speech one would want to hear.  One of the slides I showed them is of a classic yin-yang sign.  Yin is often thought as a more receptive and tranquil energy, while yang can be seen as a more active and fiery energy.  They complement each other - in fact need each other to make up the whole.  During this "Life skills" course we want access to both these energies - an increasing ability to be present, receptive, mindful, appreciative and also an increasing ability to be clear, value-directed, better able to act in ways that promote flourishing.  This clarification of respected qualities and of goals-for-roles can be thought of as yang - as too can our earlier work on this course building better self-care with diet, exercise and so on.

I talked last week about the key health and wellbeing benefits of good relationship networks.  One way of understanding this is through the lens of self-determination theory's need-satisfaction model.  See, for example, the article "Friendship, need satisfaction and happiness".  I asked participants to look at their answers to questions about their personal community map, the values that had emerged from the "Respected figures exercise", and the funeral speeches about their relationships roles.  I then suggested they begin to choose particular goals that they could work towards in their relationships.  In the fine self-determination paper "Persistent pursuit of need-satisfying goals leads to increased happiness" , participants were asked ""For the next six months, we would like you to give special attention to a psychological need - namely, the need for (autonomy, competence, or relatedness)." ... Relatedness was defined as occurring when "you feel a sense of connection with important others - you understand and care for these others, just as those others understand and care for you." ... Participants then brainstormed "some ways in which your (... relatedness) need is not currently being met," ... After this open-ended task, treatment participants were asked, on the next page, to list "four goals you can pursue, over the next six months, to better satisfy your (... relatedness) need," ... Participants received some general suggestions about types of goals they could list in their assigned condition, but received no specific instructions about what to pursue."  In a similar - and broader - way I asked the "Life skills" group to begin working on relationship goals.

They were also encouraged to keep up - and possibly extend and develop - their exercise, diet and other self-care work.  I added too the "Forehead" focus in the Autogenics and encouraged everyone to keep working with last week's "Reminder dots" exercise.  As usual they were given a "Practice record" and a "Reflection & intentions" sheet.

And for next week's details, click "Life skills ... session 8".

 

H: Life skills for stress, health & wellbeing, session 8

It was the eighth session of this twelve session group last night.  I wrote about the seventh session last week.  Participants had their usual handout of a dozen slide miniatures covering the material we were to explore.  See slides 1-6, Powerpoint or slides 1-6, PDF and slides 7-12, Powerpoint or slides 7-12, PDF.  We began with an Autogenic relaxation/meditation session using the "Forehead focus" that participants had already been working with.  Then at the check-round, because several people were away on holiday, we had more time to address two or three individual issues that came up. 

The main additional focus of the evening was around relationships and how we approach them.  Two weeks ago we looked at the mortality risks of poor relationships, and began working with "Personal community maps".  Last week we personalized this more, exploring our values through the "Respected figures exercise" and our hopes with the "Funeral speeches exercise".  This week I extended this work on values, roles, hopes & goals by talking more about Self-Determination Theory.  Participants received several handouts on Needs, Goals, Motivation and the questionnaire on Relationship need satisfaction - all downloadable from the "Wellbeing, time management & self-determination" page of this website.  

This twelve session course is about "Life skills for stress, health & wellbeing".  Happily the skills and focus that help one of these three areas are likely to help the other two areas as well.  So, for example, good diet and adequate exercise make major differences to our physical health and mortality AND they also make major differences to our stress resilience too.  In a similar way, life skills and focus that build our wellbeing ALSO help with stress resilience and with our physical health.  Recent research highlights the validity of this understanding.  See, for example, Sin & Lyubomirsky's 2009 article "Enhancing well-being and alleviating depressive symptoms with positive psychology interventions: a practice-friendly meta-analysis" and Chida & Steptoe's 2008 article "Positive psychological well-being and mortality: a quantitative review of prospective observational studies".  So this evening's Life skills class focused on interventions to build wellbeing, and we can be confident that there will be a spill-over effect for both stress levels and general health.

Self-determination theory underlines increasing satisfaction of our needs for Autonomy, Competence and Relatedness as major ways to build wellbeing - see, for example, the 2010 paper "Persistent pursuit of need-satisfying goals leads to increased happiness: A 6-month experimental longitudinal study".  I asked the group to begin working in this way - particularly with their needs for Autonomy and Relatedness.  Increasing Autonomy involves leading a life that is more "self-chosen", that increasingly fits with our personal values.  Last week's "Respected figures" and "Funeral speeches" exercises are great for clarifying what this is likely to involve.  I linked this work on increasing Autonomy with increasing Relatedness (intimacy & shared activity) as well.  I asked participants to check to see whether their "Respected figures" exercise from last week had highlighted any particular ways of relating to other people that they deeply respected.  Similarly their "Funeral speeches" exercise would have underlined how they wanted to be with family, relatives, friends and others.  Finally there was a link as well with the "Personal community map" exercise they have been working with.  This clarification of values, lifetime goals, and relationships is a very rich and important way to identify autonomous goals for how we can relate better.

I linked this too with Jennifer Crocker's work on "Egosystem & ecosystem" or as the Beatles put it "The love you take is equal to the love you make" (the line that John Lennon is reported to have said was Paul McCartney's best lyric).  Everyone had a chance to complete Crocker's "Compassionate & self-image goals scale" and I talked a bit about how this a pretty good validation of the Beatles' words.  For some people this linked with what had emerged from the "Respected figures" exercise.  And I talked too about Goodwill practice and how this can be usefully added to the Autogenics.  Amongst other reasons for this is Barbara Fredrickson's research showing the way that Goodwill practice can build positive emotions and improved functioning and life satisfaction.

The Autogenic exercises they were to work on involved using any of four "Forehead exercises" once daily and either the longer or shorter "First goodwill exercise" once daily.  The standard relaxation and mindfulness "Forehead exercise" options are given on the "Autogenic training, session 7" page of this website.  The additional energising (typically morning) and quieting (typically evening) options are given on the "Autogenic training, session 8" page.   I also introduced the possibility of linking compassion practice to the standard Autogenic Training sequence.  There are a further 12 practice recordings as well as explanatory information on the "Compassion & criticism" webpage.  Participants were given the "Suggestions for goodwill practice" and "Goodwill practice record" as well as a CD with the three initial "Goodwill" tracks: "Goodwill & Autogenics 1: introduction" - this is a brief 3 minute MP3 file introducing the initial practice.  There are fuller details in the written Suggestions handout.  "Goodwill & Autogenics 1: 16 minutes" - this initial exercise begins with an Autogenic Training relaxation and moves on to a Goodwill practice focusing on somebody that one feels particularly caring for.  "Goodwill & Autogenics 1: 28 minutes" - a longer version of the meditation exercise given above.  There is some evidence suggesting that longer practices are more helpful.  The usual "Reflection & intentions" and "Practice record" were also provided.   

And now you can move on to "Life skills ... session 9" .

I: Life skills for stress, health & wellbeing, session 9

Yesterday was the ninth evening of this "Life skills" training.  I wrote about the eighth session last week.  The sequence of regular weekly classes now moves on to increasing gaps between sessions - so it's three weeks until the tenth, a further five weeks until the eleventh, and then an additional eleven weeks until the final twelfth session.  My hope is that we will be able to arrange occasional follow-up meetings even after that.

This ninth session was partly a review of the territory we have covered over the last two months.  Participants had their usual handout of a dozen slide miniatures covering the material we were to explore.  See slides 1-6, Powerpoint or slides 1-6, PDF and slides 7-12, Powerpoint or slides 7-12, PDF.  They also had a - less detailed than usual - "Practice record".  Especially important was this session's "Reflection & intentions sheet".  For CD's, they had four which covered the twelve "Goodwill" recordings to be found on the "Compassion & criticism" page of this website.  For those who hadn't already received them, they were also given the "Suggestions for goodwill practice", and too the additional energising (typically morning) and quieting (typically evening) standard Autogenic options given on the "Autogenic training, session 8" page.  

We explored once more the several overlapping reasons why it makes good sense to try out the Goodwill practice.  These reasons included points made at last week's session about Self-determination theory, values, ecosystem & egosystem, and building positive emotions.  I talked too about the "Behavioural systems model" and the potential value of moving deliberately and more often to a care-giving internal stance.  I mentioned some of the fascinating recent research in this area, including the way that goodwill practice helps us be more aware of others and the way that our interpersonal warmth so often is reflected back by others.  See "Loving-kindness meditation increases social connectedness" and "Deconstructing the "reign of error": interpersonal warmth explains the self-fulfilling prophecy of anticipated acceptance".

At the start of the course, participants had filled in a series of initial assessment questionnaires.  Now at the end of the first two month intensive phase of the training, they were asked to fill most of these questionnaires in again to assess what is changing and what isn't.  The questionnaires included a couple of IAPT measures -  the depression & general anxiety PH-9/GAD-7/phobia scale and the 5 areas disability scale.  These general distress/disability measures are good, but may miss significant symptoms - for example of specific anxiety disorders.  I included a more personalised assessment of the difficulties participants individually most wanted help with at the beginning of the course and we now repeated this personal target symptoms scale.  We also repeated a couple of mindfulness/self-compassion scales - the 5 facet mindfulness questionnaire and the short form of the self-compassion scale - and a couple of wellbeing measures - Fredrickson's positive:negative emotional ratio and Diener's satisfaction with life scale.  

A good three quarters of an hour of this session was spent in filling in the "Reflection & intentions sheet" and then pairing up to discuss what had emerged.  Participants were asked to make specific intentions about their practice priorities for the next three weeks - until the tenth session.  They explained and exchanged these intentions with their partner, and agreed to make contact with each other in about ten days to hear how things had been going.  Building longer term support like this is one of my hopes for this training course. 

 

J: Life skills for stress, health & wellbeing, session 10 (part 1 - goodwill practice)

If you want others to be happy, practise compassion.  If you want to be happy, practise compassion.    Dalai Lama 

We had the tenth session of this "Life skills" course last night.  There had been a three week gap since the ninth meeting, and there will now be a five week gap until the eleventh, and a further eleven weeks until the final, twelfth meeting.  We began with a combined Autogenics plus Goodwill practice - downloadable recordings of these Goodwill meditations are findable further down the  the "Compassion & criticism" page of this website.  Participants had their usual handout of a dozen slide miniatures covering the material we were to explore.  See slides 1-6, Powerpoint or slides 1-6, PDF and slides 7-12, Powerpoint or slides 7-12, PDF

We began with a guided relaxation/meditation practice - on this occasion involving the full Autogenic Training sequence followed by the full Goodwill Practice.  We then went round checking how course participants had been doing with these exercises over the previous three weeks.  One of the interesting themes that emerged was how important (or not) it is to experience emotional/physical feelings when working with the Goodwill practice.  In some ways this discussion seems to parallel a similar set of questions that can emerge when people are first learning Autogenics or other forms of relaxation/meditation. 

My clinical experience is that people who "feel nothing/no change at all" when they practise relaxation, are probably unlikely to persist with or benefit from the practice.  The "Relaxation response" diagram, that I show people on the first evening of the course, highlights the quite profound physical changes that occur when someone quietens and relaxes deeply.  If someone "feels nothing" when they try to relax, then they may be relaxing but not noticing the internal changes that are occurring.  It seems more likely though that they are currently simply not relaxing very well.  A metaphor I sometimes use to describe working with this initial difficulty is of driving a wedge into a log of wood.  I say that they are first likely to begin noticing some physical/psychological feelings of relaxation under very easy conditions - for example, on a day that is going well, in a peaceful, safe situation, when their mind isn't too distracted - then when they try a relaxation exercise they may get some initial experiences of a pleasant comfortable state.  The aim is to gradually "drive the wedge in deeper", so that they slowly learn to elicit these (and deeper) relaxation feelings under progressively more difficult conditions e.g. when they are feeling stressed, when the outer environment is more noisy, when they are moving around, and so on.  I often draw a parallel with learning any other skill - for example, learning to drive, or type, or swim, or even learning to walk.  The "What progress can you expect?" handout makes these points in more detail.  

My sense is that this parallels changes that can occur with Goodwill, Loving-Kindness, and Compassion meditation practices (these three terms are pretty much synonymous).  So several course participants this evening commented on not feeling any physical changes or emotions when working with the Goodwill practice.  I am however pushing for the practice to involve emotion and not just a set of thoughts.  Emotions are very physical things.  They changes the landscape of the body - heart, lungs, blood distribution, muscles, viscera - via both chemical messages in the blood stream and electrochemical messages in nerve pathways.  Emotions also change the way the brain acts - how it pays attention, processes information, and readies the individual for specific kinds of action.  See the two "What do emotions do?" slides for more on this.  See too the recent Journal of Neuroscience paper "Opposing influences of affective state valence on visual cortical encoding" showing how different emotional states literally change what we see, and there's Hutcherson et al's research paper "Loving-kindness meditation increases social connectedness" showing that " ... even just a few minutes of loving-kindness meditation increased feelings of social connection and positivity toward novel individuals ... "  Imagining and feeling into experiences of goodwill/loving-kindness/compassion does produce very real changes in the body and mind.  See the two "Moods affect us quickly & powerfully" diagrams. 

It's a fascinating area.  One helpful lens through which to view this Goodwill work is the literature on adult attachment and caregiving.  Mikulincer & Shaver have written a chapter on "Adult attachment and caregiving: individual differences in providing a safe haven and secure base to others" in the currently "in press" book by Brown et al "Self-Interest and Beyond: Toward a New Understanding of Human Caregiving".  They write "The second of these behavioral systems (after the attachment/careseeking system), caregiving, was hypothesized by Bowlby to be the motivational heart of a parent's (or other adult's) response to a child's distress or need for support or assistance. In our opinion, this system is also the core of all empathic, compassionate reactions to another person's needs. It presumably evolved originally because it increased "inclusive fitness" by enhancing the survival of multiple others with whom a person shared genes, but it is a capacity that can be extended by social learning".  I wrote last month about how our behaviours and warmth can become a self-fulfilling prophecy - see, for example, Srivastava & colleagues' "Optimism in close relationships: How seeing things in a positive light makes them so", Assad et al's "Optimism: an enduring resource for romantic relationships", Klapwijk & Van Lange's "Promoting cooperation and trust in "noisy" situations: The power of generosity", Stinson et al's "Deconstructing the "reign of error": interpersonal warmth explains the self-fulfilling prophecy of anticipated acceptance" and the whole thrust of Crocker's fine work at her "Self and social motivation lab".  Goodwill practice is relevant to all of this.  We need to maintain authenticity.  This isn't about becoming "sugary".  But as Paul McCartney put it - with what John Lennon apparently said were the best lyrics Paul had every written - "In the end the love you take is equal to the love you make".   

I'll post again tomorrow about the second part of this tenth "Life skills" session.

  

K: Life skills for stress, health & wellbeing, session 10 (part 2 - therapeutic writing)

I wrote yesterday about the first part of this tenth "Life skills" evening.  I particularly discussed development of Goodwill practice - very much in the "Nourishing positive states" section of the "Four aspects" diagram (below).  In the second half of the evening we moved on to the "Exploring & processing" section of the diagram with the introduction particularly of various forms of therapeutic writing.

Four aspects of helpful inner focus

I'm a big fan of Jamie Pennebaker's work on the value of "expressive writing".  See for example the three blog posts I wrote back in January on "Writing (& speaking) for resilience & wellbeing"For many years, "expressive writing" - delving deeply into feelings & thoughts about upsetting experiences - was the only form of "therapeutic writing" that one could validly claim had been shown to be of real use in good research studies.  This situation has now changed and continues to evolve excitingly.  Different research teams have now explored therapeutic writing that focuses on many different areas.  Examples include "best possible selves", "intensely positive experiences", dissonance between behaviour and values, growth after trauma, self-transcendence, attachment, personally respected qualities, and important life domains.

In early therapeutic - typically "expressive" - writing studies, participants were usually asked to write for 20 minutes or so on three or four consecutive days.  These instructions have now been widely varied, with writing time being anywhere between 2 and 30 minutes (or more), and intervals between writing sessions varying between a few minutes to over a week.  Gains have been surprisingly robust despite these variations! 

This evening's course participants were given a series of handouts about therapeutic writing.  One entitled simply "Therapeutic writing exercises" gave ideas for five "positive" writing topics.  These included looking at the possibility of "Posttraumatic growth", a couple of topics (personal values & important life domains) taken from self-affirmation theory (although other researchers have alternative more self-transcendent explanations for some self-affirmation gains), and a couple (best possible selves & intensely positive experiences) that I described last year in the blog post "Writing for health & wellbeing".  There's now a five week gap before the next "Life skills" evening, and I've asked course members to experiment with writing about at least a couple of these five "positive" topics.  

I also gave them handouts on Jamie Pennebaker's "expressive writing".  These included one written by me, and a series of slide miniatures (slides 1-6 and slides 7-12) giving a more academic view of the "expressive writing" research underpinnings.  Pennebaker's website gives further information and writing suggestions.  I have asked participants to also try out "expressive writing".  Traditionally this has involved writing for 15 to 20 minutes on three or four occasions, expressing one's deepest thoughts and feelings about the worst experiences of one's life.  It is rather "diving into the emotional deep end", although research shows this is a surprisingly safe and very frequently a helpful thing to do.  More recently I heard Jamie Pennebaker saying (at the BABCP conference last month) that it's now been found that simply writing one's "deepest thoughts and feelings" about "something of personal emotional importance" produces very comparable benefits.  So it's fine to choose challenging personal subjects from the past, present or even the future.  Writing about "positive" experiences should probably best be less analytical and more visual/sensory (involving the right hand side of the diagram below), while writing about "negative" experiences is probably best a mixture of delving deeply into emotions but also one's thoughts as well (so adding the left side of the diagram).  My recent blog on Emily Holmes's work discusses this and it's illustrated below:

Verbal representation v's Imagery construction

Forms of therapeutic writing about both "positive" and "negative", or more accurately "pleasant" and "unpleasant", subjects are often helpful for our health & wellbeing for months after a series of three or four writing episodes.  Writing about "unpleasant" subjects may be particularly useful for people who tend to worry or ruminate a good deal.  Therapeutic writing is a great tool to have in one's "kitbag" of self-help methods. 

And for the next session's details, see "Life skills ... session 11" .

 

L: Life skills for stress, health & wellbeing, session 11

Yesterday we had the eleventh of this twelve session "Life skills" evening class.  It's five weeks since the tenth meeting and there's another eleven weeks until the twelfth.  As usual we began with an Autogenic practice.  Especially now, when a training group has met on a whole series of occasions, these shared relaxation/meditation practices can be quite "blessed".  I've taught these kinds of skills for over thirty five years.  I have a very strong sense that the depth one goes to in a shared practice is strongly affected by the group itself - how easy and affectionate we feel with each other, how used we are to being around each other, how seriously & deeply others in the group are able to take their practice.  Precious.

There were fewer handouts than usual.  In fact participants just had a reflections/intentions sheet and their usual handout of a dozen slide miniatures covering the material we were to explore.  See slides 1-6, Powerpoint or slides 1-6, PDF and slides 7-12, Powerpoint or slides 7-12, PDF.  After the initial practice, we spent a good deal of time going round looking at how everybody had been doing.  This is another reason for starting the class with a meditation/relaxation practice.  As Barbara Fredrickson has highlighted with her broaden-and-build theory of positive emotions, when we're relaxed, peaceful, feeling good, we tend to think more clearly, remember better, relate better.  The "go-round" is likely to be more helpful for everybody, after an Autogenic practice session rather than before it. 

A couple of people had been through particularly difficult life experiences in the five weeks since the previous session.  We talked about this.  I said that the Life Skills (and knowledge) we've been developing are probably relevant in these crisis situations in at least three ways.  I used the metaphor of taking a ship into a storm to illustrate this.  So the first way the skills are relevant relates to what shape we're in as we go into the crisis - how seaworthy, how well looked after, how skilful the ship and crew are as they sail into the storm.  The second way the skills are relevant is in how one copes in the storm, the crisis itself.  Just as at sea, one may no longer be able to use many of the sails in the high winds, so we may find that our coping skills as well are strongly challenged.  One person explained that they had been so pressured that - for a few days - it was hard to eat, and certainly very hard to sit to meditate.  They had found however that they could keep taking physical exercise, that friendships continued to be a real source of support, and that they could do brief snatches of the Autogenic relaxation/mindfulness exercises.  They also said that the whole experience of being in the "storm" was less overwhelming than it had been in the past, that they had more belief that they would come through it, that it would pass.  We talked about this, and I queried also the potential value of therapeutic writing, of reappraisal methods, and of problem solving in these very difficult situations.  The third way the life skills are very relevant is in recovering after the storm, after the worst of the crisis is past.  The boat needs damage repaired, mast re-fitting, sails mending.  Many people lose their life skills practices because they're not good at getting back on track after an injury, or an illness, or a life change.  Picking up one's physical exercise, healthy eating, Autogenic & Goodwill practice, relationship involvement, and so on, is so important.  Good to do.  If ships leave harbour they are likely sometimes to encounter storms ... just as they'll probably encounter long periods of beautiful weather.  To be a good sailor is to be prepared for and able to deal with (or savour & enjoy) both good weather and bad.

Life's voyage 

This image is downloadable both as a Powerpoint slide and as a PDF file. 

Another issue we revisited in the go-round was the Goodwill practice.  I talked in some detail about this in a blog post about last time's session.  Somebody had been finding that the somewhat Buddhist-derived Goodwill practice just didn't really work for them.  They're a committed Christian and I had encouraged them to come at this more as an intercessory prayer.  They reported back this evening to say how much better this had worked for them.  This led to a discussion about the importance of linking these inner practices to our personal values and beliefs.  I talked about a very traditional elderly minister who came to one of my Autogenic Training classes many years ago.  He was very doubtful about the whole procedure but bravely went through the training.  At the end he generously said "They should teach these kinds of skills in theological college".  I personally am not a member of any particular religious group, although during my lifetime I've spent a fair amount of time in monasteries, ashrams and other retreat centres.  I do however strongly encourage people to adapt their Autogenic/Goodwill practice to link with their personal values & beliefs.  This seems to have so many advantages - including increased long term commitment to maintaining their practice.  For Christians I often recommend looking at Anthony de Mello's book "Sadhana ... Christian Exercises in Eastern Form" and for Buddhists I suggest the series of books by Jack Kornfield.

 More to follow ...

 

M: Life skills for stress, health & wellbeing, session 12

Yesterday we had the twelfth & final session of this "Life skills" evening class.  There was scheduled to have been a bit less than a three month gap since the last - eleventh - session.  However the heavy winter snow we'd experienced had resulted in this last session being postponed.

Pain assessment & information 2

This section

Pain assessment & information

For many years my work split fairly evenly between helping people with psychological difficulties and helping people with pain problems.  Quite a few people were troubled with both.  In the last several years I have done much less work with pain, although I still see some people for overall pain management.  This has been partly because I was trying to keep up-to-date with too many fields, so stepping back from pain work made sense.  It has also been partly because the flourishing of research into happiness & wellbeing has fascinated me and taken up time.  Here are a collection of pain-associated assessment and information sheets that I accumulated over the years.  They are obviously relevant for work with pain, and some (e.g. one year symptom diary) can be adapted for work with stress & psychological difficulties. 

IBS severity score & background - this is a scale that was used by Professor Whorwell and his research team in Manchester.

One year symptom diary & background - this one-year-to-a-sheet symptom diary can be used to track a variety of pain and other problems e.g. period symptoms, migraines, intermittent psychological difficulties, etc.  See too the 'background' suggestions for use sheet. 

Four day pain diary - Jensen's work suggests that 12 pain ratings - 3 daily for 4 days - is often a good way of balancing getting an adequate number or ratings with not burdening chronic pain sufferers (and clinicians) with unnecessary data collection.  This has probably been the pain diary I have used most frequently. 

One day pain diary - I occasionally have used this more fine-grained one day diary to look at hour to hour variations in pain.

One week pain diary - sometimes useful, for example if there seems a difference between weekend and weekday ratings.

Two week pain diary - I include this for completeness, but I probably used this two week diary least frequently over the years.

Pain diagrams, headfront & back - getting pain sufferers to draw/colour in where they feel pain or other unpleasant sensations e.g numbness, burning, etc, can be hugely useful in understanding and helping their difficulties.

Oswestry disability questionnaire - classic low back pain assessment questionnaire that's been around for many years.

Northwick Park neck questionnaire - neck pain questionnaire, somewhat of the Oswestry style.

Copenhagen neck questionnaire - good neck pain disability questionnaire.

Shoulder disability questionnaire - "as it says on the tin", a questionnaire to assess and monitor shoulder disability.

Knee painhip pain assessment forms and scoring - classic knee & hip pain/disability assessment questionnaires.

Low back pain, general information - I wrote this information sheet a good few years ago now, but it is still contains much that is of potential use.

Fear-avoidance & CBT approach for catastrophising - four Powerpoint slides on pain fear-avoidance loops and CBT approaches that may help.

Migraine & headache, general information - as with the low back pain information sheet (see above), I wrote this a number of years ago - but it still contains much that's of use.

Migraine & sleep hygiene - fascinating study showing major reductions in migraine duration & frequency by targeting sleep improvement.  Well worth considering!

Coping with persistent pain CD - this is a recording I made quite a while ago.  Again it still has some useful ideas on it.  It is marketed via the charity, the British Holistic Medical Association.

 

Relationships in general

Relationships are right at the heart of human health and wellbeing.  The first four sets of handouts listed below highlight the increased death rates, poorer psychological health and lowered wellbeing in those with worse relationships.  There is a rather confusing plethora of different questionnaires for assessing relationship networks.  I like the large amount of helpful information one can elicit from the "Personal community map" and associated sheets (below).  Sheldon Cohen has argued convincingly that social intimacy, social integration, and social conflict all make independent contributions to our health and wellbeing - we want higher scores for intimacy & integration and (usually) lower scores for conflict.  The community map overall question sheet and the associated brief three question current activities scale help look at all three of these important relationship components.  I use this map to identify both current relationships that can be nourished to increase overall intimacy & integration, and also to clarify when it's important to explore how to add new relationships (& new names onto the map). 

The "Relationship questionnaire" is a further way of assessing these components.  Other examples of quite widely used questionnaires are the "Social adjustment scale", "Significant others scale", and "Relationship table" (see below).  When we look at arguably the two best validated psychotherapies for depression - CBT and IPT - it appears that Interpersonal Psychotherapy focuses on relationships while Cognitive Behavioural Therapy focuses on thoughts and behaviours.  It's not so simple, and there's research suggesting CBT therapists may get better results when they too pay more attention to interpersonal factors.  

Besides these ways of taking an overview of someone's social network, I also regularly assess interpersonal style.  Usually I'll use one of the several versions available of the Inventory of Interpersonal Problems - see the "IIP-48" below.  Often helpful too in understanding interpersonal style are the attachment questionnaires on the Good Knowledge page "Relationships, couples, families & psychosexual" which also lists many other handouts & questionnaires on couples, families, children, abuse, sexuality and related areas.  Further handouts listed below are a couple on "Development & maintenance of distressed states" which can be useful when orientating people to the various parts played by relationships in producing their current state.  There are further information sheets too clarifying the interplay of life events and genetic vulnerability in depression onset, the relevance of abuse, trauma & loss, and the important "Traumatic grief scale".

There are a series of handouts on assertiveness, conflict and authenticity.  There is also one on the costs of excessive self-concealment.  There are also very useful handouts & questionnaires on relationships & wellbeing in the sequence on Self-Determination Theory (SDT) lower down the page on "Wellbeing, time management & self-determination" and in the sequence on coping survey questionnaires & the significant others list on "Depression, CBASP & neuroscience".  Clicking on the tag "Relationships" will link you through to lots of further information and research on relationships also on this website.  Additionally you can go to the "Tag cloud" and search on various other terms like "Bereavement", "Couples", "Family", "Friendship", "Mothers" and so on.    

"Strong relationships increase survival as much as quitting smoking" is a blog post about the extremely important paper "Social Relationships and Mortality Risk: A Meta-analytic Review".  The post is downloadable as a PDF file handout "Relationships & mortality"

Relationship background facts, Powerpoint handout - slides 1-6 illustrate the reduced risk of earlier death for those with better relationship networks and slides 7-12 (although rather dated) illustrate some of the psychological benefits of good relationships both for stress resilience and for wellbeing. 

Relationships are important for our health - I wrote this information leaflet a longish time ago, but it still makes very relevant points. 

Psychological needs & wellbeing 1, Psychological needs & wellbeing 2 (SDT) - I use this handout a lot to introduce discussions on wellbeing and the importance of responding to our key basic psychological needs for Autonomy, Competence & Relatedness.  Try printing them out as a two-slides-to-a-page Powerpoint handout.  For lots more on Self-Determination Theory see the handouts lower down the page at "Wellbeing, time management & self-determination".  

Personal community map - this chart is a helpful way of encouraging people to begin describing their relationships.  It may take an hour or so to fill in properly, but it can then provide a major focus for subsequent therapy.  When handing out this chart, also give the instructions and questions sheets (see below) 

Personal community map instructions - these instructions go with the "Personal community map" (above), explaining how to fill the chart in, and giving background information. 

Personal community map questions - I ask people to answer these questions as they fill in, and after they've filled in, their personal community map (see above).  Their answers help to clarify what they probably need to do to continue building personal relationships that promote health, stress resilience, and wellbeing.

Personal community map activities scale - this set of three quick questions helps monitor week to week relationship involvement.  It links with the personal community map exercise above.  It is downloadable both as a Word doc and as a PDF file.  

Relationship questionnaire & scoring - this is adapted from research showing social support, social integration and social conflict all contribute to self-esteem and health.

Social adjustment scale & instructions - this scale (Weissman et al, 1976) is good.  The SAS is well validated, but I now tend to use the more home-made "Personal community map" (above) in preference as I find the latter leads so naturally to good clinical interventions/personal change work. 

Significant others scale - this scale (Power et al, 1988) has been quite widely used to assess intimacy, practical support and social integration with significant others in one's life. 

Relationship table, sheet 1 & sheet 2 & instructions - this is an interpersonal psychotherapy (IPT) derived way of assessing relationships.

IIP-48 questionnaire & score sheet - I use this questionnaires about characteristic interpersonal style a lot.  To paraphrase Alice Miller and others "The walls we build to protect ourselves, become the prisons in which we live."  This assessment tool highlights and helps track changes in our interpersonal "prison walls."  Spikes further out away from the centre of the score sheet chart highlight aspects of our interpersonal style that are causing us particular problems.  Similarly, scores of "3" or "4" in answer to any of the individual questionnaire items may also benefit from therapeutic attention.

Development & maintenance of distressed states - I use this Powerpoint diagram a lot when discussing with people why they are in a distressed state.  It can be helpful in highlighting the importance of maintaining, precipitating and vulnerability factors - relationships may have a part to play in any of these areas.  I also point out that therapeutic gains can be made working with all three of these general sets of factors - for example, emotional processing work for past experience (both precipitating and vulnerability factors) and more standard cognitive-behavioural approaches for maintaining factors.  For a somewhat more heavily relationship-focussed version of this diagram see "Development & maintenance of relationship difficulties".  

Life events, genetics & depression onset, slides 1 & 2, and slides 3 & 4 - I typically print these slides out (in black & white) to produce two A4 sheets of a 2-slides-to-a-page handout.  They make some very useful points - for example the importance of life events (particularly involving relationships) in the onset of various psychological disorders, and the interaction of life events and genetic vulnerability.

Grief, trauma & abuse - here's a five page information handout I put together on grief, trauma & abuse a number of years ago.  It's dated but still contains much that's informative and accurate.

Traumatic grief inventory & background - after bereavement (and other experiences of loss) people often feel anxious and depressed.  Some people may suffer traumatic grief reactions - similar to posttraumatic stress disorder but characterised more by yearning than fear or avoidance.  This can be an important diagnosis to make as effective treatment may well involve other interventions besides more classic approaches to anxiety and/or depression.  This download includes both the questionnaire and some background information and research abstracts.    

Communication scales - a handout from Carkhuff & Berenson's adaption of the classic Rogerian person-centred triad highlighting key interpersonal qualities in close relationships.

Assertiveness diagram - this slide illustrates the simple, but helpful "Don't be a sledgehammer or a doormat" spectrum model of assertiveness.

There are a series of blog posts on different aspects of interpersonal conflict, several of which are also downloadable as handouts - see, for example, "Conflict: not too much, not too little - some research suggestions", "Conflict: not too much, not too little - and how to make it constructive", "Conflict: not too much, not too little - the importance of assertiveness in close relationships" and "Conflict not too much, not too little - insights from game theory".

Honesty, transparency & confrontation - this interesting 3 page handout describes the emotion-focused therapist Les Greenberg's comments on honesty/authenticity in therapeutic relationships.  His remarks however are also very relevant to other close relationships that are basically supportive but sometimes run into difficulties e.g. couples, families, and friendships. 

Self-concealment scale & related references - this is an interesting questionnaire I use occasionally to highlight the health risks of being to "self-concealing" and "private".  It links in with the overall benefits of intimacy and interpersonal trust.  It links too with the importance of clients feeling they can be really open in the therapeutic relationship.

Relationships, families, couples & psychosexual

Here are a series of questionnaires and handouts on couples, sexuality, parenting, attachment, and abuse.  The first sequence of 20 or so handouts are from a two day workshop I run - for more details including downloadable copies of the slides, see the blog post "Psychotherapy with couples & other close relationships".  Listed below these are further relevant handouts & questionnaires.

General couple assessment:  Currently I use five questionnaires at the start of therapy: the PPS, CSI-16, demographic, couple & problem areas questionnaires.  Additionally the PPS & weekly questionnaires are used before each session, the SRS is used towards the end of each session, and the CSI-16 again at the end of therapy.  Communication pattern & perceived criticism scales are of occasional use.

Overview of 5 questionnaires used by Andrew Christensen (Integrative Behavioral Couple Therapy - IBCT - expert) with scoring details: CSI-16, demographic, couple, problem areas & weekly questionnaires (see next four items listed below).  The excellent IBCT website gives access to questionnaires too and other resources.

CSI-16: the couple satisfaction index comes in various lengths; here's the 16-item version which Andrew Christensen uses as a pre/post therapy measure.

Demographic questionnaire: developed by Andrew Christensen, this measure describes basic demographic information about the couple (e.g. age, years together, children, etc.) and will be used in the first session to get to know the couple.

Couple questionnaire: used at the start of therapy to assess three areas - a.) CSI-4 which is also included in the Weekly questionnaire (see below).  b.) intimate partner violence.  c.) commitment to the relationship.

Problem areas questionnaire: again an assessment phase instrument to help in clarifying a couple's main areas of difficulty.

Communication patterns questionnaire - short formcan be useful in assessing conflict tactics.

Perceived partner criticism scale: again can be a useful measure with many couples.

Weekly questionnaire: given to each partner at the end of every therapy session to be completed and brought in for the next session.  The questionnaire tracks couple satisfaction with the CSI-4 and also asks about emerging issues that help to structure the next therapy session.

PPS: personal primary problems scale assesses key issues highlighted by couples themselves.

SRS: the session rating scale (here in NRS rather than VAS format) used towards the end of each appointment to track & (for example if any scores are less than 8) encourage discussion of the therapeutic alliance.  For more on the key importance of this kind of routine outcome/alliance monitoring see the blog post "Psychotherapists & counsellors who don't monitor their outcomes are at risk of being both incompetent & potentially dangerous".

Psychosexual assessment:

Assessment sexual function: ASEX men - the male version of the 5 question Arizona sexual experiences scale can be helpful in assessing and monitoring problems with libido, arousal and orgasm.  

Assessment sexual function: ASEX women - a female version of the scale.

Assessment sexual function: scoring - the scoring sheet gives limited but useful suggestions on assessment.

Assessment sexual interaction: frequency & enjoyment

Further handouts:

Sexual behaviour, attraction & identity results

Relationships & mortality

Attachment, ECR-RS background

Attachment, ECR-RS questions & chart

Conflict, a startlingly effective way

IBCT, 6 key areas

IBCT, 3 categories of intervention

5 principles of couple work

Life events questionnaire (the majority are relationship-related)

Network map & Related questions

Friendship: science, art & gratitude - Blog Post & Handout

Relationship depth - Diagram & Grid

Fredrickson micro-moments practices - and see her linked website complete with free monitoring/tracking tools

Reflection sheets - Day 1 & Day 2

And below are a further series of relevant handouts & questionnaires:

Intimate bond measure scale & scoring handout page 1 & page 2 - this is the scale I use most often when assessing quality of couple relationships.  I often get people to score the IBM both as they are currently actually experiencing their relationship and also as they would ideally like it to be.  Obviously the discrepancies between actual and ideal answers to the various questions provide a potential rich source for discussion and for change intentions.  In couples' therapy it's reasonably straightforward to get both partners to fill in this scale.  Sometimes when working with individual clients, I will ask them to get their partner to fill in IBM for how they experience my client in their relationship.  Sometimes, in more "delicate" situations, I will simply ask my client to fill in the IBM guessing how their partner would score them.  The scoring handouts, I usually print out as 2-slides-to-a-page Powerpoint handouts.  Page 1 provides a useful scoring grid, so that one can see how one scores in comparison to findings from research studies using the IBM.  Page 2 illustrates that staying in a couple relationship, where the care score continues at less than 20, may interfere with recovery from depression.  This latter seems less applicable for melancholic depressions (criteria in second slide on page 2).

Relationship need satisfaction scale - a 9-item scale assessing satisfaction of autonomy, competence & relatedness needs in a chosen relationship such as with a partner, friend, parent, or child.  The scale can also be used for assessing one's relationship network in general.  It's good to be scoring in the upper half of the scale for your averaged scores.  See the Good Knowledge handouts section on Well-being, time management & self-determination for more on this and related scales. 

Relationship need satisfaction background - a handout giving background to self-determination theory and the relationship need satisfaction scale.

Dyadic adjustment scale & scoring - Spanier's Dyadic Adjustment Scale was published in the mid 1970's.  I think it's a bit "creaky" as a questionnaire, but it still pulls out quite a lot of helpful information that can be pretty useful.

Dyadic happiness scale (0 - 6) - Goodwin in a classic paper entitled "Overall just how happy are you?  The magical question 31 of the Spanier dyadic adjustment scale" showed that the very simple question 31 of the original Spanier scale (see above) gave a quick and surprisingly accurate estimate of how a person would be likely to score when taking the much more time-consuming full scale.  It can be useful particularly, for example, when tracking progress week by week during couples' therapy.     

Conflict tactics scale & scoring - this scale is useful when assessing and monitoring conflict (and possibly domestic violence) and attempts to resolve conflict are an important part of the therapy. 

Relationship difficulties, 6 key areas - a sheet with space for notes on six areas considered important to assess in Jacobson & Christensen's "Integrative couple therapy".

Relationships difficulties, development & maintenance - here is a diagram I put together that encourages an overview of relationship difficulties.

Marriage/couples handout, page 1, page 2 & page 3 - this is an 18 slide talk I gave a number of years ago as part of a much larger two day workshop on relationships.  The slides print out fine as three 6-slides-to-a-page handouts.  Slide 6 on page 1 - a chart of typical marital satisfaction across the life cycle - is a diagram I quite often use for "reassurance" both to illustrate how it can be quite a challenge on marriages raising children and how the "empty nest syndrome" may be something of an illusion.

Touch, sex & caring - this two page Word handout is rather dated now, but still makes a series of very valid points.

Sexual behaviour, sexual attraction and sexual identity - this two page handout is downloadable both in Word doc and in PDF format.  Clicking through to the related blog post will give access to a whole series of internet links. 

Sexual interaction inventory - this questionnaire asks about current and desired sexual interactions.  It can be very helpful for couples to complete this and discuss how they have scored it.  It requires a fair amount of openness to do this, but it can be very worthwhile.  This opening-up-the-territory exploration can also be much helped by reading (and discussing) good books on sexuality such as the well known "Guide to getting it on" by Paul Joannides, about which one reviewer commented "It's fair to say that no matter what your level of sexual experience is, or how much of a great lover you might think you are, this book is guaranteed to put a smile on your face - and perhaps someone else's." 

IIEF-5 scale & scoring (men) - this is the 5 question version of the International Index of Erectile Function - useful for assessing and monitoring change in ability to achieve and maintain erections.

IC & BS exercises - this is an interesting set of pelvic floor muscle training exercises that can be used to help treat erectile dysfunction non-pharmacologically.

Sensate focus exercises, introduction - this introduction to sensate focus exercises for sexual problems is taken from Greenwood & Bancroft's book "Counselling for sexual problems".  I put together this handout when I did a psychosexual training a number of years ago.  There are a series of more recently published books on sexual problems that it may be worth looking at.  Examples include Ford's "Overcoming sexual problems" (which describes sensate focus and other exercises well), the related book by Crowe "Overcoming relationship problems", and the McCarthys' "Rekindling desire".

Sensate focus exercises, instructions, exercise one, exercise two, exercise three, exercise four, exercise five, exercise six - practical behavoural interventions for sexual problems make very good sense.  It's very important not to get caught into only talking about difficulties.  In a similar way though, in my experience as a therapist, it's also very important to take time to make time to discuss sensitively and encouragingly issues that are triggered by working with the exercises ... and not to apply the exercises in too much of a one-size-fits-all kind of way.  Here Vicki Ford's book (see above) is probably well worth getting hold of.  Even in our so-called liberated age, most couples feel cautious about discussing sexual issues.  Many couples never openly discuss sex in any kind of detailed way.  It's not surprising.  This is tender territory where it's easy to end up feel misunderstood or hurt.  It's also important territory, where discussion and problem-solving can be tremendously helpful.

Parental bond measure scale & scoring handout - here is another scale (like the Intimate Bond Measure at the top of the page) that I use a lot.  Typically this use falls into one of two areas.  One is in assessing the quality of parenting a client has experienced earlier in their life.  This can be very helpful and it's often important to emphasise that it's fine that this is simply the client's subjective memory of their childhood experience rather than some unachievable recording of what precisely took place.  The point is that it is subjective remembered experience that correlates with subsequent effects in us as adults - so it is precisely scores on scales like the PBI that we are interested in.  Quite often clients feel "guilty" for negative scores they may give their parents.  Part of the therapeutic work is in emotionally processing these feelings, so that we can move on as adults.  The second main area where I find it helpful to use the PBI is in assessment of a client's (or our own) behaviour as parents.  We can guess - often pretty accurately - how our child would score us.  Sometimes we may even ask an older or grown up child to score the questionnaire about us.  It's then fascinating to ask them to score how they actually experienced us and how they would ideally like it to be/have been - again providing targets for clarification and change work.  Obviously we need to be cautious about potentially setting up parent-child conflicts (or dishonesty) here, but if carefully managed this kind of assessment can be great - quite often in the surprise and joy experienced by a parent when their child actually scores them much better than they'd feared.

Parents & children handout, page 1 & page 2 - here are 12 slides from a talk on parenting I gave a number of years ago.  It was part of a much larger two day workshop on relationships.  The slides print out well as two 6-slides-to-a-page handouts.

Attachment, compassion & relationships - this is a handout version of a blog posting introducing ideas about attachment and the possibility of working to change attachment style using forms of imagery and meditation.

Assessing attachment in adults - another handout version of another blog posting, this time discussing assessment of attachment in adults. 

Relationship questionnaire - a quick adult attachment assessment questionnaire developed by Kim Bartholomew.  Useful in introducing four key attachment categories, but less "accurate" than the ECR-R below.

Experiences in Close Relationships - Revised (ECR-R) - this questionnaire (and the related ECR) are currently (2009) probably the best self-report assessment instruments for attachment in adult close relationships.

ECR-R scoring chart - here is a chart onto which one can position scores from the ECR-R questionnaire (see above).  The Powerpoint version is a little clearer, but here also is a Word version.

Abuse screening, child/adult & sexual/physical - here is a helpful brief screening scale for both child & adult experiences of sexual & physical abuse.

Adverse childhood experiences (ACE) scale & background - Adverse experiences in childhood and adolescence are common.  In a major US survey of 7 adverse experiences - psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned - over half those surveyed reported at least one such experience in childhood, and about 25% reported two or more such experiences.  Increasing numbers of such experiences in childhood and adolescence is associated with step by step increases in the subsequent adult risk of suffering from depression, alcohol abuse, smoking, obesity, risky sexual behaviour, suicide, heart disease, skeletal fractures,  liver disease, chronic lung disease, and cancer.  Identifying and helping adults at risk because of such childhood experiences should be a health priority.  For more details of the ACE study and the 30 or more research papers published, see www.cdc.gov/nccdphp/ace

 

Sleep, ADHD & fatigue

This section contains handouts, questionnaires and information sheets about sleep, ADHD, and fatigue.  The sleep handouts are mostly based on Colin Espie's excellent self-help book "Overcoming insomnia and sleep problems" and the intention is that the handouts would be used in conjunction with this book - see the bottom of the page for more details.  The Pittsburgh Sleep Quality Index is an alternative way of assessing severity of sleep problems and tracking progress - it is more convenient than assessment with a sleep diary but less accurate. 

Pittsburgh sleep quality index (PSQI) - the PSQI asks the subject to look back over the last month and assess various aspects of their sleep.  It is unlikely to be as accurate as a two week sleep diary (see below), but it is a convenient measure as it can be done "on the spot".  The PSQI is copyrighted by Daniel Buysse - see his paper "The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research".  Permission has been granted for clinicians to use in their practice and for researchers to use in nonindustry studies. For other uses of the scale, the owner of the copyright should be contacted.

Sleep diary and instructions - a key component of Espie's CBT programme is the use of this weekly diary form to both assess the sleep problem initially and then monitor progress.

Sleep diary, measuring progress - this is a form that can be helpful when measuring overall progress using information from the sleep diaries.

Sleep advice - fairly standard general advice about improving sleep. 

Sleep stimulus control - this and sleep restriction (see below) are probably both the most challenging and the most useful components of a CBT approach for insomnia.  

Sleep restriction therapy - see above for comment on the central importance of this method.

Sleep personal history - Colin Espie's suggestions for questions that it's helpful to consider when assessing insomnia.

Sleep other disorders - again a set of helpful diagnostic reminders when considering other important causes of sleep difficulty besides classic insomnia.

Sleep CBT programme overview - an overview of key points in Espie's CBT approach for insomnia.

Sleep average needs with age - suggestions for average sleep needs at different ages. 

Sleep contents of thoughts - the Glasgow Contents of Thoughts Inventory (GCTI) looks at the kinds of thoughts that may interfere with getting to sleep.

ADHD - ASRS checklist - a World Health Organization screening questionnaire for adult Attention Deficit Hyperactivity Disorder.

Epworth sleepiness scale (ESS) - is a way of assessing the likelihood that somebody will doze off in a variety of situations.  The ESS is copyrighted by Murray Johns - "A new method of measuring daytime sleepiness: the Epworth Sleepiness Scale".  Permission has been granted for clinicians to use the ESS in their practice and for researchers to use it in non-industry studies. For other uses of the scale, the owner of the copyright should be contacted.

Fatigue severity scale - one of the two fatigue questionnaires that I use.

Tiredness questionnaire - the fatigue assessment questionnaire I most commonly use. 

 Espie, C.  (2006)  "Overcoming insomnia and sleep problems"  London: Robinson.  [AbeBooks]  [Amazon UK]

 

Wellbeing, calming & mindfulness skills

Here are a bunch of handouts that I use largely in the territory of wellbeing, mindfulness and relaxation.  Some are assessment and monitoring questionnaires.  Some provide orientating information.  Some describe specific exercises to do.

Bus driver metaphor (available as both Word and PDF handouts) - this is a classic ACT (acceptance & commitment therapy) metaphor.  I've posted a blog post on this often helpful way of viewing things.  It's sensible though to also understand possible limitations of this metaphor

Acceptance & action questionnaire - this is a widely used 9-item ACT measure of one's ability to "accept" difficult experiences and still "act" effectively.  It is available both as a Word document and as a PDF file.

"Naming emotions is another useful self-regulation & mindfulness strategy" - like mindful 'acceptance' and reappraisal, naming/labeling emotions is another useful strategy.  This blog post explains why and links to downloadable Word doc & PDF handouts.

Attention, focus & time - this is a Powerpoint slide that I put together and use as a printed-out handout when discussing what we spend our time paying attention to, and how certain forms of attention focus are likely to be more helpful than others.

Four aspects of inner focus - this is another Powerpoint slide I print out to illustrate some overlapping aspects of mindfulness, meditation, relaxation, self-hypnosis, and other related practices.  Here is the same diagram as a Word document, as well as a slightly adapted version and a component version as further Powerpoint slides. 

Savouring, mindfulness & flow - a simple slide illustrating overlaps and distinctions between these three forms of attentional focus.

Transdiagnostic wellbeing therapy - I put this Powerpoint picture together in a rather tongue in cheek way in a discussion with Tom Borkovec.  Despite its quite light-hearted origin, the diagram makes some useful points. 

Ryff definitions and background - Carol Ryff and colleagues have spent many years developing and testing a multi-dimensional model of wellbeing.  The Ryff definitions handout is a sheet describing their six important components of wellbeing - self-acceptance, positive relationships with others, autonomy, environmental mastery, purpose of life, and personal growth.  The background download is a personal communication from Carol Ryff back in about 2000 giving details of the full 20 item scales and the many associated research papers.  

Ryff 3 item screening scale - I use this 3-items-for-each-of-Ryff's-6-wellbeing-components questionnaire as a screen to help clarify what aspects of wellbeing an individual might most usefully focus on.  Typically I would suggest working on components with the biggest ideal/actual discrepancies. 

Ryff 14 item scales: autonomy, environmental mastery, personal growth, positive relationships, purpose in life, and self-acceptance - I would usually focus work on the one or two wellbeing components highlighted by general discussion and the initial 3 item screening questionnaire (above).  I then move on to using the relevant 14 item Ryff scales to assess and track progress when we work on these selected components.

Satisfaction with life scale and background - this is Ed Diener's famous and very widely used Satisfaction With Life Scale (SWLS).  I've also included background details interpreting the scores and providing links.  If you'd prefer to download these handouts as PDF's (rather than Word docs), then here's a SWLS PDF and here a background PDF.  

Diener & colleagues have also published helpful short scales for assessing "Flourishing" and "Positive & negative experiences".  These seem good.  For more details and downloads see the post "Two new, easily usable scales for assessing wellbeing"

Positive & negative affect schedule (PANAS) - the PANAS too is widely used in wellbeing research.  Many researchers have used an amalgam of the SWLS and the PANAS to get a wellbeing measure - adding the SWLS & positive affect PANAS scores ("proud" is treated as a positive affect in the PANAS) and subtracting the negative PANAS score.

Oxford happiness inventory (adapted) - this is the slightly truncated Oxford Happiness Inventory (OHI) used in Sonja Lyubomirsky fine book "The How of Happiness".  It makes good sense to use this truncated form as the full version tends to tap into assessing mania as well as "happiness".  The OHI, like the Ryff scales, adapts well to setting specific change targets after assessing the gap between one's actual and ideal scores.

Process visualisation slides 1 & 2 and slides 3 & 4 - I print these out as 2 slides to a page handouts.  Slide 4 highlights the actual exercise, while slides 1 to 3 provide some background.

Gratitude & appreciation record, suggestions and miniatures - this is a delightfully simple and potentially very helpful happiness-boosting intervention.  The miniatures can be printed out as a six slide to a page Powerpoint handout providing background information.  The suggestions sheet explains how to do the exercise, and the record sheet is filled in as one follows these instructions.  I believe humans (and many other animals) tend to take fairly static aspects of their environment for granted.  I suspect this has adaptive survival advantages in hunter-gatherer environments.  Part of the cost is the hedonic treadmill where we rapidly take for granted precious every day facts - our ability to function, our relationships, the beauty of nature, the taste of food, so many things.  As has been said "We tend to only notice the really important things in life when they're gone."  This gratitude noting exercise readjusts the thermostat of our appreciation.  It will probably then slide back and may benefit from being readjusted by doing this exercise for a week every month or some other regular reminder.   

Coming to our senses -  a nice little awareness exercise.  I think I picked this up year's ago when reading some work by Milton Erickson.

Relaxation response - a diagram I use when I'm teaching "calming skills" and starting off with a focus on learning to elicit the "relaxation response".

What progress can you expect? - here's a handout I often use when I start teaching somebody "calming skills".  The aim is to encourage them to link to what they already know about the time and effort needed to learn any worthwhile new ability.

Dealing with mental chatter - this is an orientation sheet providing one way of looking at the huge challenge of "paying attention" or "mindfulness".

Attention & mind-wandering - these print out as a 6 slides to a page set of Powerpoint miniatures.  They illustrate why I tend now to emphasise a little bit more concentrative "effort" in the initial stages of a mindfulness or relaxation exercise than I used to before coming across this work. 

Mindfulness assessment (MAAS), diary, and background - the Brown & Ryan developed MAAS is a fairly unidimensional measure of mindfulness.

Five facet mindfulness questionnaire - full/long version (FFMQ) is downloadable as a Word doc and in PDF format.  Ruth Baer et al's FFMQ is a more multidimensional mindfulness measure.  I've also shrunk it down to an abbreviated three facet version (TFMQ) for my work with some people (this was done before the FFMQ-SF became available - see below).  The TFMQ download contains a fair amount of background orientating information as well.

For more about both the full FFMQ and the short form FFMQ-SF, see the blog post "A better way to measure mindfulness".

Five facet mindfulness questionnaire - short form (FFMQ-SF) - the short form of the FFMQ has only 24 questions compared to the full form's 39 (an approximately 40% reduction in length).  It is well validated (see Bohlmeijor et al, 2011) and is downloadable both as a Word doc and in PDF format.

Practice records: relaxation month, relaxation week and mindfulness week - these scales can be used to track how relaxation (and mindfulness) practices are going.  If I'm teaching these skills, it can be very useful to see the trainee's practice records - for trouble-shooting any issues that are emerging.  The cd or ncd column simply indicates whether the trainee used a practice CD or not.