Last Spring, I went walking and camping in Glen Affric.  Amongst other things, being away on my own in the hills gave me a chance to think creatively.  Once I was back I wrote a blog post about developing a next generation stress management course.  I said "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 the broader overview ... probable ingredients for the course - besides the relaxation/mindfulness exercise - 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.  I'm looking forward to it!" 

Well I've finally put something together and hope to run the first new-look "Lifeskills for stress, health & wellbeing" course later this Spring:

Here are a set of handouts and questionnaires that I often use when I'm running interpersonal process groups.  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.  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 support, group therapy, and so on.  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 encourage would-be course participants to complete when considering when 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 belief/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.  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.

This post describes the "Needs, beliefs & behaviours" diagrams, best viewable on screen in PDF format (slides 1 & 2 and slides 3 & 4), but also downloadable in Powerpoint format (slides 1 & 2 and slides 3 & 4).  The post below is downloadable as a Word format handout. 

introduction:  The needs/beliefs/behaviours model can be useful in many situations.  Primarily it helps makes sense of how we feel, think and act in our lives.  It explains different forms of adaptive and maladaptive behaviours, why they have arisen, and what can be done to put them right.  Life, of course, is much more complex than any model - the countryside is richer and much more fascinating than any map.  However maps help us to find our way, to explore, and to get to where we want to go.  This needs/beliefs/behaviours map is a good one.  I hope it helps you on your journey.  

basic needs & the five behavioural systems:  Living organisms flourish when their needs are met.  It makes good sense, from the point of view of evolutionary psychology, that we are pre-programmed with behavioural systems that help us meet these basic needs to survive and to  reproduce.   The researchers Phil Shaver and Mario Mikulincer describe five behavioral systems that they have studied so far - attachment (care seeking), care giving, exploration, sex and power.  They argue that each of these systems is activated by appropriate external (or internal) circumstances.  It's a bit like using different computer software programmes depending on the specific task one is facing - for example word processing, slide preparation, database management, and so on.  In a similar way, the care seeking attachment system is activated by threats to safety, the care giving system comes on line when one is drawn to provide support and encouragement, the exploration system acts to learn about external and internal experiences, the sexual system is orientated to promote sexual activity with a desirable other, and the power system competes for and protects valued resources.  For more on this see the handout & blog post "Behavioural systems: attachment (care seeking), care giving, exploration, sex, & power" . 

Although I have described these five systems as being like a set of different programmes making up a suite of computer software, they can be conceptualised in other helpful ways too.  Another good metaphor is of the five behavioural systems as members of a musical quintet - say a jazz quintet.  We want each of the systems - each jazz player - to be able to play excellently.  Sometimes a player will have a solo, but mostly there are blends of several instruments playing together.  So a conversation between friends can be seen as ‘music' involving a shifting blend of care seeking, care giving, and exploratory systems - possibly with sexual and power systems putting in occasional appearances as well!  Even an interaction as apparently straightforward as a conflict or a sexual experience will usually not just involve the power or sex behavioural systems.  Exploratory, care giving and care seeking systems are also likely to join the music.

Some "blends" may be particularly powerful or functional styles of music.  So in relationships, the person-centred triad (that I often think of as a hopefully well-balanced three-legged stool) of authenticity, caring and empathy is a rich blend of potentially all five behavioural systems.  In a similar way self-determination theory's model of three meta-needs (autonomy, competence and relatedness) can inform and be informed by these five basic systems.    

toxic beliefs & dysfunctional behaviours:  Ideally, as we grow up, our five behavioural systems learn to function very well - coming on line when the appropriate external or internal situation occurs, operating to a successful outcome, and then going off line again.  Unfortunately it's probably very rare for someone to grow up only experiencing excellent learning environments and interacting with people - parents, siblings, teachers, friends, school - who encourage them to ‘play' the different behavioural systems appropriately and well.  What then happens - in these poor learning situations - has probably been best researched with the care seeking (attachment) system.  See, for example, the handout & blog post "Attachment, compassion & relationships".  The successful, so-called, secure-base attachment script runs something like "If I come across difficulties, I can seek comfort and support from significant others, this will be provided, I'll feel better and be able to go back to other activities soothed and confident."  If in key attachment relationships this primary attachment strategy is repeatedly unsuccessful in eliciting understand-ing, care and encouragement, people then develop internal working-models of self and others that are much less confident or trusting.  They will increasingly be likely to develop so-called secondary strategies involving hyperactivation (fight) or hypoactivation (flight) of the basic programme.  With the care seeking attachment system, hyperactivation leads to unproductive worry, vigilance to signs of rejection, and excessive demands (anxiously attached), while hypoactivation involves strong emotional inhibition, self-reliance and emotional distancing (avoidantly attached).

Mikulincer & Shaver propose that all five of the behavioural systems they have studied have primary strategies for attaining their key goals of security, safety provision, exploration, sexual activity, and power.  They further propose that when these primary strategies have been repeatedly thwarted during an individual's early development and subsequent life experience, then there is a tendency to switch to secondary strategies.  Again for all five systems these secondary strategies are likely to involve either hyperactivation (intensify the system's primary strategy) or hypoactivation (suppress or down-regulate the primary strategy).  The authors have developed and tested assessment questionnaires for all five behavioural systems and are continuing their expanding research programme.  See, for example, the handout & blog post "Assessing attachment in adults".   Other forms of assessment that can be helpful here include the "Adverse childhood experiences questionnaire", the "Parental bond inventory", and the "Intimate bond measure".  These two latter scales - PBI and IBM - clarify the success of our care seeking system and, if our children or partner complete them, also the success of our care giving system.  The "Early maladaptive schemas" descriptions, the "Inventory of interpersonal problems", and the "Personal community map" questions all also throw light on how well our basic behavioural systems are achieving their goals.

It's fascinating to consider the relevance of these ideas to so many areas - for example, burnout/compassion fatigue, overintrusive caring, agoraphobia/phobic avoidance, procrastination/perfectionism, sex addiction/promiscuity, hypoactive sexual desire, lack of assertiveness, and bullying/domestic violence/aggression.  These ideas don't dictate therapy, but they can certainly usefully inform therapy. 

healing, psychotherapy & personal growth:  So what happens when - largely because of poor learning experiences - aspects of our basic behavioural systems don't function as well as we would want them to.  It often seems helpful to work at all three corners of the needs/beliefs/ behaviours diagram.  It can be good to contact and validate our needs for care seeking, care giving, exploration, sex, and power.  This links with healthy primary emotions that direct and activate us to get these needs met.  See the handout "Emotions, arriving & leaving" for a simple way of conceptualising this - and for highlighting the distinction between healthy primary emotions and toxic secondary emotions & beliefs that we have been brainwashed into through bad learning environments.  And see too "Emotions, awareness & regulation" to illustrate the value of feeling our emotions so that we can be informed & energised, but not swept away.

New life experiences can give us better learning opportunities - for example a responsive, caring, encouraging partner, teacher, boss or friend.  Therapeutic relationships, one-to-one or in a group, can also help in this way.  Observing healthy behavioural systems in action is good.  And sometimes more direct work on toxic beliefs may be very useful.  From a cognitive therapy perspective this may involve trauma work.  Methods from emotion-focused therapy and schema work - such as dialogue techniques - can also help a lot.  And there's a place too for incorporating ideas from self-criticism/self-compassion therapies. 

A focus on new and healthier behaviours can be crucial too.  Behavioural activation methods and behavioural experiments come into their own here.  So too does value-directed action and mindfulness.  In a way this is ‘sacred' work or - like gardening - it's weeding, providing support, nourishing, and celebrating the new growth as it comes.

This blog post is also downloadable as a Word format handout. 

The cover picture on January 16th's British Medical Journal is of a blazing sun with the words "Vitamin D deficiency" underneath it.  Inside there is a major review by Pearce and Cheetham entitled "Diagnosis and management of vitamin D deficiency".  They have looked at all English language articles that they could identify on vitamin D.  Their conclusion is "Vitamin D deficiency and insufficiency are common in the UK.  Health professionals have been slow to respond to this problem even though the issue has been highlighted in the literature for a number of years ... vitamin D insufficiency now seems unequivocally linked to several ... common and morbid conditions. Local initiatives have been implemented to address this issue, but the high number of patients presenting with symptomatic vitamin D insufficiency highlights the fact that we have some way to go. A change in UK public health policy is long overdue."

They point out that "A recent nationwide survey in the United Kingdom showed that more than 50% of the adult population have insufficient levels of vitamin D and that 16% have severe deficiency during winter and spring.  The survey also demonstrated a gradient of prevalence across the UK, with highest rates in Scotland, northern England, and Northern Ireland."  The first point in their text box highlighting "Tips for the non-specialist" states "Suspicions regarding a suboptimal vitamin D status in someone at risk are likely to be correct."

The key concern is that such widespread deficiency is not just an issue for our bone health.  Again quoting the article "Several observational studies have shown that vitamin D insufficiency, although not enough to cause symptomatic bone and muscle disease, is associated with an increased risk of mortality and of several common diseases including cardiovascular disease, type 2 diabetes, bowel cancer, breast cancer, multiple sclerosis, and type 1 diabetes. An expert consensus is developing that optimal vitamin D status, reflected by optimal calcium handling and best health, is when serum concentrations of 25-OHD are 75 nmol/l (30 µg/l) or more." 

Over 90% of humankind's vitamin D supply is derived from ultraviolet B sunlight exposure but, as Pearce & Cheetham point out "Unfortunately, for six months of the year (October to April), all of Scandinavia, much of Western Europe (including 90% of the UK), and 50% of the North American landmass lie above the latitude that permits exposure to the ultraviolet B wavelengths necessary for vitamin D synthesis, leaving millions of people reliant on exogenous sources of vitamin D."  These "exogenous sources" include artificially fortified foodstuffs (some breakfast cereals, margarines, and infant formula milk), oily fish, and egg yolks.  So there aren't many food sources.  Supplementation is a good option for many people. 

The article suggests one classify vitamin D status from the easily testable serum level of 25-hydroxyvitamin D concentration as a.) <25 nmol/l, status deficient, manifestation rickets & osteomalacia, treat with high-dose calciferol.  b.) 25-50 nmol/l, status insufficient, associated with increased disease risk, treat with vitamin D supplentation.  c.) 50-75 nmol/l, status adequate, give lifestyle advice.  d.) >75 nmol/l, status optimal, no additional management needed.

For deficiency, Pearce & Cheetham recommend adults be treated with 10,000 IU calciferol daily or 60,000 IU weekly for 8-12 weeks (to convert IU to micrograms, divide by 40).  Children need a different dosing regime.  For insufficiency - or maintenance therapy after deficiency - they recommend adults continue to take 1,000-2,000 IU calciferol daily or 10,000 IU weekly.  Again for infants & children they recommend a different regime depending on age.  Clearly these recommendations aim to keep people at optimal vitamin D status with their 25-OHD level >75 nmol/l.

For more detail and access to free full text information, see the blog post I wrote back in the autumn of 2008 "Vitamin D - time to take action".

Last month I blogged about exercise safety in "Exercise 1: checking it's safe to start", about the helpful GPPAQ - General Practice Physical Activity Questionnaire - described in "Exercise 2: UK Department of Health, resources for assessment & advice", about the excellent advice on how to exercise in "Exercise 3: US Department of Health & Human Services, resources for assessment & advice", and about "Exercise 4: pedometers can help us walk more".  Last week I posted the 5th in this series with "Exercise 5: the recommendation to do strengthening exercises".  Today's post is the 6th and last of the sequence - here I want to talk a little about where to exercise, what choices are available, and broader national & international exercise-relevant links.

The internet is a great resource for this kind of detective work.  Resources like "Meetup.com" are a good place to look for others who might be interested locally in forms of exercise you would like to participate in. 

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 Scottish walking group.  All these websites have good links to networks of other useful exercise-related resources - for example "Cycling Scotland", "JogScotland", the National Outdoor Training Centre "Glenmore Lodge" (a particular favourite of mine), and the "Physical Activity & Health Alliance".

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".

I read a lot of research.  When I find an article of particular interest I download it to my bibliographic database - EndNote - which currently contains nearly 14,000 abstracts. 

Every few weeks I scan through all the articles I've found interesting in the previous month (in the general areas of stress, health & wellbeing) and then filter them into three narrower, more specific mailings.  One is to the communal email list of the British Association for Behavioural & Cognitive Psychotherapies (BABCP).  This set of abstracts focuses particularly on cognitive therapy in its many applications (anxiety, depression, psychotic disorders, etc).  Click on BABCP mailing to see the 30 papers (mostly from January journals) that I recently sent out.

A second mailing is to various people involved with Depression Alliance Scotland (DAS).  DAS is the only Scottish-based charity specifically working for people with depression who live in Scotland.  I've been on their Clinical Advisory Board for some years.  These abstracts focus more on depression and many are about antidepressant medication as well as others which overlap with the BABCP mailing on psychotherapy.  Click on DAS mailing to see the 9 papers recently sent out.

The third mailing is to the editor of the British Holistic Medical Association (BHMA) newsletter.  Back in the early 1980's I was on the working party that set up the BHMA.  I'm not much involved with them now - partly because many of their original objectives have been achieved and are now mainstream.  This month's BHMA mailing contains 40 abstracts covering wellbeing, dietary supplements, obesity, health in 85 year olds, couples, workaholism, alcohol abuse, diet & depression, and more.

This post is also downloadable as a Word format handout. 

I blogged a couple of weeks ago on "Exercise 3: US Department of Health & Human Services, resources for assessment & advice" and quoted the fine 2008 "Physical activity guidelines for Americans" with its recommendation that - besides regular 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 wanted to write about what specific exercises one might do to strengthen these major muscle groups but - before I do - I would also like to comment on a research finding that isn't that widely known.  Many, maybe most, people know that aerobic exercise reduces mortality risk to a large extent because it helps keep our hearts in good shape.  How many people know that increased muscular strength is also - and independently from aerobic fitness - associated with reduced risk of death?  So back in 2002 Tanasescu et al reported that "Men who ran for an hour or more per week had a 42% risk reduction (cardiovascular) compared with men who did not run. Men who trained with weights for 30 minutes or more per week had a 23% risk reduction compared with men who did not train with weights."  Buchman et al, looking at an older population, found that muscular strength was associated with reduced all cause mortality and commented "These results were similar when men and women were analyzed separately."  More recently still, in a large study following over 8,000 men, Ruiz & colleagues reported "Muscular strength is inversely and independently associated with death from all causes and cancer in men, even after adjusting for cardiorespiratory fitness and other potential confounders." and in a still more recent paper focusing on cancer they found "Higher levels of muscular strength are associated with lower cancer mortality risk in men, independent of clinically established measures of overall and central adiposity, and other potential confounders." 

Fascinating.  In his 2006 paper "The underappreciated role of muscle in health and disease", Wolfe writes technically but interestingly "Muscle plays a central role in whole-body protein metabolism by serving as the principal reservoir for amino acids to maintain protein synthesis in vital tissues and organs in the absence of amino acid absorption from the gut and by providing hepatic gluconeogenic precursors. Furthermore, altered muscle metabolism plays a key role in the genesis, and therefore the prevention, of many common pathologic conditions and chronic diseases."  Muscle tissue is good for our bodies metabolically and also it simply helps us function better.  See for example Rantanen et al's study "Midlife hand grip strength as a predictor of old age disability" or O'Reilly et al's "Quadriceps weakness in knee osteoarthritis: the effect on pain and disability" or Young & Dinan's report that "Even healthy elderly people lose strength at a rate of some 1-2% a year and power at a rate of some 3-4% a year ... The resulting weakness has important functional consequences for the performance of everyday activities. In the English National Fitness Survey, nearly half of women and 15% of men aged 70-74 years had a power to weight ratio (for extension of the lower limb) too low to be confident of being able to mount a 30 cm step without a hand rail."

Besides effects of strength on mortality risk and daily functioning, it's well worth noting that strength training seems (on current evidence) to be as effective as stamina training for treatment and prevention of stress, depression and other psychological symptoms.  The recent "SIGN guidance on non-pharmaceutical management of depression" is clearly positive about the benefits of exercise and specifically mentions both aerobic (e.g. walking & jogging) and anaerobic (e.g. weight training) forms.

Being aware of this kind of research emphasises the good sense in following the 2008 US guideline's recommendation " ... on at least two days per week ... 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."  But what exercises should one use to do this?  If you want to be really technical, you can have a look at the freely downloadable "position stand" from the American College of Sports Medicine (ACSM) "Progression Models in Resistance Training for Healthy Adults".  They also produce a series of books - for example "ACSM's guidelines for exercise testing and prescription".

For a more readily practical book on muscle strengthening, it's easy to get lost amongst the choices.  Searching, for example at Amazon, yields pages & pages of different books.  I'm not an expert here.  Of the several choices that look pretty good, I would highlight Murphy's "The body you want in the time you have".  He gives a series of twice weekly options (many would be suitable for both men & women) and which would be even quicker to do if one follows the US guideline's suggestion of only doing 8 to 12 reps per session.  Also worth considering are Delavier's "Strength training anatomy", and Pagano's "Strength training for women".  I'm sure many of the other options are also excellent.  If you want books on stretching as well, Walker's "The anatomy of stretching" looks good, and I notice an old favourite of mine - Anderson's "Stretching" - is coming out in a new edition soon.

The Scottish Intecollegiate Guidelines Network (SIGN) published their guidance on "Non-pharmaceutical management of depression" today.  SIGN comment:  "Depression Alliance Scotland proposed the development of this guideline based on feedback from service users who were seeking information about interventions other than prescribed antidepressants which could be helpful in managing their depression.  The Scottish Integrated Care Pathway (ICP) for depression sets standards for appropriate care and treatment of people with depression. It states that for those who choose a non-pharmacological approach, or for whom medication is not effective, there should be the offer of a brief depression-focused psychological intervention.  There is a need for accessible and robust evidence based information about the alternatives to prescribed antidepressants to be available to both GPs and service users."

They go on to say:  "This guideline provides an assessment of, and presents the evidence base for, the efficacy of non-pharmaceutical therapies, encompassing psychological therapies, structured exercise and lifestyle interventions, and a range of alternative and complementary treatments, many of which are not routinely available within the NHS.  This guideline will be of particular interest to those developing mental health services, health care professionals in primary and secondary care (eg GPs, community psychiatric nurses, clinical psychologists and psychiatrists) and patients with depression and their carers.  It may also be helpful to voluntary organisations and exercise professionals working in exercise referral schemes, public or private fitness centres, and physical activity promotion."

The guidance is freely accessible/downloadable as the full 44 page "Non-pharmaceutical management of depression in adults: a national clinical guideline", as a brief 2 page "Quick reference guide" and as a 32 page "Treating depression without using prescribed medication: booklet for patients and carers".

How good is this guidance?  It's good.  Of course there are areas one can criticise, but overall it's excellent.  A big thank you to the group of clinicians, researchers and members of the general public, who volunteered and worked for years to put this guideline together.  The obvious comparison is the recent English/Welsh "Updated NICE guidelines on treating depression".  SIGN's effort is welcome because it steers clear of the much written about subject of antidepressant medication and concentrates on the crucially important area of non-pharmaceutical management.

What are the key points?  Well SIGN's "A grade" recommendations (grading reflects the strength of the underlying research evidence) are for various forms of psychotherapy - behavioural activation (BA), cognitive behavioural psychotherapy (CBT), and interpersonal psychotherapy (IPT).  For self-help, SIGN give an A grade to guided self-help based on BA or CBT (including via computer programmes).  Their still strong "B grade" recommendations (good underlying research backing, but not as extensive as for A grades) are for problem solving therapy and short term psychodynamic psychotherapy.  There's a B grade recommendation too for group mindfulness-based cognitive therapy (MBCT) to reduce risk of relapse for people who have already suffered three or more episodes of depression.  Interestingly and encouragingly, there's a further B grade recommendation for forms of structured exercise.

SIGN also make a series of "best practice" points about appropriate training of psychotherapists, appropriate styles of self-help group, the potential value of couples-focused therapy, and the importance of healthy lifestyle.  Sadly, SIGN have fallen into line with the typical establishment position on St John's wort, suggesting that health professionals should not recommend its use because of concerns about standardisation of dose and interactions with other medications.  In the original draft guideline, SIGN gave St John's wort an A grade recommendation.  I wrote extensively about this in "Draft SIGN non-pharmacological depression treatments guideline, 3rd post: herbs & supplements".  The points I made are still valid.  In fact, in a burst of enthusiasm, I wrote nine blog posts about the original SIGN draft guideline.  Several of these commentaries still seem worth reading - for example the already mentioned post on St John's wort, and another on the "Therapeutic alliance in the treatment of depression".  Overall though, a big thumbs up for this guideline, for all who contributed to it, and for Ruth Lang, retired Information and Support Officer for the charity Depression Alliance Scotland, who inspired and initiated the whole process.

This blog post is downloadable as a Word format handout 

Earlier this month, I blogged about exercise safety in "Exercise 1: checking it's safe to start" , about the helpful GPPAQ - General Practice Physical Activity Questionnaire - described in "Exercise 2: UK Department of Health, resources for assessment & advice", and excellent advice on how to exercise in "Exercise 3: US Department of Health & Human Services, resources for assessment & advice".  In today's post, I want to talk about the value of pedometers - the little gadgets we can use to count the number of steps we take.

Pedometers can be surprisingly effective at motivating us to walk further.  Bravata & colleagues looked at 26 research studies on pedometers in their paper "Using Pedometers to Increase Physical Activity and Improve Health: A Systematic Review" (see below for link and full abstract).  They found that, overall, pedometer use led to more than 25% increase in distance walked over the average 18 week duration of the investigations.  They concluded "The results suggest that the use of a pedometer is associated with significant increases in physical activity and significant decreases in body mass index and blood pressure."  More recently still, Cobiac & colleagues wrote in their paper "Cost-Effectiveness of Interventions to Promote Physical Activity: A Modelling Study" (see below), "There are many options for intervention, from individually tailored advice, such as counselling from a general practitioner, to population-wide approaches, such as mass media campaigns, but the most cost-effective mix of interventions is unknown."  After reviewing the literature, they concluded  "Based on current evidence of intervention effectiveness, the intervention programs that encourage use of pedometers ... and mass media-based community campaigns ... are the most cost-effective strategies to implement and are very likely to be cost-saving."

Wikipedia has an interesting & informative article about pedometers and the Scottish "Paths to Health" website also makes some helpful comments.  Probably most useful overall is the practical advice given on page 47 of the full "Physical activity guidelines for Americans, 2008"  where they state: 

"For adults who prefer walking as a form of aerobic activity, pedometers or step counters are useful in tracking progress toward personal goals. Popular advice, such as walking 10,000 steps a day, is not a Guideline per se, but a way people may choose to meet the Guidelines. The key to using a pedometer to meet the Guidelines is to first set a time goal (minutes of walking a day) and then calculate how many steps are needed each day to reach that goal.

Episodes of brisk walking that last at least 10 minutes count toward meeting the Guidelines. However, just counting steps using a pedometer doesn't ensure that a person will achieve those 10-minute episodes. People generally need to plan episodes of walking if they are to use a pedometer and step goals appropriately.

As a basis for setting step goals, it's preferable that people know how many steps they take per minute of a brisk walk. A person with a low fitness level, who takes fewer steps per minute than a fit adult, will need fewer steps to achieve the same amount of walking time.

One way to set a step goal is the following:

1. To determine usual daily steps from baseline activity, a person wears a pedometer to observe the number of steps taken on several ordinary days with no episodes of walking for exercise. Suppose the average is about 5,000 steps a day.
2. While wearing the pedometer, the person measures the number of steps taken during 10 minutes of an exercise walk. Suppose this is 1,000 steps. Then, for a goal of 40 minutes of walking for exercise, the total number of steps would be 4,000 (1,000 × 4).
3. To calculate a daily step goal, add the usual daily steps (5,000) to the steps required for a 40-minute walk (4,000), to get the total steps per day (5,000 + 4,000 = 9,000).

Each week the person gradually increases the time walking for exercise until the step goal is reached. Rate of progression should be individualized. Some people who start out at 5,000 steps a day can add 500 steps per day each week. Others, who are less fit and starting out at a lower number of steps, should add a smaller number of steps each week."

So the bottom line is (if you use, or want to use, walking as a significant part of your overall exercise programme), consider getting a pedometer.  Online stores like Amazon UK stock a wide variety.  As Cobiac & colleagues found in their research - a pedometer is likely to pay for itself many times over if it helps you become a bit fitter.

Next week I'll blog on "Exercise 5: the recommendation to do strengthening exercises".

Bravata, D. M., C. Smith-Spangler, et al. (2007). "Using Pedometers to Increase Physical Activity and Improve Health: A Systematic Review." JAMA 298(19): 2296-2304.  [Free Full Text]
Context Without detailed evidence of their effectiveness, pedometers have recently become popular as a tool for motivating physical activity. Objective To evaluate the association of pedometer use with physical activity and health outcomes among outpatient adults. Data Sources English-language articles from MEDLINE, EMBASE, Sport Discus, PsychINFO, Cochrane Library, Thompson Scientific (formerly known as Thompson ISI), and ERIC (1966-2007); bibliographies of retrieved articles; and conference proceedings. Study Selection Studies were eligible for inclusion if they reported an assessment of pedometer use among adult outpatients, reported a change in steps per day, and included more than 5 participants. Data Extraction and Data Synthesis Two investigators independently abstracted data about the intervention; participants; number of steps per day; and presence or absence of obesity, diabetes, hypertension, or hyperlipidemia. Data were pooled using random-effects calculations, and meta-regression was performed. Results Our searches identified 2246 citations; 26 studies with a total of 2767 participants met inclusion criteria (8 randomized controlled trials [RCTs] and 18 observational studies). The participants' mean (SD) age was 49 (9) years and 85% were women. The mean intervention duration was 18 weeks. In the RCTs, pedometer users significantly increased their physical activity by 2491 steps per day more than control participants (95% confidence interval [CI], 1098-3885 steps per day, P < .001). Among the observational studies, pedometer users significantly increased their physical activity by 2183 steps per day over baseline (95% CI, 1571-2796 steps per day, P < .0001). Overall, pedometer users increased their physical activity by 26.9% over baseline. An important predictor of increased physical activity was having a step goal such as 10 000 steps per day (P = .001). When data from all studies were combined, pedometer users significantly decreased their body mass index by 0.38 (95% CI, 0.05-0.72; P = .03). This decrease was associated with older age (P = .001) and having a step goal (P = .04). Intervention participants significantly decreased their systolic blood pressure by 3.8 mm Hg (95% CI, 1.7-5.9 mm Hg, P < .001). This decrease was associated with greater baseline systolic blood pressure (P = .009) and change in steps per day (P = .08). Conclusions The results suggest that the use of a pedometer is associated with significant increases in physical activity and significant decreases in body mass index and blood pressure. Whether these changes are durable over the long term is undetermined.

Cobiac, L. J., T. Vos, et al. (2009). "Cost-Effectiveness of Interventions to Promote Physical Activity: A Modelling Study." PLoS Med 6(7): e1000110.  [Free Full Text] 
Background: Physical inactivity is a key risk factor for chronic disease, but a growing number of people are not achieving the recommended levels of physical activity necessary for good health. Australians are no exception; despite Australia's image as a sporting nation, with success at the elite level, the majority of Australians do not get enough physical activity. There are many options for intervention, from individually tailored advice, such as counselling from a general practitioner, to population-wide approaches, such as mass media campaigns, but the most cost-effective mix of interventions is unknown. In this study we evaluate the cost-effectiveness of interventions to promote physical activity.  Methods and Findings: From evidence of intervention efficacy in the physical activity literature and evaluation of the health sector costs of intervention and disease treatment, we model the cost impacts and health outcomes of six physical activity interventions, over the lifetime of the Australian population. We then determine cost-effectiveness of each intervention against current practice for physical activity intervention in Australia and derive the optimal pathway for implementation. Based on current evidence of intervention effectiveness, the intervention programs that encourage use of pedometers (Dominant) and mass media-based community campaigns (Dominant) are the most cost-effective strategies to implement and are very likely to be cost-saving. The internet-based intervention program (AUS$3,000/DALY), the GP physical activity prescription program (AUS$12,000/DALY), and the program to encourage more active transport (AUS$20,000/DALY), although less likely to be cost-saving, have a high probability of being under a AUS$50,000 per DALY threshold. GP referral to an exercise physiologist (AUS$79,000/DALY) is the least cost-effective option if high time and travel costs for patients in screening and consulting an exercise physiologist are considered.  Conclusions: Intervention to promote physical activity is recommended as a public health measure. Despite substantial variability in the quantity and quality of evidence on intervention effectiveness, and uncertainty about the long-term sustainability of behavioural changes, it is highly likely that as a package, all six interventions could lead to substantial improvement in population health at a cost saving to the health sector.

They taught me more about, in the midst of all this trauma and suffering and uncertainty - of remaining true to who you are,
and what love can be about in those moments. And there are three or four of those that really stand out very strongly,
whose lives were very different but who were kind of my teachers.
A therapist describing the impact on himself of working with clients struggling with AIDS

You can access a downloadable Word format version of this post by clicking here.

I have already written a couple of blog posts on therapeutic writing - an initial "Writing (& speaking) for resilience & wellbeing 1: introduction" and the more recent "Writing (& speaking) for resilience & wellbeing 2: traumas & difficulties".  Jamie Pennebaker and colleagues first started publishing research on expressive writing back in 1986.  Subsequent work has rightly highlighted the value of writing (or speaking) deeply, honestly and emotionally about one's personal stresses.  Crises are typically profoundly upsetting.  Quite often though participants report that, when they write about the same issue on a series of occasions, the topic becomes a bit less painful.  Some successful research has used writing instructions that deliberately tries to help subjects "process" the traumas that they have faced (Gidron, Duncan et al. 2002 - abstracts & links to all papers mentioned are given further down this post), and other researchers have even encouraged subjects to explore learning and growth that might have occurred following their crisis (Stanton, Danoff-Burg et al. 2002; McCullough, Root et al. 2006; Watkins, Cruz et al. 2008).

This territory should be approached cautiously and sensitively by therapists.  What a nightmare it might be to go for help because of a horrible trauma that has happened in my life, only to find my therapist trying to push some pre-conceived idea on me that - not only has this awful thing occurred - but also I'm now supposed to somehow find "benefits' from the trauma!  A good friend, who has had more than his share of dreadful life events, calls them AFGO's - "another f***ing growth opportunity". 

Richard Tedeschi and Lawrence Calhoun at the University of North Carolina have been particularly active in researching this area of possible posttraumatic growth (Tedeschi and Calhoun 2004; Calhoun and Tedeschi 2004).  They highlight:  "Most of us, when we face very difficult losses or great suffering, will have a variety of highly distressing psychological reactions. Just because individuals experience growth does not mean that they will not suffer. Distress is typical when we face traumatic events.  We most definitely are not implying that traumatic events are good - they are not. But for many of us, life crises are inevitable and we are not given the choice between suffering and growth on the one hand, and no suffering and no change, on the other.  Posttraumatic growth is not universal. It is not uncommon, but neither does everybody who faces a traumatic event experience growth.  Our hope is that you never face a major loss or crisis, but most of us eventually do, and perhaps you may also experience an encounter with posttraumatic growth."

They also explain:  "what is posttraumatic growth?  It is positive change experienced as a result of the struggle with a major life crisis or a traumatic event. Although we coined the term posttraumatic growth, the idea that human beings can be changed by their encounters with life challenges, sometimes in radically positive ways, is not new. The theme is present in ancient spiritual and religious traditions, literature, and philosophy. What is reasonably new is the systematic study of this phenomenon by psychologists, social workers, counselors, and scholars in other traditions of clinical practice and scientific investigation.  what forms does posttraumatic growth take?  Posttraumatic growth tends to occur in five general areas. Sometimes people who must face major life crises develop a sense that new opportunities have emerged from the struggle, opening up possibilities that were not present before. A second area is a change in relationships with others. Some people experience closer relationships with some specific people, and they can also experience an increased sense of connection to others who suffer. A third area of possible change is an increased sense of one's own strength - "if I lived through that, I can face anything". A fourth aspect of posttraumatic growth experienced by some people is a greater appreciation for life in general. The fifth area involves the spiritual or religious domain. Some individuals experience a deepening of their spiritual lives, however, this deepening can also involve a significant change in one's belief system."

This is thought-provoking and potentially wise territory.  New possibilities, deepening of relationships, an increased sense of strength, appreciation of life, existential and spiritual change.  Tedeschi and Calhoun developed the "Posttraumatic growth inventory" as a questionnaire to explore these possibilities.  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 and freely downloadable research papers.  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.  This might occur after they have already written and/or talked more directly about what happened and shared the emotions and thoughts associated with the trauma.  When I use this scale, it is sometimes as much for its "educational function" in alerting the person to these issues.  And, as the quote from one of their research papers at the head of this blog post highlights, personal growth can be experienced by therapists too who work with trauma survivors (Arnold, Calhoun et al. 2005). 

Arnold, D., L. G. Calhoun, et al. (2005). "Vicarious posttraumatic growth in psychotherapy." Journal of Humanistic Psychology 45(2): 239-263.  [Free Full Text] 
Previous investigations of the impact of trauma-related psychotherapy on clinicians have emphasized the hazardous nature of such work. The present study is the first exploration of clinicians' perceptions of trauma work to investigate in depth the positive consequences of working with trauma survivors. A sample of 21 psychotherapists participated in a naturalistic interview exploring the impact of trauma work with a particular focus on (a) changes in memory systems and schemas about self and the world (the hallmarks of vicarious traumatization) and (b) perceived psychological growth.  In addition to reporting several negative consequences, all of the clinicians in this sample described positive outcomes. These descriptions of positive sequelae are strikingly similar to reports of growth following directly experienced trauma and suggest that the potential benefits of working with trauma survivors may be significantly more powerful and far-reaching than the existing literature's scant focus on positive sequelae would indicate.

Calhoun, L. G. and R. G. Tedeschi (2004). "The Foundations of Posttraumatic Growth: New Considerations." Psychological Inquiry 15(1): 93-102.  [Free Full Text] 
In response to comments on our model of posttraumatic growth, we consider the validity of reports of posttraumatic growth, appropriate methodology to use to assess posttraumatic growth, and its relation with other variables that appear to bear a resemblance to posttraumatic growth (e.g., well-being and psychological adjustment).  The potentially important role of proximate and distal cultural factors is also addressed.  Clinicians are encouraged to use interventions that facilitate posttraumatic growth with care, so as not to create expectations for posttraumatic growth in all trauma survivors, and to instead promote a respect for the difficulty of trauma recovery while allowing for the exploration of possibilities for various kinds of growth even in those who have suffered greatly.

Gidron, Y., E. Duncan, et al. (2002). "Effects of guided written disclosure of stressful experiences on clinic visits and symptoms in frequent clinic attenders." Fam Pract 19(2): 161-6.  [Free Full Text]
 BACKGROUND: Psychosocial variables such as major stressful life events/daily stressful events have been associated with health care utilization. OBJECTIVE: Our aim was to examine the effects of a guided disclosure protocol (GDP) of past traumas on symptoms and clinic visits among frequent clinic attenders. METHODS: Forty-one frequent clinic attenders (>/=2 visits/3 months) took part. Patients were randomly assigned individually to either a casual content writing control group (n = 19) or a trauma content writing experimental GDP group (n = 22). GDP patients wrote about an upsetting event chronologically (day 1), verbally described their thoughts and feelings and described the event's impact on life (day 2), and finally wrote about their current perspective on and future coping with the event (day 3). Three months later, patients were reassessed blindly for symptoms and clinic visits, and an average of 15 months later they were assessed blindly for clinic visits again. RESULTS: Compared with controls, GDP patients reported lower symptom levels at 3 months (2.3 versus 5.2), and made fewer clinic visits during the 3 (1.3 versus 3.0) and 15 month (5.1 versus 9.7) follow-ups. The percentage of GDP patients making >/=10 visits during the 15 month follow-up was smaller (10%) than among controls (33%). CONCLUSIONS: The findings extend previous findings to frequent clinic users, using a new form of written disclosure aimed at shifting trauma from implicit to explicit memory. The GDP may be an inexpensive additional intervention in primary care for reducing symptoms and clinic visits among frequent clinic users.

McCullough, M. E., L. M. Root, et al. (2006). "Writing About the Benefits of an Interpersonal Transgression Facilitates Forgiveness." Journal of Consulting and Clinical Psychology 74(5): 887-897.  [PubMed]
The authors examined the effects of writing about the benefits of an interpersonal transgression on forgiveness. Participants (N = 304) were randomly assigned to one of three 20-min writing tasks in which they wrote about either (a) traumatic features of the most recent interpersonal transgression they had suffered, (b) personal benefits resulting from the transgression, or (c) a control topic that was unrelated to the transgression. Participants in the benefit-finding condition became more forgiving toward their transgressors than did those in the other 2 conditions, who did not differ from each other. In part, the benefit-finding condition appeared to facilitate forgiveness by encouraging participants to engage in cognitive processing as they wrote their essays. Results suggest that benefit finding may be a unique and useful addition to efforts to help people forgive interpersonal transgressions through structured interventions. The Transgression-Related Interpersonal Motivations Inventory-18-Item Version (TRIM-18) is appended.

Stanton, A. L., S. Danoff-Burg, et al. (2002). "Randomized, controlled trial of written emotional expression and benefit finding in breast cancer patients." J Clin Oncol 20(20): 4160-8.  [PubMed]
PURPOSE: Expressing emotions and finding benefits regarding stressful experiences have been associated in correlational research with positive adjustment. A randomized trial was performed to compare effects of experimentally induced written emotional disclosure and benefit finding with a control condition on physical and psychological adjustment to breast cancer and to test whether outcomes varied as a function of participants' cancer-related avoidance. PATIENTS AND METHODS: Early-stage breast cancer patients completing medical treatment were assigned randomly to write over four sessions about (1) their deepest thoughts and feelings regarding breast cancer (EMO group; n = 21), (2) positive thoughts and feelings regarding their experience with breast cancer (POS group; n = 21), or (3) facts of their breast cancer experience (CTL group; n = 18). Psychological (eg, distress) and physical (perceived somatic symptoms and medical appointments for cancer-related morbidities) outcomes were assessed at 1- and 3-month follow-ups. RESULTS: A significant condition x cancer-related avoidance interaction emerged on psychological outcomes; EMO writing was relatively effective for women low in avoidance, and induced POS writing was more useful for women high in avoidance. Significant effects of experimental condition emerged on self-reported somatic symptoms (P =.0183) and medical appointments for cancer-related morbidities (P =.0069). Compared with CTL participants at 3 months, the EMO group reported significantly decreased physical symptoms, and EMO and POS participants had significantly fewer medical appointments for cancer-related morbidities. CONCLUSION: Experimentally induced emotional expression and benefit finding regarding early-stage breast cancer reduced medical visits for cancer-related morbidities. Effects on psychological outcomes varied as a function of cancer-related avoidance.

Tedeschi, R. G. and L. G. Calhoun (2004). "Posttraumatic Growth: Conceptual Foundations and Empirical Evidence." Psychological Inquiry 15(1): 1-18.  [Free Full Text] 
This article describes the concept of posttraumatic growth. its conceptual foundations, and supporting empirical evidence. Posttraumatic growth is the experience of positive change that occurs as a result of the struggle with highly challenging life crises.  It is manifested in a variety of ways, including an increased appreciation for life in general, more meaningful interpersonal relationships, an increased sense of personal strength, changed priorities, and a richer existential and spiritual life.  Although the term is new, the idea that great good can come from great suffering is ancient. We propose a model for understanding the process of posttraumatic growth in which individual characteristics, support and disclosure, and more centrally, significant cognitive processing involving cognitive structures threatened or nullified by the traumatic events, play an important role. It is also suggested that posttraumatic growth mutually interacts with life wisdom and the development of the life narrative, and that it is an ongoing process, not a static outcome.

Watkins, P. C., L. Cruz, et al. (2008). "Taking care of business? Grateful processing of unpleasant memories." The Journal of Positive Psychology 3(2): 87-99.  [Abstract/Full Text] 
In this study we investigated the impact of grateful processing on bringing closure to unpleasant emotional memories. After recalling an open memory, participants were randomly assigned to one of three writing conditions. For three sessions, participants wrote about neutral topics, the unpleasant event itself, or positive consequences from the event from their open memory that they felt they could now be grateful for. Results showed a significant effect of writing condition, and the pattern of means were as predicted: those in the grateful condition showed more memory closure, less unpleasant emotional impact, and less intrusiveness of the open memory than the other writing conditions. Grateful reappraisal of unpleasant memories may help individuals emotionally process these events, thus bringing emotional closure to these incidents. This might be one reason that grateful people tend to be happy people.