14 |
Relapse prevention: your ‘blueprint’ for survival |
What is my ‘message in a bottle’? It is that I don’t need to suffer with anxiety any more and that I need to remember to use all the tools in my toolkit!
Murat, 21
One of the big advantages of CBT is that the gains that you make in treatment can be maintained. In other words, once you finish CBT, you should have learned skills and techniques that will stand you in good stead for the rest of your life. This self-help book is designed to be read, used, followed and then re-read as necessary, with the exercises repeated as you come across stressful and anxious periods in your life. Anxious situations will inevitably occur, as they do for everyone. It is how you deal with them that matters.
Once you have used this book and made progress to prevent the anxiety recurring, we suggest you complete the relapse prevention worksheet, worksheet 14.1. It is best to do this after you’ve read Parts 1 and 2. We also recommend that you type this up (unless you have very neat handwriting) as it’s an important document that will summarize everything you’ve learned from reading this book and doing the exercises. It is important this document is easy to read when you come back to look at it in a few months, years or even decades. You can see how both Nicky and Stefan went about filling in this worksheet and there’s a blank one for you to use at the end of the chapter and in the appendices.
Remember that when Nicky went for help, she and her psychological wellbeing practitioner (PWP) – her supporter from the GP practice – realized that she had a number of different symptoms of anxiety. These were:
• Panic attacks – Nicky experienced very strong panic attacks when she thought that there was something different about her breathing, and she thought that she would suffocate and die.
• OCD – She was nervous about eating anything, and had started to check food carefully before she could eat anything at all.
• PTSD – She felt traumatized by the experience since she had genuinely thought that she might die. She had nightmares about it, and wouldn’t go near anything that reminded her of it.
• Social phobia – Nicky thought that other people thought she was pathetic, and she had started to become anxious about being around other people, particularly her brothers, because of this.
With her psychological wellbeing practitioner, Nicky worked through the chapters in this book. She started with the Panic Disorder chapter, because this seemed to be the most problematic part of her anxiety. The PWP helped her to understand what was happening, and to do behavioural experiments to show her that she was not going to suffocate when her breathing changed. The PWP also helped her to pick out sections from the OCD chapter that would be helpful – in particular stopping checking her food. Nicky was able to work on her social anxiety by making herself think about other people, not herself, when she was in social situations. The PWP also helped her to see that the way that she had reacted was natural and understandable – the experience with the chicken bone had been very frightening – and that she was not a wimp. Realizing this made it easier for her to be around other people. Finally, by talking about what had happened in the course of therapy, and having a chance to adjust to it, Nicky’s PTSD symptoms got a lot better, and she no longer woke in the night with nightmares about dying.
How did my anxiety start?
When I choked.
What made my anxiety persist? Clue: refer to the diagram that you drew for the anxiety problem you’ve been experiencing. Think of the meaning you were placing on particular events, and what you were doing to try to improve the situation but which might have backfired, e.g. avoidance.
Because . . . I started to feel so frightened if anything about my breathing wasn’t right that I got anxious and hyperventilated – a self-fulfilling prophecy.
I avoided going out or eating very much, especially chicken, so I carried on thinking it would happen again if I did.
I thought that being in this situation was my fault for being pathetic and so I assumed everyone else thought that, too.
What have I learned in this self-help book that has been useful? Clue: Put as much as you can here.
Anxiety makes you breathe so fast that it feels like you can’t get enough oxygen, and this can make you think you’re dying, and then you panic.
Actually the physical response to breathing so fast is physically normal and it cannot lead to any serious physical problem.
My thoughts are not ‘the truth’ sometimes – I have to learn to stand back from them and make sure that they really fit the situation. I will try to remember to examine the evidence.
DO NOT AVOID THINGS – it just keeps the problems going and makes everything worse.
What situations might lead to a setback for me? Clue: think about some of the triggers that led to the development of the problem in the first place, or other stressors in your life.
I have realized that I am quick to imagine that other people think I’m stupid. Before this realization I hadn’t appreciated that I tended to feel a bit inferior. I need to make sure that I stop trying to mind-read.
I’m mainly OK about eating, but I think I still worry if I’m somewhere strange and I’m given something to eat and don’t know what’s in it.
What will be the early warning signs of a setback for me? Clue: Think back to a recent episode of anxiety – what signs were there that this episode might be about to happen? Catching your anxiety early is going to be helpful.
The last time I had a problem was when I was invited to dinner and I didn’t want to go – I started to have all the same fears that something would go wrong, I’d choke, I’d make a fool of myself etc. etc.
I think early warning signs would be my wanting to avoid foods, situations and people again, checking my food, or starting to worry about breathing.
What will I do about it? Clue: have a realistic plan for how to tackle setbacks.
Remind myself of what I’ve learned.
Anxiety can make my breathing go funny, but I understand that now. I know how to control my breathing if I need to do so.
Phone my Mum. She’s been really good at following what I’ve been doing, and she’s agreed that if I start ‘having a worrying reaction’ she’ll make me go out, and encourage me to eat things.
How will I distinguish between having a setback and being back at square one? Clue: if you have a difficult period, you don’t want to cata-strophize it and think you have learned nothing from going through this book. Distinguish between a lapse (or slip) and a full relapse.
I don’t think this is going to be a problem – I don’t think that I could ever go back to square one now that I understand what happened. I feel pretty confident that taking the steps above make me a more confident and happier person.
How do I see myself in:
1 month:
I hope that I’ll be back to doing most of what I could do last summer – I might still be a bit nervous though, but I think that’s understandable.
6 months:
Good! I’ll be back to normal. Actually I hope that my having worked so hard and so successfully to overcome my anxiety problems will have made me a nicer person – I’ll be much more understanding if someone in my aerobics classes seems to be having trouble now.
1 year:
I would like to get involved in some work assisting people with anxiety problems. Perhaps I could learn to run classes for breathing and relaxation as well as doing aerobics.
5 years:
No idea. It’s too far ahead; I don’t have a clue what I’ll be doing. I’m pretty confident I won’t be having major problems with anxiety, though.
Finally, what is my ‘message in a bottle’? Clue: If you could only remember three things you have learned from this book, what would they be?
Don’t panic!
It was understandable that I developed problems – I did nearly die after all.
When you get anxious you ‘hyperventilate’. Rapid breathing is a normal part of anxiety and not a sign that you’re about to die.
Avoiding and checking makes the problem worse, not better, even if it seems to help at the time.
This and the following relapse prevention worksheets adapted with permission from D. Geenberger and C. Padesky (1995) Mind Over Mood. New York: Guilford Press.
Stefan’s story
Remember Stefan? He is a Czech builder who was working in England and sending money home, but when the economic situation became difficult, he started to develop troubling symptoms of generalized anxiety disorder (GAD). He started to worry all the time about what could go wrong. He was having difficulty sleeping, and was tense and irritable. He was low in spirit, and missed his wife and young children. After a while Stefan realized that something was wrong, and he started to talk a lot to his wife about his concerns. He also did a lot of research on the internet and with self-help books.
How did my anxiety start?
It started when the economic situation got worse, and everyone got nervous about spending money. I had one job that was cancelled because the customer couldn’t afford it. And Magda was pregnant again, so I was really worried about money.
Why did my anxiety persist? Clue: refer to the diagram that you drew for the anxiety problems you’ve been experiencing. Think of the meaning you were placing on particular events, and the types of behaviours that you were engaging in to improve the situation but which might have backfired, e.g. avoidance.
I started to worry about everything – I thought I wouldn’t get another job, and that the people I was working for hated what I was doing. I avoided asking them about friends of theirs I knew wanted me to do work on their house because I assumed they’d say they’d changed their minds. Then because I was avoiding I got more worried about the lack of work, and then more anxious – exactly the kind of vicious cycle that the book describes!
What have I learned in this self-help book that has been useful? Clue: Put as much as you can here.
I’ve learned to recognize that I tended to worry all the time and have learned the difference between ‘real’ and ‘hypothetical’ worries. As a result I’ve learned how to solve real problems in a more systematic way and when it is sensible to dismiss hypothetical worries. This has been really good, because I’m not spending the whole day winding myself up any more.
I thought the idea of ‘behavioural experiments’ was a bit strange at first, but when I do try to do them it helps me to find out whether what I am afraid of will come true.
Keeping track of my anxiety on a regular basis was really useful as I could easily gauge the level of my anxiety and how it was changing.
I like the idea of cognitive errors, too – it was really helpful to realise that I was just seeing the worst in everything and forgetting all the good I’ve done.
What situations might lead to a setback for me? Clue: think about some of the triggers that led to the development of the problem in the first place, or other stressors in your life.
The really big situation is if I can’t get work – because then I would be really worried that I wouldn’t be able to support Magda and the kids.
What will be the early warning signs of a setback for me? Clue: Think back to a recent episode of anxiety – what signs were there that this episode might be about to happen? Catching your anxiety early is going to be helpful.
Not sleeping is a sure sign, and also if I realize that I’m spending all day worrying and focussing on things I’ve done wrong.
What will I do about it? Clue: have a realistic plan for how to tackle setbacks.
I will, firstly, not think that I have to cope on my own, and remember that it was really helpful to talk to Magda. I think that she and I could make a list of things she can remind me of, like 1) remember the difference between real and hypothetical worries, 2) remember not to focus on small faults, and also to talk to other people when I’m worrying what they think, 3) try not to get too caught up in my thoughts. I could also make a list of all the kind words that people I’ve worked for have said, so at least I can think that if there is work going I’ll stand a good chance of getting it.
How will I distinguish between a setback and being back to square one? Clue: if you have a difficult period, you don’t want to catastrophize it and think you have learned nothing from going through this book. Distinguish between a lapse (or slip) and a full relapse.
When I was at my worst I wasn’t sleeping or eating much, and I was really irritable and found it difficult not to snap at everyone. And I imagined terrible situations, like Magda and the kids wandering in the snow with no shoes. This is really different from when I have bad days now.
How do I see myself in:
1 month:
A lot better. It’s true I’d rather be at home, but actually work is going well here, and people do like me. If I remember to put what I’ve learned into practice and not worry so much, then it’s much easier to see a more positive view of the future.
6 months:
About the same.
1 year:
What I’d really like to be able to do is to find work at home – it’s even possible that Magda could go back to teaching, even with the new baby, and I could look after the children. We’d have a bit less money, but at least we’d be together. She’s said that she feels she’d like to be back in the world again. Or I could try again to get enough work at home. Even if that’s not possible, then I am much more confident that I can keep work going here.
5 years:
I’m just keeping my fingers crossed but I am optimistic about my future now!
Finally, what is my ‘message in a bottle’? Clue: If you could only remember three things you have learned from this book, what would they be?
Anxiety is understandable, and you can manage it if you take a step back, think about what is keeping the problem going and then make changes.
I have to take active steps to stop worrying, or else it just takes my life over.
Remember the behavioural experiments: Have the courage to check things out with people.
Now that you have had a chance to see Nicky and Stefan’s relapse prevention worksheets, have a go at filling in the blank one below.
Worksheet 14.1: Relapse prevention worksheet
How did my anxiety start?
Why did my anxiety carry on? Clue: refer to the diagram that you drew for the anxiety problem you’ve been experiencing. Think of the meaning you were placing on particular events, and what you were doing to try to improve the situation but which might have backfired e.g. avoidance.
What have I learned in this self-help book that has been useful? Clue: Put as much as you can here.
What situations might lead to a setback for me? Clue: think about some of the triggers that led to the development of the problem in the first place, or other stressors in your life.
What will be the early warning signs of a setback for me? Clue: Think back to a recent episode of anxiety – what signs were there that this episode might be about to happen? Catching your anxiety early is going to be helpful.
What will I do about it? Clue: have a realistic plan for how to tackle setbacks.
How will I distinguish between having a setback and being back at square one? Clue: if you have a difficult period, you don’t want to cata-strophize it and think you have learned nothing from going through this book. Distinguish between a lapse (or slip) and a full relapse.
How do I see myself in:
1 month:
6 months:
5 years:
Finally, what is my ‘message in a bottle’? Clue: If you could only remember three things you have learned from this book, what would they be?
It is worth helping the person you are supporting quite actively with this worksheet to ensure that it is as comprehensive as possible and therefore as useful as possible to look back upon when times are tough in the future.
Overcoming anxiety problems is not easy. We hope that you have used the range of techniques described in this book and that doing so has helped you to overcome your anxiety. If you have not made improvements, or not as many as you would like, then don’t despair. Self-help books such as this can help some people, but they’re not for everyone. Some people need the extra help that working with a therapist can bring. Some people also benefit from medication for anxiety. Your GP will be able to discuss with you whether a referral to a therapist, or some kind of medication, would be the right way forward for you. We do hope that the book has helped you to make some improvements in your anxiety, so that you are able to live a happier and more fulfilling life. If this is the case, be sure to give yourself a pat on the back, and we hope you enjoy your new-found freedom.