Minding the Body

--

David H. Barlow, PhD


 

Anne Marie Albano, PhD

Gillian Butler, PhD

David M. Clark, PhD

Edna B. Foa, PhD

Paul J. Frick, PhD

Jack M. Gorman, MD

Kirk Heilbrun, PhD

Robert J. McMahon, PhD

Peter E. Nathan, PhD

Christine Maguth Nezu, PhD

Matthew K. Nock, PhD

Paul Salkovskis, PhD

Bonnie Spring, PhD

Gail Steketee, PhD

John R. Weisz, PhD

G. Terence Wilson, PhD

Minding the Body
W o r k b o o k

Jason M. Satterfield

1

1
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About TreatmentsThatWork ™

One of the most difficult problems confronting patients with vari-

ous disorders and diseases is finding the best help available. Everyone
is aware of friends or family who have sought treatment from a seem-
ingly reputable practitioner, only to find out later from another doc-
tor that the original diagnosis was wrong or the treatments recom-
mended were inappropriate or perhaps even harmful. Most patients, or
family members, address this problem by reading everything they
can about their symptoms, seeking out information on the Internet,
or aggressively “asking around” to tap knowledge from friends and
acquaintances. Governments and health care policy makers are also
aware that people in need don’t always get the best treatments—
something they refer to as “variability in health care practices.”

Now health care systems around the world are attempting to correct
this variability by introducing “evidence-based practice.” This simply
means that it is in everyone’s interest that patients get the most up-
to-date and effective care for a particular problem. Health care pol-
icy makers have also recognized that it is very useful to give con-
sumers of health care as much information as possible, so that they
can make intelligent decisions in a collaborative effort to improve
health and mental health. This series, TreatmentsThatWork™, is de-
signed to accomplish just that. Only the latest and most effective in-
terventions for particular problems are described in user-friendly
language. To be included in this series, each treatment program must
pass the highest standards of evidence available, as determined by a
scientific advisory board. Thus, when individuals suffering from
these problems or their family members seek out an expert clinician
who is familiar with these interventions and decides that they are ap-
propriate, they will have confidence that they are receiving the best
care available. Of course, only one’s health care professional can de-
cide on the right mix of treatments.

This collaborative, skill-based program is designed to help you cope

with your illness and improve your quality of life. It starts with the
 basic idea that you are more than your disease. You are a whole,
unique person whose goals and needs should be considered. You will
learn proven methods to manage stress and relax. If you experience
anxiety, depression, or anger, you will use practical tools to manage
and improve your mood. An important part of this program is
building social support, with a focus on relationships with caregivers
and on resolving conflicts. You will attend to practical concerns about
your medical care and work toward effective symptom management.
You may also address your spiritual health and learn key strategies to
promote personal growth and resilience.

It is important to find peace with your past, appreciate the present,

and still keep looking forward and setting goals. Participating in this
program can be a first step to regaining control of your life and in-
creasing its quality. This program is most effective when carried out
in collaboration with a trained facilitator.

David H. Barlow, Editor-in-Chief

TreatmentsThatWork™
Boston, Massachusetts

vi
Contents

Overview 

Module 1: Stress and Coping

Session  Medical Illness and Stress 

Session  Stress, Thinking, and Appraisals 
Session  Coping with Stress: Problem-Focused and
Emotion-Focused Strategies 

Module 2: Mood Management

Session  Illness and Mood: Depression 

Session  Illness and Mood: Anxiety 
Session  Illness and Mood: Anger 

Module 3: Social Supports

Session  Social Support Network 

Session  Communication and Conflict Resolution 

Module 4: Quality of Life

Session  Management of Medical Symptoms 

Session  Quality of Life: Setting Goals and Looking
Forward 
Session  Resilience, Transcendence, and Spirituality 

Appendix Recommended Readings and Other

Resources 
This page intentionally left blank
Overview

Welcome to the program! You are taking a positive step toward cop-
ing with your illness and improving your quality of life. This work-
book is designed to be used in conjunction with a course of therapy
as described in the corresponding facilitator guide. You and your fa-
cilitator will be working together to adapt this program to best suit
your needs. This workbook will help you identify what issues are im-
portant to you and what areas you need to work on. This might in-
clude dealing with stress, improving your mood, building social sup-
port, managing your medical care, or developing your spirituality.

Each workbook chapter corresponds to a program session with your

facilitator. You should bring the workbook to every session. During
the session, you will use the workbook to start exercises designed to
help you learn new skills. You are also encouraged to take notes in
the margin or in the space provided at the end of each chapter. After
every session, you should review the workbook and do the assigned
homework. The homework will help you practice the new skills
you will need to manage your mood and cope with your illness.
Throughout the book are recommendations for additional readings
if you are interested in exploring a topic further.

Your active participation and partnership with your facilitator are es-
sential to getting the most out of the program. Having a serious ill-
ness can make attending sessions or completing homework difficult
at times. If you are having trouble, speak with your facilitator about
how to overcome obstacles. Remember, this program is for you and
your facilitator is on your team. You may also want to involve fam-
ily members or caregivers in parts of this program. No one can
do this program for you, though—how much you accomplish is up
to you.

This program will get you started on acquiring a new set of skills and
perhaps a new perspective. Your learning does not end with the pro-
gram, but continues as you apply the skills to the challenges of hav-

1
 ing a serious illness. Just because you are sick does not mean you are
finished growing as a person. Even if you are at the beginning of the
end of your life, there are things you and your family can do to help
bring about a “good death.” This workbook can provide guidance as
you enter the last leg of your journey.

2
Module 1
Stress and Coping
This page intentionally left blank
Session 1 Medical Illness and Stress

Goals

■ To learn about the program

■ To learn about the concept of mind-body medicine

■ To understand the cycle of medical illness and stress

■ To start becoming aware of your stress and its symptoms

■ To set initial personal goals

■ To practice breathing for relaxation

Program Overview

Having a chronic disease can be incredibly stressful. The disease

affects your body but it may also affect the way you feel, how you
think, and how you operate in the world. Your overall sense of well-
being or wholeness could be at risk. In this program, you will learn
what you can do to help yourself feel better mentally, physically, and
spiritually. The first session will cover the basics of stress, followed by
other sessions on managing symptoms and moods, thinking pat-
terns, problem solving, coping, communication, social support,
spirituality, and planning for the future. When you finish the pro-
gram, you will have a new set of ideas and skills to help you cope
with the challenges of having a serious illness.

Program Philosophy

This program is rooted in cognitive-behavioral therapy, which fo-

cuses on the connections between how we think, feel, and act. It re-
quires your active participation to capture, analyze, and understand
what you are thinking, feeling, and doing. With the guidance of

5
 your facilitator, you will learn practical skills to manage your stress
and your illness. Although these practical skills are valuable on their
own, this program is also designed to help you recognize and appre-
ciate the healing potential of your relationships with family, signifi-
cant others, medical providers, and even your source of spiritual
strength.

This program addresses the needs of anyone with a serious, chronic

illness regardless of how advanced that illness might be. You may be
newly diagnosed or you might be approaching the end of life. Key
social and spiritual issues will be addressed but these concerns should
not be limited to terminal illness only. We can all benefit from
strengthening our relationships, resolving conflicts, specifying our
values, and making choices about our spirituality. Regardless of your
illness or its severity, the overall goal of this program is to assist you
in achieving the highest quality of life possible while living with (or
dying from) your disease.

Program Format

There are  regular weekly sessions. Each session is approximately 

minutes long. The first part of each session will begin with a review
of the prior week’s homework or practice exercises. You and your fa-
cilitator will then explore the new topic for the day, such as defining
stress, managing moods, coping with medical symptoms, etc. The
final part of the session will be spent on discussion and practical ex-
ercises meant to illustrate the topic for the day. Each session will cor-
respond to a chapter in your workbook. In between sessions, you will
be asked to think about some of the ideas discussed and to see if you
can apply them to your daily life. Although learning the ideas is im-
portant, it is more important to see how these ideas work for you in
your unique circumstances. Your facilitator will help you tailor the
skills that you learn to meet your personal needs. If possible, you
may repeat sessions that are especially relevant to your needs or ses-
sions that contain content that is totally new to you. Many partici-
pants also find it helpful to schedule a few “booster sessions” after the
program ends. You will have the opportunity to discuss this with
your facilitator as the program progresses.

6
Program Guidelines

It is important that you try to attend every session. If this is not pos-
sible, let your facilitator know so you can make other arrangements
to learn the material. Your facilitator understands that your medical
symptoms, family responsibilities, transportation, or other issues
might make it hard to attend every week and will work with you
around these obstacles.

Each session will require your active participation. You should bring
your workbook to every session. You may want to add notes, write
down questions, or highlight important ideas in the workbook dur-
ing the session. Your facilitator will actively participate too. As a
team, the two of you will explore your illness, your stress, and useful
skills to improve your quality of life. During the session, you are en-
couraged to “dig” as deeply as you are comfortable. Taking greater
risks will mean receiving greater rewards. Remember that everything
shared in session is confidential, with only a few notable exceptions
such as suicide or abuse.

At the end of each session, you and your facilitator will develop a
homework assignment to practice what was learned in session. You
may choose to include family and/or friends in one or more sessions
or homework assignments. Discuss with your therapist how to in-
volve others throughout the program.

Mind-Body Medicine

Most medical care focuses on your body. It seeks to treat a disease or

eliminate a symptom. Even if the treatment is successful you may
still feel bad or sense that something essential is missing. The doctor
treated your body but forgot to take care of you as a whole person.
It may leave you confused, disappointed, and searching for some-
thing better.

You may already be familiar with the term mind-body medicine,

which focuses on the interaction between the mind and the body. Its
main principle is that emotional, mental, social, spiritual, and be-
havioral factors can directly affect an individual’s health (see Fig. .).

7
 Emotions

Thoughts Behavior

Mental and
Physical Health

Social
Spirituality Relationships

Figure 1.1
Mind-Body Medicine

This program uses a mind-body approach to focus on you as a whole

person. This approach will help you improve your quality of life and
reduce unnecessary suffering.

This program will teach you important mind-body skills that will
help you achieve your goals and better manage your disease. First, it
is important to recognize that the way you think affects the way you
feel and the things you choose to do. Together your thoughts, feel-
ings, and behaviors can have a significant impact on your physical
health regardless of your illness. Throughout this course, we will
work on ways to influence the way you physically feel by changing

8
 the things you do and the ways you think. We will also take a closer
look at your spirituality and your social relationships.

It is important to remember that mind-body medicine is not about

placing blame. Someone does not develop a disease because of a bad
attitude. As you will learn, attitude is important but it is not the only
thing we have to consider. We are biological beings and biological
systems sometimes go awry or simply wear out over time. Our atti-
tudes can help us cope, but we should not see them as magical causes
or cures for disease.

Medical Illness and Stress: A Vicious Cycle

Serious medical illness can lead to stress, depression, anxiety, and a

lot of physical discomfort. Feeling stressed can make you more phys-
ically ill and being physically ill can make you more stressed. It’s a vi-
cious cycle if left unchecked. Although this program can’t cure any
disease, it can help you break the vicious cycle of stress and physical
illness. You will learn how to manage your stress and your illness
more effectively. To prepare, answer the following questions:

. What is your primary medical diagnosis?

. What symptoms (or side effects of treatment) are you experi-

encing (pain, shortness of breath, fatigue, insomnia, loss of ap-
petite, etc.)?

. Do you think these symptoms or side effects can be improved?

Which ones? How much?

9
 . How is this disease being treated (medications, diet, exercise,
physical therapy, oxygen, chemotherapy, etc.)?

. What does managing your disease require you or your loved

ones to do?

What Is Stress?

Everyone is stressed at some point—especially if they are physically

ill. Illness is not the only source of stress—work, money, children,
relationship issues, etc. can all contribute to stress. Events that cause
stress are called “stressors.” Stressors can be acute (one time) or
chronic, stand alone or “chained” events, internal or external, real or
imagined, in the past or anticipated in the future. We can think of
stress as the tension or pressures that are a natural part of living.
However, sometimes this tension can be a heavy burden to bear, par-
ticularly when mental or physical energy is at a low point. You feel
“stressed out” when the demands placed on you exceed your ability
to cope.

Categories of Stress Symptoms

Stress can make its appearance through physical, behavioral, emo-

tional, cognitive, and social symptoms. Here is a list of examples for
each category.

Physical: shortness of breath, pounding heart, stiff or tense muscles,

headaches, upset stomach, clenching jaw or fists, dizziness, trem-
bling, diarrhea, grinding teeth, sweating, feeling faint, loss of in-
terest in sex, tiredness, restlessness

Behavioral: overeating, loss of appetite, trouble sleeping, accident

proneness, using more alcohol, avoiding tasks, sleep problems,

10
 Stressor (examples) Stress Symptoms: examples
• Medical bills • Physical: fatigue, insomnia
• Marital conflict • Behavioral: feeling jittery
• Cancer treatment • Emotional: irritability
• Loss of job • Cognitive: worrying
• Social: avoiding friends

Figure 1.2
Stress Pathway

trouble completing work assignments, fidgeting, tremors, crying,

smoking more

Emotional: irritability, anger, worry, trouble concentrating, negative

attitudes, loneliness, feeling down or depressed, feeling tense,
grouchiness, inability to relax

Cognitive: anxious or racing or slowed thoughts, fearful anticipa-

tion, poor concentration, difficulty with memory

Social: avoiding others, isolating, not wanting to be alone, venting,

getting easily irritated with others

Figure . shows the first few boxes in the stress pathway that we will
be exploring over the next couple of sessions.

Case Example

■ Thomas recently had a heart attack. It was his second in just 2

years. He had surgery (again) and was in cardiac rehab (again) but
his body just didn’t feel the same. He knew permanent damage had
been done to his heart and he sensed that he had begun a slow, down-
ward spiral. He worried about his wife, his kids, and his grandkids.
He worried about his medical bills. He wanted to act like everything
was okay but he knew it wasn’t. He was incredibly stressed and very
scared. He started sleeping a lot during the day, sneaking cigarettes (he
quit years ago), and forgot his medications more often. He did his
physical exercises regularly but skipped his support group and avoided
talking about his feelings with his family. As he felt his stress continue

11
 to rise, he started having more aches and pains—and his blood pres-
sure started climbing. His disease made him stressed but his stress was
worsening his disease. Thomas was in desperate need of effective stress
management. ■

Stress Reflection Questions

A first step in effective stress management is identifying your stressors

and assessing your stress symptoms. Use the reflection questions below
to consider how your stress might fit into the boxes in Figure ..

. What are some of your primary causes of stress (i.e., stressors)?

. How does stress affect you? What stress symptoms do you

have?

Physical:

Behavioral:

Emotional:

Cognitive:

Social:

. How can friends, family, or others tell when you are stressed?

. What’s the most stressful thing about your physical illness?

. What makes your stress symptoms better or worse?

12
My Intake Assessment Results and Initial Goals

You will probably have an initial intake visit before beginning this
program. Intake visits are intended to identify personal needs, symp-
toms, and areas of highest priority. Results of this intake might in-
clude your levels of stress, depression, anxiety, or anger. It may also
include a rough “score” for your social supports and quality of life.
You and your facilitator will discuss the results of this intake. These
results plus the stress symptoms you have listed above can be used to
formulate some initial goals. Record the assessment and/or stress
symptom information on the My Initial Program Goals form near
the end of the chapter. Include how you’d like to see things change.
Goals should be concrete, specific, and realistic when possible. Ex-
amples of goals might include getting – quality hours of sleep per
night, decreasing average daily pain rating to a  out of , talking
with estranged son, etc. Your goals will probably develop or change
throughout the program, but these initial, modest goals will help
you get started with the coping process.

Breathing Exercise

During this session, you practiced a breathing exercise for relaxation.

This exercise is one of the easiest ways to learn how to relax. Re-
member that when relaxed, it’s impossible to feel tense and stressed.
You should practice this exercise often to help relax the mind and the
body.

This breathing exercise uses what is called diaphragmatic or belly

breathing. The diaphragm is a dome-shaped muscle under the
ribcage that helps fill the lungs with air when breathing deeply. The
goal of this exercise is to learn how to use the diaphragm in order to
take the most air into the lungs.

To begin, get into a comfortable position with the back as straight as

possible (e.g., sitting up straight in a hard backed chair with feet flat
on the floor). Put one hand on your stomach and the other on your
chest. Inhale slowly and watch which hand moves. Shallow breaths
move the hand on the chest; diaphragmatic breaths move the hand
on the stomach.

13
My Initial Program Goals

A. Medical Problems
. List your most troubling medical symptoms and circle a number to rate how severe each symptom
is now. Circle a number in the third column to indicate the symptom level you could accept (make
sure this is a realistic and modest goal). See the example provided.

List of Medical Symptoms Current Symptom Severity Symptom Level I Could Accept

Mild Severe Mild Severe

Shortness of breath            

           

           

           

           

           

           

           

. Provide any specific details about how you’d like your medical symptoms to change. (Example: “I’d
like to get – hours of good sleep most nights.”)

14
B. Psychological Issues
Based on your intake assessment and your stress symptom exercise, which of the following psycholog-
ical issues might be an area for improvement? Circle those you think are most important. Write down
how you’d like them to change. General ideas are okay for now.

Psychological Issues How I’d Like Them to Change

I’d like to learn how to deal with the frustrations of waiting
Example: Anger in the doctor’s office.

Stress

Depression

Anxiety

Anger

Other:

C. Social and Spiritual Issues

. List any social or relationship issues that you might want to address. How would you like to see
things change?

. List any spiritual issues you might want to address. How would you like to see things change?

D. Quality of Life
. Write in a number for your current, overall quality of life using the – scale below.
Lowest Highest
 –––––––––––––––––––––––––––––––––––––––––––––––––– 
. What one or two things could most improve your quality of life?

15
 Now, slowly inhale through your nose. As you breathe in, count
slowly to  and feel your stomach expand with your hand. Hold the
breath for  second. Then slowly breathe out while also counting to
. When you inhale, think of the word inhale. When you exhale,
think of the word relax.

Inhale  . . .  . . .  . . . Hold  . . . Relax  . . .  . . .  . . .

Continue breathing in this pattern for a few minutes. Feel yourself

becoming more relaxed with every time you exhale.

Homework

✎ Review this chapter and answer the questions in the spaces pro-
vided.

✎ Complete the My Initial Program Goals form.

✎ Practice breathing exercise on a daily basis.
Notes:

16
Session 2 Stress, Thinking, and Appraisals

Goals

■ To learn about the cognitive component of stress management

■ To start thinking in more helpful ways

■ To recognize common habits of mind

■ To apply thinking exercises to stress appraisals

■ To capture and rethink cognitions and appraisals

Cognitive Component of Stress Management

The cognitive component of stress management refers to how your

thoughts make a major contribution to how you feel and how you
cope. In fact, your feelings, thoughts, and behaviors (coping behav-
iors and otherwise) are intimately related (see Fig. .). By examin-
ing each corner of this “feeling–thoughts–behavior triangle,” you
will develop a better understanding of how you got where you are
and what you should do to go about changing your situation.

The most important thing to remember about thoughts and feelings

is that they are not facts. A thought is just an opinion—your best
guess at explaining or understanding what’s going on. Opinions
should always be open to reevaluation and change. A feeling (or
emotion) is just a chemical signal that tells you that you need to pay
attention to something and possibly intervene. It grabs your atten-
tion but it doesn’t prove that anything is right or wrong. The feeling
could easily be a false alarm based on misinformation.

This program will teach you how to make a habit of carefully con-
sidering your thoughts and feelings. This is particularly important

17
 Feelings

Thoughts Behaviors
Figure 2.1
Feelings-Thoughts-Behaviors Trangle

when the stakes are high. To begin, you need to learn the “A-B-C’s”
of cognitive therapy. A stands for Activating event, B for Beliefs, and
C for emotional and behavioral Consequences (see Fig. .). You
may sometimes have thoughts like “That doctor made me angry” or
“This disease depresses me.” Using our A-B-C language, these
phrases claim that A, an activating event (i.e., the doctor’s appoint-
ment or having the disease), causes C, the emotional or behavioral
consequences (i.e., anger or depression). See Fig. ..

Although this isn’t necessarily incorrect, it misses an important

middle step—B, or the beliefs and thoughts a person has about the
activating event. The reason that people have different reactions to

Activating Event →→→→ Consequences (behaviors, emotions)

Figure 2.2
Common Perception

18
 Activating Event → Beliefs (thoughts) → Consequences

Figure 2.3
The A-B-Cs of Cognitive Therapy

similar events is that they have different beliefs and thoughts. As you
will learn, there is no right or wrong way to think about an event.
However, some ways of thinking are more helpful or hurtful than
others.

Helpful Thinking

The following are some elements or types of thinking (partially

adapted from Muñoz et al., ). As you review these, note how you
can examine your beliefs and change them to be more helpful.

Helpful Thinking Is Balanced

You might see everything as the same shade of gray. You may only
notice the losses, the disappointments, or the “failures.” Over the
course of your illness you may experience many irreversible changes
in physical function or appearance. In this situation, it becomes
difficult to see anything but losses. However, it is very rare for any-
thing to be absolutely good or absolutely bad. There are always two
sides to every coin. If a situation seems bad, it helps to look at the
other side of the same situation or take a broader view of life. For ex-
ample, rather than just thinking of things you’ve lost, you can also
think of things you’ve gained. A helpful habit to develop is to always
asking yourself, “What’s the other side of the coin?”

You will find that many little positive events can add up to some-
thing really significant. Remember, balanced thinking is not wearing
rose-colored glasses. It is seeing both the good and the bad, feeling
encouragement and discouragement. It helps you change what you
can, accept what you cannot, and seek to eventually find the silver
lining of your illness experience.

19
Helpful Thinking Is Flexible

Things can seem unchangeable and hopeless. You may think in

terms like “always” or “never.” In reality, few things always stay the
same, particularly if you create conditions in which change can
occur. Your ability to change and adapt is essential to your survival
and quality of life. It is important to keep an open mind to infor-
mation that might change your point of view. Not everything is
changeable, but life is full of unexpected surprises.

Though your disease cannot be cured, there is much you can do to

manage the symptoms and the side effects of treatment. It may seem
like you have exhausted all of the usual options. However, a fresh
opinion or a more flexible perspective can often show the way to new
ideas and interventions. This program is an example of a new op-
portunity for change. Hospice may be beneficial. You may also want
to explore new medications and treatments as they become available.

Even if you have done everything you can to manage your symptoms
and side effects, it is still worthwhile to be flexible in how you think
about the approach of death. We often think of death as a “bad out-
come” that should always be avoided if possible. However, you have
the opportunity to use your approaching death as motivation to ac-
complish important tasks. You can take this time to resolve relation-
ships, forgive yourself and others, express love, impart wisdom, ex-
plore your spirituality, settle financial issues, etc.

Helpful Thinking Is Nonjudgmental

In depressed thinking one often places blame on oneself or criticizes

one’s own character. Rather than seeing the mistake as just a mistake,
this kind of thinking makes an overall criticism of who one is as a
person rather than what one did. Insulting yourself or others is
nearly always hurtful. Try talking about the behavior rather than the
person’s character. Remember, no one is perfect. We all have bad
days and make mistakes. All we can do is take responsibility, make
things right (if possible), learn, and move onward.

You may blame yourself for your disease. Nonjudgmental thinking

does not absolve you of responsibility for choices you’ve made (e.g.,
smoking). However, it does encourage you take a more compas-

20
Helpful Thoughts Exercise

For this exercise, use the thoughts listed below in the first column. Identify what is wrong with these
thoughts by circling the category or type in the second column that best describes each thought. Then in
the last column write new, more helpful thoughts to replace the original hurtful thoughts.

Hurtful Thinking Type? New Helpful Thought

“I’m stupid for believing I’d Unbalanced Hope is a sign of kindness and compassion.
get better.” Inflexible Setbacks happen but so do leaps forward.
Judgmental

“This pain will never relent.” Unbalanced

Inflexible
Judgmental

“When it rains, it pours.” Unbalanced

Inflexible
Judgmental

“I’m too ugly to be seen in Unbalanced

public.” Inflexible
Judgmental

“He’ll never understand me.” Unbalanced

Inflexible
Judgmental

“I’ll always be disappointed.” Unbalanced

Inflexible
Judgmental

“My life is falling apart.” Unbalanced

Inflexible
Judgmental

“I must deserve my illness.” Unbalanced

Inflexible
Judgmental

21
 sionate and balanced look at other factors that influenced those
choices (e.g., everyone in the family smoked). It also helps disentan-
gle your self-worth from your behavior (e.g., smoking does not make
one a bad person). Remember that we are all inherently flawed be-
ings who sometimes make bad choices with bad consequences.

Habits of Mind

In addition to unbalanced, inflexible, and judgmental thought pat-

terns, there are a number of thinking habits that we often automat-
ically use. These “habits of mind” can all be helpful or hurtful de-
pending on the situation. Review Table . and note which of these
habits sound familiar to you.

Table 2.1 Common Habits of Mind

Magnification Blowing things up, making them bigger than life, making mountains out of
molehills

Minimization Discounting, making molehills out of mountains

Personalization Assigning personal meaning or significance to nonpersonal events, taking per-

sonal offense when none was intended

Mind reading Making assumptions about what another person is thinking

Fortune telling Making a prediction about what might happen in the near or distant future

Filtering Selectively attending to certain details, either focusing on all negative or all posi-
tive details

All-or-none thinking Seeing no shades of gray, everything seems all good or all bad, no continuum

Catastrophizing Similar to magnification, imagining things are much worse than they are, assum-
ing the worst-case scenario will come true

Overgeneralization Coming to a broad conclusion based on only one or a few incidences

Emotional reasoning Assuming that having a strong feeling makes something true

Adapted from Burns ().

22
Capturing Cognitions Exercise

Cognitions simply refer to your thinking. These may be thoughts that

happen so quickly in response to an event that they are called “auto-
matic thoughts.” Cognitions might also be core beliefs, memories,
images, predictions about the future, etc. They may be about your-
self, your illness, your relationship, or the world in general. To de-
velop your skills in reworking cognitions, it is important to first learn
how to self-monitor, or “capture,” the thoughts you might be hav-
ing. The following questions will help you begin to capture thoughts
related to your illness. We will return to these captured thoughts
later.

. When you hear the name of your disease, what thought pops
to mind?

. What are some thoughts you have about your treatment?

About medications?

. What thoughts do you have about the way your family and
friends have responded to your illness?

. What does this say about you? Your friends? Your family?

. What thoughts do you have about your ability to cope and the
help you have available?

23
 Primary Appraisal
Stress Symptoms:
• Physical
• Behavioral
Stressor • Emotional Coping
• Cognitive
• Social
Secondary Appraisal

Figure 2.4
Stress and Coping Pathway

Linking Thinking with Stressor Appraisals

Recall Figure . from Session , which clearly mapped the pathway
between stressors and stress symptoms. Figure . builds on this
model by inserting appraisals (i.e., the middle step, or the B, in an
A-B-C model). It also adds the next step—coping.

Appraisals should be considered cognitions or the best guesses that

you make regarding a stressor and your coping resources. As cogni-
tions, appraisals are subject to all of the habits of mind already dis-
cussed. A first step in stress management is tuning into the appraisals
you have made and considering whether or not these appraisals are
helpful or hurtful.

You will need to pay attention to two types of “stress appraisals.” Pri-
mary appraisals are your thoughts about the stressor (e.g., does the
stressor matter, is it important, how serious is it, how will it affect my
life or my family, etc.). Secondary appraisals are your best guesses
about your coping ability and resources (e.g., have I dealt with this
before, can I handle it, do I have the skills I need to resolve this issue,
are other people able to help, do I or we have the necessary time,
money, energy to fix this, etc.).

Primary Appraisals (of Stressors)

Common thinking traps for primary appraisals (of stressors) include

the following:

24
. Overestimating the likelihood that a bad event (stressor) will occur.
In this situation, the stressor is anticipated but hasn’t actually
happened (e.g., “my pain will get much worse, I will have to sit
in an oxygen tent, my kids will never forgive me”). Although
some worry may help you prepare for future bad events, there
comes a point when worrying is just adding on more unneces-
sary suffering. The skills to avoid this trap include making
more accurate estimations of what events will occur and decid-
ing whether or not worry will help you prepare for the future.

. Overestimating the “badness” or negative consequences of a stressor.

In this situation, you have catastrophized the actual or possible
outcomes of a stressor. You assume that the consequences are
much worse than they really are. For example, you may feel
very stressed about missing a doctor’s appointment and fear
that you will be dismissed from his practice and never get good
medical care again.

. Overestimating the duration or permanence of stressor. Chronic

stressors generally cause more stress than short-term stressors. It
is important to be accurate and flexible in your thinking. These
key skills will help you avoid the erroneous belief that things
will never change (e.g., “it seemed that my nausea would never
go, away but the new meds and the diet change took care of it.”)

. Considering worst-case scenarios with multiple bad outcomes. This

trap is inviting when a stressor is novel, unclear, or ambiguous.
For example, when you first received your diagnosis, you may
have imagined a bleak future with all sorts of terrible conse-
quences. Learning more about the stressor helps you have more
realistic expectations about what is likely to happen and when.

Important questions to ask to improve primary appraisals include

the following:

■ How likely is this stressor to occur?

■ Is it helpful to worry about this right now?

■ Have I been wrong before? Have I worried too much

before?

■ What are the likely outcomes if it does occur?

25
 ■ How long will it last?

■ How accurate have I been in the past?

■ What are the best-case and worst-case scenarios?

■ Can I live with the worst-case scenario?

■ Could I learn more about the stressor or find someone who

can answer my questions?

Secondary Appraisals (about Coping)

Common thinking traps for secondary appraisals (about coping) in-

clude the following:

. Overestimating what it will take to cope with a stressor

. Underestimating personal ability to cope with a stressor

. Underestimating or forgetting important coping resources such

as time, money, energy, knowledge, etc.

. Underestimating or underutilizing friends, family, and others

who might be willing and able to help

Important questions to ask to improve secondary appraisals include

the following:

■ What resources are realistically needed to cope with this

stressor?

■ What are high and low estimates on how much of these re-
sources will be required?

■ What resources do I have at my easy disposal?

■ What new resources could I possibly acquire?

■ Have I coped with similar stressors in the past? How?

■ Have I underestimated my ability to cope in the past?

■ Who is in my social support network and what help can

they provide?

26
 ■ Are there new people or services I can recruit to assist with
coping (e.g., social services, church help, hospice, neighbors)

Rethinking Appraisals

Remember that stress appraisals are a very specific type of cognition

that you have about stressful situations (primary appraisals) and
your ability to cope (secondary appraisals). The cognitive compo-
nent of stress management requires you to capture your appraisals
and reassess how accurate and helpful they are. The Appraisal Work-
sheet included near the end of this chapter will help you capture,
evaluate, and rewrite appraisals. You may photocopy this form from
the book or download multiple copies from the TreatmentsThat-
Work™ Web site at [Link]/us/ttw.

You should expect some difficulty at first with this exercise, especially
the last step, but throughout this course you will get better at it. You
may want to first refer back to the Capturing Cognitions exercise. In
that exercise you considered your illness as the stressor and your
thoughts about it were types of appraisals. An example is provided
to illustrate how this process might work.

Appraisal Worksheet Example

Initial situation: Maria becomes short of breath when she walks to the
mailbox. She thinks, “Oh no! I’m going downhill fast. Now I can’t even
walk to the mailbox. My lung disease is out of control. This is terrible!”

Step : Identify the stressor

The stressor is her perceived physical decline due to lung disease and the
associated dire vision of her future.

Step : Capture appraisals

Primary appraisal: My lung disease is raging out of control. I will be

housebound and helpless in a few months.

Secondary appraisal: There’s nothing I can do cope with this. There is

no cure. There is no hope.

27
Appraisal Worksheet

What is the initial situation or trigger?

STEP : Name the stressor (e.g., your illness, vision of the future, finances, relationships, etc.)

STEP : Capture your appraisals

Primary appraisals (thoughts you have about the stressor):
(Hint: How bad is it? How important is it? What’s the worst-case scenario? What does it mean?)

Secondary appraisals (thoughts about coping and resources):

(Hint: What will coping require? Will it work? Can you handle it? Do you have enough resources or
supports?)

28
STEP : Evaluate your appraisals
Important questions to ask to improve primary appraisals:
• How likely is this stressor to occur?
• Is it helpful to worry about this right now?
• Have I been wrong before? Have I worried too much before?
• What are the likely outcomes if it does occur?
• How long will it last?
• How accurate have I been in the past?
• What are the best-case and worst-case scenarios?
• Can I live with the worst-case scenario?
• Could I learn more about the stressor or find someone who can answer my questions?
Important questions to ask to improve secondary appraisals:
• What resources are realistically needed to cope with this stressor?
• What are high and low estimates on how much of these resources will be required?
• What resources do I have at my easy disposal?
• What new resources could I possibly acquire?
• Have I coped with similar stressors in the past? How?
• Have I underestimated my ability to cope in the past?
• Who is in my social support network and what help can they provide?
• Are there new people or services I can recruit to assist with coping (e.g., social services, church
help, hospice, neighbors)
STEP : Rewrite your appraisal (based on the above evaluation)
My new primary appraisal:

My new secondary appraisal:

29
 Step : Evaluate appraisals

Maria asks herself the list of questions for both primary and secondary
appraisals (see worksheet). She assesses the accuracy of her thoughts and
finds that she is catastrophizing, or magnifying how bad her symptoms
are or how bad they will get.

She also searches for any untapped resources that she could use to help her
cope.

Step : Rewrite appraisals

Primary appraisal: Yes, my lung disease is incurable and probably pro-

gressive. But I’ve had peaks and valleys in the past. I have good days and
bad days. Just last week I was able to play ball with my grandson with-
out too much difficulty. I have some control over my symptoms.

Secondary appraisal: My oxygen really helps but I haven’t been using it

that often in public because it sort of embarrasses me. I can use my oxygen
more regularly and I can ask my doctor to review my meds again . . . Even
if I do lose more physical function, I can ask my family for more help and
enjoy their support indoors. I’m blessed to have family who love me.

Homework

✎ Review the Helpful Thoughts exercise.

✎ Review your answers to the Capturing Cognitions exercise.
✎ Complete the Appraisal Worksheet.
✎ Continue doing breathing exercises on a daily basis (optional).
Notes:

30
Session 3 Coping with Stress: Problem-Focused and
Emotion-Focused Strategies

Goals

■ To use appraisal to guide coping

■ To learn about problem-focused coping

■ To learn about emotion-focused coping

■ To practice using affirmations

■ To begin disputing beliefs

Using Appraisals to Guide Coping

By now you should have a fairly solid idea about the stress process.
First you experience a stressor, then you make appraisals, and then
you have stress symptoms (see Fig. . in Session ). This session fo-
cuses on the next step—how you cope with stress. Coping here
means making the best response you can to any type of problem that
comes your way. The key to successful coping is to be able to match
the coping strategy with the needs of the stressful situation.

Before selecting a coping strategy, it is important to make and check

your primary and secondary appraisals. Remember that primary ap-
praisals are about the nature and importance of the stressor. Sec-
ondary appraisals are about your coping abilities and resources. The
Appraisal Worksheet (from Session ) is a strategy to improve the ac-
curacy and usefulness of your appraisals. Once your appraisals have
been rewritten and improved, the stressor(s) should be broken down
into more manageable components that can be prioritized and more
easily analyzed to help you choose the best coping strategies.

31
 Examples of important questions to break down and analyze ap-
praisals are given below.

. What’s the most important stressful situation (i.e., the main stressor)?

When multiple or chronic stressors are present, it is sometimes

quite difficult to identify the main cause of stress. You may be
aware of the physical sensation of stress or tension but be un-
aware of what is causing it. Here are a few questions to help you
uncover the cause of a stressful feeling:

■ What were you doing or thinking when the feeling

started?

■ What thoughts or activities make the feeling stronger

or weaker?

■ Have any new problems emerged or have chronic prob-

lems changed recently?

■ If you could magically erase one problem in your life to

make it better, what would you pick?

. What are the stressful elements of the situation, and which ele-
ments are most important?

It is helpful to break a stressor down into more manageable

pieces and prioritize them. Specific stressful elements might re-
quire different coping strategies. For example, an upcoming doc-
tor’s appointment might be causing a robust stress response. Ele-
ments of the stressor could include lack of transportation to the
visit, uncertainty about how to prepare, fear of not remember-
ing the doctor’s instructions, dread of hearing bad news, the pain
of walking up a flight of stairs to the doctor’s office, etc. Each of
these elements might require a very different coping strategy ap-
plied at a particular time.

. Are these elements changeable or unchangeable?

This step helps you decide if you should roll up your sleeves and
try to change something (i.e., problem-focused coping) or if you
should practice acceptance and mood management (emotion-
focused coping). Remember, if something is not under your

32
 control, efforts to force a change aren’t likely to be helpful. In-
stead, you should use emotion-focused coping. Most situations
require a mixture of both problem-focused and emotion-focused
coping, but in different proportions at different times.

. Will this be a short-lived or chronic situation?

Chronic situations are generally less changeable and require a

greater proportion of emotion-focused coping. Acute (short-
term) stressors may be unlike anything you’ve ever encountered
before and present special coping challenges. Thinking about
duration helps one set more realistic expectations.

. What am I able to do now? Later? What about my family and

friends?

After identifying and prioritizing the stressor elements, you

should revisit your secondary appraisals about your ability to
cope and your available coping resources. By looking at more
manageable pieces of the stressor, you may see more opportuni-
ties for coping or ways in which others can help out.

Example

The following example illustrates this process of asking questions to

make appraisals.
Jane is feeling extremely stressed about her health. She’s taking
loads of medications, seeing a half dozen doctors, and still feels
very weak and in pain.

. What is the stressful situation?

Jane’s continuing poor health.

. What are the stressful elements of the situation? Which are

most important to her? (Ask Who? What? Where? When?)

She has to take loads of complicated medications every day that

have side effects

She has many doctor’s appointments every week.

She feels weak, especially in the evenings.

33
 She has unrelieved physical pain, especially when she sits upright
or stands for too long.

Her future is uncertain and she fears being helpless and in greater
pain (most important).

. Are the stressful elements changeable or unchangeable?

Element . Medications: Jane cannot change the fact that she has
to take medications, and the routines are often quite complex.
Some hassle seems inevitable. However, she can change the tech-
niques she uses to remember taking them and she can discuss
changing medications with her doctor. After Jane has addressed the
things that can be changed about her medication she needs to ad-
dress her feelings.
. Will this be a short-lived or chronic situation?

It appears that Jane will have to stay on medications since her dis-
ease is not curable. Taking meds will be a chronic situation. She
may be able to simplify the regimen, but she will have to work on
accepting the continuing need for meds.

. What is Jane able to do now? Later? What about her family

and friends?

Jane is able to call her doctor(s) to request a review of her medica-

tions. She can be very clear about her goal to reduce or combine
the medications she is taking. She can change to a pharmacy that
will fill her pillbox for her. She can ask her husband to help her
with her medications. She can talk with her diabetic friend who
seems to have a good system for medication management.

Coping Exercise

The above example looked only at the medication element of her

problem. Work through the other stressful elements on your own:

Element . Frequent doctor’s appointments

Are these changeable? Chronic? What can Jane or others do about it?

34
 Element . Weakness

Is this changeable? Chronic? What can Jane or others do about it?

Element . Physical pain

Is this changeable? Chronic? What can Jane or others do about it?

Element . Fears of the future

Is this changeable? Chronic? What can Jane or others do about it?

Remember that the choice of coping strategies assumes that Jane’s

appraisals are accurate and helpful.

A Summary of Using Appraisals to Guide Coping

Pulling together material from this session and Session , the ap-
praisals and coping steps can be summarized as follows:
. Identify the stressful situation.

. Write, evaluate, and rewrite the primary appraisals.

. Write, evaluate, and rewrite the secondary appraisals.

. Break the stressor down into smaller, manageable pieces (the

stressful elements) and prioritize them.

. Decide whether these elements are changeable or unchangeable.

. Match problem-solving coping strategies to changeable ele-

ments and emotion-focused coping to unchangeable elements
(see next sections).

35
Problem-Focused Coping

Problem-focused coping strives to improve those aspects of the situa-

tion (or stressor) that can be changed. Many of the common symptoms
of serious illnesses (e.g., insomnia, pain, shortness of breath, depres-
sion) are changeable, although % relief might not be possible.
Since many stressors are partly changeable, your challenge will be to
determine which elements you should try to change. You will also
need to decide how many attempts you should make before moving
to acceptance and emotion-focused coping.

In problem-focused coping you can often use a structured problem-

solving approach. The following steps may be used repeatedly.

. Get the right attitude.

. Define the problem and your goal.

. List your options.

. Pick an option.

. Put it into effect and check your progress.

Remember to focus on a small piece of the stressor, set modest goals,

and take each problem-solving step one at a time. This will help you
to better cope with whatever hassles and bigger problems come
along. Remember that these steps only apply to problems that can
be changed. By trying to change only things that can realistically be
changed, you might save a lot of precious time and energy. Strategies
for problems that cannot be changed are covered in the next section.

Before starting to problem solve, read through the detailed description

of each step. Once you have an idea of the entire process, turn to the
worksheets for each step and begin filling them out. You may photo-
copy these forms from the book or download multiple copies from the
TreatmentsThatWork™ Web site at [Link]/us/ttw.

Step 1: Get the Right Attitude

The first step in solving a problem is recognizing it and believing you

can do something about it. You will know when you are faced with
a problem, because your body will tell you, through either stress,

36
 anger, depression, anxiety, or confusion. Consider these feelings, like
any other bodily sensation, as signals that you are facing a problem.
When you notice that you are feeling an emotion, stop and think
about what is going through your head. What were you just doing?
What were you thinking about?

It is important to have faith that you can solve the problem. When
you are depressed, it is very common to feel hopeless. It seems there
are no solutions to a problem. When you feel and think this way, you
are less likely to want to solve your problems. Try using the “yes-but”
approach to making thoughts more problem oriented. Use the Get
the Right Attitude Worksheet for practice.

Example 1

Unhelpful attitude: It’s hopeless. I’ll never be able to find a doctor who
understands my illness.

Yes-but approach: YES, it is hard finding a good doctor, BUT there are
hundreds of doctors in the area and I can ask my family or friends for
their input and advice. I won’t know until I try.

Example 2

Unhelpful attitude: I can never remember what my doctor tells me in

our visits. It’s hopeless to think I am going to be able to do what she asks.
Yes-but approach: YES, I have had trouble remembering what my doc-
tor tells me, BUT I can ask him to write it down, bring a tape recorder,
or ask my friend to come to the appointment with me.

Step 2: Define the Problem and Set Your Goal

Once you have the right attitude, you get to work by defining your
problem and your goal. A problem (or stressor) defined is a problem
half-solved. It is important to figure out exactly what is causing you
stress or getting in the way of meeting your goals. You will then be
in much better shape to tackle the problems and come up with help-
ful solutions.

37
 What Is the Problem?

The first thing to do is to uncover all the elements of the problem or

stressful situation. Your best bet is to act like a good investigative re-
porter. Reporters are taught to get only the facts of a situation and
to answer the following questions: who, what, where, when, and
how? It is important to use concrete and specific terms when defin-
ing the problem. Try to stay away from vague statements, interpre-
tations, or judgments. Use the Problem Definition Worksheet for
practice. The worksheet uses several guiding questions to help you
uncover facts about the problem. After finding more facts, redefine
the problem, including its specific elements. Your facilitator may
help you identify a few key examples to get you started.

What Is Your Goal?

After you have figured out what the problem(s) is, the next step is to
determine your goal. A goal is the outcome you would like to see
happen when you address the problem. Goals should also be speci-
fic and concrete. Another important aspect of defining your goal is
to be realistic. You need to make sure that the goal is something you
can reach, so you aren’t disappointed. While it is okay to aim for the
stars, think of the practical steps to get you there.

What Are the Obstacles to Your Goal?

Once you have figured out the goal, the next step is to figure out
what the obstacles are. Obstacles are the people, places, feelings, or
other things that might make achieving your goal more difficult.
Obstacles are important to define, as solutions will generally be
based on how to overcome the obstacles. You should think about
what happens when you try to cope with a stressor. Do you get anx-
ious? Does someone interfere with you reaching your goal? Is the
goal too unrealistic?

See the Set Goals and Identify Obstacles Worksheet. You may have
multiple goals and obstacles for one problem. Remember to keep
goals modest. If they are easily achieved, you can always set new
goals.

38
Step 3: List Your Options

Once you have defined your problem, goals, and obstacles you have
to come up with ideas to solve the problem. When you are depressed,
afraid, or sick, this is very hard to do. Your thinking may be unbal-
anced, inflexible, and judgmental. You may be relying on unhelpful
“habits of mind,” such as selectively attending to past failures or for-
tune telling bad events. You may judge your ideas before you’ve had
a chance to really consider them. During this part of problem solv-
ing, you are not allowed to discard any solution, no matter how silly
you think it is. The goal here is to come up with as many possible so-
lutions as you can, at least  of them. Use the List Your Options
Worksheet for practice. To start listing options, review your goal and
think about your resources. Just start to brainstorm ideas and write
down anything that comes to mind.

Step 4: Pick an Option

Once you have come up with a list of solutions, decide which one to
use first. No solution should be discarded completely in case the one
you chose does not work. Even if a chosen option fails, you may have
learned something important (i.e., what not to do). Although you
may feel discouraged or even hopeless, you can’t be certain that there
is no way out until you have exhausted all of your options. A first so-
lution can be selected by answering the following questions:

. Does the solution meet my short-term goals?

. Does the solution meet my long-term goals?

. What kind of effect does this solution have on me? Does it

help me, or does it create new problems for me?

. What kind of effect does this solution have on others? Does it

help them, or does it create new problems for them?

. How likely am I to be able to put this solution into effect?

. How likely is it to work?

Once you answer these questions for each solution, you must pick
the solution for which the pros most outweigh the cons. Use the Pick
an Option Worksheet for practice. List your top five possible solu-

39
 tions in the left-hand column. Rate each solution with a ⫹, , or
⫺ for each dimension listed in the middle columns. A rating of ⫹
would mean the solution performs well on that dimension or has a
positive effect on self or others. A rating of  means that solution
might have minimal or no effect. A rating of ⫺ means that solution
has a negative impact or doesn’t satisfy the goal at all. In fact, it might
pull you further away from your goal. Add up the numbers for each
solution and put the total in the right-hand column. The solution(s)
with the highest number may be your best choice. In the end, it
might take several solutions done at the same time to address all of
the aspects of a given problem. Alternatively, as more is learned
about the situation, you might want to go back to the original list of
options and add new ideas to try out.

Step 5: Put It into Effect and Check Your Progress

Now that you have a plan for a solution, you have to set it in mo-
tion. Only by trying it out can you assess its effectiveness. First, pick
a time and date to put the plan into effect. Any necessary people or
resources should be rallied or put into action.

Once the solution has been carried out, the outcome should be eval-
uated. You need to assess why the solution worked or did not work.
It is important to answer the following questions:

. What was the outcome?

. Was the outcome better, as good, or worse than I expected?

. Would I use the solution again?

. What would I do differently? What does this say about my

problem?

. Did I gather more information that was useful in redefining

the problem?

. Can I now move on to another problem?

Remember that acting to change even little things in a big, stressful

situation can make a difference in how you feel. No situation is ever
% unchangeable. Use the Implementation and Evaluation Work-
sheet to practice. The solution you are implementing is the solution

40
 selected after the Pick an Option exercise. This stage helps you think
about how to launch the solution then check to see how it is work-
ing. The plan for implementation requires you to first think about
any preparations you need to make. For example, if your solution for
nausea (the problem) is to take a new nausea medication, you would
need to call your doctor and arrange to get the meds before you can
start implementing the solution. The evaluation portion requires
you to revisit your initial goal and assess whether your implemented
solution has helped you achieve that goal.

Emotion-Focused Coping

All of us have to acknowledge that there are certain elements in

nearly every stressful situation that we cannot change. It’s important
to work to change what is changeable, but then also work to cope
with your feelings about what’s not changeable. For example, you
can’t change your medical diagnosis, but you can change how you
feel about it.

Strategies for Emotion-Focused Coping

While you can’t change certain things, you can make yourself feel
better about them. If you feel better emotionally, your thoughts and
behaviors may shift in more helpful directions (recall the
feelings–thoughts–behavior triangle). Examples of emotion-focused
coping strategies are as follows:
■ Seeking social support
■ Talking on the phone
■ Going out to dinner
■ Reading
■ Watching television
■ Using the Internet
■ Exercise
■ Focusing on the positives
■ Keeping a gratitude journal

41
 ■ Listening to music
■ Humor (films, cartoons, books, laughing)
■ Medications
■ Pets
■ “Mall therapy” (shopping)
■ Volunteer work
■ Relaxation
■ Art projects
■ Writing stories
■ Praying

Future sessions on depression, anxiety, and anger will offer addi-

tional mood management strategies, many of which are emotion-
focused coping. Think of other strategies you’d like to add to the list
and write them here. Remember that these strategies may not solve
the problem, but they will help you feel better emotionally.

Steps for Emotion-Focused Coping

The steps for emotion-focused coping are similar to those for prob-
lem-focused coping.

. Get the right attitude (“I CAN affect my mood”).

. Define the problem and your goal (which is to feel better,

enjoy yourself, or forget about your problem).

. List your options (such as those in the list of strategies above).

. Pick an option.

. Put it into effect and check your progress (i.e., the effect on
your mood).

42
Affirmation Exercise

A powerful way to affect your moods is to use daily affirmations.

Affirmations are brief, positive statements about yourself or your en-
vironment that provide comfort or inspiration or stimulate thought.
To begin, complete the following phrases.

Things I’m proud of:

.

.

.

.

Memories that make me smile:

.

.

.

.

Things I like about myself:

.

.

.

.

“Signature strengths” I still have regardless of my illness:

.

.

.

.

In order for affirmations to have a lasting positive effect on your mood,

it is important to repeat or even rewrite them regularly. Some suggest

43
 that “savoring” these affirmations once a day is the “minimum” dose.
There are also a number of affirming and inspirational books you
might want to pick up (see Appendix for more information):

Love, Medicine, and Miracles by Bernie Siegel

Kitchen Table Wisdom by Rachel Remen

Chicken Soup for the Soul: Stories to Open the Heart and Rekindle the
Spirit by Jack Canfield and Mark Victor Hansen

A-B-C-D Exercise

Another very useful emotion-focused coping skill is cognitive re-

structuring. It may not change the situation, but changing the way
you think will change the way you feel. In the A-B-C-D exercise we
simply add one extra step to the A-B-C’s of cognitive therapy—D
for “Dispute.” Remember that the A-B-C exercise helps you under-
stand why you feel a particular way or choose a particular behavior.
Through the A-B-C-D exercise you can also challenge beliefs and
possibly change the emotional or behavioral consequences. Figure .
demonstrates this process.

To practice disputing beliefs, use the A-B-C-D Form at the end of

this chapter. You may photocopy this form from the book or down-
load multiple copies from the TreatmentsThatWork™ Web site at
[Link]/us/ttw.

See Figure .. for a completed example. Although disputing beliefs

can be challenging, you should use what you have learned in Session
 regarding balance, flexibility, judgment, and other habits of mind.
The skills you have been learning on the rewriting of appraisals will

Activating Event → Beliefs → Consequences → Dispute

Figure 3.1
A-B-C-D Model

44
A-B-C-D Form

First complete the A box, then complete the B, C, and D boxes.

Activating event (start here) Consequences

My program facilitator asked me to complete 1. I feel sad and anxious.
an ABCD exercise. 2. I feel insecure and start remembering bad
school memories.
3. I procrastinate doing my homework.

Beliefs Dispute
1. This is too hard. I’ll never get it right. 1. This is my first try. Things are always
2. There’s too much to learn and remember. hardest when they are new.
3. I’m embarrassed to show this to anyone. 2. My facilitator told me this was tough for
What if I do it wrong? everybody. She knows it’ll take practice
4. I’ve never been good at school stuff. to get it right.
3. I only have to do as much as I am able. It is
the effort that is most important. I can
keep trying.

Figure 3.2
Example of completed A-B-C-D Form

45
 also be applicable. You may use the “yes-but” technique or ask some
of the following strategies:

■ What is the other side of the coin? Is there a middle

ground?

■ If your best friend had this thought, what would you say to
support him or her?

■ What is the evidence to support this thought? Is there evi-

dence that argues against it?

■ Check this opinion out with others. Do they see it the

same way?

■ Be sure to talk about behaviors and not character.

■ Find the truth in what was said and learn from it. What
can you do to solve this situation?

Once you have disputed a belief, the next step is to evaluate the im-
pact it had on your mood. The degree to which your mood has im-
proved reflects the A-B-C-D exercise’s effectiveness as a emotion-
focused coping strategy.

Homework

✎ Complete the Coping Exercise.

✎ Complete the Get the Right Attitude Worksheet.
✎ Complete the Problem Definition Worksheet.
✎ Complete the Set Goals and Identify Obstacles Worksheet.
✎ Complete the List Your Options Worksheet.
✎ Complete the Pick an Option Worksheet.
✎ Complete the Implementation and Evaluation Worksheet.
✎ Use affirmations on a daily basis.
✎ Complete at least one A-B-C-D Form.

46
Notes:

47
Get the Right Attitude Worksheet

. Write down the sensations, circumstances, or feelings you were having when you noticed you were
getting stressed.

. In the space below, write down all the thoughts you have about this situation or problem.

. In the space below, use the yes-but or other techniques to play devil’s advocate with the discouraging
thoughts. Consider what kind of attitude will be most helpful to solve this problem. It is okay to be
your own “cheerleader.”

48
Problem Definition Worksheet

. Write down the general problem or issue that grabbed your attention.

. Write down exactly what happened. (The trigger or other circumstances might help you figure out the
problem.)

Who was involved?

What happened?

What were you doing?

Where were you?

When did this happen?

How did this happen?

REMEMBER! Use the “detective” approach. Don’t make assumptions; get the facts instead! If you can’t
answer these questions, be your own investigative reporter!

. Review the facts, then redefine your problem. If it has several elements, then list all of the elements
separately. Each element might require a different list of solutions.

49
Set Goals and Identify Obstacles Worksheet

. What is the problem element you have defined?

. What would you like to change in the short term?

. What would you like to change in the long term?

. What outcome(s) would make you believe that this problem has been successfully addressed?

. What are the obstacles to achieving your goal? What might get in the way?

50
List Your Options Worksheet

Problem definition:
List  possible solutions to this problem. Remember, DON’T MAKE JUDGMENTS—JUST WRITE
WHAT COMES INTO YOUR HEAD!

.

.

.

.

.

.

.

.

.

.

51
52
Pick an Option Worksheet

. In the first column, list the top five most feasible solutions.
. In the middle columns, use a ⫹, , or –  to rate the quality of the possible solution for each dimension.
. In the last column, add up the numbers for each solution. The one with the largest number is the best solution.

Satisfies Satisfies
Short-Term Long-Term Impact on Impact on Likelihood Final
Solution Goals Goals Self Others of Success Rating

.

.

.

.

.
Implementation and Evaluation Worksheet

Problem definition:

Solution to be implemented:

. Plan for implementation:

Any needed preparations or early steps?:

Date to act:

. Evaluation:

a. If the situation worked:

How well did it work?

Why did it work?

What could you do differently to make it better?

b. If the situation didn’t work:

Why didn’t it work?

Were there negative effects?

What could you do differently?

53
A-B-C-D Form

First complete the A box, then complete the B, C, and D boxes.

Activating event (start here) Consequences

Beliefs Dispute

54
Module 2
Mood Management
This page intentionally left blank
Session 4 Illness and Mood: Depression

Goals

■ To learn about depression

■ To begin treating your depression if relevant

■ To monitor activities

■ To schedule pleasant activities

Case Example: Part 1

■ Barbara was almost always in physical pain—mostly from severe

arthritis in her hips and knees, but more recently it had moved to her
back. She had a long list of medical problems including heart disease
and had suffered at least one minor stroke a couple of years ago. She
often jokingly said, “I think the warranty on this old heap has finally
expired!” She had been coping fairly well until about a month ago,
when her daughter (and only friend) moved to another state. She felt
sad nearly always. She had stopped sleeping well, had gained about 15
pounds, and noticed that her energy was unusually low. She was for-
getting things more frequently and felt more jumpy and on edge.
She’d noticed, too, that very gradually she’d become less patient with
herself—in fact, she was downright harsh on herself now. In her worst
times, she sometimes wondered if it would be better if she just went to
sleep and didn’t wake up. Barbara was clinically depressed. ■

Definition of Depression

Being sick and stressed can have a very harmful effect on your mood.
The way you feel emotionally is greatly affected by how you feel
physically. As a result, you may have to deal with being afraid and

57
 depressed on top of being physically ill. However, there are ways to
effectively manage feelings of fear and depression, as we will discuss
in this session.

The term depression can refer to

■ a brief feeling,

■ a longer lasting mood, or

■ a chronic medical disease.

All of these instances of depression affect the way your body feels,
how you think, and, potentially, how you behave.

Depression is “normal” as a feeling or mood. Everyone gets depressed,

sad, or blue sometimes. Remember that feelings are ways to get your
attention and provide information. A feeling of depression often ac-
companies the perception of loss (e.g., of a loved one, a job, inde-
pendence, appearance, income, health, etc.). Being sick often means
losing a lot, either temporarily or permanently. You may initially feel
depressed as a result of these losses. You then must accept your losses,
adapt to new circumstances, and move onward. Sometimes, though,
it is too difficult to accept these losses and move onward. Depression
may then develop into a medical disease (as in Barbara’s case) that
can last for weeks, months, or even years.

Complete the My Signs and Symptoms of Depression form and dis-

cuss it with your therapist. If you have five of these symptoms most
of the day nearly every day for at least  weeks, you may have major
depression. If you meet the criteria, major depression is another
chronic disease that should be a focus of your treatment.

You may have some depressive symptoms without having full-blown

major depression. When depression is a “normal” reaction to loss it
doesn’t necessarily require professional treatment. However, you
may still find counseling helpful or try the self-help suggestions in
this chapter. Identifying losses, grieving, coping, and moving on-
ward is hard and often painful work. This program aims to help you
through this important process.

58
My Signs and Symptoms of Depression

Note if the following is true for you:

. You have had a low, sad, or depressed mood almost continuously for at least  weeks.

Yes No

. Your low mood impairs your ability to care for your health and/or accomplish your other everyday
tasks.

Yes No

. Your low mood is beginning to negatively impact people around you and harm your social relation-
ships.

Yes No

. You have been unable to enjoy the things you usually enjoy for the past couple of weeks.

Yes No

Circle a number to indicate which of these common symptoms you experience and how often you
have them.
All the
Never Sometimes Often Time
Irritable mood    
Appetite or weight change (in either direction)    
Changes in how much you sleep
(in either direction)    
Feeling tired all the time    
Changes in how you move (e.g., feeling jittery
or slowed down)    
Poor concentration or poor memory    
Feeling worthless or guilty    
Thinking a lot about death, dying, or suicide    

59
Antidepressant Medication

If you are suffering from major depression, you may want to con-
sider medication. There are many effective antidepressant medica-
tions currently on the market. Most are covered by insurance and
some are available as inexpensive generics. The newer drugs have
fewer side effects and some have fewer drug–drug interactions
(which may be important if you are already on multiple medica-
tions). If you are interested in treating your depression with drugs,
speak to your medical doctor.

If you do decide to take an antidepressant, it is important to take

your medication every day even if you aren’t feeling depressed that
day. Antidepressant medications need time to affect how your brain
works and they need to stay at a certain level to remain effective. Side
effects may appear right away (e.g., drowsiness, dry mouth), but typi-
cally it takes – weeks before the medications begin to show a ther-
apeutic effect. If a particular medication doesn’t seem to help, your
doctor can increase the dosage or prescribe a new medication.

Choosing an Antidepressant

How can you know which antidepressant is right for you? Unfortu-
nately, there is currently no test that tells us who will respond to
which antidepressant. Most choices are based on simple trial and
error. Since it takes – weeks to know if a medication will work, it
may take several months of trying different meds before finding the
one that works. This process may be improved by considering some
of the following issues.

. Have you ever tried any antidepressants in the past? If so, what
was the dose and duration of the trial? What were the side
effects? Did it work for you?

60
 . What side effects are least desired? Are there any side effects
that would be considered beneficial (e.g., drowsiness if you
have insomnia)?

. Do you have a biological family member who has responded

well to an antidepressant?

. What does your insurance cover? If you are not insured, what
is the cost of the medication?

Other Medications

If you do not respond to one antidepressant, remember that there

are other antidepressants you can try, as well as other classes of medi-
cation. If you are experiencing substantial fatigue or agitation, you
may want to ask your doctor about using stimulants or anxiety medi-
cations as an adjunctive treatment for depression.

Side Effects

All medications have potential side effects. Some side effects may
fade over time. Others may be easily managed just by changing the
dosing time or taking the medication with food. If side effects are
bothersome to you, talk to your doctor about how to manage them
or trying another medication.

Therapy or Professional Counseling

Fortunately, medications are not the only option for treatment of

major depression. Psychotherapy or professional counseling has also

61
 been shown to be effective. Unlike with medications, counseling can
also be helpful if you have “normal” depressive symptoms. If you are
interested in additional therapy for your depression, discuss with
your doctor or therapist what types of therapy might be best for you.

What to Expect

Almost any type of therapy requires patience and ongoing personal

investment and work. If you have major depression, you will most
likely need at least – visits to make lasting progress. Therapy
typically starts with one or more intake sessions during which infor-
mation is shared to make a diagnosis, decide upon a treatment, and
set the goals of therapy. This is also your opportunity to interview
the therapist and share any questions or concerns.

The sessions after the intake will vary widely depending on the type
of therapy chosen. In general, the aim of therapy is to help you learn
new ways to manage your moods and the daily stresses in your life.
The goal is for you to continue growing and changing even after the
therapy is over. Remember that even if your first attempt at therapy
was not successful, you may want to try another therapist or a differ-
ent type of therapy.

Case Example: Part 2

■ After a lot of encouragement from her daughter, Barbara finally

told her doctor about her low mood, insomnia, weight gain, poor con-
centration, and other symptoms of depression. As her daughter had sus-
pected, Barbara was diagnosed with major depression—another disease
on top of her other medical illnesses. She started an antidepressant but
was initially reluctant to go to therapy. Why should she open her heart
to a stranger? What if they wanted her to do something she didn’t want
to do? What if she failed at it? After about 2 months of medications,
she felt better, but she was still alone and she still had all of her other
illnesses to cope with. Finally, she found a coping skills class (and the
courage to attend). Much to her surprise, her back pain greatly im-
proved and she started making friends at a local senior center. Two
years after her depression diagnosis, she still had severe arthritis and

62
 heart disease, but she was teaching an art class for seniors and had
even gone on a couple of “friendship dates.” She had successfully moved
from the active treatment of depression to an ongoing self-help program
to manage her mood. ■

Self-Help

While there is no “right” way to cope with “normal” depression,

strategies typically involve some mixture of self-help, social support,
and counseling. You may first want to try the exercises included in
this program. For additional exercises, you may try one of the self-
help manuals available, such as Feeling Good by David Burns and
Mind Over Mood by Greenberger & Padesky. Other self-help strate-
gies are listed here.

Develop Self-Awareness

Improving self-awareness will give you greater understanding and

more control over your feelings. It helps to identify and label im-
portant feelings as they occur. This skill involves the ability to both
detect and filter emotions. Detection refers to the ability to know that
an emotion is occurring. Filtering refers to the ability to decide
which emotions should be attended to and which emotions can be
left alone.
Turn to the Emotion Detection and Filtering Worksheet. Write
down the ways that you know that you are feeling sad or depressed.
For example, you may have physical symptoms such as fatigue or loss
of appetite. Or you may have negative thoughts or changes in beha-
vior. How would an outside observer know you are feeling down?
How do you know?

After listing ways to detect depression in yourself, begin a list of

guidelines that help you decide when to invest the time to under-
stand and perhaps change a particular emotion. For example, your
“filters” may be based on any of the following:

■ intensity of emotion (i.e., strong emotions get attention

first)

63
Emotion Detection and Filtering Worksheet

Emotion Detection

. How does depression (or other emotion of interest) affect you? What signs or clues can you look for?

Physical:

Behavioral:

Emotional:

Cognitive:

Social:

. How can friends, family, or others tell when you are having this emotion?

Emotion Filtering

. Is the detected emotion new? Does it warrant exploration?

. If you ignore the emotion, will it go away? Will there be any negative consequences?

. What will be gained from exploring the emotion?

. What triggered the detected emotion? Is the trigger an important issue you need to address?

. Do you have the time, energy, and ability to try to understand or manage this emotion right now?

64
 ■ novelty (i.e., new emotions may be important to explore)

■ duration (e.g., transient blips may not be worth worrying

about)

■ triggers (e.g., emotions triggered by marital conflict get

high priority)

■ current energy or ability levels (e.g., processing emotions is

typically not a good idea when exhausted or in pain)

Once you’ve decided that a feeling is worth exploring further, ask

yourself, “Why do I feel this way right at this moment?” Try to
understand the feeling as much as possible, including its relationship
to your thoughts and behaviors (identify the A-B-C’s). Once a feel-
ing has been detected and understood, you can then choose the best
way to manage that feeling. For example, if a feeling arises from cog-
nitive imbalance, you can do an A-B-C-D exercise (see Session ). If
the feeling reflects an accurate perception of an unchangeable situa-
tion, you can focus your efforts on lifting your mood (see Emotion-
Focused Coping in Session ).

Acknowledge and Grieve Losses

It’s normal to have feelings of loss and sadness when dealing with a
chronic disease. It’s okay to cry (or rage) alone or with friends and
family. It is healthy to recognize and express your grief in whatever
way you are able. As you may know, grief often waxes and wanes over
time. You may feel overwhelmed one day but relatively stable and ac-
cepting the next.

It is important to acknowledge your losses and the meaning of those

losses. As a result of your losses, you may fear that you will become
an unbearable burden on your loved ones. Or you may fear you will
become unlovable or beyond support. Although the losses associated
with your disease may be irreversible, there are things you can do to
feel better. It helps to reinforce important relationships, recognize
and savor things not lost, and use other coping strategies such as cog-
nitive restructuring or activity scheduling.

65
Work for Mental Balance

As with stress, “normal” depression can be worsened by unhelpful

ways of thinking. When losses are recent or have special significance,
they often loom large, and you may feel that you will never get over
them. While acknowledging losses is important, you should not for-
get the valuable things you still have in your life. The following ques-
tions will help you acknowledge current positives or gains and achieve
better balance:

. What makes you look forward to the future?

. What things make you feel grateful?

. Has this illness helped you reorder your priorities? What are
your priorities?

. Has this illness brought others closer to you?

. Has this illness caused you to change in any positive way?

. Has this illness made you more spiritual?

66
. What are other good things going on in your life that are sepa-
rate from this illness?

You may experience a sense of loss especially when you think about
the past or the way things used to be. It is easy to idealize things that
have been lost and to forget things that were permanently gained.
The following questions will help you work toward balance in think-
ing about the past.

. a. What was the downside of working full time at full effort?

b. Now that you can no longer work, is there something to be

gained in this transition?

. a. How close were you to your family and friends when you
were “fully functional?”

b. Has this illness moved any obstacles out of the way of inti-
macy?

. a. Were you ever depressed, anxious, or stressed when you

didn’t have this serious medical condition? Was life really as
good as you remember?

67
 b. What were the highs and the lows? If there could be lows
when you were healthy, can’t there be highs when you are
sick?

. What were some of your biggest lifetime accomplishments that

will survive you? What is your legacy? What makes you proud?

Be Goal Directed

It always helps to have something to look forward to, whether it’s a

trip, an anniversary, or something much smaller. Recall the initial
goals you set in Session . Are these goals still relevant? Have you
made any progress toward these goals? Consider any steps you can
take toward achieving these goals. If new goals have emerged, write
these down in the spaces provided:

Activity Monitoring and Scheduling

Activities (or behaviors) are closely related to mood. When an indi-

vidual is depressed, she is usually less active, which makes her feel
more depressed, which makes her less active, and so on (a classic
downward spiral). Activity monitoring is a way to assess both quan-
tity and quality of activities in your life. Activity scheduling is a
method used to mindfully change the type or number of activities
chosen. By engaging in more pleasant activities, you may be able to
improve your mood.

68
Activity Monitoring

You have already been practicing the important skill of self-monitoring.

You have been monitoring your cognitions, appraisals, and solution
outcomes. You have been paying careful attention to what you think,
do, or feel and how these relate to each other. You can use this in-
formation when making choices about how to best improve your
quality of life.

With activity monitoring, you should direct your attention to your

daily activities or behaviors. These activities include things that you
have to do (e.g., chores, appointments) and things you want to do
(e.g., talking with a friend, eating out). A comprehensive record of
activities helps you uncover patterns in both activity levels and types
of activities that are chosen. You may discover that evenings and
weekends tend to have unstructured time (and consequent boredom
or low mood). You may also discover that your days are filled with
chores but little time is taken for enjoyment or stress reduction.

Turn to the Activity Record and Scheduling Form. You may photo-
copy this form from the book or download multiple copies from the
TreatmentsThatWork™ Web site at [Link]/us/ttw. This
form can be used to monitor (i.e., record) current activities and to
schedule future activities. Monitoring current activities can help you
identify open periods of time or periods of low mood that need to
be filled with enjoyable activities. In the session, you started activity
recording by filling out what you had done thus far that day. Con-
tinue to record your daily activities for the next week. You can in-
clude as much detail as you like, but be sure to capture at least one
thing per hour if you are able. Broad descriptions such as “doctor’s
appointment” or “watched TV” or “walked the dog” are fine. At the
end of each day, you should also rate your mood on a simple –
scale, where  is your best mood ever.

Activity Scheduling

With activity scheduling, you make a conscious effort to either bal-

ance out your activity choices or fill the typical empty times in the
week with uplifting activities. Rather than just recording what you
have already done, you make plans for what you’d like to do in the
near future. It is important to have a “healthy” diet of activities—

69
 i.e., a balanced mixture that gives a sense of accomplishment and
pleasure, social contact and solitude, relaxation and stimulation,
comfort and challenge, etc. The key is seeing that you have activity
choices. You can then select which activities will most improve your
mood.

Scheduling pleasant activities is an effective yet simple mood man-

agement strategy. While illness may limit or prevent certain activi-
ties, there are many things you can still do that will help you enjoy
your days and feel less depressed. When you were going over this ses-
sion with your facilitator, you reviewed a list of pleasant activities
and scheduled a few to do for the next week. You may want to review
that list of pleasant activities again to see if there are other things
you’d like to try. Also review the Activity Record and Scheduling
Form to remember what pleasant activities you wrote down with
your facilitator. You will be using the same form—the Activity
Record and Scheduling Form—to both record what you do and
plan what you want to do in the next week. Remember that you can
add or change activities as you go along.

Homework

✎ Complete the My Signs and Symptoms of Depression form.

✎ Make a plan for treating your depression, if relevant.
✎ Complete the Emotion Detection and Filtering Worksheet.
✎ Answer questions in the Self-Help section and try strategies.
✎ Review the Pleasant Activities List.
✎ Use the Activity Record and Scheduling Form to monitor ac-
tivities and schedule at least one or two new pleasant activities.

Notes:

70
Pleasant Activities List

. Wear clothes I like . Loan something

. Be outdoors (beach, country . . . ) . Get a massage or foot rub
. Help others I respect . Learn to do something new
. Watch or talk about sports . Be with relatives
. Watch a play, concert, ballet . . . . Talk on the telephone
. Buy things . Have daydreams
. Do artwork or crafts . Watch movies
. Read sacred works . Kiss
. Add flowers or color to my room or house . Do odd jobs around the house
. Read books or magazines . Eat out
. Hear a lecture or sermon . Reminiscence, talk about old times
. Enjoy a drive . Get up early in the morning
. Watch TV . Visit friends
. Play board games . Write in a diary
. Complete a difficult task . Say prayers
. Solve a puzzle, crossword . Meditate, do yoga . . .
. Take a long bath or shower . Read the newspaper
. Write or read stories, poetry, music . . . . Do exercise
. Sing . Walk barefoot
. Go to a church function . Play or watch someone play frisbee or catch
. Go to a meeting . Listen to music
. Play a musical instrument . Sew or do needlework
. Take a nap . Go to a barber or beautician
. Solve a personal problem . Be with someone I love
. Put on makeup, fix hair . . . . Sleep late
. Support a friend . Start a new project
. Sit in the sun . Prepare or order a new or special food
. Plan or organize something . Watch people
. See, listen to, or smell nature . Build or watch a fire
. Listen to the radio . Sell or trade something
. Give gifts . Repair things
. Take pictures . Write letters, cards, or notes
. Work on finances . Care for a houseplant
. Hear jokes or comedy routines . Take a walk
. See beautiful scenery . Collect things
. Eat good meals . Do things with children
. Improve health (fix teeth, get new glasses . . .) . Play with pets
. Be downtown . Read cartoons, comic books . . .
. Go to a museum or exhibit . Use my strengths
. Do a job well . Consider an interesting question

Source: Adapted from Muñoz and Miranda ()

71
72
Activity Record and Scheduling Form
Record your activities for the week. At the end of each day, rate your mood on a scale of  to  ( = worst mood,  = best mood). Also schedule
pleasant activities by writing them in ahead of time. When you have completed a pleasant activity, circle it. If you didn’t complete it, cross it out.

Time Sunday Monday Tuesday Wednesday Thursday Friday Saturday

 A.M.
 A.M.
 A.M.
 A.M.
 A.M.
 P.M.
 P.M.
 P.M.

 P.M.
 P.M.
 P.M.
 P.M.
 P.M.
 P.M.
 P.M.
 P.M.
DAILY MOOD                                                                      
Session 5 Illness and Mood: Anxiety

Goals

■ To learn about anxiety

■ To learn steps for dealing with anxiety

■ To begin treating your anxiety if relevant

■ To develop a mental hygiene program

Case Example: Part 1

■ Jeff was only 46 years old when he was diagnosed with lung cancer.
The surgery and chemotherapy had gotten all the cancer but he was left
feeling violated, drained, and scared. Although 10 years had passed, he
still wasn’t back to what he considered good physical condition. And
now he worried about everything—his job, his house, his car, his fam-
ily, even the government. He knew he made mountains out of molehills
but it seemed like he couldn’t help it. He felt jittery, tense, and irritable
most of the time. He had strange aches and pains, indigestion, dizzi-
ness, and this awful tightness in his chest. He knew it wasn’t cancer,
but what if it was? Jeff was anxious. ■

Definition of Anxiety

Everyone feels some anxiety sometimes, and people who are seri-
ously ill may feel a lot of anxiety a lot of the time. By anxiety we
simply mean feeling nervous, worried, troubled, uneasy, stressed out,
or fearful. Anxiety can refer to an emotion, a physical state, and a
frame of mind. The feeling of being stressed out often includes a
fairly large component of anxiety. When you are anxious, you sense
a threat looming on the horizon, and you are not sure if you can
handle it effectively.

73
 Your body responds to threat by making you tense and alert so you’re
ready to face the problem. This is called the “fight-or-flight” response
because in addition to being a signal, it prepares you to either fight
an attack or flee from the threat. This system works well unless you
have a false alarm and there’s really no threat. It can also be unhelp-
ful when you have to face a problem that can’t be directly fought or
avoided. This system was designed to address short-term, changeable
stressors. When the problem is chronic or unchangeable, the flight-
or-flight response can do more harm than good.

Just like with depression, you need to monitor and understand your
level of anxiety and what’s causing it. Start by completing the My
Symptoms of Anxiety form.

Dealing with Anxiety

Here are steps for dealing with symptoms of anxiety:

Step : Identify the cause(s) of your anxiety.

Step : Choose an intervention that addresses the root problem
and/or the symptoms.

Step : Adopt new mental health habits to minimize future anxiety.

Step 1: Identify the Cause(s) of Your Anxiety

Think of emotions as internal flare guns that go off to grab your at-

tention. They often say, “Hey, wake up! Something’s wrong! Pay
attention!” In this way, emotions can be useful, but you have to be
able to read and respond to the signal. To decide if you should heed
this warning signal and what you might need to do, you first must
identify and understand what is making you anxious. Often it is the
ambiguity or newness of a situation that causes the most anxiety.
Learning more about the cause of anxiety provides important infor-
mation on how to cope and gives you a sense of control.

74
My Symptoms of Anxiety

The following is a list of common anxiety symptoms. Note which ones you have experienced in the past
week. Circle how often you have had these symptoms and how intense they have been.

Frequency Intensity

Excessive worry Never Sometimes Often Always          

Difficulty concentrating Never Sometimes Often Always          

Restlessness Never Sometimes Often Always          

Fatigue Never Sometimes Often Always          

Irritability Never Sometimes Often Always          

Muscle tension Never Sometimes Often Always          

Tension headaches Never Sometimes Often Always          

Trouble sleeping Never Sometimes Often Always          

Feeling jumpy or keyed up Never Sometimes Often Always          

Feeling dizzy or lightheaded Never Sometimes Often Always          

Trembling Never Sometimes Often Always          

Difficulty breathing Never Sometimes Often Always          

Sweating (not due to heat) Never Sometimes Often Always          

Numbness or tingling Never Sometimes Often Always          

Heart racing Never Sometimes Often Always          

Stomachache Never Sometimes Often Always          

Withdrawal or avoidance Never Sometimes Often Always          

Catastrophic or “doomsday” thoughts Never Sometimes Often Always          

Panic attacks Never Sometimes Often Always          

75
 The following questions can help you identify and understand the
sources of your anxiety.

. When you first started having these anxious feelings, what was
going through your mind?

. Are there particular times, places, or people that create these

anxious feelings within you?

. What things do you usually worry about?

. What scares you the most?

. Are there particular images, memories, or thoughts about the

past or future that make you feel anxious?

. Why do you think these things bother you? What might they
mean?

. Do these worries remind you of anything in your past?

76
 You may have many anxieties tied to your illness. These questions
will help you think more about the causes of your illness-related
anxiety.

. What scares you most about your illness?

. What illness-related symptoms cause the most fear?

. What do you fear the most when you think about your illness
getting worse?

. What scares you the most about dying?

. Do these worries touch on any family memories of illness or

death?

Step 2: Choose an Intervention

The next step is to select an intervention that addresses the cause and
symptoms of anxiety. Once you have been able to identify the cause,
the first task is to figure out if there is anything practical you can
do to resolve it (i.e., problem-focused coping from Session ). Ques-
tions to ask yourself include the following:

■ Are there any immediate steps I can take to change the

situation or at least learn more about it?

77
 ■ Are there people who can help?

■ What resources are available?

Try to use the problem-solving steps from Session . It is also often

helpful to break a large stressor down into more manageable stressor
elements (see Session ). Don’t forget to use your social supports and
medical team when facing problems. After you have done what you
can to address the cause of your stress, you may want to try some ex-
ercises to help yourself relax. Several of these exercises are described
under self-help. As you try them out, decide which of them you’d
like to practice on a regular basis.

Step 3: Adopt New Mental Health Habits

While Step  helps you in managing the anxiety symptoms of the

moment, Step  helps you to prevent recurrence and improve anxi-
ety management skills. Mental health habits are daily routines or ac-
tivities that help keep the mind and emotions free of unnecessary
clutter or generally keep levels of arousal low. You should draw heav-
ily on your newly developed skills of self-monitoring, cognitive bal-
ance, improving stressor appraisals, problem solving, emotion-focused
coping, and relaxation. If you have more substantial anxiety symp-
toms, good mental health habits might include anxiety medications
and ongoing therapy. At the end of this session, you will begin de-
veloping your “mental hygiene plan” for the upcoming months.

Self-Help

There are many skills you can learn that can help you relax and cope
with your anxiety more effectively. You have already learned dia-
phragmatic (belly) breathing, balanced thinking, cognitive restruc-
turing (A-B-C-D), problem solving, and activity scheduling. These
interventions were introduced for stress and depression, but they
may work equally well for anxiety. Remember that in addition to
structured exercises, making minor changes to your environment
can often reduce tension and anxiety—e.g., playing soft music,
using aromatherapy, adjusting the lighting or temperature, etc. You

78
 may also want to try the following self-help books (see the Appen-
dix for more information):

The Relaxation and Stress Reduction Workbook by Martha Davis,

Elizabeth Eshelman, and Matthew McKay

The Anxiety and Phobia Workbook by Edmund Bourne

The PTSD Workbook: Simple, Effective Techniques for Overcoming

Traumatic Stress Symptoms by Mary Beth Williams and Soili
Poijula

An End to Panic: Breakthrough Techniques for Overcoming Panic Dis-

order by Elke Zuercher-White

Relaxation

There are several different techniques that can be used to evoke a re-
laxation response—i.e., lower heart rate, blood pressure, decreased
muscle tension, etc. The relaxation response can be seen as the near
opposite of the fight-or-flight response. Techniques include diaphrag-
matic breathing, progressive muscle relaxation, meditation, yoga,
guided imagery, Tai Chi, etc. You may want to sample a variety of
methods before selecting a regular practice. Once selected, you should
fit relaxation practice into your regular schedule. You may want to
audiotape the relaxation or guided imagery instructions included in
this chapter. There are also a number of commercial relaxation CDs
that you might find helpful.

Diaphragmatic Breathing

A good place to start the fight against anxiety is with your breathing.
When we get nervous, our breathing changes. It is common for
breathing to get shallow or rapid. Some people even hold their
breath. Unfortunately, these automatic responses only make anxiety
symptoms worse.

When you notice anxiety, the first thing to think is “Breathe!” and
try to keep breathing as slowly and deeply as possible. Remember
that the best breaths come from the belly. Refer to the breathing ex-
ercise at the end of Session .

79
Progressive Muscle Relaxation

A common response to feeling nervous or worried is to tense the

muscles in the neck, back, shoulders, or other areas of the body. You
may be so used to tensing up that you don’t even realize you’re doing
it. One way to relax the mind is by systematically focusing on each
muscle group in the body and trying to relax it. This is called “pro-
gressive muscle relaxation,” or PMR.

After you have learned PMR in the session, use the following in-
structions to practice PMR at home. You should tense each muscle
group for  seconds, then release the tension and relax for about
– seconds. When relaxing, say the word relax silently to yourself
with each breathe out. Focus on the difference between the sensa-
tions of tension and relaxation. Practice each muscle group twice in
a row and then end with whole body relaxation.

The following describes how to create tension in each muscle group:

. Arms—first put your arms straight down and press them into
your sides, then make a tight fist with each hand and curl your
forearms upward

. Legs—flex your feet and pull your toes toward your upper
body, while pulling your knees together and lifting your legs off
the floor

. Stomach—pull your stomach in toward the spine very tightly

. Chest—take a deep breath and hold it

. Shoulders—imagine your shoulders are on strings and are

pulled up toward the ears

. Neck—press your neck back and pull your chin down toward
the chest

. Mouth, jaw, throat—clench your teeth and force the corners of

your mouth back into a forced smile

. Eyes and forehead—squeeze your eyes tightly shut while

pulling your eyebrows down and toward the center

80
 After tensing and releasing all eight muscle groups, count from  to
 to deepen relaxation. Breathe slowly for a minute, repeating the
word relax with every exhalation. Then count from  to  to return
to a state of alertness.

Guided Imagery

You should first complete either the standard diaphragmatic breath-

ing exercise or the PMR exercise. After you have achieved a relaxed
state, use guided imagery to deepen your relaxation experience. Some-
thing like the following may be used (consider audiotaping this or
having someone else read it in a slow, calming voice):

Now that you have reached a state of relaxation through breathing,

continue to breathe in deeply and continue to feel to your muscles re-
laxing, relaxing, relaxing. With each exhale imagine the tension leav-
ing your body to be replaced with a sense of calm and wellness. Con-
tinue to breathe and continue to relax . . . Begin to create a mental
image of the most peaceful place you can imagine. This place can be
whatever and wherever you’d like it to be. Infuse it with a sense of
calm, a sense of safety, and a sense of peaceful joy. Look around this
place and notice what you see. Notice objects both near and far. You
may be indoors or you may be outdoors. It is your place to create how-
ever you’d like. Notice any sounds, any smells, any tastes. Notice the
temperature. It may be warm or it may be cool. Just continue to
breathe in and relax and imagine your place of refuge. Notice how
good your body feels in this peaceful place. You feel relaxed, at ease, free
from pain, and free from worry. You may be alone or you may be with
others. This is your world, your refuge, your place for comfort. Just con-
tinue to breathe, continue to drink in your surroundings, continue to
enjoy the place you’ve created. . . . Take a last look around at this para-
dise you’ve created and remember that it is yours to return to at any-
time you want. Anytime, anywhere, your sanctuary awaits you. Just
continue to breathe in and relax . . . On the count of , I want you to
start wiggling your fingers and your toes. I want you to start saying
goodbye to your place of sanctuary but remind yourself that you can re-
turn as often as you’d like.  . . .  . . .  . . .

81
Medications for Anxiety

There are a number of medications that can help decrease the symp-
toms of anxiety. These drugs range from relatively mild and slow act-
ing to rapid and sedating. Some drugs can be taken on an as-needed
basis, while others must be taken every day. The best drug for a par-
ticular patient depends on the kinds of symptoms the patient is hav-
ing. If you are interested in trying medications for anxiety, ask your
health care providers for more information. If you are on multiple
medications already, be sure to ask about drug–drug interactions and
safety. Remember that some of the most popular and effective anxi-
ety medications are also antidepressants that must be taken every day
(drugs such as Zoloft®, Paxil®, Celexa®, or Effexor®). Be sure to ask
what kind of medication you have been given and whether you have
to take it every day.

Therapy or Counseling

Individual or group therapy can also help decrease the symptoms of

anxiety. Therapy often helps identify the cause of the anxiety and helps
generate solutions on how to solve it. It can also be helpful just to share
one’s fears with another person and get some advice or support.

Although a number of different types of therapy have proven help-

ful for anxiety, cognitive-behavioral therapy (CBT ) has been shown
to be the most effective. There are many variants of CBT for anxi-
ety; most include training in how to breathe, how to relax major
muscle groups, and how to think about problems in ways that are
helpful, and some element of being exposed to and coping with the
feared object or situation. Like CBT for depression, CBT for anxi-
ety teaches clients practical coping skills that they can integrate into
everyday life. Treatment is usually short term (– visits), but it can
be as long or as short as needed.

If you are interested in other types of counseling in addition to

this program, your health care providers can help with a referral for
treatment.

82
 Case Example: Part 2

■ After years of feeling anxious, Jeff finally sought help. His anxiety
wasn’t severe enough to be called a psychiatric disorder, but it was clear
that his worrying was affecting his body and hurting his quality of life.
With the help of his doctor, he created a treatment plan that included
frequent physical exercise (walking), eliminating caffeine, and taking
a meditation class at the nearby community college. He actively tried
to “stay out of his mind” and be more in the present moment. He
started spending more time with friends and family. Although his
anxiety didn’t go away entirely, it became something he could live
with—particularly since he now felt that he was finally living and en-
joying his life. ■

Your Mental Health Hygiene Program

By now you have experienced a number of exercises to promote bet-

ter mental health and reduce anxiety. You should begin to create a list
of promising practices that you may incorporate into your everyday
life. It is important to think of these interventions as essential activi-
ties of daily living, just like taking a shower or brushing your teeth.
Staying in good mental health requires a “nutritious diet” of activi-
ties for your mind and your spirit. Start your list of mental hygiene
activities on p.  and begin testing them out. You may want to try
several different activities before settling on your final program. You
may also discover new exercises to add as this program moves forward.

Homework

✎ Complete the My Symptoms of Anxiety form.

✎ Make a plan for treating your anxiety, if relevant.
✎ Start filling out My Mental Hygiene Program form.
✎ Practice at least one mental hygiene intervention such as di-
aghragmatic breathing, PMR, or guided imagery on a daily
basis or as often as you are able.

83
 ✎ If time permits, continue practicing a skill you learned in an
earlier session, such as A-B-C-D exercises, problem solving, or
pleasant activity scheduling.

Notes:

84
My Mental Hygiene Program
Was it
Mental Health Habits to Try Tried it? Liked it? Effective? Keep it?

. Diaphragmatic breathing

. Progressive muscle relaxation

. Guided imagery

. Pleasant activity scheduling

. A-B-C-D exercise

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

85
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Session 6 Illness and Mood: Anger

Goals

■ To learn about anger

■ To identify your angry feelings

■ To identify the source(s) of your anger

■ To learn how to problem solve around anger

■ To learn about how to ease your mind

■ To learn how to accept and forgive

Definition of Anger

Being sick isn’t easy. Being sick isn’t fair. You don’t deserve to suffer
and you don’t deserve all of these difficult changes in your life. So
why did it happen? Why you? Why like this? Why now? These and
similar questions are common for people coping with medical ill-
nesses. We’ve learned to appreciate justice and fairness. We’ve learned
to be responsible and accept the consequences of our actions. But
sometimes the scales just don’t seem to even out. Sometimes things
just don’t feel right or just. Understandably, you might be left feeling
angry or robbed.

Angry feelings can come out in all sorts of ways. Do any of the fol-
lowing sound familiar?

■ You snap at your family or friends over little things.

■ You withdraw from normal social contacts.

■ You see happy, healthy people and resent them.

■ You feel like you’re losing or questioning your religious

faith.

87
 ■ You feel a hard knot of anger twisting in your stomach.

■ You have tension headaches, neck aches, or backaches.

■ Your mind keeps going around and around with thoughts

about the injustice of your situation.

■ You have trouble sleeping or relaxing.

■ You drink more alcohol or take medications to make you

feel numb or forget.

■ You feel entitled to special treatment and consideration.

■ You feel anger or blame toward the medical profession.

■ You skip your medications or ignore your doctor’s recom-

mendations out of spite.

■ Your attitude toward life becomes bitter and pessimistic.

■ You feel a need to blame and accuse others for your

misfortune.

Remember everyone gets angry sometimes. It’s a normal emotion

just like any other. It is a natural response to perceived unfairness or
mistreatment. Anger motivates us to acknowledge the injustice and
do something to correct it, protect ourselves, and protect our loved
ones. However, with life-altering events such as serious medical ill-
ness, it’s sometimes easy to get stuck with a lot of anger that has
nowhere to go. There’s often no clear person or thing that can be
blamed. There is no clear injustice or violation of rights. Even if an
injustice can be identified, it is hard to correct or find retribution. In
short, a serious medical illness may challenge some of the basic as-
sumptions you have about the fairness of life or your rights. You may
be left feeling shocked, confused, afraid, depressed, or very angry.

As with other emotions, anger can affect the way you think and what
you do. It may even affect your physical health. It can certainly be re-
sponsible for a lot of interpersonal conflict, sleepless nights, and un-
necessary suffering. This session will help you detect your anger early
and mindfully decide how you want to respond. (You may also want
to read Anger Kills: Seventeen Strategies for Controlling the Hostility that
Can Harm Your Health by Redford and Virginia Williams or When

88
 Anger Hurts: Quieting the Storm Within by Matthew McKay, Peter
Rogers, and Judith McKay. See the Appendix for more information.)

When anger arises we really have three options—expression, sup-

pression, or defusion. We can verbally or physically express our anger
in a variety of ways that are constructive or destructive. We can sup-
press our anger or push it onto a back burner and hope it doesn’t
come out as sulking or other indirect or passive-aggressive ways. Or,
finally, we can defuse our anger by soothing our tense minds and
bodies and addressing the situation that triggered the anger. Just like
with “habits of mind,” we have habits in how we experience and re-
spond to anger. Some of us have lifelong habits of intensely express-
ing anger, while others may have learned that anger is “bad” and
should always be suppressed.

Although there is no foolproof way to cope with anger, the follow-

ing steps might offer some assistance. Depending on the situation,
the most helpful strategy could be constructive expression, tempo-
rary suppression, defusion, or some combination of these three.

Step 1: Identify Your Feelings

Remember that sometimes feelings can lurk outside of your aware-

ness—you can be upset and not realize it. Just as you monitor your
thoughts and activities, you should monitor your bodily sensations
for clues about your emotional state. Other clues include having
friends or family mention that you seem angry, having any of the
“symptoms” of anger listed in the previous section, or having angry
daydreams or fantasies. Use the My Anger Habits Worksheet to
begin identifying your angry feelings and how you tend to express
them.

Step 2: Identify the Source of Your Anger

Remember that anger is usually about the perception of injustice

perpetrated by another person, place, event, or thing. Anger is not
necessarily rational. Feelings don’t always make perfect sense. Many
people who are physically ill are angry at some point, but they can’t

89
My Anger Habits Worksheet

. What signs or symptoms do I have when I am angry?

Physical:

Behavioral:

Emotional:

Cognitive:

Social:

. How can others tell when I am angry? How does anger come out?

. Do I allow myself to feel angry? If yes, how do I express anger?

. If no, how do I suppress anger? What happens if I suppress it? Does it come out in other ways?

. Do I tend to defuse anger? How? Does it work?

. Where do my habits of anger come from? Any family similarities?

90
 really blame it on anyone or anything. Some people get mad at God.
Some people blame themselves or their past health habits (e.g.,
smoking). Some people feel like they are being punished. Others
blame genetics or environmental pollution. Sometimes anger is
simply an expression of suffering. It can be a way of letting others
know we are in pain, we are afraid, or we are depressed.

It is important to determine if the “problem” is about your inner

pain or about an external grievance (or perhaps a bit of both). At this
identification stage, it is important to suspend judgment. Do not as-
sess the rationality or use of being angry—just figure out where the
anger is coming from.

Keep in mind that once anger is set in motion, it is easier to become

angry about any number of things that are unrelated to the original
cause. When you are angry in the moment, remember to “rewind the
tape” enough to uncover what made you angry in the first place. Un-
covering the accurate cause of anger will be important to finding a
resolution. Use the Anger Solutions Worksheet near the end of this
chapter after you have read about all the steps for anger manage-
ment. You may photocopy this form from the book or down-
load multiple copies from the TreatmentsThatWork™ Web site at
[Link]/us/ttw.

Step 3: Problem Solve

After identifying the feeling and its source, the next step is to decide
what, if anything, can be done about it. Not all problems can or
should be “fixed.” If the problem or cause of the anger is deemed
changeable, apply the steps of problems solving:

. Clearly identify the problem.

. List potential solutions.

. Choose a solution based on the pros and cons of each option.

When completing the Anger Solutions Worksheet at the end of this

chapter, the following questions may help you to identify the problem.

91
 . Is it a problem involving another person? (See Session  on
communication and conflict negotiation)

a. Is it something the person did wrong? Can he make atone-

ment or compensation? How can the scales be balanced?
Would an apology help?

b. How much of the anger is about a recent event, and how

much is from the buildup of my past with this person?

c. What is the other person’s perspective?

. Does it seem tied to the management of my disease?

a. Would improved communication with my medical team

help? Have I rallied all the professional support available to
me? (See Session )

b. Is it about new symptoms or a symptom that has gotten

worse? (See Session  on symptom management)

c. Is the fear based primarily in fear and uncertainty about

my illness? (See Session  on anxiety management)

. Is the source of my anger mostly coming from inside? (See

Step )

a. Is my anger mostly about my way of thinking? (See Ses-

sion  on types of thinking and habits of mind)

b. Am I angry because I am depressed, lonely, or feeling

hopeless? (See Session  on depression)

c. Have I lost touch with my faith or source of spiritual

strength? (See Session )

. Is my anger reasonable and expected?

a. Am I just really cranky and irritable right now?

b. Am I taking this too personally?

c. Is my thinking balanced, fair, and nonjudgmental?

d. What would an outside observer say about this situation?

92
Step 4: Ease Your Mind

Sometimes the source of your anger cannot be directly addressed or

corrected. Sometimes the anger comes from inside or it comes from
wounds received long, long ago. If you are mad at the universe or
someone who’s passed away, there’s really nothing practical that can
be done to change the situation. However, you can do something to
change the way you feel. You can cope with the feelings rather than
trying to solve a problem that has no solution.

Here are a few ideas to help you defuse your anger:

Challenge Habits of Mind

As was learned in Sessions  and , everyone takes thinking short-

cuts. Everyone develops habits of mind that sometimes serve us well
but sometimes create unnecessary pain and suffering. In the case of
anger, thinking is often judgmental (a person, place, or thing is la-
beled and judged), thinking is inflexible, and only one unbalanced
side is considered. Try changing your thinking to be more balanced,
flexible, and nonjudgmental. Use the A-B-C-D exercise to challenge
unhelpful thoughts and beliefs.

Distraction

Once anger has started, it is difficult to stop. Anger affects our bod-
ies but it also hijacks our thoughts, causing us to ruminate obses-
sively about the perceived injury. Sometimes this rumination only
worsens the situation or deepens our anger. When your mind feels
stuck this way, it helps to take it elsewhere by using distraction. Try
reading a book, watching a movie, inviting someone over for a visit,
or doing an art or writing project. Pick something that you find ab-
sorbing. Write down here a few distractors that are effective for you:

.

.

.

93
Relaxation

Review and practice the breathing, PMR, and guided imagery exer-
cises from Session . Remember that anger creates tension but relax-
ation washes tension and anger away. It is impossible to remain con-
sumed by anger if you are physically relaxed. Relaxation exercises
may also help distract you from ruminating.

Focus on the Positive

Although there are loses and injustices in everyone’s life, there are
also triumphs and reasons to be grateful. It is important to make a
conscious effort to establish balance. This means actively and con-
sciously recognizing the positive aspects and taking a moment to
savor them. Try starting a gratitude journal or a list of things you are
thankful for. You might also want to create a list of “wins,” life suc-
cesses, pleasurable memories, etc. You’ll learn more about these
strategies in Sessions  and .

Help Others

Sometimes we can make meaning out of pain and sadness by using

our experience and wisdom to help others. Consider volunteering,
calling a friend who needs you, or writing about your experiences in
an inspirational way. What do you have to offer?

Improve Your Health

Sometimes physical exercise and improving one’s diet can help a per-
son feel better both mentally and physically. Try eating healthy foods
that make you feel better or releasing your anger through physical
exercise (you should speak with your doctors about specific details).

Medication

Certain medications can help alleviate the negative effects of stress,

anxiety, depression, and anger. If applicable, you should speak with
your doctors about whether this option fits for you.

94
Get Support

Sometimes just telling another person about your anger can be help-
ful. Let others know how you feel and that you only want them to
listen. It is important to note, however, that talking about your anger
does not become elaboration and escalation of anger. Share the
“strong” feelings of anger but also to be sure to share the more vul-
nerable feelings that lie underneath. It is difficult for listeners to con-
nect with anger and offer useful support. Anger repels. It is much
easier to empathize with what might lie underneath (see Session  on
getting support).

Step 5: Accept and Forgive

Sometimes the most constructive way to cope is to simply let go and

move on. Accepting a situation or forgiving an injustice doesn’t
mean surrender, resignation, or giving up. It doesn’t mean forget-
ting. It doesn’t indicate weakness or passivity. Sometimes acceptance
and forgiveness are the hardest but strongest things a person can do.

Acceptance and Letting Go

You’ve probably heard the famous serenity prayer: “God grant me

the courage to change the things I can, the serenity to accept the
things I can’t, and the wisdom to know the difference.” The fact is,
we simply cannot control or change everything, no matter how hard
we try. You cannot make your illness go away. You cannot roll back
time and erase past mistakes. You can only accept the situation as it
is and move onward with your life. You can’t change the problem,
but you CAN change the way you feel. Sometimes people feel better
when they accept that there is nothing they can do to get better.

Acceptance can simply mean letting go of trying to change an un-

changeable situation. The following ideas might help you in the pro-
cess of letting go.

■ We are powerless to control another person even if we love

them dearly.

■ Everyone has to make and learn from their own mistakes.

95
 ■ Sometimes taking away another person’s pain keeps them
from learning.

■ Even the strongest people are sometimes powerless.

■ You can place blame, but you can’t force someone to accept
blame.

■ Sometimes things happen for reasons we will never under-

stand.

■ People and relationships come as whole packages—good

and bad.

■ I cannot understand what it is like to be you and you can-

not be me.

■ I can affect my health but I cannot control it. Even the

most advanced machines sometimes break down and can-
not be fixed.

■ Regretting the past prevents me from appreciating the pres-

ent and dreaming about the future.

■ If I want someone to change, I can start by changing

myself.

■ Good people sometimes do bad things. We are all guilty

sometimes.

■ Sometimes letting go means accepting the unknown and

being afraid but remembering our sense of faith and trust.

Forgiveness

Forgiving simply means choosing to let go of past injuries. You can

then invest your limited energy elsewhere. The forgiver receives the
most benefit. You may forgive someone else or yourself for past mis-
takes. Either way, forgiveness starts with making a choice—the
choice to release anger and move on. It is important to remember
that forgiveness is an ongoing process. Its many steps are as follows:
Step : Identify the insult, injury, or violation that has occurred.
This includes striving for balanced thinking and owning your
own role in the situation.

96
 Step : Own the outcome. This involves admitting that the illness
or injury is permanent and is now yours to cope with. Although
the external wound might have healed, if you are still angry or
changed in some way, the injury continues. Own it. It is now
part of who you are.

Step : Determine accountability. Someone or something is held ac-

countable for causing the harm. You might find that you are ac-
countable or that no one can be held accountable.

Step : Balance the scales. You are not a hopeless and helpless vic-
tim. Do something to rectify the problem if possible (see Step 
of this session, or Session  on conflict resolution).

Step : Choose to forgive or release a grudge. Try empathizing with

the responsible party. What was she thinking or feeling? What
was it like for her growing up? How was or is she hurting? How
much is staying angry costing you? Costing her? This step is not
about making excuses. It is about finding explanations that help
us better understand why something happened.

Turn to the Acceptance and Forgiveness Worksheet at the end of this

chapter when you are ready. You may photocopy this form from the
book or download multiple copies from the TreatmentsThatWork™
Web site at [Link]/us/ttw. At this point, you should identify
any interpersonal conflicts or other areas in need of work. Later ses-
sions will explore conflict resolution. For more on the process of for-
giveness, consult the following books (see the Appendix for more in-
formation):

Forgiving the Unforgivable: Overcoming the Bitter Legacy of Intimate

Wounds by Beverly Flanigan

Forgive for Good: A Proven Prescription for Health and Happiness by

Fred Luskin

Importance of Reconciliation at the End of Life

Many believe that acceptance and forgiveness are especially impor-

tant at the end of life. Although much of life may have been about
work, finances, or daily stressors, in the end it is our relationships
that matter the most. If there are ongoing conflicts or unresolved dif-

97
Anger Solutions Worksheet

Step : Identify Your Feelings

Name what you are feeling now (e.g., anger, rage, irritation, frustration, contempt):

What are the signs or symptoms?

Biological:

Cognitive:

Emotional:

Behavioral:

Social:

Step : Identify the Source of Your Anger

. What made you angry? Was it a person, place, thing, event, or idea?

. What happened right before you felt angry? What was going through your mind?

. Who are you angry with? Does the person know you are angry?

98
. What’s the injustice? What “right” has been violated?

. Is this anger really about you feeling sad? Or grieving? Being in physical pain? Being sick? Is this anger
your way of expressing distress?

Step : Problem Solve

Is this problem or situation changeable? ________________________

If yes, then follow the steps of problem solving from Session . List possible solutions, weigh the pros
and cons, and put your solution into action.

If no, then move to Step .

Step : Ease Your Mind

List the strategies you would like to try to ease your mind. Be sure to practice them regularly.

.

.

.

Step : Accept and Forgive

Does managing your anger require you to forgive someone or accept a situation you cannot change?

If yes, see the Acceptance and Forgiveness Worksheet.

99
 ferences in your life, it may be important to work for a reconciliation
while there is still time. The “advantage” of having a chronic illness
(in contrast to a sudden and unexpected death) is that it gives you
time to do the “work” of closing out your life. That may include for-
giving yourself, forgiving others, and expressing love and gratitude. Al-
though your illness may cause you to no longer be able-bodied, it may
assist you in becoming able-hearted.

Homework

✎ Complete the My Anger Habits Worksheet.

✎ Practice the five steps of anger management using the Anger
Solutions Worksheet.

✎ Identify and begin reflection using the Acceptance and Forgive-

ness Worksheet.

✎ Continue relaxation or other skill practice as needed.

Notes:

100
Acceptance and Forgiveness Worksheet

Step : Identify the insult, injury, or violation that has occurred.

Step : Own the outcome. Admit that the illness or injury is permanent and is now yours to cope with.

Step : Determine accountability. You may find that no one can be held accountable.

Step : Balance the scales. Do something to rectify the problem if possible.

Step : Choose to forgive or release a grudge. Try empathizing with the responsible party.

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Module 3
Social Supports
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Session 7 Social Support Network

Goals

■ To learn about types of support

■ To identify your support network

■ To evaluate your support network

■ To learn steps for expressing support needs

■ To take care of your social supports

Definition and Types of Social Support

Your social support network is simply the people in your life who are
there for you when you need them. Social support is something we
all need, especially when we’re ill. Support can be long distance or in
person. It can be ongoing or one time only. There are several differ-
ent types of support.
Emotional support includes behaviors and words that make you feel
cared for, understood, and supported—for example, a kind
word, crying together, or holding hands.

Informational support includes advice, information, problem solv-

ing, or suggestions on how to deal with a particular situation.

Practical support can be practical actions such as driving you to an

appointment or doing your laundry. It can also be providing
practical objects or resources such as money.

Giving and Getting Support

We all give and receive varying kinds of support throughout our

lives. Sometimes being ill means we need a lot of each kind of sup-

105
 port. Sometimes being ill means we lose friends or supports. We may
also have a lot of conflicts and misunderstandings with loved ones.
Those conflicts often arise from differences between the kind of sup-
port that is needed or expected and the kind of support that is actu-
ally received. For example, a patient returning from a doctor’s
appointment really needs to vent and get emotional support. In-
stead, his family member starts giving advice and problem solving
(i.e., giving informational support instead of emotional support).
The patient then feels unheard and unsupported and the family
member wonders what went wrong. Both people are at fault in this
scenario. The patient should have expressed his needs more clearly
and the family member should have asked instead of just jumping in
with advice.

Another common problem has been called “compassion fatigue,” or

caregiver burnout. If the tasks of caregiving are chronic and over-
whelming, caregivers sometimes grow impatient or resentful. The
caregivers then end up feeling guilty about their negative feelings,
causing them to be even more stressed. They truly want to help and
meet all of their loved one’s needs, but they are only human and can
only do so much. Just as you need to be aware of and express your
needs, your caregivers also need to be attuned to what they need as
caregivers. Often this might mean a few days off, respite care, or
creating a care schedule in which others take “shifts” to help you.
Other ideas on caring for caregivers are provided near the end of this
chapter.

Social Support Network

Think about the people in your social support network, including

medical professionals, neighbors, pets, or other potential supports.
Write down the names of these individuals on the Social Support
Network Diagram. Their location on the diagram should be based
on how close they are to you (i.e., closer people are closer to ME at
the center) and what kind of support they are able to provide (i.e.,
emotional, informational, practical). If they can provide more than
one type of support, write down their names more than once. This
will help you know who is most likely to give you what you need.

106
My Social Support Network Diagram

In each section, write the names of individuals who provide that kind of support. Place each name closer
or further away from Me depending on how close you are to the person.

Emotional

ME

I n f
cal

orm
ti
ac

ati o
P r

l na

107
Evaluating Social Supports

Evaluate your social support network by answering the following questions:

. How are your current supports doing in terms of meeting your needs?

. What grade would you give the overall social support you currently receive?

. What do you think is missing?

. What support are you grateful for?

. Do you need to add new people to your list?

. Do you wish your social supports were closer to you? Who do you want to be in your inner circle?

108
After evaluating your social network, you may realize that you need
to expand your list of supporters. Remember that support and sup-
porters can come in all shapes and sizes. Some sources of support we
sometimes don’t think about include the following:

■ Religion or spirituality

■ Inspirational books or articles

■ Movies or TV shows

■ Pets

■ Memories

■ Neighbors
■ Music

■ Nature or the outdoors

■ Community support groups

■ On-line chat rooms and groups

■ Social workers

■ Health providers

■ Medical newsletters

■ Volunteer groups and advocates

■ Art

Add a few of your own ideas in the spaces provided. Think about
how you can better draw on these sources of support.

After evaluating your support diagram, you may realize you have
enough people but there are too few people in your “inner circle.”
Select the individuals you would most like to bring closer to you.
How can you go about building intimacy and closeness with these
individuals? Remember that shared time together is a key ingredient,

109
 as is a mutual desire to grow closer. How can you express your need
to get to know them better? What’s a useful first step? Remember
that building intimacy takes time and that not everyone is willing or
able to participate. Write down one key individual below, along with
a few key intimacy-building ideas.

Name of individual:

Intimacy-building ideas:

Expressing Support Needs

When you experience stress, it is essential that you be able to express

yourself to get the support you need. You might need to vent. You
might need a hug. You might need money. You might need to let
someone know about physical pain or trouble breathing. Whatever
your needs, it is important to do the following:

. Realize you need help and what specific kind of help you need.

. Believe that you deserve help.

. Believe that expressing your need and getting help will be useful.

. Assertively ask the person best suited to your needs to help you.

. Accept help graciously.

. Nurture and care for your social supports.

After you review these steps, write down any thoughts you have
about support on the My Thoughts about Social Supports Work-
sheet at the end of this chapter. It is common to have doubts, wor-
ries, or reservations about needing more support. Just remember that
every transition is a struggle at first. Sometimes acceptance and
openness can ease the way forward. Use your thought-balancing or
A-B-C-D skills to rewrite these thoughts into more helpful forms if
needed.

110
Step 1: Realize You Need Help and What Specific Kind of Help You Need

Depending on the situation, you might need all three types of sup-
port (emotional, informational, and practical). You also might need
help from more than one person. Identify what you need, when you
need it, and who is best suited to help.

Step 2: Believe that You Deserve Help

Remember, nobody deserves to suffer and struggle alone. You de-

serve as much compassion as you would extend to others. Be com-
passionate to yourself and allow others to help you. You deserve
it. Others deserve an opportunity to express their love and feel use-
ful. It isn’t about being a burden. It is about sharing our journey, re-
gardless of the terrain.

Step 3: Believe that Expressing Your Need and Getting Help Will Be Useful

This step is all about hope—not hope for a cure, but hope that ask-
ing for and getting help will make a difference in how you feel.
When you are sick or in pain it’s hard not to feel hopeless. It may
seem like you’ve tried everything. It may seem like asking for help
just won’t do any good. It’s okay to be skeptical, but go back to
square one and try again. Only this time, follow each step carefully
and see if you can’t improve your chances of getting the help you
need. In fact, if you carefully choose whom to ask, when to ask, how
to ask, and what to ask for, your chances of getting a response will
be much higher. It might not work every time, but it’s sure worth a
try. If someone lets you down, go to someone else.

Step 4: Assertively Ask the Person Best Suited to Your Needs to Help You

This step involves knowing your social supports and their strong
points. It also requires knowing how to communicate effectively. Re-
call your Social Support Network Diagram. Who was on it? What
were their special strengths? After you know what kind of support
you need, who on your list can provide it? Once you’ve picked whom
you are going to ask, how do you ask? If possible, be sure to pick a

111
 time when your support person is able to consider your request and
respond. Remember Step —you deserve support!

Step 5: Accept Help Graciously

When accepting help, it’s important to be gracious to your helper

and gracious to yourself. Sometimes accepting help can be hard to
do—especially if it feels like someone is helping you all the time.
Things have changed, and that might be very difficult to accept. Cer-
tainly no one wants to have more limitations or be able to do less.
But it might be unavoidable. You can only do as much as your body
and mind will allow.

Remember that your loved ones need to be able to express their love.
They may feel helpless too. They need to feel like there’s something
they can do. They need to repay you for all the support you’ve given
them. Your illness might be hard for them and they might need to
receive outside support for themselves, but they also need to give
support—to give support to you.

Step 6: Taking Care of Your Social Supports

Being medically ill doesn’t mean you can’t give support to the people
you care for. Who do you currently support? What types of support
do you give? What’s your forte or strong point? Are you giving too
much and feeling drained? Are you giving too little and not feeling
useful? What can you as the person in need do to help?

How I Can Care for My Caregivers

Here are some suggestions for taking care of caregivers:

. Give your caregiver a vacation. Ask others to step in and take

over temporarily.

. Encourage your caregiver to get some support for himself. This

may include a caregiver support group.

112
 . Make sure you let your caregivers know how much their care
and love mean to you.

. Involve more than one person in your care if possible. A shared

load is a lighter load. Consider making a care schedule—i.e., a
calendar where people can sign up for “shifts” or periods when
you need support.

. Ask your doctor, nurse, or social worker about community

resources for caregivers or go online to see what might be
available (see Appendix).

. Offer your caregiver what support you’re able to give —e.g.,

money, affection, laughter, gratitude.

. Help your caregivers stay organized and informed—for ex-

ample, invite them to doctor appointments, allow them to
speak with your nurse, or provide them with medical records
or vital contacts related to your health care or support.

. Don’t forget to savor the good times. Share old stories, photos,
music, or things that take you back to easier times.

. Schedule a shared pleasant activity such as music, a meal, or a

movie.

Now list a few ways in which you can care for your social supports.
These should be concrete but realistic. Be sure to include when and
where you will put these into effect.

Care Strategy With Whom When Where

113
Homework

✎ Complete the My Social Support Network Diagram.

✎ Evaluate your social support network and identify areas that
need improvement.

✎ Complete the My Thoughts about Social Supports Worksheet.

✎ Seek or provide new support as needed.
✎ Continue with mood management and/or relaxation strategies.
Notes:

114
My Thoughts about Social Supports Worksheet

Thoughts about deserving help: New helpful thoughts:

My medical bills are costing a fortune. I would do the same and more for them.
I can’t ask for more. It’s ok to receive.

Thoughts about successfully getting help: New helpful thoughts:

I’ve asked before. This will never work. Maybe I asked the wrong person at the wrong time.
It’s worth another try.

Thoughts about support being effective: New helpful thoughts:

There is nothing anyone can do. Even if they can’t cure me, we can enjoy our time
together.

Thoughts about accepting help New helpful thoughts

I’m a giver, not a taker. I feel so needy! Sometimes allowing others to care for us is a gift to
them.

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Session 8 Communication and Conflict Resolution

Goals

■ To understand the importance of good communication

■ To learn active listening skills

■ To learn how to express yourself effectively

■ To learn conflict resolution

■ To understand the importance of quality time for strong

relationships

■ To get the most out of your health care

Importance of Good Communication

Relationships are like cars—both need regular maintenance or they

begin to have trouble and break down. We should always expect to
do some minor tune-ups and sometimes a major overhaul. When
one or both people in the relationship are medically ill, regular rela-
tionship maintenance is even more essential. “Maintenance” almost
always requires clear, open communication and sharing. Spending
quality time together is also an important element of strengthening
relationships.

Though we are born with the capacity for speech and hearing, com-
munication is an acquired skill that some say takes lifelong practice.
Communication is especially hard when it involves emotionally
charged issues such as illness, money, religion, and sex. To further
complicate matters, each of us comes with different family and cul-
tural traditions about how, when, and what to communicate. A re-
lationship often involves learning to “speak the language” of your
partner and vice versa. Good communication involves work from

117
 both sides of the fence—the person speaking or communicating and
the person listening.

Tips for Good Communication

. Try to assume an attitude of partnership and equality. You may

not see eye to eye, but you are both valuable human beings
with a perspective worth understanding.

. Pick a good time when both of you are ready and able to talk
and other demands or distractions aren’t pressing.

. Limit the discussion to the issue at hand, even though the

temptation might be to do it all while you have the person
there. Save other issues or conflicts for later. Don’t drag in the
past, since we all remember it differently.

. After you have expressed your point of view, specify exactly

what you want the other person to do.

. Give a clear rationale about why you need the person to do this
and how important it is to you.

. Check with the other person to make sure she understood your
request or the issue at hand. For example, you might say, “I just
want to make sure I was able to effectively express what I need
you to do. Can you tell me what you just heard?”
. Get a clear response from the other person and double check to
make sure you understood her. For example, “Good. It seems
like we’re on the same page. So what is it you are able to
do? . . . If I heard you correctly, you agreed to do such-and-
such. Is this right?”

. If the other person’s response is what you needed to hear, then

express your gratitude or other ways it makes you feel. Then
think of the next steps to put her response into action.

. If the other persons’ answer is not what you wanted, then try
to understand why. Alter the request or begin negotiating an
acceptable solution.

118
Active Listening

Despite common belief, listening is not a passive process. As we lis-

ten we can’t help but add our own subjective interpretations and
make our own connections. However, beginning with a sense of
partnership allows us to hear more of what is being said before jump-
ing to conclusions. It takes an active effort to stay with the speaker
and check to see if we’ve understood what they are trying to com-
municate. Listening also involves giving clues that we’re listening,
asking questions, and providing feedback.

Tips for Listening

Optimize Your Environment and Attitude

■ Eliminate distractions such as TV, telephone, etc.

■ Make sure you’ve eaten and/or have something to drink

■ Provide privacy if necessary

■ Suspend judgment and try to listen with an open mind

Improve Your Nonverbal Cues

■ Make and keep eye contact (unless cultural rules view eye
contact as rude or too direct)

■ Lean slightly forward toward the speaker

■ Keep an open, relaxed posture

■ Use nods or “uh-huhs” to indicate you’re still with the

speaker

Improve Your Verbal Cues

■ Use clarifying questions but don’t change the subject

■ Do not interrupt with your own story

119
 ■ Use empathic statements (“I’m so sorry that happened”) to
indicate your concern
■ Paraphrase what you heard after the speaker finishes to
make sure you heard correctly
■ Ask the speaker what she’d like you to do before jumping
to action

Obstacles to Listening

Although listening might sound simple, it’s not. For many of us,
there are common obstacles that prevent us from being good listen-
ers. Many of them are similar to the “habits of mind” discussed in
Session . These can include the following:
■ Blaming, labeling, or judging
■ Jumping to conclusions
■ Mind reading
■ Rehearsing what we want to say instead of listening
■ Being distracted and thinking about something else
■ Competing for status, power, or “air-time”
■ Being argumentative
■ Focusing on minor issues or inconsistencies
■ Giving unsolicited advice
■ Getting angry or irritable (usually from a perceived injus-
tice or violation)
■ Not being empathetic or able to “step in the other person’s
shoes”
■ Being self-absorbed with our own stories
■ Thinking we are “better” than the person talking
■ Playing the “yes-man”
Think of which obstacles are a problem for you. What have you no-
ticed about your and others’ listening patterns? Where were these
patterns learned? Do you believe these patterns are changeable?

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 What might be a first step for improvement? Jot down a few notes
below.

How to Express Yourself Effectively

Remember that listening is only one half of the equation. The other
half involves expressing yourself effectively. This expression may be
verbal, written, emotional, and other nonverbal forms of discourse
that convey information. There is no “right” way to communicate,
but there are ways that are more or less effective in achieving your
goals.

Record the ways you communicate on the My Ways of Communi-

cating form. This form is divided into ways of listening and express-
ing, followed by an evaluation of how effective your communication
habits have been.

Your communication style is influenced by your family and cultural

background. These important factors may also make it difficult to
learn new communication skills. See the My Communication Fam-
ily Tree exercise and draw your family tree as in Figure ..

The following example uses a simple genogram format in which a

circle represents a female, a square represents a male, and a horizon-
tal bar joining two shapes represents marriage. In this family tree,
Rachel is a single woman with one brother and no aunts or uncles.

121
My Ways of Communicating

. Think about your typical communication style. Consider your rate and quantity of speech—fast or
slow, a lot or a little. Is the content clear and organized? Do you take turns or dominate the conver-
sation? What kinds of nonverbal communication do you tend to use?
When I am the talker:

. Think about your typical listening patterns. Do you interrupt? Share your own stories? Multi-task?
Roll your eyes? Make eye contact? What are your thoughts, feelings, and behaviors?
When I am the listener:

. When you are having a bad day, how does your communication change?

. Evaluate your communication style:

Do these habits work in certain contexts only? With certain people only?

If these habits are not terribly effective or cause greater conflict, what is it that goes wrong?

What is the obstacle or habit of mind that gets in the way?

How much is due to you, your partner, and the situation?

What grade would you give yourself as a talker or a listener?

122
 Grandpa Grandma Grandpa Grandma

Dad Mom

Brother Rachel

Figure 8.1
Example of a Family Tree

Conflict Resolution

Regardless of how strong a relationship might be, there are bound to

be misunderstandings and other conflicts. Given how common con-
flicts are, it’s important to know what to do when one arises. Con-
flicts can be overt (loud argument, slamming doors), indirect (with-
drawing or refusing to speak to someone), or hidden (pretending
that everything is ok but showing anger in a passive-aggressive or in-
direct way). Conflicts might be with family or friends but could also
be with medical providers, health insurance companies, or random
people you encounter in day-to-day life.

Effective conflict resolution skills involve three key elements:

. Assertiveness

. Learning to fight “fair”

. Negotiation

123
My Communication Family Tree

In the space below, draw your family tree going back two generations ( your immediate family, your par-
ents and grandparents). Be sure to label each shape. You might want to place a star by individuals who
were especially important in influencing your communication style. After you have drawn the figure, re-
flect on the communication style of both your immediate and extended family.

. What was the overall communication style of your family (e.g., loud and boisterous, quiet and re-
served, highly emotional and expressive, stoic and serious, direct or indirect, etc)?

. How did people express themselves? Verbally? Written? Nonverbally?

. How did people listen?

. How well did this work? When did it cause problems?

. In what ways is your communication style similar to or different from your family’s style?

. Are there any changes you’d like to make in your communication style? Which family members will
support this? How will you learn and practice?

124
Assertiveness

Assertiveness means being able to clearly and directly express your

thoughts, feelings, and needs (your “rights”) without violating the
rights of others. Assertiveness is NOT being aggressive or attacking.
Assertiveness is NOT being passive or withdrawn. No one is as-
sertive % of the time, and you should “choose your battles”
wisely. The key is to be able to be assertive and to know when to do
it. This involves first caring about yourself and recognizing your
“rights” as a human being—particularly as a human being with a
chronic illness. Some general rights include the following (adapted
from Davis, Eshelman, & McKay, ):

■ Putting yourself first sometimes

■ Coping with your illness in your own way

■ Receiving high-quality medical care and pain management

■ Making your own mistakes

■ Doing a mediocre or poor job

■ Having your own feelings, opinions, and values

■ Feeling hopeful even when it seems hopeless

■ Changing your mind

■ Speaking up when you are treated unfairly

■ Asking for clarification if you don’t understand

■ Asking for support

■ Ignoring advice

■ Being rewarded and encouraged

■ Saying “no” (or saying “yes” or “maybe”)

■ Being alone

■ Exploring spirituality in whatever way you define it

■ Not taking responsibility for someone or something else

■ Being treated with dignity and respect

125
 As part of the progression of your disease, you may have lost your in-
dependence, control, and autonomy. You may find it hard to assert
your needs when you already feel like a burden and don’t want to ask
for more. Friends and family might have begun to treat you like a
child (though with the best of intentions). However, it is important
for both you and your caregivers to recognize that you are still an
adult with adult needs regardless of your level of disability. As you
near the end of life, you have a right to respect, dignity, and care.

Complete the Promoting Assertiveness exercise to challenge beliefs

about assertiveness that might get in your way.

Case Example

■ It had been so long since Derek had stopped talking with his son, he
had forgotten why. He knew it had to do with the divorce and all the
things that had been said and done in the heat of the moment. But the
divorce was over and tempers had cooled long ago. Derek really missed
his son and wanted to be a part of his son’s life—especially now that
Derek was having more and more shortness of breath from his emphy-
sema. So Derek picked up the phone and called his son. They set up a
time when both of them could meet face to face. He knew a lot needed
to be said, but a lot could probably go unsaid, too. What was impor-
tant was his love for his son and his willingness to work through the
conflict. He hoped he could remember how to communicate well and
“fight fair.” ■

Fighting Fair

Fighting (or conflict) is as inevitable as death and taxes. It’s bound to

happen to everyone at some time or another. The key is to learn the
rules of constructive conflict that can help resolve the issue rather
than making it worse. Unfair fighting can be attacking, hypercriti-
cal, loud, angry, unfocused, and sometimes violent, but unfair fight-
ing can also be characterized by sulking, withdrawal, and passive-
aggressive behavior. Refer to Table . for some common features of
unfair fighting and constructive conflict.

126
Promoting Assertiveness

Use the A-B-C-D steps: Activating event ¡ Beliefs ¡ Consequences ¡ Dispute

Scenario :
Activating event: You are asked to take a medication that hasn’t worked for you in the past, but you are
afraid to disagree with your doctor.

Beliefs that interfere with being assertive:

Consequences:

Dispute:

Scenario :
Activating event: You had a rough, sleepless night and you really don’t think you can meet your friend
for lunch as you had promised. You’ve cancelled before and you feel really guilty.

Beliefs that interfere with being assertive:

Consequences:

Dispute:

Scenario : (Create your own)

Activating event:

Beliefs that interfere with being assertive:

Consequences:

Dispute:

127
Table 8.1 Features of Unfair Fighting and Constructive Conflict
Unfair Fighting Constructive Conflict

Bad timing-ambushed, too rushed, too many Setting a good time for both people
distractions
Blaming Stating the specific issue at hand rather than jump-
ing to blame
Too many issues from the past and present get Sticking to only one issue per conflict
brought up at once
Covering vulnerable feelings with anger or Expressing the full range of one’s emotions
righteousness
Not hearing the other person Active listening
Making impossible demands Proposing specific changes
Threats and ultimatums Describing consequences
Insults or “barbs” Partnership, equality, and respect
Escalation Taking time to cool off, staying focused
Sour endings or no resolution Shared resolution or agreeing to disagree

Adapted from McKay, Davis, & Fanning ().

The following questions might assist you in understanding your

fighting style and identifying areas for improvement. Although there
may be overlap with your general style of communication, your
fighting style may differ in important ways. Compare your responses
to the examples in the table.

■ When was the last time you had a fight with someone?

■ What happened? What were your thoughts, feelings, and

behaviors?

■ What was the other person’s response? Were you satisfied?

If not, what needed to happen?

■ Was the problem an issue of communication? Listening or

speaking?

■ Was it a conflict of goals or needs? Expectations?

■ Did both of you follow the rules of constructive conflict?

Was it unfair fighting?

■ What would you do differently if you could do it over?

128
Negotiation

The final set of skills needed for conflict resolution has to do with
the art of negotiation. When each party has different and competing
needs, it is important to find a middle ground. Each negotiation has
four potential stages. Your approach to each of these stages will
greatly influence both the outcome and the process of the negotia-
tion. Even very difficult negotiations with very high stakes can be ac-
complished with respect and partnership.

. Preparation: Before talking about the problem, know how you

feel and what you want. What are acceptable outcomes? Where
can you bend? Remember that flexibility is a key skill, but so is
assertiveness and knowing what you need.

. Discussion: Both parties describe the facts of the situation and

provide information. You need to understand the other person’s
reasoning and feelings and vice versa.

. Proposal and counterproposal: Both parties make offers and look

for common ground. You will have to adapt and change your
offers as needed.

. Agreement and disagreement: Is there enough common ground?

Have you planned on a course of action? Have you “agreed to
disagree?”

The following negotiation tips might be helpful the next time con-
flict arises.
. Understand and manage your feelings. Perfectly good and rea-
sonable people can have differing opinions and needs. Are you
experiencing strong emotions? Why? What are the actual stakes
involved? Do a little soul searching if you get stuck or over-
whelmed.

. Separate the people from the problem. It doesn’t have to be

about personalities. Most people have the same general goals
(e.g., to be happy, loved, successful) but may have different
ideas of how to go about achieving them.

. Express empathy and sensitivity. Everyone needs to feel heard,

even if you don’t agree with them and can’t give them what

129
 they want. Try to understand the person. Empathy, active lis-
tening, and emotional honesty are all essential.

. State your interests or motivations as a way to find common

ground. Maybe your motivations are in line but your methods
are different.

. Have a “BATNA,” or Best Alternative To a Negotiated Agree-

ment. If you can’t get exactly what you want, what is a good
Plan B?

. Try to be flexible. Brainstorm alternatives together. What can

each of you live with?

. Give a little to get a little. “Giving in” this time might help you
the next time around.

. If things get too heated or too stuck, postpone negotiations.

. Share positive feedback and appreciation after you’ve reached

an agreement.

Caring for Your Relationships: Quality Time

Remember that relationships need attention, even when there isn’t

anything to be fixed. An important part of strengthening a relation-
ship is spending “quality time” together. Even when we’re healthy
this can sometimes be a challenge. When we’re ill, the competing de-
mands of doctor’s appointments, medication side effects, limited
mobility, etc. can all make quality time seem almost nonexistent.

The following is a partial list of shared activities others have tried and
enjoyed in the past. These activities can strengthen your relationships.
They may also help you both feel less depressed and anxious.

130
Shared Activities List

. Having a nice or informal dinner . Having a dinner party

. Playing sports . Doing an art or crafts project

. Playing board games . Singing or playing music

. Sharing and discussing cards or old photos . Providing child care or enjoying the company
of children
. Watching TV and discussing the show
together . Writing letters or cards

. Going to the movies . Phone conversations or e-mails

. Baking together . Swapping backrubs

. Reading aloud to one another . Going to church or spiritual services

. Going dancing (or watching) . Caring for pets

. Going for walks . Praying together

. Solving puzzles or crosswords . Participating in community or political groups

. Sitting outdoors . Playing computer or video games

. Talking about current events . Using the Internet

. Going for a drive . Going to a museum exhibit

. Listening to music together . Sharing coffee or tea

. Going to a concert or play . Eating at a restaurant

. Gardening . Traveling

. Shopping

131
Getting the Most out of Your Health Care

Getting the Most from Your Health Care Providers

In order to best work with your health care “team,” it is important

to be able to name all members and understand their roles. Com-
plete the My Health Care Team Form, including contact informa-
tion and role descriptions.

Forming a positive, nurturing relationship with your health care pro-

viders will help them provide you with high-quality health care. The
following suggestions can help you build these relationships. Re-
member that you are a key member on this team.

. Develop an empathic understanding of what your doctor does.

Your doctor probably seems rushed. She may seem abrupt, dis-
tracted, uninterested, or even short-tempered. It is important
to remember that your doctor may have been up all night, may
have dozens of very complex (and very upset) patients in just
one day, or may have personal problems of her own. There are
a million and one high-stress things for her to do, and pressures
from health insurers are only getting worse. Although this isn’t
an excuse, it is a reason to not take her response personally. If
it seems right, give her a second chance before moving on to
someone else (assuming you have a choice). If you don’t have a
choice, express some empathy but let her know how you are
feeling—e.g., “Doc, I’m sorry things are so busy and stressful
around here, but I’m really counting on you to hear what I
have to say. . . .”

. Remember that your doctor is just a person. Doctors make mis-

takes. They have bad days. They may get cranky or annoyed.
You might remind them of a family member they lost, or the
issue you have might cause them some embarrassment. Your
doctor may be someone substantially younger and less experi-
enced in life than you. Although doctors may have “heard it
all,” they still have emotional reactions, no matter how good
their poker face might be. Although being human means mak-
ing mistakes, it also means being capable of learning and grow-

132
My Health Care Team

My primary doctor is

Contact information: Phone:

Fax:

E-mail/other:

His/her role:

Specialist or other health care provider ():

Contact information: Phone:

Fax:

E-mail/other:

His/her role:

Specialist or other health care provider ():

Contact information: Phone:

Fax:

E-mail/other:

His/her role:

Specialist or other health care provider ():

Contact information: Phone:

Fax:

E-mail/other:

His/her role:

You may want to include other important team members and contact information (e.g., pharmacist,
nurse, psychologist, physical therapist, clinic, transportation, etc.) on another sheet.

133
 ing. Your physician may grow with you or perhaps because of
you. Don’t be intimidated. Your doctor is human too.

. Give positive feedback. Most doctors are critical and perfection-

istic by nature. They worry that they have missed something or
feel like they are a step behind in keeping up with all the latest
medical advances. Let you doctor know when she does some-
thing right, says something meaningful, or provides good service.

. Although doctors are pressed to be efficient, don’t be afraid to be

yourself. When appropriate, share information about your life,
your family, or things that make you a unique individual. Most
doctors won’t have much time for this kind of exchange, but
when the opportunity arises, take it. It is much more rewarding
to care for a person than to care for a body with a disease.

Gettting the Most out of Your Doctor’s Visits

Remember that you are a partner in your health care. You get a
“vote” and may provide important information for diagnosis or
management. However, being a partner also means that you (and
your caregiver) have the responsibility to prepare before a doctor’s
appointment. If you are not sure what would be most helpful, ask
your doctor. Some ways to prepare include bringing your list of cur-
rent medications with dosages and frequencies (or the pill bottles),
bringing a list of the most important things you would like to dis-
cuss in that visit, and doing any “homework” you might have been
assigned (e.g., recording blood sugar levels, tracking frequency of
certain symptoms). Other suggestions include the following.

. Know your medical history. It will save a lot of time if you can
bring a medical summary or copies of past medical records.
Bring information on your family’s medical history too. Be sure
to include a record of past medications and medical tests that
you may have already tried (rather than reinventing the wheel
with each new doctor.)

. Ask questions and take notes. If you tend to forget what you
need to ask when you are in the appointment, write down the
most important questions and bring them with you to the visit.
Don’t be afraid to jot down questions or other notes while your

134
 doctor is talking (she probably takes notes while you are talk-
ing too). You might also want to bring a friend or family mem-
ber to help you recall what was said or you could tape record
the visit. A lot might get said in those  minutes!

. Express how you feel. Your doctor isn’t a mind reader. She may
not know you well enough to read your emotional signals or
she may be too distracted to catch your emotional clues. If you
are afraid, angry, or sad, let her know about it. Practice your
new communication skills.

. Summarize the visit. Before your doctor ends the visit and walks
out the door, be sure to attempt a summary of what was dis-
cussed in the visit and what you are now supposed to do. This
helps the doctor and you see how well you communicated with
one another, clarifies any changes to the treatment plan, and
reminds both of you what needs to be done before the next
visit.

. Ask for other help. If you run out of time but need more infor-
mation about your disease, treatments, or testing, ask if there is
another health care team member who can help out. Doctors
can often refer you to a health educator, nurse, or behavioral
medicine specialist with special expertise in chronic disease
management.

How to Communicate with Your Doctor’s Answering Service

The most challenging (and frightening) times are when urgent medi-
cal issues emerge during evening or weekend hours and the doctor’s
office is closed. You can greatly alleviate anxiety and facilitate the
process of getting help if you follow a few simple steps.

. During regular working hours, ask staff at your medical clinic

about their procedures for after-hours coverage. All clinics have
an answering service with an on-call system or some agreement
with a local hospital that can provide urgent or emergency
medical care. Keep these after-hours contact numbers posted in
several places in your house—e.g., by the phone, on the refrig-
erator, etc.

135
 . If you have a special agreement with your doctor (e.g., an un-
usually high but needed dose of pain meds), be sure your doc-
tor makes a note in your medical chart. The on-call doctor may
not be familiar with your case and the note can save a great
deal of time and frustration.

. Before making the after-hours call, jot down a few notes about
what happened and why you are calling. It is easy to get flus-
tered on an after-hours call and forget to share critical informa-
tion. Before calling, you should make sure that this is not an
issue that could wait until the morning.

. If you get an answering service (and not a qualified medical

professional), leave the important information, including a
call-back number. If it is not a life-or-death situation, allow
your doctor  minutes to get back to you before calling again.
If you call back, verify that the answering service has the cor-
rect information and call-back number.

. When the doctor calls you back, remember that you might not
get your regular doctor. Doctors usually take turns providing
after-hours coverage. This new doctor may not have your med-
ical chart and may not be aware of any of your medications or
other arrangements you might have made with your regular
doctor.

. If you are having a medical emergency such as chest pains, take

steps to get yourself to an emergency room unless you and
your doctor have already come up with another plan (e.g., take
a nitro pill or aspirin then wait a few minutes).

. Remember to not be afraid to assert yourself—the “squeaky

wheel” does often get the oil. However, a little etiquette can
often accomplish your goals more effectively without wasting
your energy on anger.

136
Homework

✎ Complete the My Ways of Communicating form.

✎ Complete the My Communication Family Tree form and an-
swer reflection questions.

✎ Complete the Promoting Assertiveness form.

✎ Try practicing some communication or conflict skills with a
friend or family member.

✎ Schedule a “quality-time” activity with a friend or family

member.

✎ Complete the My Health Care Team form.

Notes:

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Module 4
Quality of Life
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Session 9 Management of Medical Symptoms

Goals

■ To learn how to manage your medical symptoms

■ To review tips for coping with chronic pain

■ To review tips for coping with insomnia or sleep problems

■ To review tips for coping with other common medical

symptoms

Important Note

You should always consult with your physicians before making any
changes to your medical care. You may want to use this session to
develop ideas to run by your medical team.

Managing Medical Symptoms

There is no easy way to live with pain, shortness of breath, insom-

nia, nausea, or any of the other difficult medical symptoms or side
effects that often accompany serious medical illnesses. However,
there are things you can do to manage these symptoms. Symptoms
may never completely go away, but they may become easier to deal
with. In terms of symptom management, it can be helpful to think
of your physician as simply the “coach” and yourself as the “star
player” most responsible for success. Although the initial game plan
(i.e., medications, surgeries, etc.) is determined by your doctor, it is
you who must carry it out. In addition to following the doctor’s in-
structions, you select your own strategies and make modifications
for effective symptom management (be sure to check these out with
your doctor first).

141
 Review the following problem-solving steps adapted for symptom
management.

Step 1: Get the Right Attitude

You are probably not new to the idea of symptom self-management.

You may have a long history of successes and failures. Remember
that you are the “star player” and you need to step up to manage your
disease whenever possible. Even if you have been unsuccessful in the
past, new attempts bring new opportunities for success. It is okay to
remain skeptical, but try out an option before discounting it.

Step 2: Identify the Problem and Think about Your Goals

The first step is to think about your symptoms, priorities, and de-
sired outcomes. It is important to keep your goal small and keep it
specific. For example, rather than having the goal “I want my leg to
be pain-free,” a better goal would be “I would like to manage my leg
pain enough to allow me to walk down the stairs and out of my
apartment once a day.” Remember, small goals do not mean giving
up hope, but do require breaking a daunting task down into small,
achievable pieces. As the saying goes, “Every journey begins with
one step.”

Step 3: List Specific Options to Achieve Your Goal

The next step is to think of specific ways that can help you achieve
your goal. You might use self-monitoring to gather information on
the symptom (e.g., intensity, frequency, triggers, etc.). Also remem-
ber to use the steps of problem solving in Session . This chapter in-
cludes specific suggestions to address the most common medical
symptoms and side effects. You should test out one strategy then
evaluate its effectiveness. If it doesn’t work, there are almost always
other strategies to try. List your initial ideas on the Symptom Man-
agement Worksheet. You may photocopy this form from the book or
download multiple copies from the TreatmentsThatWork™ Web
site at [Link]/us/ttw.

142
Step 4: Choose the Best Option

Recall the process of choosing the best option in Session . You may
want to turn to the Pick an Option Worksheet on p. . Of the op-
tions listed, you should consider the pros and cons of each choice,
the impact on yourself and others, and how likely it is to achieve
your goal.

Step 5: Implement the Option and Evaluate the Outcome

After the best option has been selected, you should develop an im-
plementation plan—i.e., when, where, and how to start trying the
new strategy. Make sure to have a self-monitoring plan in place to
evaluate the impact of this new intervention. For example, for in-
somnia use an ongoing sleep diary; for pain, make pain ratings, etc.
See the following discussion of specific symptoms for more detailed
examples.

Chronic Pain

It’s hard to think, it’s hard to act, it’s hard to do anything if a nagging
(or screaming) pain is always present. Medications can help and
should be used as prescribed, but they can have side effects and
they’re not always % effective. Since pain may vary from day to
day, your management strategies need to have some flexibility. To
best manage the pain, you should have interventions that address its
two components.

Pain ⫽ Physical Sensation ⫹ Emotional Suffering

Physical Sensation

Undoubtedly, there’s a physical component to pain. Nerves send

pain messages to the brain, indicating that something is injured or
just not quite right. The acute pain signal is meant to convey im-
portant information about something going on in the body so the
person can do something about it. However, the physical pain sen-
sation can also be chronic (i.e., from an “injury” that can’t be re-

143
 paired). Or it can be a false alarm caused by nerve misfiring or the
brain misreading signals as pain (e.g., as in fibromyalgia, phantom
limb pain, etc). The physical sensation can come and go, sometimes
with no predictable reason. It can be described with different quali-
ties such as sharp, burning, throbbing, or aching.

There are many different pain medications that can help dull or per-
haps totally eliminate the physical sensation of pain. It may take sev-
eral attempts before the right medication and dosage are found.
There are also a number of non-medication interventions that might
help reduce the physical sensations of pain. You should work closely
with your primary care provider or a pain clinic to develop a com-
prehensive pain management plan. This plan should be based on
what works best for your particular pain.

Some examples of non-medication interventions are the following:

■ Physical therapy (stretching, exercises)

■ Hydrotherapy or spa treatments, hot showers or baths

■ Electrotherapy or transcutaneous electrical nerve stimulation

■ Ultrasound

■ Acupuncture and acupressure

■ Massage (done by a professional or layperson, with massage

chairs or pads)

■ Walking aids (e.g., crutches, insoles, braces)

■ Supportive devices (e.g., pillows, bandages, sling)

■ Therapeutic heat and cold (e.g., heating pad, ice packs)

■ Soothing or hot creams (e.g., Icy Hot, Ben Gay, capsaicin

ointments)

■ Progressive muscle relaxation to reduce muscle tension

■ Physical exercise

■ Weight loss

■ Yoga
■ Nutritional changes

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Emotional Suffering or Distress

The physical sensation of pain is only half the equation—and some-

times it is the easiest half to manage. The other half of the equation
is the emotional suffering or distress tied to the experience of being
in pain. It’s important to remember that pain is stressful, and chronic
pain means chronic stress. In other sessions we have already talked
about the links between stress and physical well-being. Remember
that your attitude or how you think about your pain can directly in-
fluence the intensity of your pain or suffering. Depression, anxiety,
and hopelessness all make the experience of pain far worse. Refer to
the sessions on dealing with stress, depression, and anxiety if these
seem to be factors contributing to your emotional suffering. Re-
member that “pain may be mandatory, but suffering is negotiable.”

Ways to Reduce the Emotional Distress Component of Pain

■ Deep breathing to reduce anxiety and tension

■ Massage (the intimacy and support can also ease emotional

suffering)

■ Relaxation tapes

■ Mindfulness—either meditation or developing the habit of

being present to all that is around you

■ Self-hypnosis

■ Music—for relaxation or distraction

■ Problem solving—provides a sense of control, mastery, and

hope

■ Biofeedback

■ Mental imagery

■ Pacing, time management

■ Self-talk—affirmations, reframing, balancing thoughts,

A-B-C-D exercises, etc.

■ Distraction—e.g., TV, talking to friends, hobbies

■ Support or therapy groups

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 ■ Individual therapy or counseling

■ Social support

■ Humor

Planning for Pain

The first step is to use your self-monitoring skills to rate your pain
and other important factors on a regular basis. Use the Pain Diary
provided to record this information. You may photocopy this form
from the book or download multiple copies from the Treatments
ThatWork™ Web site at [Link]/us/ttw . After selecting and
implementing a new pain intervention, you can then re-rate the in-
tensity and quality of your pain.

With the help of a primary care provider or pain specialist, you

should be able to come up with a “pain plan” that includes medica-
tion and non-medication strategies to be used on a regular basis. You
should also have a “panic plan” that includes what you should do if
you have serious breakthrough pain. Remember that pain can and
should be controlled. Work with your caregivers or medical provid-
ers to complete the Pain Management Plan and Pain Panic Plan
forms at the end of the chapter.

Insomnia or Sleep Problems

Difficulty sleeping is a very common and troubling consequence of

serious medical illnesses or other conditions. Sleep problems can in-
clude trouble falling asleep, trouble staying asleep, or waking up too
early. Insomnia can be caused by many different things, including
chronic pain, worry or anxiety, depression, taking too many naps
during the day, alcohol use, caffeine or other stimulants, staying up
too late, lack of exercise, sleep apnea or other trouble breathing, not
keeping a regular sleep schedule, side effects of certain medications,
and other causes. Treatments for insomnia fall into two categories,
medication and cognitive-behavioral interventions.

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Medication

Medications for insomnia can include sleeping pills (i.e., sedatives),

pain pills, and psychiatric medications such as antidepressants. In
general, sleeping pills are considered a short-term fix, since most of
them have side effects and some can be habit forming. However,
sleeping pills can be very useful when you are facing a particularly
tough time or if all other insomnia treatment options have been ex-
hausted. It is important that sleeping pills not be used as a way to es-
cape from depression or pain, although they can be used in addition
to medications for these problems.

Since pain is a common cause of insomnia, getting better pain con-

trol through better pain management is often a good solution. For
some people, pain medications also have the side effect of sedation
which can be beneficial when taken before bedtime. Be sure you’re
making the best use of your pain management before adding new
medications to make you sleep.

Depression and anxiety are also common causes of insomnia, and

both can be treated with medications. Because of the drowsiness side
effect of many antidepressants, they may be prescribed to help with
sleep even if a patient does not meet criteria for depression. Unlike
many sleeping pills, these antidepressants do not carry the risk of
physiologic dependence. Many physicians will first try an anti-
depressant sleep aid before moving to sleeping pills.

If you are already taking medications to help you sleep, it is important

for you to know what kinds of drugs they are and how to properly take
them. You may find it helpful to write down any questions you have
about sleep medications for your next doctor’s appointment.

Cognitive-Behavioral Interventions for Sleep

There are a number of non-medication ways to improve sleep. Mak-

ing changes in behavior and thinking may work just as well or bet-
ter than sleeping pills. Of course, these interventions may take more
effort and motivation on your part. Here are some suggestions com-
monly called “sleep hygiene”:

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 CAFFEINE: This stimulant is found in coffee, tea, some sodas,
and even some over-the-counter medications (like Excedrin).
Try not to have any caffeine after lunchtime. Remember that
even though you might be able to fall asleep after having
caffeine, it might still be interfering with your quality of sleep
(i.e., you can’t get to the deeper, more restful stages of sleep).

SUGAR: Some people can be very sensitive to sugar (like sweets,

candies, etc.). Try not to have any sugar or sweets close to bed-
time (at least – hours before bed should be sugar-free).

FLUIDS: Limit your fluid intake several hours before bedtime to

avoid late night trips to the bathroom.

NAPS: Many people can fall asleep for short periods of time dur-
ing the day. Naps can feel satisfying or refreshing, but can greatly
interfere with your ability to sleep at night. Do not take day-
time naps. If you must nap, limit yourself to a -hour nap near
lunchtime.

EXERCISE: If your physical health permits, regular exercise may

deepen your sleep. Do not exercise within a few hours of sleep.

CONSISTENT SLEEP SCHEDULE: Varying the time you get up

can negatively affect your sleep. It is especially important to get
up at the same time every day—even on the weekends—regard-
less of how well you slept.

BEDTIME: Only go to bed when you feel sleepy. Tossing and

turning in bed can cause you to associate your bed with frustra-
tion and wakefulness.

WAKING UP: Many people wake up in the middle of the night

(or much too early) and can’t get back to sleep. If this happens to
you, try to relax and fall back to sleep. If you cannot fall back to
sleep within – minutes, get out of bed and do something in
another room. Return to bed only when you begin to feel sleepy
again.

BED: It is important not to use your bed for reading, watching TV,
or other activities. Use your bed only for sleep or sex.

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 CLOCK WATCHING: If you tend to look at the clock every few
minutes, turn it around or cover it up. Looking at it only makes
you more anxious.

THOUGHTS: Don’t get mad at yourself for not being able to fall
asleep. Insomnia is a very common condition. Remind yourself
that insomnia cannot last forever (even though it seems that
way) and insomnia cannot kill you. Remind yourself that there
are things you can do to make it better. Eventually, your mind
and body will force you to go to sleep. Use your newly acquired
thought-balancing or A-B-C-D skills if needed.

SNORING: If you wake yourself up snoring and find you can sleep
better on your side, sew a pocket onto the back of your pajama
top and insert a tennis ball. This keeps you from rolling on your
back in the middle of the night.

BEDTIME RITUAL: Sometimes a relaxing nighttime routine can

get you ready for sleep. Try a glass of warm milk, a warm bath, a
backrub, soothing music, or reading a relaxing book.

SLEEP ENVIRONMENT: Make sure your sleep environment is

conducive to sleep—maintain quiet (maybe use masking “white
noise” such as a fan), keep at a comfortable temperature (not too
hot or cold), have fresh sheets, etc.

Remember to use your skills of self-monitoring and problem solv-

ing. If sleep is a problem for you, create a sleep diary form with your
facilitator. The form should capture sleep quantity, sleep quality,
daytime fatigue, daytime naps, and other factors deemed important.
As you try new sleep interventions, monitor and evaluate any
changes in your sleep. Learning how to create and use these types of
forms is an important but advanced skill that may help you with
many other symptoms or problems. If you have difficulty creating
this form on your own, be sure to add it to the agenda for your next
session with your facilitator.

Dealing with Other Symptoms

The following are management suggestions for other common

symptoms. You should notify your doctor of any management sug-

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 gestions you would like to try. Remember to follow the structured
steps of problem solving for each symptom. Use the Symptom Man-
agement Worksheet at the end of this chapter.

Nausea (Feeling Sick to Your Stomach)

. Eat salty and bland foods such as dry toast and crackers (unless
a salt-restricted diet has been recommended).

. Eat small, frequent meals and snack at bedtime.

. Eat only foods you like and foods that smell pleasant.

. Eat food cold or at room temperature so it has less taste and

smell.

. Sip all liquids and eat foods slowly.

. Try a liquid calorie supplement such as Ensure.

. Report nausea to your doctor and take medications as pre-

scribed.

. Rest for at least  hour after each meal.

. Relax, take deep breaths, distract yourself with TV, etc.

. Don’t force food or liquids if you’re feeling nauseated.

. Try ice chips or popsicles if drinking liquid is too much.

. Take all pills with a lot of liquid (unless otherwise indicated).

Dry Mouth

. Drink plenty of fluids (unless you have been instructed to limit

fluid intake). Always keep a bottle of water with you.

. Drink fluids with meals to moisten food and help swallowing.

. Use ice chips, hard sugarless candies, frozen grapes, or sugarless

gum to stimulate saliva production.

. Add liquids to solid food (e.g., sauces, gravy, yogurt).

. Keep lips moist (if you are on oxygen, petroleum jelly is not
recommended).

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 . Use good mouth care (brushing, flossing, mouth rinses).

. Avoid spicy, hot, or acidic foods.

. Avoid foods that require a lot of chewing.

. Use artificial saliva (available over the counter).

Constipation

. Increase use of high-fiber foods such as bran, wheat germ, raw

fruits and vegetables, juices, dates, prunes, etc. or take over-the-
counter fiber supplements.

. Increase fluid intake unless otherwise instructed by your doctor.

. Increase physical activity as much as possible (e.g., walking).

. Use laxatives or stool softeners as directed, but remember that

regular reliance on them might cause problems later.

. Avoid foods that cause constipation such as cheese, eggs,

bananas, etc.

. Remember that you don’t have to have a bowel movement

every day. Once every few days is okay.

. Don’t overstrain yourself trying to move your bowels. Try to

create a regular schedule, but accept that some days it might
not work.

Swelling in Arms, Legs, Hands, and Feet (Edema)

. When sitting in a chair, keep feet elevated.

. Rest in bed with the swollen part elevated above heart level.

. Eat as well as you can, especially foods high in protein.

. Take medications as prescribed (these might include diuretics

or “water pills”).

. Ask the doctor if you should modify your diet.

. Sometimes stockings or other supportive garments can help.

Ask your doctor.

151
Shortness of Breath

. Remain calm. Shortness of breath is common and usually

passes quickly if caused by overexertion. When your body re-
laxes, it needs less oxygen.

. Sit upright in chair or raise your head with pillows (do not lie
flat).

. Take medications or treatments prescribed for the problem

such as oxygen or inhalers.

. Inhale through your nose and exhale through pursed lips.

. If spitting up mucus note the amount, the color (normal is

clear or white), and if there is an odor.

Final Tips

All of these practical suggestions can go a long way toward manag-

ing medical symptoms. However, in order for them to work their
best, it is important for you to be in the right frame of mind. Some-
times feeling stressed, nervous, or depressed can make physical
symptoms much worse. Remember to use your skills for stress man-
agement and coping with depression and anxiety. Refer back to the
corresponding chapters in the workbook as needed. You may also
want to bring it up in the session as an additional agenda item to be
discussed in future sessions.

Don’t forget to share these symptom management suggestions with

your caregivers. Caregivers could use some advice on helping you
manage symptoms, too.

Homework

✎ Consult with your medical team about trying out new symp-
tom management strategies.

✎ Complete Symptom Management Worksheet.

✎ Complete Pain Diary (if relevant).

152
✎ Complete Pain Management Plan (if relevant).
✎ Complete Pain Panic Plan (if relevant).
✎ Create and use sleep diary (if relevant).
Notes:

153
Symptom Management Worksheet

Step : Get the Right Attitude

Write down any thoughts that might be discouraging you to try symptom management. Use your
thought-balancing and other skills to rewrite these thoughts.
Unhelpful Thought: New Helpful Thought:

Step : Identify the Problem and Think about Your Goals

a. What symptoms (or side effects) do you have that are most troubling?

b. If you could pick only one symptom to change, what would it be?

c. What would be an initial goal for this symptom? List a concrete, specific change you’d like to
see. You might need to measure your “baseline” before you can determine how much change
you’d like.

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Step : List Specific Options to Achieve Your Goal
(Be sure to check the symptom management suggestions in this chapter.)

.

.

.

.

.

.

Step : Choose the Best Option

Consider the pros and cons, impact on self and others, and probability of success.

Step : Implement the Option and Evaluate the Outcome

a. When, where, and how will you try out this new strategy?

b. How will you know if it is working? Think about how you can self-monitor this symptom to
see if it changes over time.

155
156
My Pain Diary
Did It Help?

Describe Situation Rate Initial Rate Initial What Did You Do? Re-rate Re-rate
(What were you doing, what was Physical Emotional (See Pain Management Plan for Physical Emotional
going on around you, what was Sensation Distress ideas. Include meds and Sensation Distress
Day/Time helping or hurting?) (1–10) (1–10) other interventions.) (1–10) (1–10)

Ideas and Comments:

My Pain Management Plan (A Work in Progress)
Medications (Prescription and Over the Counter)

Medication Name Dosage and Frequency What It’s Good For Special Instructions

Example: Ibuprofen 600 mg; every Inflammation, Take with food to

4–6 hours muscle aches, prevent stomach upset
general pain

Other Ways to Manage My Pain

Type of Intervention Dosage and Frequency What It’s Good For Special Instructions

Example: Physical 15–20 minutes every Flexibility, strength, Follow order given by
therapy stretches morning and evening and endurance physical therapist,
and exercises remember gains may be
slow but will be
long lasting

157
My Pain Panic Plan

Use this plan for serious breakout pain not controlled by the usual interventions. This plan should be
collaboratively developed with your physician and shared with anyone who might be caring for you.
Having this preset plan decreases anxiety and minimizes unnecessary trips to the emergency room.

. Medications (all changes should be discussed with your doctor)

When pain grows out of control and nothing seems to work, it often helps to increase the dose of a cur-
rent medication and/or add in another as-needed medication. Based on your doctor’s advice, list the fol-
lowing changes that can be safely made.

Changes in frequency or dosages to existing medications:

New medications to add in as needed:

. Non-medication options
In addition to medication changes, it helps to have a premade list of nonpharmacologic interventions
that can help with breakthrough pain or the panic that often accompanies serious changes in pain. For
example, you might list the phone numbers of friends or family who can come over to sit with you until
the crisis passes. You might also list breathing exercises, prayer, massage, heat, or other interventions that
have provided relief in the past.
List the top interventions that might help with the pain or your distress:

. Call your doctor’s office or answering service to report the pain crisis
Ask your doctor when you should call her office to report a change in pain. Whether or not your pain
needs urgent medical attention depends on the type and cause of pain that you are having. If you are
unsure, call your doctor. Be sure to call the doctor who manages your pain.

My doctor’s number is:

. Find a way to get to the nearest emergency room

If your pain fits the description for what your doctor has defined as an emergency (e.g., crushing chest
pains that run down your arm), call  or find a way to get to the nearest emergency room.

The nearest emergency room is:

158
Session 10 Quality of Life: Setting Goals
and Looking Forward

Goals

■ To learn about palliative care and hospice

■ To personally define quality of life

■ To set quality-of-life goals

■ To review medical goals including advanced directives

■ To consider doing a legacy project

Introduction to Palliative Care and Hospice

Palliative care focuses on “care” rather than “cure.” Quality of life

(QOL) is seen as equally important as quantity of life. Quality of life
is different for every person, and in this session you will develop your
own personal definition. Palliative care can include hospice. Some
people have the mistaken impression that hospice means inpatient
hospitalization or “banishment” to a nursing home for the dying. In
fact, there are many levels of hospice care, starting with a very basic,
one-time palliative care consultation directed at improving comfort
and quality of life. Remember, accepting palliative care does not
necessarily mean giving up on curative care. You may want to discuss
your options with your doctor.

Quality of Life

What is meant by “quality of life?” While there is no official defini-

tion, it is typically thought to have several elements, including the
following:

■ Functionality (physical ability, ability to work, ability to

care for self, etc.)

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My Quality of Life (QOL) Worksheet

Quality of life is defined differently for different people. Use the list below to start capturing the factors
that contribute to your quality of life. Write additional factors in the blank boxes provided. Additional
items might include things like music, art, reading, cooking, or other things that bring you joy. Circle
how important each factor is to your quality of life.

Degree of Importance
QOL Elements Not Important Very Important
Physical/Practical      

Mobility      

Pain      

Sleep      

Energy      

Money      

     

Mental Health      

Depression      

Anxiety      

Anger      

     

Social Relationships      

     

Spirituality      

     

     

     

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 ■ Mental health

■ Social relationships

■ Spirituality

Some of these categories may be more or less important to you. Your

values may also change over time. For example, your inability to
work may affect your quality of life greatly at first, but may matter
less as you adjust. You may also begin to value other aspects such as
spirituality more.

To develop your personal definition of quality of life, complete the

My Quality of Life Worksheet. After you have developed your own
definition, go ahead and rate your current quality of life on the fol-
lowing scale.

Quality of Life Visual Analog Scale

Circle the number that best represents your current overall quality of life. Higher numbers
represent higher quality of life. Although this may vary from day to day, try to think of your
average quality of life for the past week or two. Remember to use your own definition of
quality of life. From time to time, you may want to revisit this scale and make a new rating.

 . . .  . . .  . . .  . . .  . . .  . . .  . . .  . . .  . . .  . . . 

Remember that although some aspects of quality of life may be be-

yond your control, there is always some percentage that can be con-
trolled. This may mean reducing the negative factors (e.g., pain, in-
somnia) or increasing the positive ones (e.g., more time with family).
For uncontrollable impacts on quality of life, refer back to emotion-
focused coping in Session . In addition, Session  will cover re-
silience and transcendence.

Goal Setting for Improved Quality of Life

Because things are nearly always changing, the goal of maximizing

quality of life has to be an ongoing effort. Just because you are seri-
ously ill doesn’t mean you have to give up living and growing. In fact,

161
 illness can sometimes help us grow faster and grow further than if
we’d stayed healthy. In helps to have some goals to keep some sense
of direction and purpose and have something to look forward to.

Start with short-term goals by thinking of what your goals are for
today. Remember to keep goals very specific and realistic. For ex-
ample, a goal of “being happy” is a bit vague and gives no idea about
how to achieve it. A goal of “visiting my granddaughter after this ses-
sion and sharing old stories” is specific and realistic and can make
you happy. Try to make a “goal of the day” every morning for the
next week or two. Goals may include walking the dog, cooking a
special meal, watching a favorite movie, calling your sister, or sweep-
ing the kitchen floor. Daily goals may bring pleasure or they may
give you a sense of accomplishment—you may even consider setting
one goal of each type. For further suggestions see the Pleasant Ac-
tivities List in Session . You may also refer to Sessions  and  for
goals involving social support and building intimacy. The Goals of
the Day form is included at the end of this chapter.

You should also set larger quality-of-life goals for the week, the
month, or the year. While there’s no guarantee that you will be able
to finish these “projects,” there’s no reason why you can’t at least start
them and enjoy the process. These goals can refer to material
changes, personal growth, relationships, enjoyment, business,
health, lifestyle, etc. Refer back to the initial goals you set in Session
. Do these goals still fit? How do they mesh with your personal def-
inition of quality of life? Change these goals or set new medium to
longer term goals using the My Quality of Life Goals form at the
end of this chapter. Examples of short- and long-term goals are in-
cluded on the form to help you get started. Be sure to refer back to
the elements you rated most highly on the My Quality of Life
(QOL) Worksheet. The overall goal is to maximize your quality of
life in whatever way you define it.

Achieving Quality of Life Goals

Thinking of and setting goals is half the battle; the second half is
finding a way to achieve goals. Difficulties will often arise, and you
will need to use your problem-solving skills (see Session ). Don’t

162
 forget the affirmations you listed about yourself and your signature
strengths from Session . You’ve been successful in the past—repeat
whatever works! Sometimes a little brainstorming and early prepara-
tion can go a long way.

Here are a few other suggestions:

■ Break your goals down into small, easy steps

■ If you have thoughts that discourage you, do an A-B-C-D

exercise

■ Mark and recognize your progress each step of the way

(progress may be partial achievement of the goal or it may
be any impact on QOL)

■ Remember that no one achieves % of their goals %

of the time

■ Make sure goals are realistic and key resources are available

■ Allow yourself to work at your own speed—sometimes a

leisurely pace improves quality of life

■ View obstacles or setbacks as a challenge

■ Don’t be afraid to ask for support or help when you need it

(refer to Session )

■ Ask for advice or feedback when needed

■ Avoid “all-or-none” thinking—it helps to be flexible

■ Let your creativity flow

■ Remember that quality of life for you and your family and
friends is the ultimate goal

■ Assess your QOL progress regularly and adjust goals as needed

Medical Care Goals

One good QOL goal to have is seeking out and obtaining high-qual-
ity medical care. This includes being treated as a collaborative part-
ner in your care. Though you might not be able to evaluate the qual-

163
 ity of biomedical interventions, you can still evaluate other aspects
of your medical care. For example, how are you treated as a patient?
Are your treatment preferences respected? Think about what you
want or need from your provider. If necessary, take steps to improve
the quality of your medical care. If there is an interpersonal problem
or conflict with your medical providers, review the steps of conflict
resolution and the section Getting the Most out of Your Health Care
in Session . If there is a symptom management issue affecting your
quality of life, revisit the Symptom Management Worksheet from
Session .

When your disease becomes more advanced, medical care may have
to be stepped up. There may come a time when you are unable to ex-
press your wishes. One way to help ensure that you get the treatment
you want is to fill out advanced directives.

Advanced Directives

Advanced directives are legal documents that are used if you lose the
ability to make your own decisions or express your wishes. These
legal documents are available at most doctors’ offices, hospitals, and
hospices and can even be found online. Be sure to discuss with your
doctors which forms need to be filled out. Laws and regulations vary
by state, and different hospitals may have different procedures or
forms.
Advanced directives can include a living will and a durable power of
attorney for health care.

Living Will

This document specifies what types of medical treatments and

death-delaying measures a person wants if she becomes very ill. It in-
cludes things like the individual’s preferences for resuscitation, arti-
ficial breathing, tube feeding, what to do if in a coma, etc. It is to-
tally unrelated to a regular will, which specifies inheritances, etc.

A living will can include a do-not-resuscitate (DNR) and do-not-in-

tubate (DNI) order. At the patient’s request, the DNR /DNI order
is placed in the medical chart and instructs medical personnel to

164
 allow the patient to die peacefully rather than shocking her heart or
running tubes down her windpipe for a breathing machine.

Durable Power of Attorney for Health Care

This document designates a particular individual to make medical

decisions on the client’s behalf should she be unable to make those
decisions herself. This individual can be a family member, friend, or
other person. This document is much broader than a living will and
covers many more types of possible care decisions.

Preparing Advanced Directives

Advanced directives are a way for you to still have control and power
even when ill or disabled. Regardless of your health status, it’s always
a good idea to be prepared. The following are steps to take:

. Discuss your options with family, friends, and medical provid-

ers. Your doctor can explain medical terms and likely scenarios.

. Complete the appropriate forms with special attention to your

state of residence. It’s not necessary to consult an attorney un-
less desired. A doctor, social worker, or other medical team
member can provide the forms and help with completion. One
popular form that walks you through this process is called
“The Five Wishes” and is widely available for free online. For
further information or more forms, contact organizations such
as the National Hospice Foundation or
[Link].

. Designate an individual if filing a durable power of attorney

for health care (or DPOA for health care). You don’t have to
have a living will to complete a DPOA for health care form.
Since no one can predict all possible medical situations in a liv-
ing will, the durable power of attorney might be your best bet
if you only want to fill out one form. You should talk with
family and friends about who might be the best agent to desig-
nate. Remember, the best individual is the one who will be able
to carry out your wishes. Sometimes the person closest to you
is not the best choice.

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 . Distribute your directives and keep them nearby. Doctors,
medical clinics, family members, etc. should all have copies.
Also, keep several copies in accessible locations around your
home (e.g., on the refrigerator, by the bed).
. Periodically review and update your directives. Since circum-
stances, people, and preferences change, it’s a good idea to oc-
casionally review the advanced directives and make any neces-
sary changes. Make sure to inform all involved parties of any
changes made.

End-of-Life or Legacy Projects

Although there is a lot of “business” to take care of regarding the

management of serious disease, there are a number of other more en-
joyable tasks to help you through this life stage. Refer back to your
subjective definitions for quality of life and the initial goals you have
listed to maintain or improve your QOL. Consider adding a legacy
project to your list of QOL goals. An end-of-life or legacy project is
meant to improve the social, psychological, and spiritual aspects of
quality of life. (Of course, many of these projects can be beneficial at
any life stage.) Examples of creative projects are described as follows.

Creating a Video Diary

Videotape yourself and/or family and friends telling stories, sharing
feelings, etc. The videotape may become a treasured gift of recorded
history for the next generation. It may also initiate important con-
versations with loved ones about past events, current feelings, and
reasons for gratitude. Variations might include audiotapes or CDs of
favorite music, singing, or storytelling.

Creating a Work of Art

Sometimes nonverbal expressions of feelings such as paintings,
drawings, or sculptures can have powerful impacts on emotional
well-being. Artistic talent is irrelevant. The art does not have to be
shared, and materials can be as simple as paper and crayon. Some-
times a shared art project can be an important bonding experience
with family or friends.

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Writing a Letter

People often don’t take the time to express their feelings in writing.
Think about someone who has been important in your life or about
someone or something for which you are grateful. You can write a
“fan letter” or a letter expressing your gratitude and admiration. The
letter may lift both your and the receiver’s mood. You may even con-
sider writing letters without sending them or writing letters to
people who can no longer be reached.

Preparing for the End of the Program

There is only one session remaining in this program. The last session
will focus on spirituality and “looking ahead.” Be sure to bring your
own agenda items as well. You should review the entire workbook
over the next week and jot down any questions, requests, or obser-
vations. Congratulations on making it this far! Remember that even
though this program may end, the skills you have learned will re-
main with you.

Homework

✎ Finish the My Quality of Life (QOL) Worksheet.

✎ Finish Goals of the Day form.
✎ Finish My Quality of Life Goals form.
✎ Consider doing a legacy project.
✎ Review the entire workbook and prepare for the last session.
Notes:

167
Goals of the Day

Write in one enjoyable goal (e.g., watching a movie) and one accomplishment goal (e.g., washing the
dishes) for each day. At the end of the day, check off the goals that were completed. Carry them forward
if needed. Remember to keep goals small and realistic.

Enjoyable Goal Achieved? Accomplishment Goal Achieved?

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

168
My Quality of Life Goals

Begin to set short-, medium-, and long-term goals that will improve your quality of life. Be sure to refer
back to your personal definition of quality of life. Include the highest rated elements to have the greatest
impact. A short-term physical goal might be “call my doctor about getting new nausea medication.” A
medium-term goal for nausea might be “develop an anti-nausea shopping list and menu for my daughter
who does all the cooking.” A long-term goal might be “finish a program to desensitize myself to the
smell of meat.”

Short-Term Medium-Term Long-Term

Physical/Practical

Mental Health

Social

Spiritual

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Session 11 Resilience, Transcendence, and Spirituality

Goals

■ To work toward resilience and transcendence

■ To understand the importance of spirituality and personal

growth

■ To review the program

■ To plan the next steps

Case Example

■ Hester’s parents got divorced when she was only 3 years old. Her
dad disappeared completely and her mom drowned her sorrows in
vodka and cigarettes. When Hester was 11, she was sexually molested
by a male relative of a neighbor who was supposed to be keeping an eye
on her. When she was 17, Hester got mugged and still has the scar
from where her throat was nearly cut. At 37, she found a lump in her
breast and was told it was cancer. She had a mastectomy and chemo-
therapy. Today, at the age of 49, Hester is the Executive Director of a
very successful non-profit agency that provides mental health care to
adolescent girls at risk and pairs them with a “big sister” to help them
grow and thrive. Her agency has helped over 150 girls graduate from
high school and move on to college. As she looks ahead, she hopes these
girls will pass the gift on to their daughters and their daughters’ daugh-
ters. When a local reporter asked her how she could personally come
through so much and still give so much back, Hester answered, “My
wounds are my strength. Without them, I’d never realize how impor-
tant it is to feel loved.” ■

171
Resilience and Transcendence

Resilience is roughly defined as the capacity to succeed despite the

odds. It is the ability to bounce back despite substantial injury. Re-
silient individuals have often endured great hardship but have man-
aged to pick themselves up, dust themselves off, and continue for-
ward on their journey. Transcendence takes resilience one step
further: not only does the individual survive the hardship, but they
are able to learn and grow from that hardship in a way that makes
them a better or stronger person. Stories abound of individuals who
have grown from injuries or disabilities, or even from learning they are
terminally ill. They may no longer be “able-bodied” in the traditional
sense but they have become “able-hearted” or “able-spirited”—an ac-
complishment far more valuable than mere physical functioning.

Ways to Promote Resilience

Given your illness, you may not feel particularly resilient. You may
often feel tired, in pain, or just overwhelmed with the daily tasks
of coping. Fortunately, there are ways that you can become more
resilient.

Find a place of refuge or sanctuary. Everyone needs a “space” to get

away from the stressor(s) that is challenging his ability to cope. That
place might be a physical location such as a garden, beach, church,
or friend’s house. It might also be a mental space where you can go
to find rest and relaxation—e.g., meditation, guided imagery, etc.

Embrace impermanence. Remember that all things come to an end.

Good things end, but so do bad things. Pain does not last forever,
nor does suffering. You can probably recall very good and very bad
times in your life. In the midst of those times, change might have
seemed impossible. But the situation did change. Things always
change, even if we can’t see how at the moment.

Believe in control. Although some things are out of your control, you
often have more influence than you believe you have, even if it only
means controlling your mood and not the situation. You can man-
age how you think about a situation. You can control whom you do

172
or don’t talk to about the situation. You can control how you choose
to cope with an unchangeable situation. Regardless of what comes
your way, you always have some element of control.

Draw on the power of relationships. It is difficult to bear life alone, but

with support, we can bear almost anything. Support can come from
family, friends, pets, or our sense of spirituality. Remember not to be
a “lone ranger.” Ask for help and accept it gratefully.

Find the “why.” Suffering without a sense of meaning or purpose is

perhaps the worst suffering of all. Search for the reason why you
should pick yourself up and continue forward. The “silver lining”
of your chronic illness might be the opportunity to grow close to
loved ones and carefully prepare for handing things off to the next
generation.

Find a role model. It is hard to know how to move forward if you

have never seen anyone do it before. Support groups offer a good way
to see how others are coping. Inspirational stories and biographies
are another good way to see how others have coped or transcended
adversity (see suggested reading list in the Appendix).

Use a “perspective meter.” Suffering is relative to the individual. It

arises from the perception of what you have lost. You may be so en-
grossed in your losses that you forget to look at the bigger picture.
What gains are still in your life? What gains might be around the cor-
ner? If you look at the sum total of your life, what are things you can
still savor?

Don’t take it personally. Everyone gets sick and everyone dies. Every-
one. If you are lucky, you get some advanced warning and are able
to prepare for your death. You may have been given the opportunity
of appreciating your last days instead of having them end abruptly
(as in a sudden accidental death). You have every right to feel a wide
range of emotions, but what is happening isn’t a personal attack on
you. What is happening isn’t a cosmic injustice or crime. It is sad and
it is difficult but it is a natural part of being alive. Let others share
this important time with you. It is your time to be center stage.

173
Spirituality and Growth

Many see spirituality as an important tool for growth and transcen-

dence. Serious illness often activates questions of spirituality regard-
ing ultimate meaning, purpose, and even beliefs about what happens
after we die. Spirituality, however, doesn’t necessarily refer to a par-
ticular religion or set of beliefs. In the broadest sense, it refers to
thinking about issues larger than us—i.e., issues about meaning,
connection, purpose, and value. It’s up to you to decide if spiritual-
ity is important and, if so, what form that spirituality might take.

Remember that the end of life can be just as special and spiritually
meaningful as the beginning. It’s a time to resolve old conflicts, a
time to make peace with yourself and your environment, a time to
fully realize what’s important and what isn’t. Being sick often brings
things into focus. Although we all must die, being sick makes our
mortality seem more real and our life more precious. An ending
seems like it may be within sight. As one patient said, “If you go to
a play but don’t know when it ends, would you pay attention? I think
I see the ending and I’m glued to the stage.”

The following questions are meant to guide and provoke thought.

Remember there are no “right” answers.

. Is spirituality important to you or your family?

. What are your spiritual beliefs?

. What are your spiritual practices?

. Do you have a spiritual counselor, priest, or clergy? Where do

you go for spiritual guidance?

174
 . What gives you a sense of strength or meaning?

. What effect will your illness have on your spiritual practices or

beliefs?

. How will your spiritual practices affect your health or health

behaviors?

. What are some of the larger questions you’ve been thinking

about since you became ill?

. What do you think happens after you die? Is there anything

you need to do to prepare for that?

. How can others help you maintain your source of spiritual
strength and meaning during this illness?

175
Spiritual Growth Items

You may want to include some spiritual growth items on your lists of
short- and long-term goals. Remember spirituality can include com-
munion with nature, appreciation for science and mathematics, or
whatever larger-than-life system you see as worthy of awe. Spiritual
practices can include prayer, meditation, music, communion, fellow-
ship, being in nature, etc. Although spirituality can be practiced alone
(as with prayer or meditation), belonging to a spiritual community can
accomplish the goals of both spiritual and social connections.

Recap and Summary

In short, the organization of the program was as follows:

Sessions –: Stress and Coping—stress, breathing, cognition and

habits of mind, appraisals, ways of coping, problem solving,
A-B-C-D excercise

Sessions –: Mood Management (Depression, Anxiety, Anger)—

activity scheduling, relaxation, acceptance, forgiveness

Sessions –: Social Supports—types of support, support networks,

communication, listening, assertiveness, conflict resolution,
negotiation

Sessions –: Quality of Life—symptom management, end-of-life

tasks, goal-setting, legacy projects, spirituality, looking forward

You are not expected to have become an expert in any of the skills
presented by the end of this program. However, at this point you
should be able to identify fruitful areas where you can work for
greater mastery.

Program Feedback and Planning Next Steps—Action Plan

The following questions will help you evaluate your experience in

this program and develop an action plan.

176
. What is the single most important, memorable, or useful thing
you learned from this program?

. How will your participation in this program continue to affect

you?

. Are there any concepts, ideas, or other areas of importance that

the program didn’t cover or maybe didn’t spend enough time on?

. If you could do this program all over again, what would you
change about it? What would you do differently?

Use the My Action Plan form at the end of this chapter to develop a
specific approach to continue learning, growing, and developing
your self-management skills after today’s final session. Although you
have already established short-, medium-, and long-term goals, this
plan will specify what strategies you would like to use on a regular
basis. Over the past  sessions, you have learned many strategies to
identify, monitor, and manage stress, mood, relationships, and
medical symptoms. You probably prefer some strategies over others;
choose whatever works best for you and include these as part of your
action plan. Be sure to reflect on your answers to the program eval-
uation questions.

Described next are some additional ideas you may want to include
in your action plan.

177
Keeping a Journal: Three Variations on a Theme

It is a long-held belief that expressive writing such as keeping a diary

or journal can promote health, and research is starting to prove it. In
most versions, you are asked to write about an emotionally charged
event for – minutes—e.g., write about an event that really upset
you, detail what happened, why you think it happened, how it
affects your life, etc. Specific instructions and variations can be
found in Pennebaker’s book, Writing to Heal ().

A second variation provides a more focused and mood-uplifting

journal format that influences selective attention and promotes sa-
voring. Do this every day over the next several weeks to see how it
affects your mood. At the end of each day, take about – minutes
to answer three questions. You might want to jot down your answers
for today now. Notice any impact this has on your mood.

. What surprised me today?

. What moved me today?

. What inspired me today?

A third variant of the journal combines journaling with creating an

end-of-life legacy project. You can combine journal entries (written
or electronic) with poetry, art work, old photos, or MPs of favorite
songs, etc. The journal can be a collaborative effort with loved ones
or be passed on as a gift for others to enjoy. The goal is to be creative
and expressive while savoring positive memories and improving mood.

178
Letters to the Medical Team

The idea of gratitude or “fan” letters was presented in Session . As

mentioned earlier, these letters can be shared or they can be saved as
a collection of memoirs. Consider whether there are any medical
professionals to whom you would like to write a letter to express your
appreciation.

End of Program

Congratulations on completing the program! Though this signals

the end of scheduled therapy, you will continue to improve your
quality of life and grow as a person. Be sure to keep practicing and
building on the new skills you have learned. The Appendix includes
a brief list of books you may enjoy as part of your self-study, as well
as information on helpful Web sites and organizations. You may con-
sider setting up a “booster session” with your facilitator. Be sure to
ask for additional assistance if you should need it in the future. Best
of luck on the rest of your journey!

Notes:

179
My Action Plan

What skills and/or strategies would you like to practice to gain more expertise? Examples are provided,
but you may add additional items. Be specific and realistic.

Calming Strategies How Often? When? Where?

Diaphragmatic (belly) breathing

Progressive muscle relaxation

Guided imagery

Meditation

Behavioral Strategies How Often? When? Where?

Activity scheduling

Scheduling quality time

Physical exercise

Communication

Conflict resolution

Legacy projects

Journaling

-questions journal

Gratitude/fan letters

Cognitive Strategies How Often? When? Where?

Positive affirmations

Thought balancing/helpful thoughts

A-B-C-D exercise

Rewriting appraisals

Problem solving

Forgiveness/acceptance

180
Appendix Recommended Readings and Other Resources

Inspiration and Spirituality

Bolen, J. (). Close to the bone: Life-threatening illness as a soul journey (th
Anv. Rev. ed.). San Francisco: Conari Press.
Canfield, J., & Hansen, M. V. (). Chicken soup for the soul:  stories to
open the heart and rekindle the spirit. Deerfield Beach, FL: Health Com-
munications.
Chodron, P. (). When things fall apart: Heart advice for difficult times
(New ed.). Boston: Shambhala Publications.
Frankl, V. (). Man’s search for meaning. Boston: Beacon Press.
Kabat-Zinn, J. (). Wherever you go, there you are: Mindfulness meditation
in everyday life (th Anv. ed.) New York: Hyperion.
Remen, R. (). Kitchen table wisdom: Stories that heal (th Anv. ed.). New
York: Riverhead Books.
Salzberg, S. (). Loving-kindness: The revolutionary art of happiness (Rev.
ed.). Boston: Shambhala Publications.
Siegel, B. (). Love, medicine, and miracles: Lessons learned about self-healing
from a surgeon’s experience with exceptional patients. New York: Harper
Paperbacks.
Siegel, B. ().  prescriptions for the soul: Daily messages of inspiration,
hope, and love. Novato, CA: New World Library.

Mood and Stress Management

Burns, D. (). Feeling good: The new mood therapy (Rev. ed.). New York:
Avon.
Davis, M., Eshelman, E., & McKay, M. (). The relaxation and stress re-
duction workbook (th ed.). Oakland, CA: New Harbinger Publications.
Greenberger, D., & Padesky, C. (). Mind over mood: Change how you feel
by changing the way you think. New York: Guilford Press.
Hayes, S. (). Get out of your mind and into your life: The new acceptance
and commitment therapy. Oakland, CA: New Harbinger Publications.
McKay, M., Davis, M., & Fanning, P. (). Thoughts and feelings: Taking
control of your moods and your life (rd ed.). Oakland, CA: New Har-
binger Publications.

181
 Pennebaker, J. W. () Writing to heal: A guided journal for recovering from
trauma and emotional upheaval. Oakland, CA: New Harbinger Publi-
cations.
Seligman, M. (). Learned optimism: How to change your mind and your life.
New York: Free Press.
Seligman, M. (). Authentic happiness: Using the new positive psychology to
realize your potential for lasting fulfillment. New York: Free Press.

Anxiety and Panic

Bourne, E. (). The anxiety and phobia workbook (th ed.). Oakland, CA:
New Harbinger Publications.
Willliams, M. B., & Poijula, S. (). The PTSD workbook: Simple, effective
techniques for overcoming traumatic stress symptoms. Oakland, CA: New
Harbinger Publications.
Zuercher-White, E. (). An end to panic: Breakthrough techniques for over-
coming panic disorder (nd ed.). Oakland, CA: New Harbinger Publi-
cations.

Anger and Forgiveness

Flanigan, B. (). Forgiving the unforgivable: Overcoming the bitter legacy of
intimate wounds. New York: Wiley.
Luskin, F. (). Forgive for good: A proven prescription for health and happi-
ness. New York: HarperOne.
McKay, M., Rogers, P., & McKay, J. (). When anger hurts: Quieting the
storm within. Oakland, CA: New Harbinger Publications.
Williams, R., & Williams, V. (). Anger kills: Seventeen strategies for con-
trolling the hostility that can harm your health. New York: HarperTorch.

Communication and Conflict Resolution

Fisher, R., Patton, B. M., & Ury, W. L. (). Getting to yes: Negotiating agree-
ment without giving in (nd ed.). Boston: Houghton Mifflin.
McKay, M., Davis, M., & Fanning, P. (). Messages: The communication
skills book (nd ed.) Oakland, CA: New Harbinger Publications.
McKay, M., Fanning, P., & Paleg, K. (). Couple skills: Making your
relationship work (nd Rev. ed.). Oakland, CA: New Harbinger Publi-
cations.

End-of-Life Issues
Byock, I. (). Dying well: The prospect for growth at the end of life. New York:
Riverhead Books.
Lynn, J., & Harrold, J. (). Handbook for mortals: Guidance for people fac-
ing serious illness (New ed.). New York: Oxford University Press.

182
McFarlane, R., & Bashe, P. (). The complete bedside companion: No-non-
sense advice on caring for the seriously ill. New York: Fireside.
Nuland, S. (). How we die: Reflections on life’s final chapter. New York:
Vintage.
Olive, B. (). Time to say goodbye: What everyone needs to know. Milwaukee,
WI: LeMieux International Ltd.

Additional References
Muñoz, R. F., & Miranda, J. (). SFGH Depression Clinic Group Treat-
ment Manual. Unpublished manuscript.
Muñoz, R. F., Ying, Y. W., Bernal, G., Perez-Stable, E. J., Sorensen, J. L., Har-
greaves, W. A., Miranda, J., & Miller, L. S. (). Prevention of de-
pression with primary care patients: a randomized controlled trial.
American Journal of Community Psychology, (), –.

Web Sites and Organizations

Aging with Dignity—The Five Wishes
[Link]
Tel: () WISHES (–)

Americans for Better Care of the Dying

[Link]
Tel: ––

Caring Connections, National Hospice and Palliative Care Organization

[Link]
Help Line: ––
Spanish Help Line: ––

Growth House, Inc.

[Link]
Tel: ––

183