The Mental Health Handbook A Cognitive Behavioural

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Introduction
Revised Edition
I am very pleased that the Mental Health Handbook has been so popular over the last eight
years and indeed I still use it myself. However, since its first publication our knowledge of
treatment strategies for mental health problems has increased substantially and so it is time
for a second edition. Although the revised edition has a new design and layout, the basic
characteristics of offering photocopiable handouts is still the same. The main theoretical
underpinning of the book is still predominantly cognitive behavioural therapy, which offers
an educational, instructive and directive approach to solving specified problems. The
handouts are an aid to therapeutic intervention and not a substitute.

I have updated existing pages and added some new ones. There are new pages in the first
section on Social Phobia, Somatic Anxiety, Coping with Worry and Trauma. The section on
Assertiveness has added pages on Overcoming Sulking. In the third section on Depression
there are new pages on Bereavement and improving Self-Care. The section on Stress has new
pages on Procrastination. Within the Habits & Behaviour section there are new pages on
various aspects of Health Psychology, which has blossomed over the last decade, including
expanded Pain Management, Chronic Fatigue, Headaches, Irritable Bowel Syndrome, an
extended section on Anger Management and extended pages on Relationship Enhancement. In
the final section, which deals more with chronic mental illnesses, is an improved section on
Coping and Managing the Symptoms of Schizophrenia, including a new self-monitoring
questionnaire.

I hope that this second, revised edition is as useful and as popular as the first edition. I would
like to reiterate that the ideas in this book do not belong to me, but, I hope, reflect our
common pool of knowledge. So, if readers have any new ideas or information that would
enhance the quality of the book, they would be received with gratitude.

Third Edition
The field of psychological therapy has developed enormously over the last decade. Cognitive
Behavioural Therapy has become more prominent and clinical services have become more
specialised. This new edition is an attempt to keep up with these changes.

There are new pages on Mindfulness, Resilience, Behavioural Experiments, Bipolar Disorder,
Responsibility, Forgiveness, Guilt and Distress Tolerance, and expanded sections on
Psychosis and OCD.

My thanks go again to all my colleagues and clients who have made this book possible.

Dr Trevor Powell

Consultant Clinical Psychologist

Berkshire Healthcare NHS Foundation Trust
April 2009

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Acknowledgements
Firstly, thanks to my wife, Meriel, for her love and support, encouragement and patience.
Secondly, thanks to Liz, and all those at CST in Reading, who typed and retyped the
document and never once made me feel a nuisance. Thirdly, thanks to Alistair Keddie,
Head of the Clinical Psychology Department, West Berkshire Health Authority, who made
this project possible.

I would also like to thank to a number of authors who gave permission to publish specific
material: Professor Isaac Marks for permission to publish the Fear Questionnaire; Dr Snaith
for permission to publish the Hospital Anxiety and Depression Scale; Dr Bob Wycherly for
permission to publish his diagram on Irrational Thinking habits; and Professor Cary Cooper
for help on the work stress questionnaire. Lastly, I would like to thank all those others,
authors, therapists and clinicians whose work has made this book possible.

Acknowledgements (Second Edition)

I would like to thank all my colleagues who have made contributions to this edition
especially Dr Mary Whalley, Alistair Keddie, Sue Cummings, Dr Margaret Roberts and
Dr Jo Smith for the use of the Early Signs Scale.

Acknowledgements (Third Edition)

I would like to thank my colleagues and clients who have helped me expand my knowledge
and horizons and have made this edition possible. Special thanks go to Rob Willson, Rhena
Branch and John Wiley & Sons for allowing the use of their helpful illustrations from
Cognitive Therapy for Dummies (2006).

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2 Resources 26 Dealing with Avoidance and Facing Fear

3 When Anxiety is a Problem 27 Graded Practice Target Sheet

SECTION 1 – MANAGING ANXIETY

4 What is Anxiety? 28 Common Questions about Anxiety

5 What Starts and Maintains Anxiety? 29 Stress Control

6 The Body’s Arousal Reaction 30 Coping with Sleeping Problems

7 How Thoughts can Increase Anxiety 31 Agoraphobia

8 How Avoidance Increases Anxiety 32 Social Phobia

9 Summary Sheet: Anxiety and How to Deal With It 33 Overcoming a Simple Phobia

10 Relaxation 34 Understanding Obsessive Compulsive Disorder

11 Progressive Muscle Relaxation Exercise 35 What Causes and Keeps OCD Going?

12 Cued Relaxation 36 OCD: Strategies for Coping 1

13 Acute Hyperventilation 37 OCD: Strategies for Coping 2

14 Procedures for Controlling Hyperventilation 38 Exercise: Theory A or Theory B

15 Information about Hyperventilation 39 Obsessive Compulsive Behavioural Checklist

16 Distraction and Safety behaviour 40 Obsessive Compulsive Target Symptom List

17 Positive Self-Talk 41 Health Anxiety

18 Positive Self-Statements for Coping with Anxiety 42 Coping with Accidents & Trauma

19 Challenges to Upsetting Thoughts 43 Effect on Life Inventory

20 Backward Chaining 44 Hospital Anxiety & Depression Scale

21 Diary Sheet 45 Physical Symptoms Inventory

22 Ways to Demolish Worry 46 Worrying Thought Questionnaire

23 Understanding Panic Attacks 1 47 The Fear Inventory

24 Understanding Panic Attacks 2 48 Blueprint

25 Ten Rules for Coping with Panic

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MANAGING ANXIETY

䡵 Books for Clients 䡵 Support Organisations

Bourne E, The Anxiety and Phobia Workbook, British Association of Behavioural and Cognitive
New Harbinger Publications, 2005. Psychotherapies: www.BABCP.com
Resources

Butler G, Overcoming Social Anxiety and National Phobics Society:

Shyness, Robinson, 1999. 339 Stretford Road, Hulme, Manchester
M15 4ZY
Hauri P & Linde S, No More Sleepless Nights,
tel 0870 122 2325
Wiley, 1996.
www.phobic-society.org.uk
Herbert C & Wetmore A, Overcoming
No Panic:
Traumatic Stress, Robinson, 1999
helpline 0808 808 0545
Ingham C, Panic Attacks, Harper Collins, www.nopanic.org.uk
2000.
OCD Action:
Jeffers S, Feel the Fear and Do it Anyway, 22/24 Highbury Grove, Suite 107,
Rider and Co, 1997. London N5 2EA
tel 0845 390 6232
Kennerly H, Overcoming Anxiety, Constable
www.ocdaction.org.uk
and Robinson, 2004.
OCD-UK:
Marks I, Living with Fear, McGraw-Hill, 2005.
PO Box 8955, Nottingham NG10 9AU
Veale D & Willson R, Overcoming Obsessive www.ocdaction.org.uk
Compulsive Disorder, Constable & Robinson,
NHS Direct:
2005.
0845 4647
www.nhsdirect.nhs.uk
䡵 Books for Professionals
Hawton K, Salkovskis P, Kirk J & Clark D,
Cognitive Behaviour Therapy: A Practical Guide Websites Outside the UK
(2nd Edition), Oxford University Press, 2009. Australia:
Bennett-Levy J, Butler G, Fennell M, Hackman www.anxietyaustralia.com.au
A, Mueller M & Westbrook D, Oxford Guide to New Zealand:
Behavioural Experiments in Cognitive Therapy, www.mentalhealth.org.nz
Oxford University Press, 2004.
South Africa:
www.anxiety.org.za

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‘Nothing in life is to be feared, it is only to be understood’

– Madame Curie –

䡵 Types of anxiety problem

Tension and anxiety are common problems. Good

When Anxiety is a Problem

About one tenth of the population every year will
see their doctor because they feel tense or

Performance
anxious. In the past doctors have traditionally
prescribed drugs for such problems, but over the
last few years research has shown that there are
more effective ways of treating anxiety. This new
approach involves teaching people how to cope,
and these methods are similar to learning a new
skill such as riding a bicycle or learning to play
the piano. Bad
Low Moderate High
These approaches can help a variety of people Anxiety
whose problems on the surface may take a
different form, but who underneath suffer the
same unpleasant feelings. Examples include the
housebound person who is terrified of going out; The graph above – known as the Yerkes-
the person who is afraid of spiders, lifts, Dodson curve – demonstrates this point.
aeroplanes, or small spaces (these problems are People were given a task which involved
called phobias); the person who experiences remembering some numbers. But as they did
panic attacks; the person who obsessively checks this they were made anxious, some a little,
things such as all the electrical appliances or some a lot, some in between. As the graph
compulsively washes their hands. Lastly, there shows, when the anxiety was low or high the
may be people who feel generally anxious people did not perform well, but when their
and who cannot tie their feelings down to anxiety was moderate they did best.
anything specific.
Anxiety becomes a problem when it interferes
with our performance or our everyday lives. This
䡵 Anxiety is a normal reaction
is when it becomes necessary to learn how to
Anxiety is a normal healthy reaction. It happens control it. Remember that anxiety is a normal
to everyone at times of danger or in worrying healthy reaction. You cannot banish it completely
situations. There is a perception of threat or from your life but you can learn to manage it.
danger to either your physical or psychological
well being. When you are anxious your bodily
system speeds up. In certain circumstances this
can be a definite advantage. It means that you
are ready for action and enables you to respond
quickly if necessary. Moderate amounts of anxiety
actually improve your performance, spurring you
on to greater achievements.

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䡵 Anxiety and your body 33 Thinking: This includes your ideas and
beliefs, your mental comments to yourself, or
When we feel anxious a chain of automatic
your mental pictures about what might
events occurs in our bodies, which prepares us
happen to you in the situation you fear.
for action. This reaction is often termed the
‘fight or flight’ response and can be traced back Looking at these parts separately, and learning
What is Anxiety?

into our evolutionary past. Imagine the primitive new skills in each area, is an important part of
caveman threatened by a wild animal. He anxiety management.
needs to be prepared for vigorous action: either
to run or to fight. We still possess this survival 䡵 Anxiety and confidence
reaction, although it is now triggered by more
subtle situations – some of which we are not Anxiety reduces confidence because it makes it
even consciously aware of. hard to do the things that were once easy. We
normally feel confident when we do things well
The reaction itself consists of the brain sending and lose confidence when we fail or avoid
a message to pump adrenalin into the situations. It is easy to get into a vicious circle
bloodstream and into the large skeletal muscles when, because we feel less confidence we
of the arms and legs. The heart beats faster as avoid a situation, and because we avoid, we
it is working harder. Because it is working feel less confident. Confidence can be regained
harder, it needs more fuel so we breathe in by learning how to cope better and gradually
more oxygen. To cool down the body, sweat and building up to take on bigger tasks.
blood capillaries come to the surface. The body
ideally needs to be as light as possible so a visit
to the toilet might be necessary. When this
chain of events occurs in a normal situation, for
example if we are pushing a trolley around a
supermarket or sitting in a business meeting, it
can be very frightening. The important thing to
remember is that the physical symptoms are
natural and not harmful, but are appearing in
an inappropriate situation.

䡵 The three systems of anxiety

Anxiety is often referred to as if it is a single
phenomenon, but this is not the case. There are
three parts to the feeling of anxiety:
1 Bodily sensations: These have already been
mentioned – they include irregular breathing,
churning stomach, sweating, trembling,
racing heart and the need to visit the toilet.
2 Behaviour: This means the way you behave
– that is what you do when faced with the
situation you fear. Especially important is the
behaviour of avoiding the situation, either
not going into the situation, or getting out of
it as quickly as possible.

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䡵 Why do anxiety These examples make clear two things:

symptoms begin? 1 Thoughts and beliefs can become distorted
There is usually a combination of causes. and exaggerated (and the person may realise
Two of the important ones are: that it is just that) about what will happen in
the feared situation. Anticipating something
1 The amount of stress you are under: You

What Starts and Maintains Anxiety?

bad is going to happen can create a vicious
may have a single major problem, or more circle of anxiety.
likely a number of smaller problems which
all add up to a large amount of stress. Stress 2 There is often direct avoidance of the feared
can be measured to some extent by the situation. There may also be a network of
amount of changes that have taken place in ‘safety behaviours’, such as, always carrying
your life recently. Being physically tired, run a tranquilliser ‘just in case’, or always
down and having many changes or traumas carrying a plastic bag in case of being sick,
makes you more vulnerable to anxiety. or always sitting close to the door. All these
avoidance behaviours prevent you from truly
2 The kind of person you are: Some people realising that you can cope with anxiety and
have a more sensitive emotional nervous that the dangers are not real. Your irrational
system. Their bodies’ arousal response might beliefs continue because they are never
be triggered more quickly and take a longer proved wrong.
time to calm down. Some people have
learned from their parents in their early
䡵 Common myths about anxiety
experiences how to get anxious and how
to worry. As anxiety symptoms often occur without any
obvious explanation, people often misinterpret
䡵 What maintains anxiety? them and think there is a more serious
problem.
Why does anxiety stay with you? What keeps it
going? Basically, there seem to be two reasons: 1 I’m going crazy: There is no link between
panic anxiety and more serious psychiatric
1 Because of the way you behave, especially illness.
because you avoid the situations you fear.
2 I’m going to lose control: There has never
2 Because of beliefs you have about the been a recorded case of anybody doing
situation and its consequences. anything ‘wild’, or ‘out of control’ or against
Let us look at some examples: their wishes.

‘Lift phobic’ people never go in a lift because 3 I’m having a heart attack: Although the
they may believe it will fall to the bottom of the major symptoms of heart disease include
lift shaft; ‘agoraphobics’ never go out because breathlessness and chest pain, the
they may believe they will collapse and die of a symptoms are generally related to effort and
heart attack; some people may avoid meeting will go away quickly with rest.
others because they believe that in a 4 This anxiety will harm me: Anxiety does
disagreement, they will lose their temper and not harm you physically, although it is
hit people; some people obsessively check the unpleasant and uncomfortable.
locks on the doors and windows over and over
before going to bed because they are certain 5 I’m going to faint: Very unlikely as your
that burglars will break in. heart rate goes up. You only faint if your
heart rate and blood pressure drop.

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Physical Reaction: The mind becomes focused and

preoccupied with the thought ‘what is the danger
and how can I get to safety?’
Symptom: Panic, preoccupation.
The Body’s Arousal Reaction

Physical Reaction: The brain sends a biochemical

message to the pituitary gland, which releases a
hormone which triggers the adrenal gland to release
adrenalin.
Symptom: Headaches, dizziness.

Physical Reaction: Pupils dilate.

Symptom: Blurred vision.

Physical Reaction: Mouth becomes dry.

Symptom: Difficulty swallowing.

Physical Reaction: Neck and shoulder muscles tense

– large skeletal muscles contract ready for action.
Symptom: Aching neck, backache, headache.

Physical Reaction: Breathing becomes faster and

shallower, supplying more oxygen to muscles.
Symptoms: Overbreathing, chest pains, tingling,
palpitations, asthma.

Physical Reaction: Heart pumps faster and blood

pressure rises.
Symptoms: High blood pressure.

Physical Reaction: Liver releases stored sugar to

provide fuel for quick energy.
Symptoms: Excess sugar in blood, indigestion.

Physical Reaction: Adrenalin and noradrenalin are

released.

Physical Reaction: Digestion slows down or ceases as

blood is diverted away from the stomach.
Symptoms: Nausea, indigestion, ulcers.

Physical Reaction: Muscles at opening of anus and

bladder are relaxed.
Symptoms: Frequent urination, diarrhoea.

Physical Reaction: The body cools itself by

perspiring: blood vessels and capillaries move close
to skin surface.
Symptoms: Excess sweating, blushing.

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‘The only thing we have to fear is fear itself’

– Franklin D Roosevelt –

The thoughts we have play a major part in to go completely out of control’, ‘I’m going to
increasing or decreasing our anxiety. embarrass myself terribly’, and ‘I am damaging

How Thoughts can Increase Anxiety

my health’. All these thoughts are very
Two examples may make it clearer how
frightening and tend to keep the physical
thoughts can add to anxiety and lead to it
anxiety well stocked up. It must be remembered
getting out of control.
that these thoughts are also inaccurate
distortions of what is actually happening.
Mrs Brown was alarmed to find herself
feeling dizzy while waiting at a bus stop. The vicious circle of worrying thoughts and
Then she noticed her heart was pounding physical symptoms is illustrated below:
and her legs felt as if they were giving way.
Because the symptoms came out of the Physical
blue, she was terrified that she was about to symptoms

collapse, or even die, and she continued to

feel frightened until safely home. After that,
just thinking about going out made her feel Worrying
thoughts
nervous, and sometimes brought the dizzy High stress
about symptoms
level
feeling back.

Mr Jones noticed that he felt very tense and

irritable when there was a lot of work to be
done, and it took him a long time to unwind Sometimes we are not fully aware that these
afterwards. He went to his doctor after frightening thoughts are flashing through our
starting to get headaches every evening, and mind. They occur very quickly and often
although the doctor could not find anything just below the level of consciousness. It is
wrong, the patient started to worry that important to try and identify these thoughts and
some disease might have been missed. This recognise the role they play in creating and
worry made it even more difficult for him to maintaining anxiety.
relax after work.

Although these problems seem quite different,

both were caused by a combination of worry and
physical tension. Because the feelings did not
seem to make any sense, both people started to
worry about them, although this only made things
worse. They both began to become anxious about
being anxious, or to worry more about symptoms
than the background stress that originally caused
those symptoms.

Research suggests that many people who suffer

from anxiety make matters worse for themselves
by misinterpreting these physical symptoms.
Common misinterpretations include: ‘I’m going to
have a heart attack’, ‘I’m going to die’, ‘I’m going

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‘Present fears are less than horrible imaginings’

– Shakespeare –

Avoidance is an important concept to help us same’. They generally fear that if their anxiety
understand why our anxiety is maintained and goes on increasing, something terrible will
How Avoidance Increases Anxiety

increases. Take the situation of somebody with happen – they will pass out, be sick, collapse,
agoraphobic tendencies who rushes home after have a heart attack, or go mad. On the graph
feeling panicky in a supermarket. A number of they imagine the line going up and up and off
things happen. First of all their immediate the page. But this belief is not correct. We
anxiety goes down. Second, the unconscious know from experience and experiments on
message stamped in is, ‘The only way I can anxiety that after a certain time it begins to
cope with these situations is to avoid them’. decrease of its own accord. If you leave the
Finally, when faced with the same situation – situation quickly, you will never find this out.
the supermarket – in the future, anxiety will rise
Avoiding a situation when our anxiety is rising
quickly and severely.
will produce short-term gains – a reduction in
anxiety – but long-term pain – our general level
䡵 Anxiety curve and avoidance of anxiety will increase. Once we start to avoid,
the process of ‘generalisation’ takes place and
High we begin to avoid more and more situations. It
is a slippery slope. The world closes in and we
Imagined find that our mobility is restricted.
Begin to avoid anxiety
Usually people avoid situations where there is an
element of entrapment – or where it is difficult to
escape to a place of safety quickly.
Anxiety

䡵 Safety behaviours
Avoidance can often take the subtle form of
‘safety behaviours’, or habits we get into to make
us feel safe. For example, carrying a tranquillizer,
Low ‘just in case’, carrying a plastic bag, in case we
Time are sick, holding on to something in case we
faint, or sitting close to the door. All these
This applies to the agoraphobic with a panic behaviours have the effect of depriving us of the
attack, but also applies to the obsessive knowledge that there is no real danger – we
checker, who avoids anxiety by giving in to the would have coped. For example you might think,
compulsion to check the door locks. ‘that was close, if I hadn’t had the trolley to hang
on to I might have collapsed’. If you hang on to
Each time we avoid the situation and our
the trolley, you never learn that you wouldn’t
anxiety successfully, we make it more likely
collapse. Safety behaviours are a major factor in
that the next time the feared situation crops
keeping anxiety going.
up, we will avoid it again.
All safety behaviours and situations of avoidance
What would happen if you remained in the
need to be identified and progressively
situation you fear? Would your anxiety increase,
confronted. Stop the safety behaviour and
stay the same, or decrease? Most people reply
realise ‘I can cope’.
when asked this question ‘increase’ or ‘stay the

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Physical symptoms
(eg, sweating, trembling, palpitations,
muscle tension.)

Summary Sheet – Anxiety and How to Deal With It

Mental symptoms
Life Anxiety (Worrying thoughts: will I ever get
stress better? Is there something seriously
wrong with me?)

Behavioural changes
(Avoiding situations or people, safety
behaviours, taking tranquillisers, drinking,
stopping pleasant activities.)

Loss of confidence
(When life becomes restricted due to
anxiety, loss of confidence often results.)

Feeling demoralised, depressed, hopeless.

䡵 What can I do to get better? 3 Make alterations to your lifestyle and so

manage successfully the amount of stress
1 Understand the process and how anxiety you put yourself under. This might involve
persists because of a spiralling vicious circle learning to be more assertive, managing your
between physical symptoms, worrying time better, breaking unhelpful habits or
thoughts and changes in behaviour. learning other new skills.
2 Break into this vicious circle by learning new
skills:

a Physical symptoms can be reduced by

learning relaxation or controlled breathing.

b Mental symptoms ie, worry, can be

combated by a combination of identifying
and challenging worrying thoughts and
replacing them with positive ones, and/or
distracting yourself.

c Behavioural changes can be altered by

deliberately changing your behaviour and
going back into difficult situations in a
gradual step-by-step fashion.

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‘The time to relax is when you don’t have any time’

– Sydney Harris –
䡵 Why is relaxation helpful? 3 Don’t attempt your exercise if you are hungry
or have just eaten, or if the room is too hot
Relaxation

1 When we are stressed, the muscles in our or too chilly.

bodies tense up and this muscular tension
causes uncomfortable bodily feelings, such 4 Try to adopt a ‘passive’ attitude, that is, do
as headache, backache, tight chest and not worry about your performance or
so on. whether you are successfully relaxing. Just
‘have a go’ and let it happen.
2 These aches and pains of tension can cause
mental worry, making us even more anxious 5 Try to breathe through your nose, using your
and tense. stomach muscles. Try to breathe slowly and
regularly. It is important that you do not take
3 People who are tense often feel tired. a lot of quick, deep breaths as this can
4 Relaxing slows down the systems in the make you feel dizzy or faint and even make
body that speed up when we get anxious. your tension worse. When you place your
hands on your stomach, you will feel the
5 If we can learn to turn on the bodily movement if you are breathing properly. Try
symptoms of relaxation we can turn off the this out before you exercise, to make sure
symptoms of tension. They are two sides of that you are used to the feeling.
the same coin: you can’t experience feelings
of relaxation and tension at the same time. 䡵 Relaxation in everyday life

䡵 Relaxation is a skill 1 Stop rushing around – you achieve more by

doing things calmly.
The ability to relax is not always something
which comes naturally, it is a skill which has to 2 Give yourself short breaks – relax, stretch, go
be learnt like playing the piano. The following for a walk.
exercises are designed to help you learn to
3 Adopt a relaxed posture. Deliberately relax if
relax. The Progressive Muscle Relaxation you notice yourself tensing up. Drop your
exercise (p11) is quite long and you may obtain shoulders, sit back in your chair, unclench
a tape of instructions to help you to carry out your fists.
the routine. When you are able to relax using
the first exercise, you can begin to shorten the 4 Inject pleasure and treats into your daily
routine. This should be done gradually until you routine.
are able to relax at will, as you need to.

General guidelines
1 Try to decide in advance when you are going
to practise; in this way you can better
develop a routine which you can stick to.
Make time for yourself.

2 Make sure that you choose somewhere quiet

to exercise, and make sure that no one will
disturb you during your practice.

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This exercise involves tightening and relaxing all Breath

the different muscle groups in your body, one at Slow and steady, letting yourself go each time
a time. When you tighten a muscle it becomes you breathe out.
hard and tightens around the bone, when you
relax it loosens, creating a sensation of warm Tummy
heaviness. Pull in your tummy tight, then gradually let it

Progressive Muscle Relaxation Exercise

go, feeling it relax.
Sit or lie down in a comfortable position. Set
aside 15 to 20 minutes with no interruptions or Thighs
distractions. Relax yourself to the best of your Push your heels down hard against the floor,
ability. Consider the various muscle groups one feeling the tightness in your thighs, then
at a time, and aim to learn the difference gradually let that go.
between tight and relaxed muscles. Try
constantly to concentrate on the feeling in the Calves
muscle as it goes from tight to loose. Point your toes, then gradually let that
tightness go.
Hands and arms
Clench your fists, and tense your arms; feel Let everything go, further and further, and think
tightness in your hands and arms, hold for 5 about a really relaxing scene, for example, lying
seconds then slowly relax them. Release and in the grass by a river, under a warm sun and a
relax each muscle group for 10 to 15 seconds. blue sky, or sitting by a fire in a big,
See how far they will go, but do not push. Do comfortable chair. Feel yourself getting heavier
not hold on at all; let everything go. and heavier.

Shoulders
Hunch your shoulders, then gradually let them
settle down. Proceed as above.

Forehead
Pull your eyebrows together, then gradually let
your forehead smooth out.

Eyes
Screw your eyes up tight, then gradually let
them smooth out, leaving your eyes closed,
feeling your eyeballs sink, and your eyelids
droop. Let them get really heavy.

Jaw
Bite your back teeth together, then gradually
ease off, and let your jaw get heavy.

Back of neck
Pull your chin forward on to your chest, feel
tightness, then relax.

Front of neck
Pull your chin forward on to your chest, feel
tightness, then relax.

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