Creativity: Relaxing The Left Brain

“This comprehensive workbook deserves to be in the library of every active therapist, but it shouldn’t be left on the shelf! Once again, the authors have empowered the reader with straight- forward instructions on every major approach to stress management known. From worry to chronic headaches to information overload, here is your one-stop guide to recovery.”

— R. Reid Wilson, Ph.D., author of Don’t Panic: Taking Control of Anxiety Attacks

“This text remains, after twenty years, the clearest, best-organized, and most readable book on stress management. It has achieved the status of the ‘classic’ self-help reference in the field.”

— Edmund J. Bourne, Ph.D., author of The Anxiety and Phobia Workbook, Coping with Anxiety, and Beyond Anxiety and Phobia

“An exemplary book on stress. It is lucidly written, rationally ordered, and comprehensive, and each section is densely packed with instructions and exercises which make the workbook easy to practice.”

— Somatics Magazine: Journal of the Mind/Body Arts and Sciences

The Relaxation & Stress

Reduction W O R K B O O K

Martha Davis, Ph.D. Elizabeth Robbins Eshelman, MSW

Matthew McKay, Ph.D.

New Harbinger Publications, Inc.

SIXTH EDITION

Publisher’s Note This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold with the understanding that the publisher is not engaged in rendering psychological, financial, legal, or other professional services. If expert assistance or counseling is needed, the services of a competent professional should be sought. Creativity: Relaxing The Left Brain

The material in chapter 13 that is based upon the work of Michelle G. Craske and David H. Barlow’s Master Your Anxiety and Worry, 2nd ed. (2006) pages 99–109 is used by permission of Oxford University Press.

Distributed in Canada by Raincoast Books

Copyright © 2008 by Martha Davis, Elizabeth Robbins Eshelman, and Matthew McKay New Harbinger Publications, Inc. 5674 Shattuck Avenue Oakland, CA 94609 www.newharbinger.com

All Rights Reserved

Acquired by Tesilya Hanauer; Cover design by Amy Shoup; Edited by Kayla Sussell

Library of Congress Cataloging-in-Publication Data Davis, Martha, 1947- The relaxation and stress reduction workbook / Martha Davis, Elizabeth Robbins Eshelman, and Matthew McKay. — 6th ed. p. cm. Includes bibliographical references and index. ISBN-13: 978-1-57224-549-5 (pbk. : alk. paper) ISBN-10: 1-57224-549-2 (pbk. : alk. paper) 1. Stress management. 2. Relaxation. I. Eshelman, Elizabeth Robbins. II. McKay, Matthew. III. Title. RA785.D374 2008 616.9’8–dc22 2008003637

PDF ISBN: 978-1-57224-680-5

We would like to dedicate this book to our families.

Thank you, Bill and Amanda, Don, Judy, Rebekah and Jordan.

Contents

Preface to the Sixth Edition ix

Acknowledgments xi

How to Get the Most Out of This Workbook xiii

1 How You React to Stress 1 * Sources of Stress * Fight-or-Flight Response * Chronic Stress and Disease * Schedule of Recent Experience * Prevention * Symptoms Checklist * Tactics for Coping with Stress * Tactics for Coping with Stress Inventory * Knowing Your Goal * Symptom-Relief Effectiveness * Symptom-Relief Effectiveness Chart * Further Reading

2 Body Awareness 19 * Background * Body Inventory * Stress-Awareness Diary * Record of General Tension * Further Reading

3 Breathing 27 * Background * Symptom-Relief Effectiveness * Time to Master * Instructions * Preparing to Do Breathing Exercises * Breathing Basics * Special Considerations * Breathing for Tension Release and Increased Awareness * Breathing for Symptom Control or Release * Final Thoughts * Further Reading * Recordings

4 Progressive Relaxation 41 * Background * Symptom-Relief Effectiveness * Time to Master * Instructions * Special Considerations * Further Reading * Recording

5 Meditation 47 * Background * Symptom-Relief Effectiveness * Time to Master * Instructions * Exercises * Special Considerations * Further Reading * Recordings

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6 Visualization 65 * Background * Symptom-Relief Effectiveness * Time to Master * Instructions * Basic Tension and Relaxation Exercises * Special Considerations * Further Reading * Recordings

7 Applied Relaxation Training 75 * Background * Symptom-Relief Effectiveness * Time to Master * Instructions * Special Considerations * Further Reading * Recording

8 Self-Hypnosis 83 * Background * Symptom-Relief Effectiveness * Contraindications * Time to Master * Instructions * Special Considerations * Further Reading

9 Autogenics 99 * Background * Symptom-Relief Effectiveness * Contraindications * Time to Master * Instructions * Special Considerations * Further Reading * Recording

10 Brief Combination Techniques 109 * Background * Symptom-Relief Effectiveness * Time to Master * Instructions * Further Reading * Recordings

11 Focusing 117 * Background * Symptom-Relief Effectiveness * Time to Master * Instructions * Suggestions for Focusing on Special Problems * Special Considerations * A Real-Life Example of the Power of Focusing * Final Thoughts * Further Reading * Websites

12 Refuting Irrational Ideas 135 * Background * Symptom-Relief Effectiveness * Time to Master * Instructions * Refuting Irrational Ideas * Special Considerations * Further Reading

13 Facing Worry and Anxiety 157 * Background * Symptom-Relief Effectiveness * Time to Master * Instructions * Instructions for Imagery Exposure * Special Considerations * Turn Worry into Problem Solving * Problem-Solving Worksheet * Final Thoughts * Further Reading

14 Coping Skills Training for Fears 187 * Background * The Five Steps of Coping Skills Training for Fears * Symptom-Relief Effectiveness * Time to Master * Instructions * Special Considerations * Further Reading

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15 Anger Inoculation 205 * Background * Symptom-Relief Effectiveness * Time to Master * Instructions * Special Considerations * Further Reading

16 Goal Setting and Time Management 223 * Background * Limits of Multitasking * Symptom-Relief Effectiveness * Time to Master * Instructions * Clarifying Your Values * Setting Goals * Developing an Action Plan * Evaluating How You Spend Your Time * Combating Procrastination * Organizing Your Time * Further Reading * Recordings

17 Assertiveness Training 249 * Background * Symptom-Relief Effectiveness * Time to Master * Instructions * Further Reading

18 Work-Stress Management 279 * Background * What Causes Work Burnout? * Symptom-Relief Effectiveness * Time to Master * Five Steps Toward Managing Your Work Stress * Final Thoughts * Further Reading * Website

19 Nutrition and Stress 297 * Background * Symptom-Relief Effectiveness * Time to Master * Twelve Steps to Positive Eating * Self-Assessment * Taking Charge of Your Nutritional Well-Being * Set Your Personal Positive Eating Goals Now * Final Thoughts * Further Reading * Other Resource * Websites

20 Exercise 329 * Background * How Does Exercise Reduce Stress? * What Is the Evidence? * Types of Exercise * Symptom-Relief Effectiveness * Time to Master * Developing Your Own Exercise Program * Choosing the Best Type of Exercise for Yourself * Establishing Goals * Sample Exercise Program * Special Considerations * Further Reading * Television Programs, Videos, and DVDs * Websites * Community Resources * Training Resources for Long-Distance Activities

21 When It Doesn’t Come Easy—Getting Unstuck 355 * Taking Responsibility for Your Decisions * Confront Your Excuses * Confronting Roadblocks to Stress Management and Relaxation * When Symptoms Persist * Persistence Pays

Index 361

Preface to the Sixth Edition

Today, we are inundated with all kinds of information, including a lot of information about stress and stress management. What is unique about this book is that it immediately zeros in on what is relevant to you; that is, the specific stressors in your life and how you react to them. Once you’ve identified the sources of your stress, your most disturbing symptoms, and how you typi- cally cope with them, you are directed to the techniques that will help you in your particular situation. In short, you don’t have to waste your time reading material that isn’t relevant to your specific needs; instead you can focus on simple step-by-step instructions that will teach you how to feel better now. Creativity: Relaxing The Left Brain

This workbook is based on more than twenty-five years of clinical experience working with clients who came to us with symptoms of tension and stress like insomnia, worry, high blood pressure, headaches, indigestion, depression, and road rage. When they seek help, many of these people report they are experiencing some kind of a transition, such as a loss, a promotion, or a move. This isn’t surprising, since stress can be defined as any change to which you must adapt. Most clients describe feeling worn down by everyday hassles such as dealing with inconsiderate or rude people, commuting long distances, caretaking children and elderly relatives, and man- aging tons of paperwork. One client referred to this “wearing down” process as a “death by a thousand cuts.” Indeed, unmanaged stress can have an accumulative effect that may lead to major psychological and physical illnesses. Clients also tell us about some of their less successful stress- management strategies: working harder and faster; numbing their pain and soothing themselves with drugs, alcohol, and food; worrying about their problems; procrastinating; and taking their frustrations out on others.

To date, more than 700,000 people have purchased this book to learn how to relax their bodies, calm their minds, turn around their self-defeating behavior, and take control of their hectic lives. About every five years we update this workbook, adding new strategies that the latest research and our clinical experience have shown to be effective. We eliminate techniques we’ve learned are not especially helpful, and we simplify and shorten some techniques to save you time. This allows us to keep this workbook as an up-to-date, relevant resource for professionals, a solid source of information for individuals who want to learn to manage their stress on their own, and a popular textbook in classes and workshops on stress management and relaxation.

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Recent research supports the commonsense notion that it is better to face your troubles than to run away from them. Although escaping painful feelings like anxiety, depression, and anger may make you feel better in the short run, in the long run, avoidance prevents you from having positive corrective experiences associated with facing these painful feelings. For example, drop- ping a speech class because you are worried about blowing a talk in front of a group of strangers may alleviate your anxiety immediately, but you don’t get the experience of surviving giving the talk and the confidence that comes from learning that you can do it, albeit imperfectly. Instead, you continue to live in fear of public speaking, and the next time you are faced with giving a talk in front of a group, you are still terrified. Creativity: Relaxing The Left Brain

With this in mind, we’ve added some techniques to strengthen your ability to tolerate dis- tressing feelings as well as build up your self-confidence so you can accomplish your goals more effectively. We’ve replaced the chapter called Thought Stopping with the new chapter Focusing. This chapter will teach you to explore the feelings in your body and understand what they mean. Rather than trying to suppress your feelings, you are invited to move toward accepting them and learning from them, using a simple but profound technique called “Focusing.” Typically, this lessens or eliminates the power of distressing feelings in your life.

We’ve revised the Worry Control chapter (now called Facing Worry and Anxiety) with an emphasis on facing your fear of uncertainty, using Michelle G. Craske’s and David H. Barlow’s new model of exposure. The Coping Skills Training chapter has been divided into two chapters: Coping Skills Training for Fears and a new chapter called Anger Inoculation.

Whether you want to make just a few changes in your lifestyle or you need a major life over- haul, this workbook shows you how to get started and stick with a program that is tailored just for you. Based on the feedback we’ve received from our clients and readers who’ve used these techniques, your efforts will be amply rewarded.

Acknowledgments

The authors wish to acknowledge the following contributors to the sixth edition of this book. Their expertise, experience, and collaboration have made this a more valuable edition.

Caryl Fairfull, RD, is a registered dietitian and has held leadership positions in the American Dietetic Association. She is a graduate of the University of California at Santa Barbara and com- pleted her dietetic internship at the Bronx VA Hospital in the Bronx, New York. Ms. Fairfull managed the Department of Nutrition Services for Kaiser Permanente’s Santa Clara Medical Center in northern California. She has developed nutrition care guidelines and provided indi- vidual and group nutrition counseling. She currently works at Sierra Nevada Memorial Hospital in Grass Valley, California, providing clinical nutrition services. Ms. Fairfull wrote chapter 19, Nutrition and Stress. Creativity: Relaxing The Left Brain

Cheryl Pierson-Carey, PT, MS, is a rehabilitation specialist at Kaiser Permanente in Fremont, California, and an associate clinical professor in the UCSF/SFSU Graduate Program in Physical Therapy. She holds degrees from Indiana University, Purdue University, and Samuel Merritt College. She is a member of the American Physical Therapy Association. Ms. Pierson-Carey wrote chapter 20, Exercise.

The authors would like to thank Albert Ellis, PhD for volunteering to review and give feedback on the Refuting Irrational Ideas chapter. Dr. Ellis developed Rational Emotive Behavior Therapy upon which this chapter is based.

We would also like to express our appreciation to Patricia Eaton LMFT for suggesting the case study in the Focusing chapter. Ms. Eaton is a therapist in the Psychiatry Department at Kaiser- Permanente Medical Center in Santa Clara.

How to Get the Most Out of This Workbook

This workbook teaches you clinically proven stress-management and relaxation techniques. Each technique is presented with concise background information followed by step-by-step exercises. As you practice these techniques, you will gain new insight into your personal stress response and learn how to reestablish balance and a sense of well-being in your life.

Use this workbook as a guide. Read chapters 1 and 2 first. They are the foundation upon which all of the other chapters are built. Then you will know enough about stress and your per- sonal reactions to stress to decide which chapters will be most helpful for you to read next.

Chapters 3 through 10 teach techniques for relaxation. Chapters 11 through 15 will help you with your stressful thoughts and feelings. Chapter 16 assists you in managing your time more effectively so that you can free up time to relax and do more of what is most important to you. From chapter 17 you can learn to communicate more assertively and chapter 18 gives you many options to deal with environmental and interpersonal stress at work. Chapters 19 and 20 teach the basics of nutrition and exercise. Chapter 21 gives you some suggestions on how to increase motivation, deal with problems that come up along the way, and stick to your plan. Creativity: Relaxing The Left Brain

Stress and tension are present in your life every day. Stress management and relaxation can be effective only if you make them a daily part of your lifestyle. As you are learning the skills in this book that are pertinent to you, practice them repeatedly to ensure that you will be able to carry them out anytime you need to, without having to refer to written materials. Regular conscious practice can lead to habits of regular relaxation and stress reduction at an unconscious level.

Here are some suggestions that will help you relax on a regular basis:

• Make an agreement with yourself to set aside a specific time each day dedicated to relaxation. If finding the time to do the exercises in this book is an issue, read chapter 16 on time management.

• The length of time required each day to practice the relaxation techniques in this workbook varies. Start small. Doing a relaxation exercise for five minutes on a regular basis is better than doing it only once for an hour. Aim for twenty to thirty minutes

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of relaxation time once or twice a day. Note that some people prefer to take more frequent, shorter relaxation breaks.

• You decide when is the best time to relax based on your schedule by answering these two questions: When do you need to relax most? When can you realistically break away from external demands to take some time for yourself? Here are some examples of what clients in our stress-management and relaxation classes have found most helpful and doable:

• Beginning the day with a relaxation exercise makes people more focused and proactive in dealing with the stressful demands of their day.

• Taking a relaxation break during the day can reverse growing tension that would otherwise culminate in painful symptoms such as a headache or indigestion. Creativity: Relaxing The Left Brain

• Relaxing before leaving work or upon arriving at home allows a person to let go of and decompress from the tensions of his or her busy day and to become calm and revitalized enough to enjoy personal time at home.

• Using a relaxation exercise to go to sleep quickly and then sleep soundly can result in waking up refreshed.

• Choose a quiet place where you will not be interrupted to learn the techniques. Once mastered, many of the relaxation techniques presented in this workbook can be done in stressful situations.

• Since this is a new activity for you, it is a good idea to let people around you know what you are doing. Ask them to help out by leaving you alone without distracting you. Family members, fellow office workers, and friends are usually very supportive of these exercises once they understand what you are doing and why.

• It’s best not to practice a relaxation exercise right after eating a big meal or when very tired, unless your purpose is to fall asleep.

• You will enjoy your experience more if you choose a comfortable position in a location that has a comfortable temperature, wear loose clothing, and remove your contacts or glasses.

See your health care provider before beginning the work in this book if any of the following circumstances are relevant to you:

• If you are over thirty or if your reaction to stress involves physical symptoms, such as frequent headaches, stomach problems, or high blood pressure, your doctor

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should perform a physical examination to rule out possible physical problems that may need medical attention.

• If, after starting your stress-management program, you experience any prolonged negative physical effects.

• If you have been taking medication that you may no longer need once your stress- related symptoms go away with regular practice of these exercises.

Your health care provider can be a supportive partner in your efforts to live a healthier life.

1

How You React to Stress

Stress is an everyday fact of life. You can’t avoid it. Stress results from any change you must adapt to, ranging from the negative extreme of actual physical danger to the exhilaration of falling in love or achieving some long-desired success. In between, day-to-day living confronts even the most well-managed life with a continuous stream of potentially stressful experiences. Not all stress is bad. In fact, stress is not only desirable it is also essential to life. Whether the stress you experi- ence is the result of major life changes or the cumulative effect of minor everyday hassles, it is how you respond to these events that determines the impact that stress will have on your life.

SOURCES OF STRESS

You experience stress from four basic sources:

1. Your environment bombards you with demands to adjust. You must endure weather, pollens, noise, traffic, and air pollution.

2. You also must cope with social stressors such as demands for your time and attention, job interviews, deadlines and competing priorities, work presentations, interpersonal con- flicts, financial problems, and the loss of loved ones.

3. A third source of stress is physiological. The rapid growth of adolescence; the changes menopause causes in women; lack of exercise, poor nutrition, and inadequate sleep; illness, injuries, and aging all tax the body. Your physiological reaction to environmental and social threats and changes also can result in stressful symptoms such as muscle tension, headaches, stomach upset, anxiety, and depression.

4. The fourth source of stress is your thoughts. Your brain interprets complex changes in your environment and body and determines when to turn on the “stress response.” How you interpret and label your present experience and what you predict for your future can serve either to relax or to stress you. For example, interpreting a sour look from your boss to mean that you are doing an inadequate job is likely to be very anxiety-provoking. Interpreting the same look as tiredness or preoccupation with personal problems will not be as frightening. Creativity: Relaxing The Left Brain

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Stress researchers Lazarus and Folkman (1984) have argued that stress begins with your appraisal of a situation. You first ask how dangerous or difficult the situation is and what resources you have to help you cope with it. Anxious, stressed people often decide that (1) an event is dangerous, difficult, or painful and (2) they don’t have the resources to cope.

FIGHT-OR-FLIGHT RESPONSE

Walter B. Cannon, a physiologist, laid the groundwork for the modern meaning of “stress” at Harvard in the beginning of the twentieth century. He was the first to describe the “fight-or- flight response” as a series of biochemical changes that prepare you to deal with threat or danger. Primitive people needed quick bursts of energy to fight or flee predators like saber-toothed tigers. You can thank this response for enabling your ancestors to survive long enough to pass on their genetic heritage to you. Think of occasions in your life when the fight-or-flight response served you well, such as when you had to respond quickly to a car that cut in front of you on the freeway or when you had to deal with an overly aggressive panhandler. These days, however, when social custom prevents you from either fighting or running away, this “emergency” or “stress response” is rarely useful.

Hans Selye (1978), the first major researcher on stress, was able to trace what happens in the body during the fight-or-flight response. He found that any problem, imagined or real, can cause the cerebral cortex (the thinking part of the brain) to send an alarm to the hypothalamus (the main switch for the stress response, located in the midbrain). The hypothalamus then stimulates the sympathetic nervous system to make a series of changes in the body. These changes include the following: The heart rate, breathing rate, muscle tension, metabolism, and blood pressure all increase. The hands and feet become cold as blood is directed away from the extremities and digestive system into the larger muscles that can help to fight or run. Some people experience butterflies in their stomachs. The diaphragm and anus lock. The pupils dilate to sharpen vision and hearing becomes more acute. Creativity: Relaxing The Left Brain

Regrettably, during times of chronic stress when the fight-or-flight physiological responses continue unchecked, something else happens that can have long-term negative effects. The adrenal glands secrete corticoids (adrenaline or epinephrine, and norepinephrine), which inhibit digestion, reproduction, growth, tissue repair, and the responses of the immune and inflamma- tory systems. In other words, some very important functions that keep the body healthy begin to shut down.

Fortunately, the same mechanism that turns the stress response on can turn it off. This is called the relaxation response. As soon as you decide that a situation is no longer dangerous, your brain stops sending emergency signals to your brain stem, which in turn ceases to send panic messages to your nervous system. Three minutes after you shut off the danger signals, the

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fight-or-flight response burns out. Your metabolism, heart rate, breathing rate, muscle tension, and blood pressure all return to their normal levels. Herbert Benson (2000) suggests that you can use your mind to change your physiology for the better, improving your health and perhaps reducing your need for medication in the process. He coined the term “the relaxation response” to refer to this natural restorative response. Creativity: Relaxing The Left Brain