Session 4: Stress Management for People with PD and for Carers · Session 4: Stress Management Overview Participants receive information about stress and stress management, and practise

Session 4: Stress Management for People with PD and for Carers

Anu Lankinen, Vappu Viemerö and Anne Lehtonen

Patient Education for People with Parkinson's Disease and their Carers: A Manual. Edited by Marcia Smith Pasqualini and Gwenda Simons. Copyright © 2006 John Wiley & Sons, Ltd.

Because the content of this session differs signifi cantly for carers and people with Parkinson’s disease (PD), separate descriptions are provided for each group. In addition, for both groups, each session has two different versions, designated Option 1 and Option 2. Option 1 is a “cognitive” option, which is recommended for most groups. This option focuses on how to use thoughts to reduce stress. Option 2 is a “behavioural” option, which is recommended for groups with participants who do not desire or are not able to work on a cognitive level. If time permits, both options may be followed.

Session 4: Stress Management

Session 4: Stress Management Overview

Participants receive information about stress and stress management, and practise a specifi c method of stress management. This practice is continued at home.

Materials❏ Relevant handouts❏ Stress circles fi gure (for slides or handouts)❏ Flip chart, markers, blank cards, pens for participants❏ (Optional: relaxing music)

Please note: Option 1 is the cognitive option; Option 2 is the behavioural option.

Part Contents

1

Discuss homeworkPleasant activities

Discussion of experiences with pleasant activities Up to

0:30’

2

Active InformationStress management

Option 1: Stress and stress management – The role of your thoughts

Option 2: Stress and stress management – Relaxation as a stress management method

Up to 0:50’

3

Exercise Stress management

Option 1: Learning alternative ways of thinking

Option 2: Relaxation training

Up to 1:15’

4

Homework Stress management

Option 1: Trying out alternative ways of thinking

Option 2: Daily relaxation trainingUp to 1:30’

5

AppetiserManagement of anxiety and depression

Observing changes of mood and causes of worry

Patient Education for People with PD and their Carers1 2 3 4 5

Goal:

• To support application of knowledge and skills from the previous session (Pleasant Activities) in everyday life.

Part 1Discuss Homework: Pleasant Activities 0:30’

Contents Instructions


Ask participants to briefl y describe their experiences performing pleasant activities since the last session. Encourage the participants to talk about problems that arose, such as:

• External barriers, for example distraction by others or disturbances.

• Internal barriers, for example lack of motivation or time.• Inappropriateness of chosen activity, for example the activity

was not as pleasant as expected or was too diffi cult.

Briefl y discuss these problems with the group and invite other participants to suggest solutions. Some possible solutions that could be suggested include:

• External barriers. Establish surroundings that allow you to perform pleasant activities more easily, for example, in your own room. Find a suitable time during the day to perform the pleasant activities without being disturbed.

• Internal barriers. Consider the benefi ts of pleasant activities. Perform pleasant activities together with a partner.

• Activity was not appropriate. Find more suitable pleasant activities by referring again to the Pleasant Events Schedule.

Encourage participants to continue using this exercise.

1 2 3 4 5 Session 4: Stress Management

Goals:

• To understand what stress is and what components comprise it.• To understand why stress management is important for the wellbeing of people with PD.• To understand what you can do in order to cope better with everyday situations that are

experienced as stressful.

Part 2Active Information (Option 1): Stress and Stress Management – The Role of Your Thoughts 0:30’ – 0:50’


Step 1:Appetiser discussion

Refer to the Instructions for Appetiser: Session 4 handout given out at the end of the previous session, which lists examples of common stressful situations. Ask participants to describe some of their own stressful experiences.

Choose one of the participants’ examples, and use it when explaining the rest of the steps in this section. Use the same example for all steps, pointing out that the same principles apply to other examples as well.

Example If no adequate examples are given by the participants, you can use your own, such as:

A person with PD is standing at a checkout at a supermarket with many people in the queue behind her. She has diffi culty getting the money out of her purse because her hands are shaking and she feels nervous.

When choosing the example, be sure to take into account the characteristics of the specifi c group (such as stage of PD and age).

Note for group leader

If you are running short on time (for example, if the homework discussion has taken longer than anticipated) you can ask participants to pair up with a partner and tell each other about their stressful situations, instead of having every participant describe their stressful experiences to the whole group.

Step 2: What is stress?

Stress is a state in which we interpret a situation as demanding more of us than we are capable of managing, for instance if we think that we should do something better or more quickly than we are able to.

Example At the supermarket checkout, you might think that the cashier or the other people in the queue think that you should hurry so that they don’t have to wait so long. You feel it is impossible for you to go that fast.

1 2 3 4 5 Patient Education for People with PD and their Carers

Step 3: Stress and Parkinson’s Disease

Most people with PD say that the disease has lowered their stress threshold. You may have noticed that activities you used to be able to perform automatically now demand conscious concentration and effort. It is diffi cult to concentrate on several things at the same time. In addition, if your muscle movements are slower, you cannot perform as quickly as before, and therefore are likely to feel time pressure more acutely than in the past.

Example Before the symptoms of PD appeared, you were probably able to do things like shopping quite automatically. For example, at the checkout, you might have chatted with the assistant whilst you put the shopping in your bag. Now that PD has affected your movements you may need to really concentrate on what you do. A minor disruption, such as an extra question from the shop assistant, might disturb your concentration.

PD also challenges you with new stressors (mention some of the stressful situations discussed during the appetiser).

For example, some people with PD fi nd it disturbing when people notice their symptoms, such as tremor. To make it worse, PD symptoms tend to increase in situations that are experienced as stressful.

Step 4: Components of stress

We can divide a stressful experience into several components.

1. Situation: the circumstances in which you experience stress. 2. Thoughts: your interpretation of the situation and of your ability

to cope with it. The thoughts can be seen as self-instructions, in other words, what you “say” to yourself in the situation.

3. Reactions: at three different levels:

• emotional reactions (feelings of discomfort, tension, irritability, nervousness)

• bodily reactions (muscle tension, worsening of PD symptoms)• behavioural reactions (how you act in the situation).

The components of stress are interrelated. A particular situation itself is not inherently “stressful” because what is stressful for one person might not be for another. What is important is how you interpret the situation and what you say to yourself about it.

If you think that the situation is too demanding and you can’t cope with it, your thinking infl uences your reactions at the level of muscle tension, PD symptoms and emotional reactions. These reactions feed back and infl uence your thoughts. This is called a negative stress circle.

On the other hand, if you think that you’ll handle the situation even if it is challenging, your thoughts infl uence your reactions in a positive way, and the calm reactions of your body and feelings reinforce your thinking. These factors also infl uence your behaviour in the situation. This is called a positive stress circle.


Flip Chart

Draw a negative and a positive stress circle on a fl ip chart or other medium, or show a slide displaying the stress circles. (A model of the stress circles is included in the materials component of this session.)

Example Present the following example, whilst pointing to the picture of the stress circles:

Imagine that you are at the supermarket checkout. The cashier has just told you how much your shopping costs and you are about to pay. There are quite a few people behind you in the queue. This is the situation:

You think: “Oh no, what a queue! The people behind me look angry and they seem to be in a hurry. I need to hurry up, but I can’t manage it.”

This way of thinking leads you to feel nervous (emotional reaction). The tension in your muscles increases and your tremor worsens (bodily reaction). As a consequence, you drop your wallet (behavioural reaction) and the money is scattered on the fl oor. All of this reinforces your thought that you can’t handle the situation.

This is an example of a negative stress circle. The same situation can be used to illustrate the effects of a positive stress circle:

The situation is exactly the same: you are about to pay at the supermarket checkout. You could instead think: “Well, there’s quite a queue there but they will be able to wait a moment. I will do better if I take the time I need rather than trying to rush it. Let me fi rst take a deep breath, and then I’ll get my money out. I’ll make it.”

This way of thinking helps you feel calm/emotional no matter what the situation. You don’t experience increased muscle tension and your tremor remains at a normal level (bodily reaction). You can take the money out or ask the clerk to help you. Feeling relaxed in your mind and body, your calm thinking is reinforced. Even if someone in the queue is impatient, you don’t let it spoil your day. This is an example of a positive stress circle.

Flip Chart

After presenting the example, divide the flip chart into three columns: Situation/Thought/Reactions. Further subdivide the “thought” column into two columns, with “old thought” in the first subcolumn and “alternative thought” in the second subcolumn. Similarly subdivide the “reactions” column, with “old reaction” in the first subcolumn and “alternative reaction” in the second subcolumn. Write down notes for the example as follows:


Example Situation: at checkout, with a long queue behind

Old thought: “I can’t manage this as fast as I should”

Old reactions: tremor increases, feel nervous, diffi culty getting money out

Alternative thought: “I’ll take the time I need, I can manage this”

Alternative reactions: tremor doesn’t increase, feel calm, able to fi nish the shopping

Step 5: Importance of stress management for people with PD

A little stress can have positive effects: many people say they perform at their best when they have a little pressure. Too much stress, however, is harmful for our health, and as already noted, with PD “too much” is reached much more easily. Chronic stress can lead to depression, burnout or physical illnesses. Learning to cope effectively with stress may help prevent these problems and increase our feelings of wellbeing.

Some people try to eliminate stress by completely avoiding situations that they experience as stressful. However, avoiding situations often has more negative than positive consequences for your wellbeing. For example, social situations are often experienced as stressful, but at the same time they are often associated with many positive feelings and consequences, such as when you socialise with other people. Avoiding such situations leads to social isolation and increases negative feelings connected to the situation. Instead of avoiding such situations, you can instead learn ways to cope with them.

Many situations cannot be avoided anyway, so you have to cope with them in one way or another. The old strategies you may have used in the past to manage stress may not be effective in the new situation, living with PD. Therefore, it is important to learn new strategies to handle the new situations.

Step 6: Alternative ways of thinking as a stress management method

There are many practical ways to prevent stress and cope with it, such as:

• planning daily activities in order to prevent overload• fi nding alternative ways to do things• including enough pleasant activities, rest and relaxation in your

day

In this session, however, we are looking specifi cally at how you can break the negative stress circle and manage stress by the way you think about the stressful situation and your ability to cope with it. We’ll look at specifi c situations and talk about how you could change the automatic, stress-increasing thinking or inner speech into stress-reducing thinking.


During the course of our lives, we all learn patterns of thinking and self-instruction in certain situations, so that our thoughts become almost automatic when we encounter those same situations in the future. To counteract this automatic way of thinking, you need to deliberately learn new thinking patterns. By observing your thoughts in situations in which you experience stress, you can learn to recognise stress-increasing thoughts and replace them with stress-reducing alternative thoughts.

In today’s exercise we’ll try this out.

Slides If desired, whilst explaining the contents of “active information”, you can write out the main points on a fl ip chart, or show the main points on slides or another medium.

Hand out Guidelines for Alternative Ways of Thinking in Stressful Situations. It summarises the important information about stress and provides practical instructions for using alternative ways of thinking in stressful situations.

Handout

Guidelines for Alternative Ways of Thinking in Stressful Situations


Goals:

• To understand what relaxation is.• To understand the importance of relaxation as a means to prevent, manage and

counteract the effects of stress.• To learn how to relax.

Part 2Active Information (Option 2): Stress and Stress Management – Relaxation as a Stress Management Method 0:30’ – 0:50’


Step 1: Appetiser discussion

Refer to the Instructions for Appetiser: Session 4 handout given at the end of the previous session, which lists examples of common stressful situations. Ask participants to share their own examples of stressful experiences.

All people experience stress every now and then but people with PD often experience stress much more easily than before. Therefore, the total amount of stress often increases considerably. When there’s more stress there’s also more need to counteract its effects. That’s why we are talking today about relaxation.

Step 2: What is relaxation?

Relaxation can counteract the effects of stress. Relaxation affects both the body and mind. Physically, relaxation of muscles suggests feelings of lightness and the absence of tension. Psychologically, relaxation refers to feelings of calmness and the absence of feelings of hurry and anxiety.

In everyday language, people can use the word relaxation for many kinds of activities, such as watching TV, walking calmly or engaging in their favourite hobbies. In that sense, relaxation is like a side effect of doing something you like and concentrating on things that are not stressful.

Here, however, we are talking about relaxation as a specifi c skill. It is an active, purposeful method, with which we can concentrate on the feelings in our bodies.


Step 3: Why is relaxation important for people with PD?

Most people with PD say that the disease has lowered their stress threshold. You may have noticed that activities you used to be able to perform automatically now demand conscious concentration and effort. It is diffi cult to concentrate on several things at the same time. In addition, if your muscle movements are slower, you cannot perform as quickly as before, and therefore are likely to feel time pressure more acutely than in the past.

PD also challenges you with new stressors (mention some of the stressful situations discussed during the appetiser).

For example, some people with PD fi nd it disturbing when people notice their symptoms, such as tremor. To make it worse, PD symptoms tend to increase in situations that are experienced as stressful.

Therefore, people with PD tend to experience quite a lot of stress in their day-to-day lives. Relaxation is one good way to reduce the effects of these stressors.

Step 4: How can you learn to relax?

Everybody can learn to relax. Relaxation, like any skill, requires regular practice. The more we practise the easier it is for us to become relaxed with little effort.

In the beginning, it is helpful to have a calm setting for relaxation: a quiet place where you will not be disturbed for a while. Later you will be able to relax in noisier places and in shorter amounts of time.

It is also helpful to reserve a specifi c time of the day that is only for you. You don’t necessarily need a lot of time in order to relax; even a few minutes’ relaxation can be helpful. If possible, however, it is even better if you have a bit more time, for example, at least 15 minutes. It is easier to reach a state of relaxation when you are not in a hurry.

When you are beginning a relaxation exercise, start by getting into a comfortable position, either lying down or sitting in a comfortable chair.

Breathing is a key to relaxation. The simplest way to relax is to concentrate on breathing out calmly, and letting your breath fl ow in and out at a calm pace.

However, there are many different methods that can be used to relax. In the exercise section of today’s session we’ll try out a relaxation method that combines muscle relaxation, breath control and visual imagery.

Hand out the Guidelines for Relaxation. This sheet summarises the most important points about relaxation and suggests practical instructions for relaxation training. Discuss the points on the handout and give participants an opportunity to ask questions.

Handout

Guidelines for Relaxation


Goal:

• To elaborate and apply the information from the previous section about how new ways of thinking can reduce stress.

Part 3Exercise (Option 1): Learning AlternativeWays of Thinking 0:50’ – 1:15’


Step 1:Generating alternative thoughts

From the stressful experiences that participants volunteered at the beginning of the session, choose one experience to use as a basis for the exercise.

Notes for group leader

In order to promote generalisation of the idea of alternative ways of thinking, it is better to use a different example from the one used throughout the Active Information section (e.g., paying at the cashier’s) even if someone has mentioned it. However, if you are running out of time and participants have not been able to come up with experiences you can just remind participants of this example.

If you have extra time, you can write all of the participants’ Appetiser examples on the fl ip chart, dividing each of these examples into situation/thought/reaction.

Flip Chart

As before, after presenting the example, divide the fl ip chart into three columns: Situation/Thought/Reactions. Further subdivide the “thought” column into two columns, with “old thought” in the fi rst subcolumn and “alternative thought” in the second subcolumn. Similarly subdivide the “reactions” column, with “old reaction” in the fi rst subcolumn and “alternative reaction” in the second subcolumn.

Ask participants for suggestions for alternative thoughts that could help to reduce stress in this specifi c situation. Write the suggestions under the “Alternative Thought” column on the fl ip chart. You can also give suggestions that are not mentioned by the participants (for example, the right to take your time; telling yourself to breathe deeply and calmly). Aim to generate at least as many alternatives as there are participants.

Use the Guidelines for Alternative Ways of Thinking in Stressful Situations to help generate alternatives.


Step 2: Expressing alternative ways of thinking

This exercise is conducted in “rounds”. Start with the participant whose stressful experience was picked and ask her/him to describe the situation and original stress-increasing thought. The participant sitting next to her/him then reads out one of the alternative thoughts from the fl ip chart.

All participants and the group leader take turns reading an alternative thought, going around the room twice if possible. At the end, the person who experienced the stressful situation is asked to repeat aloud one of the alternative thoughts just expressed. If time allows, the exercise can be repeated with one or more of the other stressful experiences.

Participants can remain seated throughout this exercise.


If participants show resistance towards doing this exercise, or if you notice that the participants do not understand the basic idea of alternative ways of thinking, you can replace the exercise by a discussion of practical behavioural alternatives that could be used to manage the specifi c situation.

Step 3: Discussion

After the exercise, ask the person whose example has been used:

• What was it like to hear the alternative thoughts said aloud? • How did you feel when you said aloud the alternative thought

yourself at the end, compared with the original stress-increasing thought?

• What consequences do you think the alternative thought would have for how you’d feel and behave in the situation?

• What other kinds of alternative thoughts could you use in the same situation?

Encourage other participants to share their thoughts about the exercise, too. Then suggest ways in which the same principle can be applied in real-life stressful situations, for example:

When you recognise that you are having “stress-increasing thoughts”, you can purposely think and “talk” to yourself in a stress-reducing way. This has consequences for how you cope with the situation.

Handout


Patient Education for People with PD and their Carers1 2 3 4 5

Goals:

• To elaborate and apply information presented in the previous section about relaxation training as a method of stress management.

Part 3Exercise (Option 2): Relaxation Training 0:50’ – 1:15’


Step 1: Preparation

It is usually more effective for participants to perform the exercise lying down but, if that is not possible, they can perform the exercise sitting in a chair. If desired you can play restful music in the background.

This exercise includes components from three different relaxation methods: muscle relaxation, breath control and visual imaging.

In order to be able to relax, you must fi rst be aware of the difference between tension and relaxation in your body. (Refer to the Body Awareness exercise in Session 2.)

Please get into a comfortable position. Lean against the back of your chair (if sitting)/let your weight rest evenly on the fl oor (if lying down).

Keep your legs a comfortable distance from each other. Let your feet lie on the fl oor in whatever way feels natural. Let your arms rest in a comfortable position, on the arm rests of the chair or on your thighs (if sitting)/on the fl oor (if lying down).

Close your eyes and take a deep breath.

Concentrate only on yourself. Tune everything else out. This room is starting to disappear, bit by bit, from your awareness. (Pause . . .)

The voices around you are fading to the background. (Pause . . .)

If distracting thoughts come to your mind, let them come and go away from your consciousness. Concentrate only on yourself, on your body, your breath. Let your breath fl ow in and out at its own pace. Notice that each time you exhale, you become more and more relaxed. Your body is feeling heavier, pressing against the chair/fl oor.


Step 2: Muscle relaxation

We will relax our bodies by fi rst tightening and then relaxing groups of muscles. We will go through each group of muscles twice: fi rst tightening the group of muscles, then letting them relax. When tightening the muscles, try to use only those muscles that I ask you to tighten. Let the rest of your body remain relaxed.


Talk faster when you instruct participants to tighten muscles and more slowly when you ask them to relax muscles. Have them tighten muscles for about 5 seconds each time.

1. Let’s start by concentrating on your right leg. Tighten the muscles in the leg by straightening the leg and bending the ankle. Feel the tension in the foot and the leg.

Now let the muscles relax. Feel the difference between the tension in the muscles before, and the relaxation now.

Tighten the muscles in the leg and foot one more time: straighten the leg and bend the ankle, hold . . .

And relax again. Let the muscles in the leg and foot relax more and more.

2. Concentrate now on your left leg. Tighten the muscles in your left leg by straightening the leg and bending the ankle. Hold that tightness and feel the tension in the foot and the leg.

Now let the muscles relax. Observe the sensation of relaxation in the muscles.(Repeat tightening and relaxing.)

3. Now, concentrate on your bottom. Tighten those muscles, keep tightening them.

Now, let those muscles relax.(Repeat tightening and relaxing.)

4. Concentrate now on the muscles in your back. Straighten your back by pulling your shoulders back toward the backbone. Feel the tension in your back muscles.

Now let your back muscles relax again. Stay relaxed and let the sensation of relaxation spread through your whole back.(Repeat tightening and relaxing.)

5. Direct your attention now to your abdominal muscles. Push the lower part of your back tightly (against the back of the chair/against the fl oor) by tightening up your abdominal muscles. Hold the muscles tightly and feel the tension in your abdomen.

Now let the abdominal muscles relax again. Observe the warm sensation of relaxation in your abdomen.(Repeat tightening and relaxing.)


6. Next, concentrate on your arms and hands. Tighten the arm muscles by straightening both arms and making fi sts with your hands. Hold the muscles tightly, and feel the tension in the arms and hands.

Let your arms and hands relax again. Let your arms rest comfortably and feel the warmth of relaxation. Let the sensation of relaxation get deeper and deeper.(Repeat tightening and relaxing.)

7. We will now move to the neck muscles. Tighten your neck by pushing the back of your head against the back of the chair/against the fl oor and your chin towards your chest. Keep the neck muscles tightened.

Now let them relax again. Feel the relaxation spread to your neck and your shoulders.(Repeat tightening and relaxing.)

8. Direct your attention now to your face and forehead. Wrinkle up your forehead and face, keep the muscles tightened.

Now let your forehead become smooth and relaxed again. As your forehead muscles relax, let your mind relax as well. (Repeat tightening and relaxing.)

Now that we have gone through all of the major muscles in your body, you can concentrate on the sensation of relaxation in your body as a whole. Let yourself relax more and more deeply. (Longer pause.)

Step 3: Breath control

Now I’d like you to concentrate on your breathing. Direct your attention to how the air fl ows in and out, in and out.

Breathe deeply a few times. Let the air fl ow into the lowest parts of your lungs.

Let your breathing fl ow at its own pace again. Concentrate on your exhalation. Notice that each time you exhale, your body relaxes more and more. Feel the sensation of calmness spreading through your mind when you exhale. Just let the breath fl ow . . . (Pause.)

Step 4: Visual imagery

Let’s deepen the state of relaxation with the help of a mental picture.

Imagine that you are in a place where you feel good. You could be at the seaside, in a forest, in a meadow in the sunshine, or in some other place which is especially important and safe for you, and in which you feel good. In your imagination, go to that place and imagine that you are lying or sitting in that place right now.


Let this place become as vivid to you as possible. Is it warm or cold around you? What do you see? Do you see sky, trees, plants, animals, people? What do you hear? Do you hear voices from nature, animals, people or music? What sensations do you feel in your body? How do your hands feel? How about your skin, your face? What smells are in the air? What do you feel?

Keep a clear image of this place in your mind. Observe your state of relaxation. Associate this place with the sensation of relaxation. During the next few minutes I will be quiet so that you can concentrate on relaxation (pause of about 2 minutes).

This place will become a place you can always come back to when you want to relax.

Step 5: Coming back

Now I would like for you to begin to prepare, little by little, to come back from this relaxing place of yours to the room we are in. Let the normal muscle tone fl ow back into your body. You can start by moving your hands a little. Stretch and shake other parts of your body too. Observe how each inhalation gives you renewed energy. Breathe in deeply a few times and open your eyes.

Step 6: Discussion

Ask the participants what their experiences were like.

• How did you feel during this exercise? • Was it easy to concentrate? • Which of the three ways of relaxing (muscle relaxation, breath

control or visual imagery) did you fi nd the most effective?

1 2 3 4 5

This relaxation exercise is adapted from Psychologische Interventionen bei der Parkinson-Erkrankung: Ein Behandlungsmanual by Michael Macht and Heiner Ellgring. Reproduced by permission of W. Kohlhammer GMBH.

Patient Education for People with PD and their Carers

Goal:

• To learn to apply stress-reducing methods to daily life.

Part 4Homework (Option 1): Trying Out Alternative Ways of Thinking 1:15’ – 1:30’


Step 1: Choosing a stress-reducing thought

Ask each participant to choose one alternative, stress-reducing thought that fi ts either the example of a stressful situation that they brought to the session (Appetiser) or one of their other frequently experienced stressful situations.

Although alternatives generated by the group in the previous exercise or examples from the Guidelines for Alternative Ways of Thinking in Stressful Situations can be used, emphasise that the most effective alternatives are often formulated by the person her/himself. For this homework, one alternative thought is suffi cient.

Step 2: Making a reminder card

Have each participant choose one blank (coloured) card, and write her/his chosen stress-reducing thought on the card. (You can write the thought for participants who have diffi culty writing.)

Example For example, if a participant fi nds it stressful to be at the supermarket checkout, she/he could write on the reminder card: “I have the right to take the time I need.”

Encourage participants to share what they have written on their card with other participants (if time allows).

Step 3: Using the reminder card

Instruct participants to keep the reminder card with them (for example in their pocket, wallet or handbag), and ask them to try to identify situations that are stressful as they approach or occur. At those times, they should take out the reminder card and read what they have written for this situation. If it is not possible to take out the card in the situation, they can instead just think about the card and about the alternative thought they wrote down.

Suggest that if participants do not spontaneously fi nd themselves in the stressful situation for which they have written the card, they could deliberately expose themselves to that situation (for example, going to a supermarket, even if they normally do not do this often) during the period before the next session.


Hand out Instructions for the Homework: Session 4 – Trying Out Alternative Ways of Thinking.

Handouts

Instructions for the Homework: Session 4 – Trying Out Alternative Ways of Thinking



Goal:

• To learn to apply relaxation training to daily life.

Part 4Homework (Option 2):Daily Relaxation Training 1:15’ – 1:30’


Instructions for daily relaxation training

Ask participants to practise relaxing using the relaxation exercise every day.

Homework at basic level

Performing the relaxation exercise at the “basic” level requires 1−5 minutes per day.

Homework at advanced level

Performing the relaxation exercise at the “advanced” level requires 15 minutes per day.

Hand out Instructions for the Homework: Session 4 – Daily Relaxation Training.

Ask participants to think about which level of exercise they will be able to do and when and where they will best be able to complete the exercise. Have them write down the time of day on the homework sheet. Ask if anyone has any questions.

Handout

Instructions for the Homework: Session 4 – Daily Relaxation Training


Goal:

• To help participants become aware of changes in their mood.

Part 5Appetiser: Management of Anxiety and Depression


Observe your mood

During the coming days, try to observe changes in your mood. In addition, think about what kinds of things worry you.Hand out Instructions for the Appetiser: Session 5

Handout

Instructions for the Appetiser: Session 5


Session 4: Stress ManagementMaterials

For both options:

❏ Negative and positive stress circles (to be shown on OHP, printed as handout, or made into slides).

❏ Instructions for the Appetiser: Session 5

For Option 1 only:

❏ Guidelines for Alternative Ways of Thinking in Stressful Situations ❏ Examples of Stress-Increasing and Stress-Reducing Thoughts❏ Instructions for Homework: Session 4 – Trying Out Stress-Reducing Thinking

For Option 2 only:

❏ Guidelines for Relaxation❏ Instructions for Homework: Session 4 – Daily Relaxation Training



Stress Circles

Negative stress circle

THINKING:Stress-increasing

thoughts

BODILY SENSATIONS:Bodily tension

FEELINGS:Tension

IrritabilityAnxiety

PARKINSON SYMPTOMS:Worsening of

Parkinson symptoms

Positive stress circle

THINKING:Stress-reducing thoughts

BODILY SENSATIONS:Bodily relaxation

FEELINGS:Calmness

Confidence

PARKINSON SYMPTOMS:Improvement in

Parkinson symptoms

The stress circles are adapted from Psychologische Interventionen bei der Parkinson-Erkrankung:Ein Behandlungsmanual by Michael Macht and Heiner Ellgring. Reproduced by permission ofW. Kohlhammer GMBH.




When you feel stressed it is essential to make a distinction between:

1. The situation in which you experience stress (for example, paying at the supermarket).

2. Your thoughts, self-instructions − in other words, what you silently say to yourself about the situation and your ability to cope with it (for example, “oh no, now I really have to hurry! I’ll never make it”).

3. Your reactions, such as bodily tension, worsening of PD symptoms, feelings of nervousness, avoidance behaviour.

When you feel stressed, it is not a result of the situation itself but of your thoughts. In order to diminish feelings of stress, you must therefore change your way of thinking.

In order to change your way of thinking, you must fi rst become aware of it. By observing the way you “talk” to yourself in stressful situations you can become aware of your thoughts.

The next step is to start changing your thoughts. When you catch yourself thinking in a stress-increasing way you can start to intentionally replace your stress-increasing thought with a stress-reducing thought. The table on the second page of this handout shows some examples of stress-increasing thoughts (left column) and stress-reducing alternatives (right column). You can use them as a model when formulating your own stress-reducing thoughts.

Your way of thinking may seem almost automatic because you have probably thought that way for a long time. With systematic practice, however, you will fi nd that it is possible to change your thoughts and reduce stress.



Examples of Stress-Increasing and Stress-Reducing Thoughts

Stress-increasing thought: Alternative, stress-reducing thought:

Oh no, my hands are shaking. • Let them (my hands) shake.• It is OK to feel nervous. • I am breathing deeply and calmly.

I can’t do this. • I can manage this.• I’ll do this as well as I can − that is good

enough.

I can’t do this in time. • I can take the time that I need.• There is time.• Even if I am late, it’s not the end of the world.

This is only getting worse. • I am doing fi ne.

People are staring at me. • I don’t care about other people. I am concentrating on what I’m doing.

• Let them stare!

They must think I have a hangover.

• Let them think what they think! I know better. • This is none of their business!

I must succeed. • It’s not so important, even if this doesn’t work perfectly.

• Why must I? Does it really matter?

I must be fast so that I’m not in the way of those busy people.

• They’ll have to wait. I have a right to take the time I need.

• Let them wait!

There’s nothing I can do about it.

• Let me think about what I could do before jumping to conclusions.




Being able to relax is an important way to counteract the effects of stress. Relaxation is a skill that can be learned. Systematic practice can improve the ability to relax, even in diffi cult situations. The following hints may be helpful for such practice:

1 Allow yourself to relax. 2 Allocate time for relaxation. Reserve a specifi c time for relaxation, for example,

15 minutes every evening. 3 Select a quiet place where you will not be disturbed. Close the door, switch off

telephones and ask your family members not to disturb you. 4 Get in a comfortable position. You can lie down or sit in a comfortable chair.5 Concentrate. Switch off your thoughts about the world around you, and direct your

thoughts inwards. 6 Breathe out calmly. If you have diffi culty concentrating, direct your attention to

your breathing.7 Practise regularly. The more you practise, the easier it will be to reach a state of

relaxation.8 Find your own way of relaxing. Try out different relaxation methods: tightening

and relaxing groups of muscles, listening to your breathing, imagining a peaceful scene.

9 Try out different relaxation aids. If you like, you can put on relaxing music when doing relaxation exercises. You can also try out audiotapes/CDs designed to teach relaxation.

10 Enjoy yourself!



Instructions for Homework: Session 4

Trying out stress-reducing thinking (Option 1)

Put the reminder card you made in this session in your pocket, wallet or handbag and keep it with you. When you are approaching a stressful situation, or when you are already in the situation, you can take out the card and read what you’ve written on it. If it is not possible to read the card in the situation, you can still think about what you wrote on it.

If you do not fi nd yourself in the stressful situation for which you planned the card (for instance, because you are in the habit of avoiding it), you could deliberately expose yourself to that situation in order to try out alternative thinking before the next session.

Example: You wrote a stress-reducing thought for the situation in which you must pay at a supermarket cashier with a long queue behind you. Go to the supermarket. Before you go to the cashier, read the alternative thought on your card.




Daily relaxation training (Option 2)

Try to practise relaxation training every day until the next session.

Decide fi rst what time of the day you will do your daily relaxation exercise: Each day, I will relax at o’clock.

Before doing the homework for the fi rst time, reread the instructions on the handout Guidelines for Relaxation that you were given in the session. You may also want to have this homework sheet with you so that you can check what to do.

You can choose between two homework levels. The basic level requires a minimum of one minute daily. The advanced level takes about 15 minutes daily and aims at a deeper state of relaxation.

Homework at basic level:

Take a 1−5 minute break from your obligations. (You don’t have to use a clock to keep track of the time.) Get in a comfortable position and switch off your everyday thoughts. Concentrate on listening to your breathing, focus on your exhalations. Let your breath fl ow at its own pace, and let yourself relax every time you exhale.

Homework at advanced level:

To do this homework you need about 15 minutes for yourself.

1. Start by concentrating on your breathing. Notice that every time you exhale, you feel more and more relaxed.

2. Tighten and relax groups of muscles in the same way as we did in the session. Tighten the muscles fi rst for about 5 seconds and then relax. Go through the following groups of muscles:

– right leg – left leg – bottom – back – abdomen – arms and hands – neck – face and forehead

3. Repeat tightening and relaxing one more time.4. Let yourself rest for a while. Concentrate on breathing out calmly again. If you

like, you can think of your relaxing place: imagine that you are in your favourite place and that you feel relaxed.

5. To come back from the state of relaxation, start by inhaling deeply a few times. Become aware of the noises around you, move your legs and arms a bit. Concentrate on how it feels to breathe in deeply. Notice the renewed energy it brings you. Slowly open your eyes.




The topic of the next session is management of depression and anxiety. In preparation for this session, try to observe changes in your mood during the next few days. In addition, think about what kinds of things worry you.



Session 4: Stress ManagementOverview

Participants receive information about stress and stress management and practise a specifi c method of stress management. This practice is continued at home.

Materials❏ Relevant handouts❏ Stress circles fi gure (for slides or handouts)❏ Flip chart, markers, blank cards, pens for participants❏ (Optional: relaxing music)

Part Contents

1


Discussion of experiences with pleasant activities Up to

0:30’

2

Active InformationStress management

Option 1: Stress and stress management – The role of your thoughts

Option 2: Stress and stress management – Relaxation as a stress management method

Up to 0:50’

3

ExerciseStress management

Option 1: Learning alternative ways of thinking

Option 2: Relaxation training

Up to 1:15’

4

Homework Stress management

Option 1: Trying out alternative ways of thinking

Option 2: Daily relaxation training Up to 1:30’

5AppetiserCarer’s Challenge

Observing feelings of anguish, sadness and nervousness.

Please note: Option 1 is the cognitive option; Option 2 is the behavioural option.


Goal:

• To support the application of knowledge and skills from the previous session (Pleasant Activities) in daily life.

Part 1Discuss Homework: Pleasant Activities 0:30’



Ask participants to describe briefl y their experiences performing pleasant activities since the last session. Encourage the participants to talk about problems that arose, such as:

• External barriers, for example, distraction by others or disturbances

• Internal barriers, for example, lack of motivation or time• Inappropriateness of chosen activity, for example, the activity

was not as pleasant as expected or was too diffi cult

Briefl y discuss these problems with the group and invite other participants to suggest solutions. Some possible solutions that could be suggested include:

• External barriers: Establish surroundings that allow you to perform pleasant activities more easily, for example, in your own room. Find a suitable time during the day to perform the pleasant activities without being disturbed.

• Internal barriers: Consider the benefi ts of pleasant activities. Perform pleasant activities together with a partner.

• Activity was not appropriate: Find more suitable pleasant activities by referring again to the Pleasant Events Schedule.

Encourage participants to continue using this exercise.


Goals:

• To understand what stress is and what components comprise it.• To understand why stress management is important for the wellbeing of carers of people

with PD.• To understand what you can do in order to cope better with everyday situations that are

experienced as stressful.

Part 2Active Information (Option 1): Stress Management – The Role of Your Thoughts 0:30’ – 0:50’



Refer to the Instructions for Appetiser: Session 4 handout given at the end of the previous session, which lists examples of common stressful situations. Ask participants to describe some of their own stressful experiences.

Choose one of the participants’ examples and use it when explaining the rest of the steps in this section. Use the same example for all steps, pointing out that the same principles apply to other examples as well.

Example If no adequate examples are given by the participants you can use your own, such as:

The carer is about to go to the neurologist with a person who has PD. They are running late and the person with PD is still slowly putting on clothes.

When choosing the example, be sure to take into account the characteristics of the specifi c group (such as stage of PD and age of the person they care for).


If you are running short on time (for example, if the homework discussion has taken longer than anticipated) you can ask participants to pair up with a partner and tell each other about their stressful situations, instead of having every participant describe their stressful experiences to the whole group.

Step 2: What is stress?

Stress is a state in which we interpret a situation as demanding more of us than we are capable of managing, for instance, if we think that we should do something better or more quickly than we are able to.


Example When going to the doctor with your partner/relative with PD you feel that you must arrive on time, but because of the slowness of the person with PD you see that it is impossible.

Step 3: Stress and caring for someone with PD

Caring for someone with PD requires you to confront new situations, such as those we discussed during the appetiser. Changes in the person with PD, such as slowness of movements and increasing dependence, can result in changes in your relationship and in your interaction with that person. You may often take over tasks and roles that used to be the responsibility of the person with PD.

Example Before your partner/relative developed symptoms of PD, he or she was probably fairly independent, and able to do things such as taking care of doctor’s visits. Now you may be the one who has to keep a record of doctors’ visits and other schedules. This imposes an extra burden on you, in addition to other tasks that have become your responsibility. It may be a new thing for you to have to remind your partner/relative of when you need to leave. You may be the one who has to make sure that he or she starts to prepare early enough to make it on time.

Even if your partner/relative is still independent and does not need your help, you might still have noticed that things take more time, which may lead you to feel stressed when you do things together.

Step 4: Components of stress

We can divide a stressful experience into several components.

1. Situation: the circumstances in which you experience stress. 2. Thoughts: your interpretation of the situation and of your ability

to cope with it. The thoughts can be seen as self-instructions, in other words, what you “say” to yourself in the situation.

3. Reactions: at three different levels:

• emotional reactions (feelings of discomfort, tension, irritability, nervousness)

• bodily reactions (muscle tension, sweating)• behavioural reactions (how you act in the situation).

The components of stress are interrelated. A particular situation itself is not inherently “stressful” because what is stressful for one person might not be for another. What is important is how you interpret the situation, and what you say to yourself about it.

If you think that the situation is too demanding and you can’t cope with it, your thinking infl uences your reactions at the level of muscle tension, symptoms of anxiety and emotional reactions. These reactions feed back and infl uence your thoughts. This is called a negative stress circle.


On the other hand, if you think that you’ll handle the situation even if it is challenging, your thoughts infl uence your reactions in a positive way, and the calm reactions of your body and feelings reinforce your thinking. These factors also infl uence your behaviour in the situation. This is called a positive stress circle.

Flip Chart

Draw a negative and a positive stress circle on a fl ip chart or other medium, or show a PowerPoint slide/OHP displaying the stress circles. (A model of the stress circles is included in the Materials section of this session.)

Example Present the following example, whilst pointing to the picture of the stress circles:

Imagine that your partner/relative has an appointment at the neurologist’s offi ce in half an hour. You are still at home, and your partner/relative has not put on her/his coat yet. This is the situation.

You think: “Oh no, we’re going to be late again. We’ve got to get there on time. We’re going to have to really hurry now.”

This way of thinking leads to feelings of nervousness and pressure (emotional reaction). You hurry your partner/relative (behavioural reaction), who gets nervous, too. They start to tremble even more than usual, and take even more time than normal to put on their clothes. You accuse them of being too slow and they get upset because you don’t seem to understand their condition. As a result, you both feel bad and you do not speak to each other during the car ride to the neurologist’s offi ce.

This is an example of a negative stress circle. Exactly the same situation can also be used to illustrate the effects of a positive stress circle:

The situation is exactly the same: your partner/relative has an appointment at the neurologist’s offi ce in half an hour. You could think instead: “Oh, is it that late already? I hope we’ll get there on time, but if we don’t, it’s not the end of the world. That has happened before. I’ll take a deep breath fi rst and we’ll just do the best we can.”

This way of thinking helps you feel calm (emotional reactions) no matter what the situation. You leave your partner/relative to get dressed and help them when needed (behavioural reaction). You say something encouraging, and they dress without additional problems. On the car ride to the appointment, you have a conversation about the questions you would like to ask the neurologist. This is an example of a positive stress circle.


Flip Chart

After presenting the example, divide the fl ip chart into three columns: Situation/Thought/Reactions. Further subdivide the “thought” column into two columns, with “old thought” in the fi rst subcolumn and “alternative thought” in the second sub-column. Similarly sub-divide the “reactions” column, with “old reaction” in the fi rst sub-column and “alternative reaction” in the second sub-column. Write down notes from the example as follows:

Example Situation: Doctor’s visit in 30 minutes, still at home.

Old thought: “Oh no, we’ll be late again.”

Old reactions: Angry at spouse, who starts to tremble even more.

Alternative thought: “If we arrive late, it’s not the end of the world. We’ll just do the best we can.”

Alternative reactions: Co-operation with spouse when putting on clothes, leaving for the doctor’s offi ce in peace.

Step 5: Importance of stress management for carers of people with PD

A little stress can have positive effects: many people say they perform at their best when they have a little pressure. Too much stress, however, is harmful to your health. Chronic stress can lead to depression, burnout or physical illnesses. Learning to cope effectively with stress may help prevent these problems and increase your feelings of wellbeing.


Tell the participants that these topics will be dealt with again in the following session (Carer’s Challenge). Mention that the emphasis in Session 5 will be the total burden of care, whereas today you will be dealing with specifi c situations that are part of that burden. Then continue.

Some people try to eliminate stress by completely avoiding situations that they experience as stressful. However, avoiding situations often has more negative than positive consequences for your wellbeing. For example, social situations are often experienced as stressful, but at the same time they are often associated with many positive feelings and consequences, such as when you socialise with other people. Avoiding such situations leads to social isolation and increases negative feelings connected to the situation. Instead of avoiding such situations, you can instead learn ways to cope with them.

Many situations cannot be avoided anyway, so you have to cope with them in one way or another. The old strategies you may have used in the past to manage stress may not be effective in the new situation, living with/helping a person who has PD. Therefore, it is important to learn new strategies to handle the new situations.


Step 6: Alternative ways of thinking as a stress management method

There are many practical ways to prevent stress and cope with it, such as:

• planning daily activities in order to prevent overload• fi nding alternative ways to do things• including enough pleasant activities, rest and relaxation in your

day

In this session, however, we are looking specifi cally at how you can break the negative stress circle and manage stress by the way you think about the stressful situation and your ability to cope with it. We’ll look at specifi c situations and talk about how we could change the automatic, stress-increasing thinking or inner speech into stress-reducing thinking.

During the course of our lives, we all learn patterns of thinking and self-instruction in certain situations, so that our thoughts become almost automatic when we encounter those same situations in the future. To counteract this automatic way of thinking, you need to deliberately learn new thinking patterns. By observing your thoughts in situations in which you experience stress, you can learn to recognise stress-increasing thoughts and replace them with stress-reducing alternative thoughts.

In today’s exercise, we’ll try this out.

Slides If desired, whilst explaining the contents of Active Information, you can write out the main points on a fl ip chart, or show the main points on slides or another medium.

Hand out Guidelines for Alternative Ways of Thinking in Stressful Situations. It summarises the important information about stress and provides practical instructions for using alternative ways of thinking in stressful situations.

Handout



Goals:

• To understand what relaxation is.• To understand the importance of relaxation as a means to prevent, manage and

counteract the effects of stress.• To learn how to relax.

Part 2Active Information (Option 2): Stress Management – Relaxation as a Stress Management Method 0:30’ – 0:50’



Refer to the Instructions for Appetiser: Session 4 handout given at the end of the previous session, which lists examples of common stressful situations. Ask participants to share their own examples of stressful experiences.

All people experience stress every now and then but caring for a person with PD often increases stressful experiences in daily life. Therefore, the total amount of stress often increases considerably. When there’s more stress, there’s also more need to counteract its effects. That’s why we are talking today about relaxation.

Step 2: What is relaxation?

Relaxation can counteract the effects of stress. Relaxation affects both the body and mind. Physically, relaxation of muscles suggests feelings of lightness and the absence of tension. Psychologically, relaxation refers to feelings of calmness and the absence of feelings of hurry and anxiety.

In everyday language, people can use the word “relaxation” for many kinds of activities, such as watching TV, walking calmly or engaging in their favourite hobbies. In that sense, relaxation is like a side effect of doing something you like and concentrating on things that are not stressful.

Here, however, we are talking about relaxation as a specifi c skill. It is an active, purposeful method, which we can concentrate on the feelings in our bodies.


Step 3: Why is relaxation important for carers of people with PD?

Caring for someone with PD means that you are confronted with new situations in daily life (mention some of those discussed in the appetiser).

Changes in the person with PD, slowness of movement and increasing dependence, might result in changes in your relationship and in your interaction with your partner. You may need to take over tasks and roles that previously were the responsibility of the other person. When the disease progresses, you may need to aid the person with PD in many everyday activities, resulting in both physical and psychological burden.

Even if your partner/relative is still independent and doesn’t need your help, you might have noticed that things take more time and you might feel stressed when you do things together.

Too much stress is harmful to our health. Chronic stress can lead to depression, burnout or physical illnesses. In the next session, Carer’s Challenge, we’ll talk more about ways to deal with longer term burden, whereas today we’re talking about dealing with daily stressors. Relaxation is one good method for managing and counteracting the effects of daily stress.

Step 4: How can you learn to relax?

Everybody can learn to relax. Relaxation, like any skill, requires regular practice. The more we practise the easier it is for us to become relaxed with little effort.

In the beginning, it is helpful to have a calm setting for relaxation: a quiet place where you will not be disturbed for a while. Later you will be able to relax in noisier places and in shorter amounts of time.

It is also helpful to reserve a specifi c time of the day that is only for you. You don’t necessarily need a lot of time in order to relax; even a few minutes’ relaxation can be helpful. If possible, however, it is even better if you have a bit more time, for example, at least 15 minutes. It is easier to reach a state of relaxation when you are not in a hurry.

When you are beginning a relaxation exercise, start by getting into a comfortable position, either lying down or sitting in a comfortable chair.

Breathing is a key to relaxation. The simplest way to relax is to concentrate on breathing out calmly, and letting your breath fl ow in and out at a calm pace.


However, there are many different methods that can be used to relax. In the exercise section of today’s session, we’ll try out a relaxation method that combines muscle relaxation, breath control, and visual imagery.

Hand out the Guidelines for Relaxation. This sheet summarises the most important points about relaxation and suggests practical instructions for relaxation training. Discuss the points on the handout and give participants an opportunity to ask questions.

Handout



Goal:

• To elaborate and apply the information from the previous section about how new ways of thinking can reduce stress.

Part 3Exercise (Option 1): Learning AlternativeWays of Thinking 0:50’ – 1:15’


Step 1: Generating alternative thoughts

From the stressful experiences participants volunteered at the beginning of the session, choose one experience to use as a basis for the exercise.

Notes for group leader

In order to promote generalisation of the idea of alternative ways of thinking, it is better to use a different example than the one used throughout the Active Information section (e.g., going to the neurologist’s) even if someone has mentioned it. However, if you are running out of time and participants have not been able to come up with experiences you can just remind participants of this example.

If you have extra time you can write all of the participants’ Appetiser examples on the fl ip chart, dividing each of these examples into situation/thought/reaction.

Flip Chart

As before, after presenting the following example, divide the fl ip chart into three columns: Situation/Thought/Reactions. Further subdivide the “thought” column into two columns, with “old thought” in the fi rst subcolumn and “alternative thought” in the second subcolumn. Similarly subdivide the “reactions” column, with “old reaction” in the fi rst sub-column and “alternative reaction” in the second subcolumn.

Ask participants for suggestions for alternative thoughts that could help to reduce stress in this specifi c situation. Write the suggestions under the “Alternative Thought” column on the fl ip chart. You can also give suggestions that are not mentioned by the participants (for example, the right to take your time; telling yourself to breathe deeply and calmly). Aim to generate at least as many alternatives as there are participants.

Use the Guidelines for Alternative Ways of Thinking in Stressful Situations to help generate alternatives.


Step 2: Expressing alternative ways of thinking

This exercise is conducted in “rounds”. Start with the participant whose stressful experience was picked and ask her/him to describe the situation and original stress-increasing thought. The participant sitting next to her/him then reads out one of the alternative thoughts from the fl ip chart.

All participants and the group leader take turns reading an alternative thought, going around the room twice if possible. At the end, the person who experienced the stressful situation is asked to repeat aloud one of the alternative thoughts just expressed. If time allows the exercise can be repeated with one of the other stressful experiences.

Participants can remain seated throughout this exercise.


If participants show resistance towards doing this exercise, or if you notice that the participants do not understand the basic idea of alternative ways of thinking, you can replace the exercise by a discussion of practical behavioural alternatives that could be used to manage the specifi c situation.

Step 3: Discussion

After the exercise, ask the person whose example has been used:

• What was it like to hear the alternative thoughts said aloud? • How did you feel when you said aloud the alternative thought

yourself at the end, compared with the original stress-increasing thought?

• What consequences do you think the alternative thought would have for how you’d feel and behave in the situation?

• What other kinds of alternative thoughts could you use in the same situation?

Encourage other participants to share their thoughts about the exercise, too. Then suggest ways in which the same principle can be applied in real-life stressful situations, for example:

When you recognise that you are having “stress-increasing thoughts”, you can purposely think and “talk” to yourself in a stress-reducing way. This has consequences for how you cope with the situation.

Handout



Goals:

• To elaborate and apply information presented in the previous section about relaxation training as a method of stress management.

Part 3Exercise (Option 2): Relaxation Training 0:50’ – 1:15’


Step 1: Preparation

It is usually more effective for participants to perform the exercise lying down, but if that is not possible they can perform it sitting in a chair. If desired, you can play restful music in the background.

This exercise includes components from three different relaxation methods: muscle relaxation, breath control and visual imaging.

In order to be able to relax you must fi rst be aware of the difference between tension and relaxation in your body. (Refer to the Body Awareness exercise in Session 2.)

Please get into a comfortable position. Lean against the back of your chair (if sitting)/let your weight rest evenly on the fl oor (if lying down).

Keep your legs a comfortable distance from each other. Let your feet lie on the fl oor in whatever way feels natural. Let your arms rest in a comfortable position on the arm rests of the chair or on your thighs (if sitting)/on the fl oor (if lying down).

Close your eyes and take a deep breath.

Concentrate only on yourself. Tune everything else out. This room is starting to disappear, bit by bit, from your awareness. (Pause . . .)

The voices around you are fading to the background. (Pause . . .)

If distracting thoughts come to your mind, let them come and go away from your consciousness. Concentrate only on yourself, on your body, your breath. Let your breath fl ow in and out at its own pace. Notice that each time you exhale, you become more and more relaxed. Your body is feeling heavier, pressing against the chair/fl oor.


Step 2: Muscle relaxation


We will relax our bodies by fi rst tightening and then relaxing groups of muscles. We will go through each group of muscles twice: fi rst tightening the group of muscles, then letting them relax. When tightening the muscles, try to use only those muscles that I ask you to tighten. Let the rest of your body remain relaxed.

Talk faster when you instruct participants to tighten muscles and more slowly when you ask them to relax muscles. Allow participants to tighten each group of muscles for about 5 seconds.

1. Let’s start by concentrating on your right leg. Tighten the muscles in the leg by straightening the leg and bending the ankle. Feel the tension in the foot and the leg.

Now let the muscles relax. Feel the difference between the tension in the muscles before, and the relaxation now.

Tighten the muscles in the leg and foot one more time: straighten the leg and bend the ankle, hold . . .

And relax again. Let the muscles in the leg and foot relax more and more.

2. Concentrate now on your left leg. Tighten the muscles in your left leg by straightening the leg and bending the ankle. Hold that tightness and feel the tension in the foot and the leg.

Now let the muscles relax. Observe the sensation of relaxation in the muscles.(Repeat tightening and relaxing.)

3. Now concentrate on your bottom. Tighten those muscles. Keep tightening them.

Now, let those muscles relax.(Repeat tightening and relaxing.)

4. Concentrate now on the muscles in your back. Straighten your back by pulling your shoulders back toward the backbone. Feel the tension in your back muscles.

Now let your back muscles relax again. Stay relaxed and let the sensation of relaxation spread through your whole back.(Repeat tightening and relaxing.)

5. Direct your attention now to your abdominal muscles. Push the lower part of your back tightly (against the back of the chair/against the fl oor) by tightening up your abdominal muscles. Hold the muscles tightly and feel the tension in your abdomen.

Now let the abdominal muscles relax again. Observe the warm sensation of relaxation in your abdomen.(Repeat tightening and relaxing.)


6. Next, concentrate on your arms and hands. Tighten the arm muscles by straightening both arms and making fi sts with your hands. Hold the muscles tightly and feel the tension in your arms and hands.

Let your arms and hands relax again. Let your arms rest comfortably and feel the warmth of relaxation. Let the sensation of relaxation get deeper and deeper.(Repeat tightening and relaxing.)

7. We will now move to the neck muscles. Tighten your neck by pushing the back of your head (against the back of the chair/against the fl oor) and your chin towards your chest. Keep the neck muscles tightened.

Now let them relax again. Feel the relaxation spread to your neck and your shoulders. (Repeat tightening and relaxing.)

8. Direct your attention now to your face and forehead. Wrinkle up your forehead and face; keep the muscles tightened.

Now let your forehead become smooth and relaxed again. As your forehead muscles relax, let your mind relax as well. (Repeat tightening and relaxing.)

Now that we have gone through all of the major muscles in your body, you can concentrate on the sensation of relaxation in your body as a whole. Let yourself relax more and more deeply (longer pause.)

Step 3: Breath control

Now I’d like you to concentrate on your breathing. Direct your attention to how the air fl ows in and out, in and out.

Breathe deeply a few times. Let the air fl ow into the lowest parts of your lungs.

Let your breathing fl ow at its own pace again. Concentrate on your exhalation. Notice that each time you exhale, your body relaxes more and more. Feel the sensation of calmness spreading through your mind when you exhale. Just let the breath fl ow. . . (Pause. )

Step 4: Visual imagery

Let’s deepen the state of relaxation with the help of a mental picture.

Imagine that you are in a place where you feel good. You could be at the seaside, in a forest, in a meadow in the sunshine, or in some other place that is especially important and safe for you and in which you feel good. In your imagination go to that place and imagine that you are lying or sitting in that place right now.


Let this place become as vivid to you as possible. Is it warm or cold around you? What do you see? Do you see sky, trees, plants, animals, people? What do you hear? Do you hear voices from nature, animals, people, or music? What sensations do you feel in your body? How do your hands feel? How about your skin, your face? What smells are in the air? What do you feel?

Keep a clear image of this place in your mind. Observe your state of relaxation. Associate this place with the sensation of relaxation. During the next few minutes I will be quiet so that you can concentrate on relaxation (pause for about 2 minutes.)

This place will become a place you can always come back to when you want to relax.

Step 5: Coming back

Now I would like you to begin to prepare, little by little, to come back from this relaxing place of yours to the room we are in. Let the normal muscle tone fl ow back into your body. You can start by moving your hands a little. Stretch and shake other parts of your body too. Observe how each inhalation gives you renewed energy. Breathe in deeply a few times and open your eyes.

Step 6: Discussion

Ask the participants what their experiences were like.

• How did you feel during this exercise? • Was it easy to concentrate? • Which of the three ways of relaxing (muscle relaxation, breath

control or visual imagery) did you fi nd the most effective?

1 2 3 4 5

This relaxation exercise is adapted from Psychologische Interventionen bei der Parkinson-Erkrankung: Ein Behandlungsmanual by Michael Macht and Heiner Ellgring. Reproduced by permission of W. Kohlhammer GMBH.


Goals:

• To learn to apply stress-reducing methods to daily life.

Part 4Homework (Option 1): Trying Out Alternative Ways of Thinking 1:15’ – 1:30’


Step 1: Choosing a stress-reducing thought

Ask each participant to choose one alternative, stress-reducing thought that fi ts either the example of a stressful situation that they brought to the session (appetiser), or one of their other frequently experienced stressful situations.

Although alternatives generated by the group in the previous exercise or examples from the Guidelines for Alternative Ways of Thinking in Stressful Situations can be used, emphasise that the most effective alternatives are often formulated by the person herself/ himself. For this homework, one alternative thought is suffi cient.

Step 2: Making a reminder card

Each participant should choose one blank (coloured) card and write her/his chosen stress-reducing thought on the card.

Example For example, if a participant fi nds it stressful to leave late for doctors’ appointments because her partner is so slow, she could write on her card: “If we are late, it’s not the end of the world.”

Encourage participants to share what they have written on their cards with other participants (if time allows).

Step 3: Using the reminder card

Instruct participants to keep the reminder card with them (for example in their pocket, wallet or handbag) and ask them to try to identify situations that are stressful as they approach or occur. At those times, they should take out the reminder card and read what they have written for this situation. If it is not possible to take out the card in the situation they can instead just think about the card, and about the alternative thought that they wrote down.

Suggest that if participants do not spontaneously fi nd themselves in the stressful situation for which they have written the card, they could deliberately expose themselves to that situation (for example, going to a supermarket with the person who has PD, even if they normally do not do this often) during the period before the next session.


Hand out Instructions for Homework: Session 4 – Trying Out Stress-Reducing Thinking.

Handouts

Instructions for the Homework: Session 4 – Trying Out Stress-Reducing of Thinking



Goals:

• To learn to apply relaxation training to daily life.

Part 4Homework (Option 2):Daily Relaxation Training 1:15’ – 1:30’


Instructions for daily relaxation training

Ask participants to practise relaxing using the relaxation exercise every day.

Homework at basic level

Performing the relaxation exercise at the “basic” level requires 1−5 minutes per day.

Homework at advanced level

Performing the relaxation exercise at the “advanced” level requires 15 minutes per day.

Hand out Instructions for the Homework: Session 4 – Daily Relaxation Training.

Ask participants to think about which level of exercise they will be able to do and when and where they will best be able to complete the exercise. They should write down the time of day on the homework sheet. Ask if anyone has any questions.

Handout

Instructions for the Homework: Session 4 – Daily Relaxation Training


Goal:

• To help participants become aware of changes in their mood.

Part 5Appetiser: Carer’s Challenge


Observe your mood

During the coming days, try to observe whether you experience any feelings of anguish, sadness or nervousness.Hand out Instructions for the Appetiser: Session 5

Handout



Session 4: Stress ManagementMaterials

For both options:

❏ Negative and positive stress circles (to be shown on OHP, printed as handout, or made into slides)

❏ Instructions for the Appetiser: Session 5

For Option 1 only:

❏ Guidelines for Alternative Ways of Thinking in Stressful Situations ❏ Examples of Stress-Increasing and Stress-Reducing Thoughts❏ Instructions for Homework: Session 4 – Trying Out Stress-Reducing Thinking

For Option 2 only:

❏ Guidelines for Relaxation❏ Instructions for Homework: Session 4 – Daily Relaxation Training



Stress circles

Negative stress circle

BODILY SENSATIONS:Bodily tension

FEELINGS:Tension

IrritabilityAnxiety

Positive stress circle

THINKING:Stress-reducing

thoughts andself-instructions

THINKING:Stress-increasing

thoughts andself-instructions

BODILY SENSATIONS:

Bodily relaxation

FEELINGS:Calmness

Confidence

The stress circles are adapted from Psychologische Interventionen bei der Parkinson-Erkrankung:Ein Behandlungsmanual by Michael Macht and Heiner Ellgring. Reproduced by permission of W. Kohlhammer GMBH.




When you feel stressed, it is essential to make a distinction between:

1. The situation in which you experience stress (for example, leaving late for a visit to the doctor’s).

2. Your thoughts, self-instructions – in other words, what you silently say to yourself about the situation and your ability to cope with it (for example, “oh no, now we’ll never make it!”).

3. Your reactions, such as bodily tension, feelings of nervousness, avoidance behaviour.

When you feel stressed, it is not a result of the situation itself, but of your thoughts. In order to diminish feelings of stress, you must therefore change your way of thinking.

In order to change your way of thinking, you must fi rst become aware of it. By observing the way you “talk” to yourself in stressful situations, you can become aware of your thoughts.

The next step is to start changing your thoughts. When you catch yourself thinking in a stress-increasing way, you can start to intentionally replace your stress-increasing thought with a stress-reducing thought. The table on the second page of this handout shows some examples of stress-increasing thoughts (left column) and stress-reducing alternatives (right column). You can use them as a model when formulating your own stress-reducing thoughts.

Your way of thinking may seem almost automatic because you have probably thought that way for a long time. With systematic practice, however, you will fi nd that it is possible to change your thoughts and reduce stress.



Examples of Stress-Increasing and Stress-Reducing Thoughts

Stress-increasing thought: Alternative, stress-reducing thought:

I can’t do this. • I can manage this.• I’ll do this as well as I can – that is good

enough.

We’ll never manage to get there on time when she/he is so slow.

• We’ll take the time that we need.• There is time.• Even if we are late, that is not the end of the

world.• Let them wait!

I can’t bear this. • I am doing fi ne.

I must sacrifi ce myself again. • I have the right to think of my own needs too.• No! I don’t have to do it.

I must . . . • I don’t have to . . .• I can also . . .• Would it be possible to . . .

I feel nervous. • It is OK to feel nervous. • I can breathe deeply and calmly.

I must succeed. • It’s not so important, even if this doesn’t work perfectly.

• Why must I? Does it really matter?

There’s nothing I can do about it.

• Let me think about what I could do before jumping to conclusions.




Being able to relax is an important way to counteract the effects of stress. Relaxation is a skill that can be learned. Systematic practice can improve the ability to relax, even in diffi cult situations. The following hints may be helpful for such practice:

1. Allow yourself to relax. 2. Allocate time for relaxation. Reserve a specifi c time for relaxation, for example

15 minutes every evening. 3. Select a quiet place where you will not be disturbed. Close the door, switch off

telephones and ask your family members not to disturb you. 4. Get in a comfortable position. You can lie down or sit in a comfortable chair.5. Concentrate. Switch off your thoughts about the world around you, and direct

your thoughts inwards. 6. Breathe out calmly. If you have diffi culty concentrating, direct your attention to

your breathing.7. Practise regularly. The more you practise, the easier it will be to reach a state of

relaxation.8. Find your own way of relaxing. Try out different relaxation methods: tightening

and relaxing groups of muscles, listening to your breathing, imagining a peaceful scene.

9. Try out different relaxation aids. If you like, you can put on relaxing music when doing relaxation exercises. You can also try out audiotapes/CDs designed to teach relaxation.

10. Enjoy yourself!




Trying out Stress-Reducing Thinking (Option 1)

Put the reminder card you made in this session in your pocket, wallet or handbag and keep it with you. When you are approaching a stressful situation, or when you are already in the situation, you can take out the card and read what you’ve written on it. If it is not possible to read the card in the situation, you can still think about what you wrote on it.

If you do not fi nd yourself in the stressful situation for which you planned the card (for instance, because you are in the habit of avoiding it), you could deliberately expose yourself to that situation in order to try out alternative thinking before the next session.

Example: You wrote yourself a stress-reducing thought for the situation in which you and your partner are late leaving to go somewhere (for example, to visit somebody). Plan to go for the visit. Before you start to get ready read the alternative thought on your card.




Daily Relaxation Training (Option 2)

Try to practise relaxation training every day until the next session.

Decide fi rst what time of the day you will do your daily relaxation exercise:Each day, I will relax at o’clock.

Before doing the homework for the fi rst time, reread the instructions on the handout Guidelines for Relaxation that was given in the session. You may also want to have this homework sheet with you so that you can check what to do.

You can choose between two homework levels. The basic level requires a minimum of one minute daily. The advanced level takes about 15 minutes daily and aims at a deeper state of relaxation.

Homework at basic level:

Take a 1−5 minute break from your obligations. (You don’t have to use a clock to keep track of the time.) Get in a comfortable position and switch off your everyday thoughts. Concentrate on listening to your breathing, focus on your exhalations. Let the breath fl ow at its own pace, and let yourself relax every time you exhale.

Homework at advanced level:

To do this homework you need about 15 minutes for yourself.

1. Start by concentrating on your breathing. Notice that every time you exhale, you feel more and more relaxed.

2. Tighten and relax groups of muscles in the same way as we did in the session. Tighten the muscles fi rst for about 5 seconds and then relax. Go through the following groups of muscles:

– right leg – left leg – bottom – back – abdomen – arms and hands – neck – face and forehead

3. Repeat tightening and relaxing one more time.4. Let yourself rest for a while. Concentrate on breathing out calmly again. If you

like, you can think of your relaxing place: imagine that you are in your favourite place and that you feel relaxed.

5. To come back from the state of relaxation, start by inhaling deeply a few times. Become aware of the noises around you, move your legs and arms a bit. Concentrate on how it feels to breathe in deeply. Notice the renewed energy it brings you. Slowly open your eyes.




The topic of the next session is the Carer’s Challenge. In preparation for this session, try to observe whether you experience any feelings of anguish, sadness or nervousness during the next few days.



Documents

Session 4: Stress Management for People with PD and for Carers · Session 4: Stress Management Overview Participants receive information about stress and stress management, and practise