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@CB SELF-HEALTH SYSTEMS 2850 Sixth Avenue, Suite 222 San Diego, Calif 92103 (619) 298-3464 Delivered To: Date: ____________ ____________________________ ____________________________ ____________________________ ____________________________ ======================================================= INVOICE ======================================================= Qty Description Unit Price Total ___ Self-Health Stress Manager 49.95 _____ ___ 7.25% Sales Tax (Calif only) 3.62 _____ MasterCard/Visa # ________________ Expiration Date ________________ Authorized Signature __________________________ Comments: -------------------------------------------- -------------------------------------------- -------------------------------------------- -------------------------------------------- TOTAL ______ The software shown above has been delivered and accepted by the customer. Upon receipt of this paid invoice a curren version of the software and a user ID number for phone support will be sent to the customer. ======================================================== Disk type: ___ 5.25" ___ 3.5" ======================================================== | | | | | | SELF-HEALTH SYSTEMS | | 6 STEP | | STRESS MANAGEMENT PROGRAM (tm) | | For use with | | IBM PC's & Compatibles | | | | | | | Copyright (c) 1990 SELF-HEALTH SYSTEMS All Rights Reserved ________________________________________________________________ User's Manual Copyright (c) 1990 Self-Health Systems All Rights Reserved Respiration Training, Progressive Muscle Relaxation, and Autogenic Training cassette tapes and written text Copyright (c) 1990 Self-Health Systems. All Rights Reserved. Programs and Files Copyright (c) 1990 Self-Health Systems All Rights Reserved Portions of the programs Copyright (c) 1989 Microsoft Corporation 6 Step Stress Management Program is a trademark of Self- Health Systems All other marks in this manual are the trademarks of their respective companies DISCLAIMER & WARRANTY SELF-HEALTH SYSTEMS HEREBY DISCLAIMS ALL WARRANTIES RELATING TO THIS SOFTWARE, EITHER EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. IN NO EVENT SHALL SELF- HEALTH SYSTEMS BE LIABLE OF ANY INDIRECT, CONSEQUENTIAL, SPECIAL OR EXEMPLARY DAMAGES SUCH AS, BUT NOT LIMITED TO, LOSS OF REVENUE, DATA, ANTICIPATED PROFITS, LOST BUSINESS OR ANY OTHER ECONOMIC, PSYCHOLOGICAL OR MEDICAL LOSS ARISING OUT OF OR IN CONNECTION WITH YOUR USE OF, OR INABILITY TO USE, THIS SOFTWARE. YOUR SOLE AND EXCLUSIVE REMEDY FOR ANY AND ALL CLAIMS AGAINST SELF- HEALTH SYSTEMS ARISING OUT OF OR IN CONNECTION WITH THIS PRODUCT, WHETHER BASED ON CONTRACT OR TORT, IS THE REFUND OF THE PURCHASE PRICE OR REPLACEMENT OF THE SOFTWARE. ________________________________________________________________ i SINGLE-USER SOFTWARE LICENSE You are free to copy and distribute this Software as long as you do not charge ANY fee for the Software, and as long as you include all files, documentation and copyright notices. A nominal fee may be charged for media, expenses and handling, but must not exceed $15.00. THIS SOFTWARE IS NOT FREE, NOR IS IT PUBLIC DOMAIN If you find this Software to be satisfactory after a 30 DAY EVALUATION PERIOD, and intend to continue using it for your purposes, you are obliged to send a registration fee of $49.95 to Self-Health Systems. With your paid registration, you will receive the following: 1. A disk with the latest version of the Software. 2. Three professionally produced Relaxation Tapes for use with the system. 3. A counting notebook. 4. A registered user ID number for unlimited phone support. 5. You will be placed on the list for notification of all future upgrades. MasterCard/Visa phone orders call (619) 298-3464. Your timely registration will be greatly appreciated. MULTIPLE-COPY SITE LICENSE Professionals or Companies desiring to utilize the 6 Step Stress Manager can obtain the following pricing. Quantity Price Each ──────────────────────────────────────────────── 1-9 systems ......................... $49.95 10-50 systems ......................... $39.95 50+ systems ......................... $29.95 These prices apply on one-time quantity purchase, not on accumulated totals. Site licenses are available for Professionals or Companies desiring to do in-house duplication of the software, manual and cassette tapes. Site License fees quoted on a case-by-case basis. Member Association of Shareware Professionals ii _________________________________________________________________ SELF-HEALTH SYSTEMS 2850 Sixth Avenue, Suite 222 San Diego, California 92103 U.S.A. (619) 298-3464 SHAREWARE - HONEST PRICES FOR HONEST CUSTOMERS Develop a piece of software and you quickly will be overwhelmed with the cost of marketing, packaging, and distribution. In order to be at all profitable, the mark-up on commercial software is astronomical. Wholesalers and Distributors want a MINIMUM of 50%; packaging costs another 10%; business overhead & advertising is another 30+% - leaving a very small amount for income! Although we did investigate the release of this software in the commercial market, we felt that the price that we would have to charge was just too much, and would defeat our original intent - to provide a high quality, useful tool to the public at a reasonable price. The alternative was to deliver the program through Shareware. Shareware is based on a rather unique concept these days - honesty! The truth is, most people are honest. Shareware operates on the principle that if you like, and intend to use, an authors software, then you are obligated to send that author a registration fee. There is no coercion, no force...just honesty. You will not find any of our software to be "crippled" (e.g. works only for a while, or allows a minimum of entries). We ship full-featured software and rely on your honesty and satisfaction for reimbursement. If you have not investigated the shareware market, please do yourself a favor. You will find an astonishing amount of professional software at unbelievable prices. You can test them BEFORE you buy, and can therefore choose your library carefully. This remarkable approach needs your cooperation, so please, register your software at your earliest convenience. Self-Health Systems iii COMMENTS FROM THE AUTHORS The following Stress Management program and techniques have been developed by us and many other professionals over many years. We have used these techniques with our own patients and have found them to be effective and long-lasting. In designing a self- administered program, we obviously had many professional and ethical questions to work out. The end result has been well worth the effort. We feel that this system will be of great assistance to people in a wide variety of stressful circumstances. Obviously no single approach works for all people, so we must point out a simple, but important, caveat. If this system does not seem to be working for you, you should seek the counsel of a professional. The effects of stress are oftentimes quite serious, and warrant the attention of first-hand professional intervention. A good rule of thumb...If you have any doubt, see a professional...you're worth it! Also, we'd really like to know how you are doing so we can improve the quality of help our system provides. Please take a little time to tell us your thoughts and experiences with the system. Write to: Self-Health Systems 2850 Sixth Avenue Suite 222 San Diego, CA 92103 Again, we'd like to hear from you. David W. Jacobs, Ph.D. B. Scott Diener, Ph.D. iv TABLE OF CONTENTS _________________________________________________________________ I N T R O D U C T I O N What is Stress? .............................................. 1 Symptoms of Stress ........................................... 2 Sources of Stress ............................................ 2 Useful and Harmful Coping Strategies ......................... 3 The Best Coping Strategy ..................................... 4 The Self-Health Systems Program .............................. 5 I N S T A L L A T I O N System Requirements .......................................... 7 Running the Software ......................................... 7 M E A S U R I N G Y O U R S T R E S S L E V E L - S T E P 1 Introduction ................................................. 8 Interpreting the Stress Test ................................. 8 Understanding the Graph ...................................... 9 I D E N T I F Y I N G AND A S S E S S I N G Y O U R S T R E S S O R S - S T E P 2 Subjective Units of Discomfort (SUDS) ........................ 12 The Counting Notebook ........................................ 13 E N T E R I N G S T R E S S O R S AND E S T A B L I S H I N G B A S E L I N E S - S T E P 3 Purpose of Baselines ......................................... 14 Stressor Information Card .................................... 15 Options Menu ................................................. 16 L E A R N I N G R E L A X A T I O N S K I L L S - S T E P 4 Introduction ................................................. 17 Abdominal Breathing .......................................... 18 Progressive Muscle Relaxation ................................ 19 Autogenic Training ........................................... 20 M O N I T O R I N G C H A N G E S IN S T R E S S O R L E V E L S - S T E P 5 Using the Relaxation Response ................................ 21 Fact vs Subjective Opinion ................................... 22 Graphing the Results ......................................... 23 G E N E R A L I Z I N G Y O U R S K I L L S - S T E P 6 Stimulus Generalization ...................................... 24 Response Generalization ..................................... 24 A P P E N D I C E S Counting Notebook Sheets ..................................... 27 Making Your Own Relaxation Tapes ............................. 28 v | | | | | | | | | | I N T R O D U C T I O N | | | | | | | | | | | I N T R O D U C T I O N What is stress? Since you are reading this manual, the odds are pretty good that you are feeling stressed. The manual describes some useful ways to manage stress that use your computer. (Of course, we all know that the computer itself can be a source of stress, but it can also be quite useful in doing something about it). Perhaps we ought to start by making clear what stress is all about. Stress is what happens when the arousal level in your body goes up - and stays there. People's arousal level goes up all the time. It needs to, since it's our way of getting ready to do whatever it is that needs to be done. But when we're done, we need to reduce the arousal level again. Hunting is a good example. If you were living in prehistoric times, you would periodically go out to hunt for food. If we were measuring your arousal level during the hunt, we would see it gradually go up until just before the prey was taken. At that point it would rise very rapidly, only to fall off again as soon as the hunt was over. The arousal level would look like this: ┌──────────────────────────────────────────┐ │ │ A │ ** │ R │ *** * │ O │ *** * │ U │ *** * │ S │ ****** * │ A │ *** * │ L │ * * │ │******* ********│ │ │ └──────────────────────────────────────────┘ TIME Sleeping Hungry Hunting Eating Sleeping Unfortunately, that's not what happens to us in a modern society. The arousal pattern is much more chronic than acute. It looks like this: ┌─────────────────────────────────────────┐ A │ │ R │ │ O │ *******│ U │ ***** │ S │ ********** │ A │ * │ L │ ******** │ │ * │ │ * │ │ ***** │ │ * │ │** │ └─────────────────────────────────────────┘ TIME Alarm Traffic Fight with Etc. Clock Jam Boss 1 The reason that stress is such a problem is that from an evolutionary point of view, we are much better at handling acute stress than we are at handling chronic stress. Our minds and our bodies can get up for a problem, just so long as the problem has an end. It's when the problem goes on forever that we have our greatest difficulties. SYMPTOMS OF STRESS Stress can affect us in many ways. Stress affects the way our bodies function. When the stress level is high it can affect heart rate, blood pressure, breathing patterns, muscle tension, digestive functioning and almost any other aspect of physiological activity. In some people, the changes in bodily functioning can affect such significant medical problems as chronic head pain, hypertension, gastrointestinal distress and other disorders. We can't be sure if stress causes such disorders, but it sure can make them worse. Stress also affects us psychologically. Have you ever noticed that when you have way too much to do, the fun seems to go out of doing it? Even things you normally enjoy doing. That's because when you are stressed, the positive emotions tend to disappear and be replaced by negative ones. Stressed people are unhappy people. They are irritable, depressed and aggressive. When we're stressed we also have more difficulty processing information. We forget things like appointments and birthdays, we can't remember what we just read and have difficulty figuring out problems. Most of that is due to an inability to concentrate. When we are stressed, we have lots of intruding thoughts that make it very difficult for us to use our minds effectively. Since stress affects our minds and bodies, it isn't surprising that it can also affect how we behave. Sometimes that's obvious. Remember the legendary baseball player, mighty Casey? When he came to bat, he was a bad clutch hitter. He was probably too stressed. When we are stressed we tense up and don't behave in smooth, integrated ways. SOURCES OF STRESS It's time to start asking where all this stress comes from. Stressors (the causes of stress) can come from many kinds of situations and places. A good way to think about stressors is to distinguish between work-related, family-related and peer group- related stressors. Work-related stress arises because the vast majority of workplaces are organized around the needs of the marketplace, not the needs of the people who produce the goods and services. Most work is simultaneously demanding and repetitious, which means you have to pay close attention to uninteresting material. In addition, many work environments are organized around conserving power in as few hands as possible, which makes it impossible to have authority that fits with your responsibilities. that combination makes for a very stressful place to work in. 2 Family-related stressors tend to stem from what is called the nuclear family. Nuclear families consist of parents and children living in the same household, but excluding grandparents, uncles, aunts, cousins, etc. Families that include all those folks are called extended families, and, believe it or not, they are less stressful to live in. Extended families provide alternative parents and alternative children, baby sitters, financial help, etc. Nuclear families go it alone and the resultant lack of a support system makes for intense, difficult interactions among the members of the family. Peers also can be a source of stress. Poor communication patterns, competitive traditions and personality clashes can all make it difficult to use peer groups for support in times of stress. Well, if you are going to be stressed by all these forces, get rid of them. No work, no family, no friends. It's called solitary confinement and it's the second worse punishment we can devise. So it's clear that stress is inevitable and we need to learn how to cope with it. Actually, we have some coping techniques that work pretty well, at least in the short run. Like alcohol and other related drugs. Wrap yourself around a few martinis after work and it's amazing how rapidly the stress is replaced by a very pleasant glow. But you don't have to wait until you get home. A few of the right pills during the day and you won't hardly notice the stress at all. There are some problems with those solutions, like possible liver damage, increased tolerance levels and bad detoxification experiences, but there are those who think they are worth it. Those who don't like drugs sometimes turn to food. Usually fattening foods like hamburgers, french fries, soft drinks and candy. Many people report that this diet reduces stress, at least temporarily. Unfortunately, the effects on health and appearance are less than optimal. USEFUL AND HARMFUL COPING STRATEGIES O.K., let's think about some ways of handling these problems that are less toxic than alcohol, drugs and fattening foods. There are two ways of thinking about dealing with stress that are productive. One is to alter the stressors so that they reduce the stress. Psychologists have developed some neat ways of doing that, including cognitive restructuring, assertiveness training and active listening. No, that's not psychobabble. These are effective, learnable procedures. There are self-help books that describe these techniques, or you can visit your local therapist if you'd like some help learning them. (Your state or county psychological association will be happy to refer you to people who specialize in stress management work). We have put some of our folks to work to see if we can computerize some of these techniques and will let those of you who register the program know when they are available. 3 A second way to think about dealing with stress is to deliberately reduce the arousal level in situations in which there are many stressors. There are several ways of doing that. One of the better ones is exercise. For reasons we don't entirely understand, (which stresses us no end), there are systematic changes in mind and body that accompany exercise that are very helpful in reducing stress. Some points to keep in mind if you are going to start an exercise program: 1. Consult a physician who knows something about the effects of exercise on the body before beginning a program. 2. Develop the program gradually. If you have been sedentary for a long time, it may take as much as six months to get back into decent shape. Patience. 3. Do exercises you like. If you hate running, don't run. Swimming, biking, hiking, tennis (singles) and skiing (cross-country) are all good for you. If you hate all forms of exercise, walk. (Make believe that walking isn't exercise). Start with ten minutes a day and build it up to thirty minutes or so of brisk walking three or four times a week. The point is to get your heart rate up and keep it there for a while on a frequent basis. The effects on stress are dramatic. THE BEST COPING STRATEGY But the single best stress manager is to deliberately cultivate a low arousal level when you are around your stressors. The stress reduction program we offer here is unique in that it is computer controlled, but the general idea has been around for twenty years. If you can learn to stay in a state of relaxation (low arousal) in potentially high stress situations, you can manage most of the bad effects of stress. However, remember that relaxation is like playing the piano. You can't simply decide to play the piano, you can only decide to learn how to play the piano. So it is with relaxation. You can't simply decide to relax, you can only decide to learn how to do it. Being relaxed in the face of a lot of stress is something you need to train yourself to do. The program we have developed is designed to help you learn the necessary skills to induce a state of relaxation whenever you want to, no matter how stressed you are feeling at the time. Then, whenever you are feeling stressed, deliberately induce the low arousal state to block the effects. 4 THE SELF-HEALTH SYSTEMS PROGRAM At this point, you may be somewhat curious about the role your computer plays in this program. The answer lies in the fact that this system is designed to be self-contained, and teaches you how to regulate stress levels. The computer adds to the power and effectiveness of the program by doing some of the important things another person might do, such as providing you with information and feedback . The Self-Health Systems Stress Management Program involves working your way through six phases or steps of learning. The steps are briefly described in this section and in more detail in the sections which follow. Step 1 - ASSESS YOUR STRESS LEVEL. People differ in the amount of stress they have and the ways in which the stress manifests itself. An effective stress management program takes these differences into account. So the first step is to take a test which evaluates your stress level and stress pattern. Step 2 - IDENTIFY YOUR STRESSORS. Stressors are events that induce a stressful state. People differ in what constitutes stressors and in how stressful they are. As in Step 1, an effective stress management program takes these differences into account. The second step in this program is an identification of your stressors. Step 3 - ESTABLISH STRESSOR BASELINES. In order for you to determine the effectiveness of your stress management program, you need to know the level of stressfulness of each stressor at the start of the program. Step 3 asks you to evaluate the stressor level for one week, to establish a baseline before beginning the program. Step 4 - LEARN THE RELAXATION SKILLS. Managing the stress implies that you can reduce the arousal level, even when in the presence of the stressors. The three cassette tapes in the relaxation module are designed to teach you three specific relaxation skills which form the basis of the stress management program. Step 4 is to spend at least one week working with each of these tapes until you have overlearned the skill it teaches and can readily use it. Step 5 - RECORD AND MONITOR THE CHANGES IN YOUR STRESS LEVEL. During the time you are learning the relaxation skills and as you apply these relaxation skills to stressor situations, it is important to keep track of your progress and difficulties. Step 5 is to monitor your stress levels on a daily basis and record your observations in the stress management program. Step 6 - GENERALIZING YOUR SKILLS. Apply the relaxation skills to your thoughts and images about the stressors, to reduce their impact. As you master old stressors, you will find new ones to be managed. Step 6 is to apply the skills you have learned to new stressor situations. 5 To help achieve these steps, the program includes two components: * THE COMPUTERIZED INFORMATION AND CONTROL SYSTEM The computerized information and control system sub- components provide a system for managing the development of your stress coping skills. These sub-components are: (A) A stress test designed to measure and analyze your overall stress level. (B) A method for identifying your stressors and assessing their intensity levels. (C) A display system for showing trends over time in stress levels for different stressors. * THE RELAXATION CASSETTE TAPES. The sub-components of the tape system are three cassette tapes. These tapes help you to develop and integrate the skills to maintain a state of relaxation necessary to counter the effects of stress. The three tapes are: (A) Respiration training. (B) Muscle relaxation. (C) Autogenic training 6 | | | | | | | | | | I N S T A L L A T I O N | | | | | | | | | | | I N S T A L L A T I O N SYSTEM REQUIREMENTS IBM Compatible PC, XT or AT 512 Kilobytes memory (RAM) One 5.25" (or 3.5") Floppy Drive or One Floppy Drive and 1 Hard Drive Color (CGA,EGA,VGA), Mono, or LCD Display Dot Matrix printer RUNNING THE SOFTWARE Once the program has been unpacked, you may run the Self- Health Systems software by doing the following: Floppy Disk Systems Insert the PROGRAM disk in drive A and a formatted DATA disk in drive B. Type SH Enter Hard Disk Systems It is recommended that you place the Self-Health Systems software in its own directory. There is no limitation on how you configure the system. From the C: prompt: Type CD\Health Enter Type SH Enter In either case you will be presented with the Opening Menu as follows: ┌───────── OPENING MENU ─────────┐ ├────────────────────────────────┤ │ Stressor Counting Module │ │ Stress Test Module │ ├────────────────────────────────┤ │ Shareware Information │ │ Print Users' Manual │ │ Print Registration Invoice │ ├────────────────────────────────┤ │ Change Set-up │ │ Quit Program │ └────────────────────────────────┘ Move the highlight to the CHANGE SET-UP item and press [Enter]. You will then be asked to enter the necessary information to configure the software to your system. You may change this setup at any time, so if you make a mistake, just come back to this menu item. That's all there is to it! 7 | | | | | | STEP 1 | | M E A S U R I N G Y O U R | | S T R E S S L E V E L | | | | | | | | | Step 1 - MEASURING YOUR STRESS LEVEL The first step in this stress management program is to determine how stressed you are. We have developed a computer based stress test for this purpose. The test measures your overall stress level, as well as the levels of the physiological, emotional and behavioral manifestations of your stress. From the Opening Menu, select the "STRESS TEST" item and then select the (B)egin item from the pop-up submenu that will be displayed. This will bring the stress test up on the screen, with instructions for taking the test. You should take this test at three points in the program so it can be used to track your progress in learning to manage stress. Test 1 - Should be taken when you first begin the program. This will give you an accurate baseline of stress reactivity, and will give you something to compare your progress against. Test 2 - Should be taken after you have done Step 4 of the program. You may find that one area that was high in the beginning has dropped, only to be replaced by a high reading in another of the areas. This second test, then, allows you to monitor any subtle changes in your own coping mechanisms. Test 3 - Should be taken at the end of the program. This administration should show you that you have made considerable progress over the course of the program. Used in concert with the daily and weekly stressor graphs (described later in the manual), you can accurately see that you have made progress in learning new coping skills. The program will keep track of your scores each time you take it and cumulatively display them. Facility has been provided so that you can erase all previous test data and begin anew. INTERPRETING THE STRESS TEST Introduction Now that you have completed the stress test, the computer will automatically score it and provide you with a graph of the results. Study the graph carefully. It will tell you some things you will want to know about your overall stress level and the ways in which your stress manifests itself. But before looking at the graph, a few words of caution might be in order. Scores on tests like these are expressed in the precise language of arithmetic. In that language, 1 + 1 = 2 and 4 is twice as much as 2. Always, and exactly. But when that language is applied to the real world, there is always a little slippage. When measured precisely, a steel rod 4 inches long turns out to be only approximately twice as long as one 2 inches long. The more precise the measurement, the less certain is the application of numbers to the real world. 8 So it is with this stress test. The scores reflect your judgement of your stress level on the day you took it. On another day, when you are feeling a little differently, some of the item entries might be a little different, and the scores would be changed accordingly. Since that is the case, approach what you read here with what a famous psychologist once called "cool benevolence". Read it, think about and take it seriously enough to act on it. But don't become obsessed about the numbers. An overall stress test score of 95 is not a lot better than 100 and not a lot worse than 90. These numbers are pointers, not meters. II. Test Results Now let's look at the test results. The test consists of thirty items, each of which is scored on a 1 to 5 scale. Therefore, if you scored each one of the items at "1", the lowest possible score for an individual item, you would get a total score of thirty. If you scored each item at "5", the highest possible score for an individual item, you would get a total score of one hundred and fifty. So your overall score on this test must lie somewhere in the range of thirty to one hundred and fifty. In addition, the test items can be grouped so that they show your scores on three sub-tests: one for physical stress, one for emotional stress and one for social stress. That means we can analyze your stress levels by four scores, one for the overall test and one for each of the three sub-tests. To understand the significance of these scores, we need to understand two things. First, the structure of the stress test itself. Each test item reflects a specific kind of stress. You were asked to estimate the frequency with which that stress symptom occurs in your life. High scores mean that you are experiencing that particular symptom very frequently, while low scores mean that you aren't experiencing that stress very often. Second, the role of individual differences in the expression of their stress. No two people express their stress in exactly the same way. Everyone has their own pattern of stress expression. Therefore, to understand your stress, you need to know something about the pattern with which you express the stress. The stress test is designed to tell you something about both the frequency of expression of stress symptoms and the pattern of their occurrence. The graph will show you how you rate in four areas - Physical, Emotional, and Social stress and an Overall stress score. The higher the score on each of these, the greater the height of the bar. The screen is divided into three areas - (H)igh, (M)oderate and (L)ow amount of stress. These are labelled on the right hand side of the screen. Now, let's consider these results. Each of your four stress test scores can be compared to the score ranges on the right hand side of the graph. The score ranges reflect low, medium and high levels of stress. By seeing where your scores fit in those ranges, you can estimate your stress level for each of the four areas. 9 Let's look at the physical stress scores, which are in the first sub-test. The items in that group are concerned with the bodily symptoms of stress, like tightness in the chest, tension headaches or sweaty palms. A low score on this test indicates that you are expressing your stress in some other way. A high score on this sub-test indicates that you are the kind of person who expresses your stress somewhere in your body. Stress can be expressed in any organ system, from the skin to the activity of the heart. [Sometimes it is hard to tell if you are having a stress-related reaction or not when you are experiencing physical symptoms. When in doubt, be sure to check with your physician]. Your physical symptoms are probably stress-related if their severity varies with the intrusiveness of the stressors in your life, e.g., if the only time you get headaches is when the boss asks you to work overtime. Now we can consider the emotional sub-test, the second one in the table. This sub-test describes the emotional and cognitive aspects of stress, like being angry for no good reason or forgetting an important appointment. A low score on this test implies that stress has little effect on how you feel or think. A high score indicates that you express stress through your emotions and how you think. The most likely form of emotional expression in the early stages of stress is irritability. You know, the "short fuse". Somebody says "Good morning" and you say "What's so good about it"? Later stages of emotionally expressed stress can include irrational outbursts of anger and feelings of depression. [Stress is not the only reason for sustained feelings of negative emotionality. If you are not sure if your feelings are stress-related, you might want to confer with a psychologist or some other mental health professional]. These symptoms are probably stress-related if their severity varies with the intrusiveness of stressors in your life, e.g., if you get depressed only when your spouse (or other significant other) is giving you a hard time. The last sub-test is concerned with the social aspects of stress. If you find yourself feeling alienated from your family or angry when someone praises you, there is a possibility that you are feeling some socially related stress. A low score on this sub- test implies that you express your stress in personal, rather than social ways. A high score indicates that you tend to express your stress through your interactions with other people. For example, this can include being upset when meeting strangers, feeling confused and angry at being praised or finding it difficult to give negative feedback to someone. Such symptoms are probably stress-related if they occur in the absence of a long history of such problems, coupled with an increase in the severity of your stressors, e.g., they begin to occur while you are coping with a chronic illness in your family. The final score to consider is the overall stress test score. This is simply an integration of the scores on the three tests. If this score is low, it probably means that your stress level is not a cause for immediate alarm. You might want to use this time to learn some relaxation skills to get ready for the time when the stress levels will increase. If the score is in the moderate or high range, it probably means that your pattern of stress expression involves all three areas covered in the stress sub- tests. You can best understand it by considering the pattern of the three sub-tests in relation to each other. 10 If the pattern discloses that one area is significantly higher than the others, e.g, that you tend to express much of your high stress level emotionally, then that's what you need to deal with. If they are all high, then the stress has affected much of your life. Treat the pattern as a set of pointers to tell you what to pay attention to. Your good judgement will tell you what to do next. 11 | | | | | | | STEP 2 | | I D E N T I F Y I N G AND A S S E S S I N G | | Y O U R S T R E S S O R S | | | | | | | | | Step 2 - IDENTIFYING AND ASSESSING YOUR STRESSORS Now we can go on to the second step, which is to identify the stressors, the events that cause all that stress. Your first impulse may be to grab a piece of paper (or a blank monitor screen) and start listing all the things that are ticking you off right now. Not a bad idea, actually. It goes in the right direction. A "stressor" is any event that causes you to become stressed, and results in you becoming angry, agitated, tearful, anxious, forgetful, cranky, or depressed. Examples of stressors might include moving to a new job, arguing with a member of your family or getting calls from a collection agency. Some ways of describing stressors are more useful than others. Here are some guidelines to use when making up your list of stressors: 1. Keep the title brief. Short descriptions work best. 2. Make it concrete. Describe specific events in specific places. 3. Frequently recurring stressors tend to be of greatest interest. 4. Use events which the stress test tells you are important. If the test says you rate high on physical stress, select a stressor that gives rise to that response. 5. Make a complete list, but don't work on more than two or three stressors at a time. When you have managed two or three of them, then select others on your list. Identifying your stressors is a good start in learning to manage them, but we recommend doing something more systematic than that. We're going to ask you to keep a daily log of your stressors while you are being stressed, and while you are learning to apply new coping strategies to them. In addition, you should rate the severity of your stress reaction by assigning a SUDS level to each encounter. SUDS level? No, it's not a measurement for producing a whiter wash. SUD is an acronym for "Subjective Units of Discomfort" and since there are lots of them, they have come to be called SUDS. Stressors vary in the degree to which they induce stress. (Most of us are more stressed by losing a job than by losing our eyeglasses). We would like to be able to measure the difference in stressor effect in some way. That's where the SUDS level comes in. It gives us a method of measuring how strongly we have been affected by any given stressor. To measure the severity of a stressor, start by erecting a 1 to 10 scale in your head, where 1 is no stress and 10 is the most extreme stress you have ever felt. For any given stressor at any given time and place, you can then generate a number between 1 and 10 that describes the stress severity in SUDS levels. Practice assigning SUDS levels to stressors a few times just to get used to the idea. It will soon make sense to you. 12 THE COUNTING NOTEBOOK We want you to keep a daily counting notebook because human memory tends to be faulty, especially for unpleasant events. We tend to forget and distort unpleasant events and are not reliable reporters about their occurrence once they are over and done with. This makes it quite difficult for us to accurately judge whether or not we are making progress, or getting worse. So, in the interest of accurate information, we are asking you to keep a little notebook in a convenient place, like a shirt pocket. The pages of the notebook look like this: ┌──────────────────────┬────────────┐ │ NAME: │Date: │ ├──────────────────────┼────────────┤ │ Stressor │ SUDS Level │ ├──────────────────────┼────────────┤ ├──────────────────────┼────────────┤ ├──────────────────────┼────────────┤ ├──────────────────────┼────────────┤ ├──────────────────────┼────────────┤ ├──────────────────────┼────────────┤ ├──────────────────────┼────────────┤ └──────────────────────┴────────────┘ There are two ways to get the counting notebook. First, when you register with SELF-HEALTH SYSTEMS we will send you a packet of these in the kit you receive. Second, you will find a page of these already printed out in Appendix A of the manual. Photocopy more if you need them. Use a different page for each day, taking care to enter the date for each one. For each stressor you have identified, fill in the relevant information on the sheet. Fill in a separate sheet for each day, listing all the stressors and associated SUDS levels for that day. Now, what are we going to do with all that data? 13 | | | | | | | STEP 3 | | E N T E R I N G S T R E S S O R S | | A N D | | E S T A B L I S H I N G B A S E L I N E S | | | | | | | Step 3 - ENTERING STRESSORS AND ESTABLISHING BASELINES What are we going to do with all that data? Put it in the computer, of course. Once the data is in the computer, there are a number of things we will do with it. But the first thing to do is to establish some baselines. These baselines are measurements of the frequency and intensity (SUDS) of the stressors prior to the time you begin to use the Stress Management program. Baselines are important because they tell us about the ways in which your identified stressors impact your life now. We will use the baselines to tell how well the stress management program is working to alter that impact. Furthermore, you can use these baselines to show yourself that progress is being made. (Many times with our own patients we find that people get discouraged in the middle of a stress management program, when their stress reaction suddenly returns "full blown", and they feel that they have gotten nowhere. By keeping an accurate baseline, you can show yourself that although you may on occasion "flare up" to your old level, you are nonetheless making good progress). You should keep baseline data on each stressor for seven days before beginning the program. In order to track your baselines (and your subsequent progress), you will need to transfer your list of stressors to the computer. Data about your stressors is stored in the computer on Stressor Information Cards. The software provided with your Self-Health program allows you to establish an unlimited number of Stressor Information Cards and to access any one of them easily. The Registered version of the software will allow you to establish stressor lists for several people, while the unregistered version allows one person only. From the Opening Menu, select the "Stressor Counting Module". You will be presented with the following screen: ┌───────────────────────────────────────────────────────────────┐ │ File Print Quit Help File: STRESSOR │ ├───────────────────────────────────────────────────────────────┤ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ├────────────────────────────────────────────────┬───────┬──────┤ │ F1 = Menu Move Highlight Enter=Select Item │ TIME │ DATE │ └────────────────────────────────────────────────┴───────┴──────┘ This screen is a "window" that will be used to display and manage the list of your stressors. At the top of the screen you will see the Menu of options (File Print Quit Help). To access this menu, press the F1 key. The first letter of each menu item will be highlighted, and the first menu item, File, will be completely highlighted. 14 You may use the arrow keys to move the highlight to the Menu item you want, or you may simply press the first letter of the item. In this case, press the "F" key or press the Enter key. Either one will work. Once a Menu item has been selected, you will be presented with a "pull-down" submenu for that item. In this case, you will see the sub-menu for the File option. Move the highlight to "Add Record to File" and press Enter. You will see a Stressor Information Card appear on the screen. ┌───────────────────────────────────────────┐ │ STRESSOR INFORMATION CARD │ │ Stressor: │ │ Classification: │ │ Priority: │ │ Begin Date: │ │ End Date: │ ├───────────────────────────────────────────┤ │ DESCRIPTION │ ├───────────────────────────────────────────┤ │ │ │ │ │ │ └───────────────────────────────────────────┘ Although entering information onto the card is easy, a few guidelines are in order. Stressor - Enter the name you have given to that stressor. Be as brief and descriptive as possible. Classification - Classify the stressor as to its' source (e.g., work, family, peer group, etc.). Priority - Prioritize the importance of the stressor to you on a scale of 1 to 5, with 5 being the most important. Begin date - Type in the date you start to keep baseline data. Description - Type in a brief, but thorough description of the stressor, the circumstances under which you normally encounter it, and the coping strategies you have used in the past. When you have completed the entries, press the Enter key. Automatically, the data from the stressor information card will be stored in its own file, and the name of the stressor will be shown on the index screen. Whenever you want to enter data about that stressor into the computer, you will need to recall that card. To recall a Stressor Information Card, simply move the highlight to the stressor name on the index screen, and press the Enter key. 15 With the stressor cards in place, you can start making entries about the daily SUDS levels. To add SUDS levels data to the stressor card, take the following steps: 1. Call up the stressor information card (see above). 2. Press (C)ount. A new screen will come up that will permit you to make data entries for the date of the occurrence of the stressor, the frequency with which it occurred on that date and the SUDS level. To enter information about the SUDS level, take the following steps: 1. Type in the date (using the Enter key to separate month, day and year). The cursor will then move to the SUDS level. 2. Enter the SUDS level for the first occurrence of the stressor, and press the Enter key. 3. Enter the SUDS level for any subsequent occurrences of the stressor on that date. The program will calculate and display the number of times the stressor occurred on that date from the number of SUDS level entries. 4. Use this same sequence each time you wish to enter new SUDS level data for subsequent days. Starting with your Baseline data, then, you should track and enter the data on a daily basis. The Self-Health program will only work as well as you allow it. Inadequate or incomplete data will obviously yield inadequate results. Be as systematic as possible in noting and entering the data into the computer. Remember that the F1 key gives you access to the Options menu. By using the Options menu, you may add, modify or delete stressor information cards at any time. Similarly, you may print out the list of stressors or even the stressor cards themselves. To print out copies of your stressor information cards, select the (P)rint option from the pull-down menu. You will be presented with the following submenu: ┌────────────────────────────────┐ │ List of Stressors │ │ All Stressor Information Cards │ │ Individual Information Cards │ ├────────────────────────────────┤ │ Daily Graph │ │ Cumulative Graph │ └────────────────────────────────┘ When the sub-menu comes up, use the directional arrows to select the printing option you want to use, e.g., all the stressor information cards. 16 | | | | | | | STEP 4 | | L E A R N I N G | | R E L A X A T I O N S K I L L S | | | | | | | | | Step 4 - LEARNING RELAXATION SKILLS. This portion of the manual covers the use of the three relaxation tapes. The tapes are designed to help you learn the skills necessary to induce a state of relaxation whenever you want to. Before getting to the tapes themselves, we would like to describe what the state of relaxation is all about and to point out how best to use the tapes. First, relaxation is not diversion. Sitting in a chair with a headset on listening to acid rock may divert you from concentrating on your stressors, but it is not relaxation. Relaxation is a state of LOW AROUSAL. Physiologically, that means slow breathing, lowered levels of muscle tension, slow heart rate and decreased blood pressure. Psychologically, it means fewer thoughts, lessened urgency with regard to time and lowered levels of irritability. If you want to become relaxed, you have to learn some things about breathing control, muscular control and control of thought processes. That is what the instructions on the tapes are designed to help you do. Second, using the tapes requires that you be able to set aside time on a regular basis. You should schedule your day so that you have a SPECIFIC time to listen and practice. This time should NOT be at the very end of the day (eg. before bedtime) when you are overly tired. Early morning or evening times will generally give you the best results. If you are feeling stressed when you begin, let your mind float free of intruding thoughts and concentrate on the tape. Tell yourself that you are going to take a vacation from your worldly worries for twenty minutes or so. If at all possible, use the tapes in a quiet place so that you can concentrate better. No radio or television, turn off the phones and get some privacy. At the beginning, stick to the prescribed order of the tape use. The order has been set up to provide the most effective way to learn these skills, starting with the easiest material and proceeding to the more difficult. After you have acquired some skill, you can start using these skills without the tapes and can develop your own unique mix of the methods for inducing the relaxed state. Take your time about going from one tape to the next, so that you can learn the skill on one tape thoroughly before going on to the next one. You should probably spend a minimum of several weeks on each tape, using it on a daily basis, before going on to the next tape. If you need more time with one tape, take it. The point is to overlearn these relaxation skills so that you can call on them when you are feeling stressed. It really won't take too long to master these skills. Most people get all the relaxation skills they will ever need in a few months of consistent practice. 17 The Self-Health Tapes 1. Abdominal Breathing The first one is entitled "Abdominal Breathing". Abdominal breathing means you are going to learn to breathe with your stomach, or at least with the muscles of the abdomen as well as the muscles of the chest. It isn't hard to learn, since it's a perfectly natural form of breathing. Maybe a few words of explanation will help in understanding why it is so important to use this way of breathing while relaxing. You already know that breathing is important because it brings oxygen into your body while taking out carbon dioxide. However, it isn't as automatic as you might think. There is a rate of exchange between these two gases that is determined by the way in which you breathe. If you breathe irregularly, e.g., if you hold your breath between inhaling and exhaling, you disturb the gas exchange rate. This leads to a build-up in the carbon dioxide levels in your body. When the carbon dioxide levels build up we feel it as a tightness in the chest and a feeling of pressure in the body. Both psychologically and physically, this in turn makes it much more difficult to let go of the very muscles we are trying to relax. If you want to test this, try holding your breath for a few seconds and see how rapidly the feelings of tension start to develop in your chest and the muscles of your body. An optimal breathing pattern, on the other hand, has exactly the reverse effect. It promotes a proper gas exchange rate, thereby reducing the feelings of tightness in the chest and making it much easier for the muscles to let go. In summary, then, breathing in this fashion facilitates the gas exchange between oxygen and carbon dioxide, which in turn facilitates bodily relaxation. It is helpful because it helps slow heart rate and reduces blood pressure. On this tape you will find instructions having to do with the development of abdominal breathing patterns, the kind that will promote the relaxed state that is the opposite of stress. 2. Progressive Muscle Relaxation The second tape is called "Progressive Muscle Relaxation". It is designed to enhance your awareness of muscular tension in the major muscle groups by having you systematically practice the contraction and relaxation of the muscles. The resulting increase in sensitivity to changes in muscle tension helps you to signal when you are getting stressed and in ensuring that the muscles are kept in a relaxed state. Of course, when you are active you don't want to be totally relaxed or you would ooze all over everything. But you don't need to carry much body tension to do most of the things you do. You are better off with the minimum body tension you need to complete your tasks. 18 Progressive muscle relaxation is a form of relaxation training that does two things at once: First, it exercises a given muscle group to encourage relaxation. Second, it increases your awareness of how the muscles feel when they are relaxed. The combination of the two is helpful in simultaneously relaxing specific muscle groups while inducing a state of generalized relaxation . Progressive muscle relaxation calls for some concentration, especially in the early stages of training. It is important that you stay focussed on how the muscles feel as you do the exercises and that you do them slowly enough to get the full effect. At the beginning, set aside twenty minutes to do this routine. As you develop more skills, you will be able to achieve excellent relaxation results in far less time. Do the exercises in a warm, quiet place that is free of distractions. You can do them either seated or lying down, but in either case make sure that your neck and shoulders are well supported. A recliner chair set at about 45 degrees is optimal, although any chair, sofa or bed will do just fine. The procedure calls for you to select a muscle , e.g., the forearm muscle in your right arm. You will be asked to tighten that muscle until you feel tension in the area. When you can clearly feel the tension, you will then be asked to slowly relax the muscle, paying attention to how the area feels as the tension is reduced. This sequence is repeated, so that each muscle is worked twice during each exercise. You systematically work your way through all the muscle groups in the body (hence the name "Progressive Muscle Relaxation"). 3. Autogenic Training The final tape is labelled "Autogenic Training". This tape is designed to help control the occurrence of intruding thoughts by substituting relaxation-inducing material for stress inducing material. Autogenic training is a relaxation method which involves the use of repeated phrases to achieve its effects. These phrases are descriptions of a part of the body that is getting relaxed. For example, "My eyelids are heavy" is a phrase that might be used in Autogenic Training to achieve - you guessed it - heavy eyelids. The phrases we will be using are similar to one another. That is done deliberately, so that the repetitive quality of the phrases can produce a maximal effect. As each phrase is introduced, the tape will prompt you three times to silently repeat that phrase, with questions and pauses between repetitions. Be sure you say each phrase to yourself slowly each time you do it. Take your time with this technique. Remember, the effects accumulate with repetitions. 19 One of the great strengths of Autogenic Training is that it blocks interfering thoughts. You may be aware of a frustrating fact that occurs when doing relaxation training, i.e., when you begin to relax, there is a tendency for interfering thoughts to come creeping in. Slowly at first, then with increasing frequency, the worries of yesterday, today and tomorrow enter your thoughts. All of the "I have to...", "I ought to...", "I need to..." worries get in the way of becoming relaxed. Autogenic training is an excellent tool for managing that problem, since the autogenic phrases replace the intruding thoughts. The texts for the tapes will be found in Appendix B at the end of this manual. Pre-produced tapes are supplied with the kit that comes with registration of the program. The registration form will be found at the beginning of this manual. 20 | | | | | | | STEP 5 | | M O N I T O R I N G C H A N G E S | | I N | | S T R E S S L E V E L | | | | | | | | | Step 5 - USING THE RELAXATION RESPONSE It has probably occurred to you that learning to relax while sitting alone in a chair at home is of rather restricted value. Pleasant perhaps, but not very useful in stressful situations. You need to be able to relax when you are in stressful situations like a noisy room in a factory, or taking an important test or in an argument. In these kinds of situations, the stress response is almost automatic unless you induce a relaxation response to counteract it. To do this easily and effectively, you need a means to apply the relaxation skills you learn with the tapes so that they are usable in new situations. This section of the program helps you learn how to generalize your at-home relaxation skills to actual stressful situations. You've probably noticed that the stress level increases when you think about a stressful situation. Research shows that the stress we experience is considerably reduced when we can think about a stressor and still remain relaxed. The Self-Health Systems program, then, next trains you to apply your relaxation skills while thinking about your particular stressors. Follow the steps below carefully. 1. Induce a state of relaxation as you have been learning to do with the Self-Health tapes. 2. Choose one of the stressors you have selected to work on. 3. Imagine being in that stressful situation, but maintain the relaxed state as you do so. (Make the image as vivid as you can. Include how things would feel and smell and taste as well as how they would look). 4. Hold the image for about thirty seconds. 5. Re-relax yourself for another thirty seconds. 6. Repeat the image a second time. 7. Do this for two or three selected stressors in your list. Repeat the exercise every day until you feel relaxed and comfortable thinking about those stressors. Once you have learned to be relaxed with thinking about a stressor, you are ready to use the relaxation response in the real world on the real stressor. A word of advice as you initiate this step. THINK SMALL. Don't try to do too much at any one time. Start with one of the least stressful stressors, preferably one which has a brief duration. (A good example would be asking a store owner for change of a dollar bill for a parking meter). When you have determined which stressor you will try, rehearse what you are going to do out loud a few times. If you have a trusted relation or friend, rehearse it with them. Get some feedback from them about how you're doing and try some alternative ways of behaving in the stressful situation. Then try it out in the real world. 21 Don't be surprised if your performance doesn't meet all your expectations. If this were easy to do, you would have done it already. A positive problem-solving attitude will help. Here are a few questions you can ask yourself that might help in the problem-solving: 1. Did you maintain the relaxation or did you get so caught up in the stressor that you forgot? 2. Can you remember just What caused you to lose your state of relaxation. Was there something specific you remember? 3. What kind of self-limiting thoughts do you remember having at the time (e.g. "I'm never going to get over this")? 4. What can you do the next time to make it go better? Before leaving this section of the manual, a few more hints may be in order. The most important thing is not to attempt too much at any one time. Because we have a tendency to do things from habit, behavior change is not easy. By taking on only one or two stressors at a time instead of six or seven, we increase the ease with which we can make appropriate changes. A second hint worth repeating is to work with stressors that mean a lot to you, even if they seem harder to manage (they are). The motivation to make the changes is greater when the issues are more central. Third, don't get caught in the psychological trap of "feelings" about the stressor situation (e.g. "But that's the way I feel"). Recognize that research shows us we can change how we emotionally react to stressors, thereby reducing the amount of stress they cause us. Finally, be sure to make the effort to incorporate what you have learned into your daily life. Take the relaxation skills you are learning and put them to work in stressful situations. You will be impressed with how much easier it is to handle your stressors when you are relaxed rather than tense. Facts vs Subjective Opinion: Keeping Track Now that the data for each stressor is being entered into the computer on some regular basis, we can do an analysis that indicates how these stressors function over time. This will tell us how your stress management program is affecting the stress. It is often the case that people will not recognize that significant change is occuring, simply because they aren't able to get FACTS about the change. Let's face it, this stuff is pretty subjective at best, and our tendency is to "go with our feelings" when it comes to judging change. 22 The Self-Health Systems program requires you to keep careful note of the occurrence of the stressors, and gives YOU the feedback and objective analysis necessary to accurately judge the nature of the changes you are making. This is done by using a graphic display for the frequency of occurrence and SUDS level data for each stressor. Here is what one of the graphic displays looks like: ┌───────────────────────────────────────────────────────────────┐ │ Period: 11/18/89 - 02/17/90 STRESSOR: Finances │ ├───────────────────────────────────────────────────────────────┤ │ ░░............................................................│ │ ░░░░░.........................░░..............................│ │ B░░░░░.░░.░░░.................░░.............................B│ │ ░░░░░░░░░░░░░.................░░..............................│ │ ░░░░░░░░░░░░░░░░░░............░░..............................│ │ ░░░░░░░░░░░░░░░░░░░░░░░.......░░..............................│ │ ░░░░░░░░░░░░░░░░░░░░░░░░......░░..............................│ │ ░░░░░░░░░░░░░░░░░░░░░░░░░.....░░..............................│ │ ░░░░░░░░░░░░░░░░░░░░░░░░░░....░░..............................│ │ ░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░.............................│ │ ░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░........................│ │ ░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░..............│ │ ░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░.........│ │ ░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░...│ │ ░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░│ │ ░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░│ │ FREQUENCY WEEKS B....B = BASELINE │ ├────────────────────────────────────────────────┬───────┬──────┤ │ Self-Health Systems Stress Management Software │ TIME │ DATE │ └────────────────────────────────────────────────┴───────┴──────┘ This display shows what has happened during a complete program to one stressor. Along the abscissa, (that's the horizontal line at the bottom of the chart) are the weeks that the program was applied. The ordinate (the vertical axis) shows the frequency with which the stress was encountered. The greater the frequency of occurrence of the stress, and the higher the stress level, the higher the bars on the graph. The graph used as an example shows that there was a falling off of the frequency with which this stressor occurred, (except for the period right in the middle of the training, which must have been a heller). One could objectively infer that the overall effects of the stressor were significantly reduced over the period of the training but, as has been mentioned, many people experience "rebounds" - periods where the effect of the stressor returns to a very high level - and subsequently abandon their attempts at control (e.g. "Here I am, right back at the same old level...nothing has really changed"). As you can see from the graph, however, there is very little doubt that this person DID achieve significant stress control. If this person simply had access to the data, they would NOT HAVE GIVEN UP! 23 Therefore, YOU SHOULD REVIEW YOUR PERFORMANCE FREQUENTLY so that you can see how well you are doing. (Don't trust your memory about your progress, and don't trust your immediate "feeling" about it either. One way or another, you'll probably lie to yourself if you do). When things are not going well, try to analyze the problem and solve it. Use the graphic information to see your solutions are working. When you want to call up any of these graphs, select the (P)rint option from the pull-down menu, and then select one of the Graph options: ┌────────────────────────────────┐ │ List of Stressors │ │ All Stressor Information Cards │ │ Individual Information Cards │ ├────────────────────────────────┤ -----> │ Daily Graph │ -----> │ Cumulative Graph │ └────────────────────────────────┘ Press "D" for daily records, or "C" for records that cover the whole twelve weeks of the program. Then use the space bar to bring up new graphical information. The graphs will display the pattern of your stress activity over time. Study these carefully. They will show you possible patterns of stress that you are not aware of. For instance, you may notice that you are more stressed on particular days, or at particular times of the day. Use the information in the graph to help you predict when and where you stress is likely to arise so that you can be better prepared to manage it. 24 | | | | | | | STEP 6 | | G E N E R A L I Z I N G | | Y O U R | | S K I L L S | | | | | | | | | Step 6. GENERALIZING YOUR SKILLS This last step in the system is intended to generalize what you have been learning about stress management to other aspects of your life. It will help if you understand how generalization happens in the first place. Generalization occurs in two ways. The first, situational similarity, states that if two situations are similar, a response learned in Situation 1 is likely to occur in Situation 2. (If you clench your jaws when you are late for a meeting, you'll probably also clench your jaws when you are late submitting a report). The second, response similarity, says that if you have learned a response in a given situation, you are likely to make similar responses in that same situation. (If being caught in a traffic jam produces muscle tension in your forehead, it will also be likely to produce muscle tension in your neck and shoulders). In either case, generalization occurs primarily on the basis of similarity between situations or responses. Therefore, in order to generalize most effectively, you need to identify the elements that make for the similarities. Let's start with being able to generalize via situational similarity. Suppose you have learned the relaxation response in one situation and want to generalize it to another. That's not as hard as it sounds since many similarities can exist from one stressor situation to another. All you need to do is find some of the similarities and use them as the avenue to generalization. Some representative examples might be helpful. Ms. A, a 26 year old administrative assistant at an advertising firm, was experiencing chronic head pain and stomach cramps which her physician told her were stress-related. An analysis of the place of these symptoms showed that at first they occurred only at work, but had then begun to show up at home as well. (The symptoms had begun to generalize from one place to another). Ms. A practised the relaxation response at home until she was able to control the physical symptoms in a reliable manner. She then began to practice the relaxation response at work until she could control the symptoms there as well. In that way, the generalization that initially spread the symptoms from one place to another was used to spread the relaxation response from one place to another. In another instance, Mr. B, a 41 year old accountant, complained of a worsening inability to concentrate and failing memory. An analysis of when this occurred showed that it was at its worst when he was working on tasks assigned by either his immediate supervisor or by his rather tyrannical elderly father. The problem was resolved when Mr. B learned to become relaxed when working on tasks assigned by his supervisor and then generalizing the relaxation to those involving his father. Response similarity can be understood in a comparable way. When you have learned to make a specific response in a given situation, other similar responses are likely to occur. Irritability is likely to generalize into anger when you have been stressed for a long time and the anger can turn into a sullen rage if it is not resolved. For another example, and as noted above, muscle tension in one area is likely to spread to other areas as well when stressed. 25 Ms. C, a 56 year old housewife, had a history of pain and soreness in the area around her jaws. In recent years she had also begun to experience tension headaches and stiffness in her shoulders and neck. Careful tracking of the symptoms showed that they occurred only when stressed by her husband or children and would begin in her jaw area, then radiate to the head, neck and shoulders. By training for relaxation of one of these groups of muscles and then generalizing that training to the others, the problem was resolved. Generalization in these examples occurred by place and person respectively. These may also be involved for you, but there are other ways in which it can occur, e.g., time or some special sensory characteristic. The key to understanding what is going on is to remember that generalization occurs via similarity of some kind. When you recognize what the basis is, it is much easier to figure out what to do. Use the generalization to work for you, not against you. 26 | | | | | | | | | A P P E N D I C E S | | | | | | | | | | | | | Appendix A: Counting Notebook Sheets ┌─────────────────────────────┐┌───────────────────────────────┐ │ Date: ││ Date: │ ├───────────────────┬─────────┤├─────────────────────┬─────────┤ │ Stressor │ SUDS ││ Stressor │ SUDS │ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ └───────────────────┴─────────┘└─────────────────────┴─────────┘ ┌─────────────────────────────┐┌───────────────────────────────┐ │ Date: ││ Date: │ ├───────────────────┬─────────┤├─────────────────────┬─────────┤ │ Stressor │ SUDS ││ Stressor │ SUDS │ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ └───────────────────┴─────────┘└─────────────────────┴─────────┘ ┌─────────────────────────────┐┌───────────────────────────────┐ │ Date: ││ Date: │ ├───────────────────┬─────────┤├─────────────────────┬─────────┤ │ Stressor │ SUDS ││ Stressor │ SUDS │ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ └───────────────────┴─────────┘└─────────────────────┴─────────┘ ┌─────────────────────────────┐┌───────────────────────────────┐ │ Date: ││ Date: │ ├───────────────────┬─────────┤├─────────────────────┬─────────┤ │ Stressor │ SUDS ││ Stressor │ SUDS │ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ ├───────────────────┼─────────┤├─────────────────────┼─────────┤ └───────────────────┴─────────┘└─────────────────────┴─────────┘ 27 Appendix B: PREPARING THE RELAXATION TAPES This section of the manual is designed to help you produce the three audio tapes that are used by the Self-Health Systems Stress Management program. If you would prefer tapes prepared in a professionally recorded format, we will send them to you free of charge when you register this program with SELF-HEALTH SYSTEMS. To register the program, complete the registration form located at the beginning of the manual. This section is arranged in two parts. Part I has some suggestions for making good quality audio tapes. Part II has the actual text for the relaxation tapes themselves. Part I - TAPE RECORDING INSTRUCTIONS These suggestions are designed to help you produce good quality audio tapes for your stress management program. Please follow the steps and suggestions carefully. 1. Prepare the tapes in a quiet environment. There is something distracting about a telephone ring, a child's voice or the drone of a television commercial when you are doing a relaxation sequence, so you don't want these kinds of noises on your tapes. If you can't find a quiet place during the day, record the tapes at night when everyone else is asleep. 2. Record each script on a separate tape. You will be using them at different times in your training and will not want to have to hunt through one cassette for the segment you want to use. 3. Use tapes that will permit you to get about twenty minutes worth of time on each tape. High quality tapes that run sixty minutes will work just fine, and will give you plenty of lattitude (you won't run out of tape at the end!). 4. Record only one script at a sitting. Your voice and your attention span will tend to wander if you do more than that. 5. Use lots of time and patience when you record. Speak in a slow, unhurried manner, keeping the microphone at a constant distance from you. 6. Use the "Pause" button on the tape recorder to stop the movement of the tape when you want to take a short break (it makes less noise than the "Stop" button) and keep a glass of water handy when you are taping for when you get dry. 7. If the sound of your own voice is not comforting to you, get someone else whose voice you do like to do the recording. Finally, be ready to try the taping several times before it works out to your satisfaction. Try things out before making any final commitments to any specific taping arrangement. Good luck and enjoy your experience. 28 Part II - TAPE TEXTS Tape I - Abdominal Breathing and Meditation [BEGIN TAPING HERE]. "Get yourself settled as comfortably as you can on the chair or bed, with your head and neck well supported. Now relax, letting the chair or bed do the work of supporting you. Just sink into the surface, taking the arch out of your neck and back muscles. Feel yourself sinking down into the chair or bed. Good. Now, let's begin by having you pay attention to your breathing pattern, without making any attempt to change it. Notice whether it is fast or slow, deep or shallow. Does it feel as if you are not getting enough air? Or perhaps too much? Are there times when you don't seem to be breathing at all? Let's begin to change that pattern around a little bit. We want to develop a breathing pattern which is regular and slow, but which lets in enough air so that your lungs feel comfortably filled and lets out enough air so that they feel comfortably emptied. To develop that pattern, we need to monitor the flow of air in and out of your lungs. One good way to do this is to monitor air flow at the nostrils. Focus your attention on your nostrils and monitor the flow of air at that point. When you inhale you can feel the cool air going down into your lungs and when you exhale you can feel the same breath, warmed by your lungs, coming back out again. Try it. Feel the cool air going down into your lungs, and the warm air coming back out again. [Insert ten second pause]. Good. Air flow is an excellent way to monitor your breathing pattern. A second way is to let yourself become aware changes in the muscles of the chest wall as you inhale and exhale. They stretch as you inhale and relax as you exhale. Try it. Feel the muscles stretch and relax as you breath in and out. [Insert ten second pause]. So there are two ways of monitoring what your breathing pattern is like: the first is the flow of air at the nostrils and the second is the feeling of the muscles in the chest wall. Let's pause for a moment now while you practice monitoring your breathing using these two cues.. [Insert sixty second pause]. 29 OK, that was good. How did it feel? Were you able to stay focussed on monitoring your breathing for that one minute period? If you were not, the odds are pretty good that you were experiencing some intruding thoughts that got in the way of staying focussed. Don't worry about that if it happened. It's a common reaction among people who are feeling stressed. When stressed, our minds become filled with "Ought to's" and "Should's" and "Have to's" and "How could I have's". Some people also report feelings of impatience as they monitor the breathing pattern, telling themselves that they should be doing more pressing things. Such interference makes it difficult to concentrate on something as quiet as monitoring breathing patterns. If you are become aware of these interfering thoughts, just silently say the word "STOP" to yourself and return to what you are doing. You may have to do this a number of times before you can stay focussed for a longer period of time, but it will happen. In fact, the capacity to stay focussed for a long time is itself an important part of stress management training. OK, let's get back to breathing. Now that you can monitor your breathing pattern, we can turn to altering it in a useful way. The basic breathing pattern is one in which the air flows in and out of your lungs in a slow, uninterrupted fashion. Take in enough air so that your lungs feel comfortably filled, then let out enough air so that they feel comfortably emptied. Do this slowly. Feel the air flow past your nostrils as it flows in and out of your lungs and feel the chest wall stretch and relax as you do so. Let's try that for a moment. [Insert sixty second pause]. Good. You may already be feeling some relaxation as you breathe in this leisurely fashion. Feelings of heaviness in your arms and legs, sleepiness, warmth in your hands and feet and a sense of withdrawal from the immediate environment are all part of the relaxation. Don't worry if you are not feeling relaxed right now. You will get better at this with practice. Now we're going to make another change in the breathing pattern. This one is called abdominal breathing. The object is to enlarge the area into which the lungs can expand as you inhale. You do this by permitting both the chest and the upper part of the abdomen to rise at the same time as you inhale, and let them fall together as you exhale. To monitor this part of the breathing exercise, place your right hand on the upper part of the abdomen, just below the rib cage and your left hand in the middle of your chest. As you inhale, the two hands should rise together. As you exhale, they should fall together. Let's try that now, monitoring the rise and fall of the hands as you do so. [Insert sixty second pause]. OK. How did that feel? Some people report a little difficulty getting the breathing co-ordinated at the beginning, but a little practice usually takes care of that nicely. 30 The last alteration in the breathing pattern is the addition of a simple meditative exercise into the breathing pattern. As you practice the abdominal breathing, silently repeat the word "one" each time you exhale. This will help control the interfering thought patterns and aid in deepening the relaxation. Let's try that now. [Insert sixty second pause]. How did that feel? By now you may be feeling the relaxation response deepening. We'll end this tape by seeing what happens when we try this breathing pattern we've been learning for a longer interval. Remember to breathe slowly and evenly, letting your abdomen rise and fall with your chest and to silently say the word "one" each time you exhale. Let's begin now. [Insert a 5 minute pause]. How do you feel now? Remember this feeling of relaxation. Let yourself get as close to this feeling as you can as you go through the day. Stay in this relaxed state as long as you like. When you are ready to get up, take a few deep breaths and stretch out all the muscles. Then rise slowly." 31 Tape 2 - Progressive Muscle Relaxation [BEGIN TAPING HERE] "With your forearms and hands resting at your sides, lift your right hand, keeping your forearm flat on the resting surface. As you lift your hand, notice the muscle tension that develops in the wrist and forearm area. The higher your hand goes, the greater the tension. Continue to raise your hand until the feeling of tension becomes very clear to you. Then, very slowly, start letting your hand come down to the resting position. As you do so, feel the relaxation move into the wrist and forearm muscles. The relaxation will become increasingly apparent as your hand comes down to the resting position. When your arm is completely free of tension, focus on the contrast between how it feels when it is tense and when it is relaxed. Begin the exercise now. [Insert thirty second pause]. Now, slowly repeat the sequence. [Insert thirty second pause]. Now let's do the left forearm. With your forearms and hands resting at your sides, lift your left hand, keeping your forearm flat on the resting surface. As you lift your hand, notice the muscle tension that develops in the wrist and forearm area. The higher your hand goes, the greater the tension. Continue to raise your hand until the feeling of tension becomes very clear to you. Then, very slowly, start letting your hand come down to the resting position. As you do so, feel the relaxation move into the wrist and forearm muscles. The relaxation will become increasingly apparent as your hand comes down to the resting position. When your arm is completely free of tension, focus on the contrast between how it feels when it is tense and when it is relaxed. Begin the exercise now. [Insert thirty second pause]. Now, slowly repeat the sequence. [Insert thirty second pause]. Good. Now that we've done both forearms, you have an idea of how we will proceed. For each muscle group, we slowly tighten it, paying attention to the increasing muscle tension. Then we slowly relax it, again paying attention to the increasing relaxation. Let's do the same thing now with the muscles of the upper arms. Slowly press the palm of your left hand down into the resting surface. Keep increasing the pressure until you feel the tension clearly in your upper arm. Then slowly relax it. Pay attention to the change in sensation as you tense and relax the muscle of the upper left arm. Begin the exercise now. [Insert thirty second pause]. 32 Now, slowly repeat the sequence. [Insert thirty second pause]. O.K. Now let's do the same thing with the right arm. Slowly press the palm of your right hand down into the resting surface. Keep increasing the pressure until you feel the tension clearly in your upper arm. Then slowly relax it. Pay attention to the change in sensation as you tense and relax the muscle of the upper right arm. Begin the exercise now. [Insert thirty second pause]. Now, slowly repeat the sequence. [Insert thirty second pause]. Good. That should help relax your arms. Before we proceed to relax some of the other muscles, a few comments might be helpful. Many stressed people find themselves somewhat impatient as they do these exercises. It feels to them as if it was a waste of time. They think they should be doing something else, something "more productive". Don't worry about those feelings. They are just part of the stress syndrome. Remember that the time you spend doing this is just for you. It is your time to reduce the stress in your life and for right now, nothing is more important than that. Let all intruding thoughts float away and come back to what we're doing here. Now let's move to the legs. We'll start with the lower part of your right leg. Slowly press the toes of your right foot into the bottom of your shoe. Become aware of the tension in your calf muscle as you do so. When the tension level becomes clear to you, slowly begin to relax your toes. Be aware of the reduction in the tension level and the corresponding increase in the relaxation level. When your toes are completely relaxed, rest for a moment. Compare how the right lower leg felt when it was tensed as opposed to how it felt when it was relaxed. Begin the exercise now. [Insert thirty second pause]. Now, slowly repeat the sequence. [Insert thirty second pause]. Now let's move to the lower part of your left leg. Slowly press the toes of your left foot into the bottom of your shoe. Become aware of the tension in your calf muscle as you do so. When the tension level becomes clear to you, slowly begin to relax your toes. Be aware of the reduction in the tension level and the corresponding increase in the relaxation level. When your toes are completely relaxed, rest for a moment. Compare how the left lower leg felt when it was tensed as opposed to how it felt when it was relaxed. Begin the exercise now. [Insert thirty second pause]. Now, slowly repeat the sequence. [Insert thirty second pause]. 33 That's fine. Next we'll do the upper part of your right leg. Slowly extend your right leg until it is fully stretched out. As you do so, become aware of the tension levels in your right thigh muscles. When the tension level is clear to you, hold it for a moment. Then slowly lower your leg, letting yourself become aware of the relaxation entering the thigh muscles as you do so. When your right leg is fully relaxed, rest it for a moment. Compare how the muscles felt when they were tense and when they were relaxed. Begin the exercise now. [Insert thirty second pause]. Now, slowly repeat the sequence. [Insert thirty second pause]. Now we'll do the upper part of your left leg. Slowly extend your left leg until it is fully stretched out. As you do so, become aware of the tension levels in your left thigh muscles. When the tension level is clear to you, hold it for a moment. Then slowly lower your leg, letting yourself become aware of the relaxation entering the thigh muscles as you do so. When your left leg is fully relaxed, rest it for a moment. Compare how the muscles felt when they were tense and when they were relaxed. Begin the exercise now. [Insert thirty second pause]. Now, slowly repeat the sequence. [Insert thirty second pause]. Good. Now that we've worked the limbs, were going to shift to the facial muscles. When people are stressed, they often carry a lot of tension in the forehead, around the eyes and in the jaw muscles. Let's see if we can get those to relax. A good way to start relaxing the forehead is to slowly bring your eyebrows together in a frown. As you do so, you will feel the tension develop between your eyebrows. When it is clear to you, slowly relax the frown until the area feels relaxed. Compare the feelings in that area when there is contraction and relaxation. Now, slowly lift your eyebrows as if you were surprised. Get them up high enough so that you can clearly feel the tension in the forehead. Then slowly lower your eyebrows until the tension has been replaced by relaxation. Compare the way the muscles feel when they are tense and when they are relaxed. Begin the exercise now. [Insert thirty second pause]. Now, slowly repeat the sequence. [Insert thirty second pause]. We'll move on now to the eyelids. Just close your eyes and slowly squeeze the eyelids shut until they feel very tense. Then slowly relax them. When they are fully relaxed, compare the feelings of tension and relaxation in the eyelids. Begin the exercise now. [Insert thirty second pause]. 34 Now, slowly repeat the sequence. [Insert thirty second pause]. OK, let's do the muscles of the jaw. Very gently press your back teeth together until you clearly feel the tension in the jaw muscles. Don't press any harder than you need to get the sensation. Then slowly let your teeth come apart and your lower jaw hang slack. Feel the difference in the jaw muscles as you let go of the tension. Begin the exercise now. [Insert thirty second pause]. Now, slowly repeat the sequence. [Insert thirty second pause]. Good. The last muscle group we'll work on will be the muscles of the lower back and buttocks. Slowly squeeze all of those muscles together, feeling the tension in the area as you do so. When the feeling is clear, slowly relax them until all the tension is gone. Compare the sensations of tension and relaxation in the lower back and buttock muscles. Begin the exercise now. [Insert thirty second pause]. Now, slowly repeat the sequence. [Insert thirty second pause]. Now, check around your body and see if there are remaining areas of tension. If there are, repeat what we have done in those areas, i.e., tensing and relaxing the muscles until the relaxation is achieved. After you feel relaxed all over, let yourself stay in that state for as long as you like, enjoying the sensations of relaxation. When you are ready to get up, take a few deep breaths, stretch all the muscles and rise slowly." Tape 3 - Autogenic Training [BEGIN TAPING HERE]. "Lean back in your chair or bed and make yourself as comfortable as you can. As you say each phrase, close your eyes and concentrate on relaxing the part of the body described in the phrase. Phrase 1 - "My left arm is heavy and limp. My left arm is letting go". Close your eyes, and slowly repeat that phrase to yourself, letting the words and the arm come together in a relaxed state. Begin now. [Insert twenty second pause]. How does your left arm feel? Does it feel heavy and limp? Don't worry if at first there is not much effect. You will need to practice this a number of times to get the effect you want. Let's try it again. Slowly now - "My left arm is heavy and limp. My left are is letting go". Begin now [Insert twenty second pause]. 35 How does your left arm feel now? Is it heavy and limp? Did you let it go? Compare the left and right arms to see if there is any difference in feeling. If there is, let the one that is more tense feel like the one that is less tense. Alright - now the third time. "My left arm is heavy and limp. My left arm is letting go". Say that over and over to yourself, silently, making a connection between the words and your arm. Begin now. [Insert twenty second pause]. Once more, check to see how your left arm feels. Is it relaxed? O.K. Now we'll shift to the right arm. Phrase 2 - My right arm is heavy and limp. My right arm is letting go". Close your eyes, and slowly repeat that phrase to yourself, letting the words and the arm come together in a relaxed state. Begin now. [Insert twenty second pause]. How does your right arm feel? Does it feel heavy and limp? Don't worry if at first there is not much effect. You will need to practice this to get the effect you want. Let's try it again. Slowly now - "My right arm is heavy and limp. My right arm is letting go". Begin now. [Insert twenty second pause]. How does your right arm feel now? Is it heavy and limp? Did you let it go? Compare the right and left arms to see if there is any difference in feeling. If there is, let the one that is more tense feel like the one that is less tense. Alright - now the third time. "My right arm is heavy and limp. My right arm is letting go". Say that over and over to yourself, silently, making a connection between the works and your arm. Begin now. [Insert twenty second pause]. Once more, check to see how your right arm feels. Is it relaxed? O.K. Now we'll shift to the left leg. Phrase 3- "My left leg is heavy and limp. My left leg is letting go". Close your eyes, and slowly repeat that phrase to yourself, letting the words and the leg come together in a relaxed state. Begin now. [Insert twenty second pause]. How does your left leg feel? Does it feel heavy and limp? Let's try it again. Slowly now - "My left leg is heavy and limp. My left leg is letting go". Begin now [Insert twenty second pause]. How does your left leg feel now? Is it heavy and limp? Did you let it go? Compare the left and right legs to see if there is any difference in feeling. If there is, let the one that is more tense feel like the one that is less tense. Alright - now the third time. "My left leg is heavy and limp. My left leg is letting go". Say that phrase over and over silently to yourself, making a connection between the word and your leg. Begin now. [Insert twenty second pause]. 36 Once more, check to see how your left leg feels. Is it relaxed? O.K. Now we'll shift to the right leg. Phrase 4- "My right leg is heavy and limp. My right leg is letting go". Close your eyes, and slowly repeat that phrase to yourself, letting the words and the arm come together in a relaxed state. Begin now. [Insert twenty second pause]. How does your right leg feel? Does it feel heavy and limp? Let's try it again. Slowly now - "My right leg is heavy and limp. My right leg is letting go". Begin now [Insert twenty second pause]. How does your right leg feel now? Is it heavy and limp? Did you let it go? Compare the right and left legs to see if there is any difference in feeling. If there is, let the one that is more tense feel like the one that is less tense. Alright - now the third time. "My right leg is heavy and limp. My right leg is letting go". Say that phrase over and over silently to yourself, making a connection between the words and your leg. Begin now. [Insert twenty second pause]. Once more, check to see how your right leg feels. Is it relaxed? O.K. Now we'll shift to all four limbs at once. Phrase 5- My arms and legs are heavy and limp. My arms and legs are letting go". Close your eyes, and slowly repeat that phrase to yourself, letting the words and the limbs come together in a relaxed state. Begin now. [Insert twenty second pause]. How do your arms and legs feel? Do they feel heavy and limp? Let's try it again. Slowly now - "My arms and legs are heavy and limp. My arms and legs are is letting go". Begin now [Insert twenty second pause]. How do your arms and legs feel now? Are they heavy and limp? Did you let them go? Compare the right and left arms and legs to see if there is any difference in feeling. If there is, let the limbs that are more tense feel like the limbs that are less tense. Alright - now the third time. "My arms and legs are heavy and limp. My arms and legs are letting go". Say that phrase over and over to yourself, silently, making a connection between your limbs and the words. Begin now. [Insert twenty second pause]. Once more, check to see how your arms and legs feel. Are they relaxed? O.K. Well done. You have finished the Autogenic Training tape for this session. If you wish, remain in this relaxed position for a long as you like, but before arising from the chair or bed, be sure to stretch your muscles and take several deep breaths. Then rise slowly while your body returns to its normal arousal levels." 37