28. 促进放松

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28 Facilitating relaxation Some people who are very tense and anxious find that counselling alone does not sufficiently reduce their symptoms to enable them to feel comfortable. Sometimes it’s advisable to refer such people to a medical practitioner or psychiatrist for assessment so that appropriate medication can be prescribed if necessary7. However, for many people who suffer from tension and anxiety» considerable benefit can be achieved through the use of relaxation techniques. Before introducing a relaxation exercise it is important, as with all other interventions, to check out with the person whether or not this is an exercise in which they would like to participate. This might involve summarising the process so that the person is aware of what to expect. Most people find it easy to learn relaxation, enjoy relaxing and can be encouraged to use it regularly. However, there are a minority of people who find relaxation techniques quite threatening. Instead of becoming relaxed during a relaxation exercise, they experience increased tension and anxiety. For some, this can be severe. Be careful to give the people you seek to help permission to stop a relaxation exercise if they find it is stressful rather than relaxing. For such people it may be useful to explore the stressful experience, if this is not too threatening, because it may well be related to other stressful experiences in their present or past. Preferably, a room used for relaxation should be quiet and have subdued rather than glaring lighting. It should be protected, as far as possible, from external noises such as phones ringing and also from the intrusion of others. It is not helpful to have someone open a door and walk in while a person is trying to relax. There are many different ways of teaching relaxation. The following relaxation exercise is one that we use. If you wish to use it, read the following instructions to the person seeking help using a quiet, slow, monotonous tone of voice. Pause between each statement for a few seconds. RELAXATION EXERCISE Lie on the floor with your head on a cushion, your hands beside you and your legs straight. Move around until you feel comfortable. Close your eyes. You will probably enjoy this exercise and find it pleasurable, but if at any time you are feeling uncomfortable and want to stop, you may either cchoose to lie quietly and ignore my voice, or you may speak up and tell me that you want to discontinue the exercise. Notice where your body touches the floor. Move yourself so that you are more comfortable. Be aware of your whole body from head to toe and stretch any part of you that is uncomfortable. Let your body press down on the floor. Notice the floor pressing up on you. It's a good feeling. You are in contact with the ground and the ground is in contact with you. Notice your breathing. Allow yourself to breathe comfortably and naturally. [Long pause] We are going to go through a series of exercises during which you will relax various parts of your body, starting from the tips of your toes and finishing at the top of your head. For each set of muscles, I will suggest that you tighten those muscles while breathing in deeply, and then relax them as you breathe out. Whenever you remember, say to yourself the word 'relax' as you breathe out. In between relaxing each set of muscles, focus on your breathing again. Breathe naturally and say 'relax' silently to yourself as you breathe out each time. By doing this you will gradually become more relaxed. If any intruding thoughts come into your mind, don't worry, just return to focusing on your breathing again. Notice your breathing now. Each time you breathe out say 'relax' silently to yourself. [Observe the person's body, and notice their breathing. When they breathe out each time say the word relax’ quietly. Do this a few times so that the person remembers to do it themselves] Notice your body. If any parts of it are uncomfortable, stretch or move so that you are more comfortable. Focus on your breathing. When you are ready, I will ask you, as you breathe in, to take a slow, deep breath and as you do this to clench your toes tightly and tighten up the muscles in your feet. [Choose the time] Breathe in deeply and tighten up the muscles in your feet. Hold your breath and keep the muscles in your feet tight for a second or two. Breathe out heavily and release the tension in your feet. Continue breathing naturally and say 'relax' to yourself each time you breathe out. [ Wait for a while as the person continues to breathe naturally] Now tense your thigh and calf muscles as you breathe in deeply. Hold your breath and keep your muscles tense. Relax as you breathe out. Breathe naturally and feel relaxed. [Pause for a while] Tense the muscles in your buttocks as you breathe in deeply. Hold your breath and keep your muscles tensed. Now breathe out and relax.. Breathe naturally and notice a feeling of relaxation flowing up your body from your feet to your buttocks. [Pause for a while] Tense the muscles in your stomach as you breathe in deeply. Hold your breath. Relax. Notice your breathing. [Pause for a while] Clench your fists as you breathe in. Hold. Relax. [Pause a while] Now tense the muscles in your arms and stretch your fingers out as you breathe in. Hold. Relax. Notice a relaxed feeling flow up from your feet through your calves, thighs, stomach, hands, arms and chest. Let your body sink into the floor and feel supported by the floor. Breathe naturally. [Pause] Tighten your shoulder and neck muscles as you breathe in. Hold. Relax. [Pause] Clench your teeth, screw up your face, close your eyes tightly and feel your scalp tighten as you breathe in. Hold. Relax. [Pause] Breathe naturally and notice the relaxed feeling moving up and encompassing your whole body. Be aware of your breathing. Each time you breathe out feel yourself becoming more relaxed. [Long pause] Soon it will be time to start getting in touch with your surroundings again. When you do this, allow yourself to feel good, to be wide awake and alert. [Pause] Notice the floor. Move your fingers and feel it. Wriggle slightly, and when you are ready, open your eyes. Lie where you are and look around. Allow yourself to take in what you see, to feel good, and to be awake and alert. When you are ready, roll over sideways and support yourself with one arm in a half-sitting position. Sit up when the time is right for you. 1 he above relaxation exercise can be taught in a counselling session, and the person can then be encouraged to practise it regularly in their own time. However, warn them about the dangers of being too relaxed. It is not advisable, for example, to drive a car in a very relaxed state. A certain amount of tension is useful so that the person’s reactions to danger are fast. 1 here fore, do not go through the relaxation exercise immediately before the person seeking your help is due to drive away! Once a person has learnt to relax by muscle tensing and relaxing they will find it easier to relax when standing up and in a tense situation. Teach them to take a few deep breaths and each time they breathe in to tighten up their muscles and then relax as they breathe out. With practice they will probably find that they are able to let themselves relax as they breathe out naturally. If teaching relaxation methods appeals to you, we suggest that you might like to learn more from the books listed as further reading below.

Learning summary Use a quiet, slow, monotonous tone of voice when teaching relaxation. Relaxation exercises can be threatening for some people. Make sure that the person seeking help understands that the exercise can be discontinued whenever they like. Observe the person's body so that your instructions are correctly timed. Warn of the danger of being too relaxed when attention is required. Further reading Davis, M., Eshelman, E.K. & McKay, M. 2008, Relaxation and Stress Reduction Workbook, 6th edn, Newharbinger, Oakland, CIA. Payne, K.A. & Donaghy, M. 2010, Payne’s Handbook oj Relaxation Techniques: A Practical Guide for the Health Cate Professional, Elsevier, Edinburgh.

TRAINING GROUP EXERCISES RELATING TO PART 4: ADDITIONAL SKILLS FOR PROMOTING CHANGE Chapter 17: Normalising 1 Practice examples for normalising Working individually for each of the case descriptions below, devise and write down suitable counsellor normalising statements. Remember that normalising can instil hope and optimism. a An elderly lady who had a successful career has recently retired. She is now bored with Life, has no interests and sees herself as a failure. b A man in his twenties who has previously enjoyed a single Life has recently moved into a close live-in relationship with a friend. He is confused because he says that he loves his friend and wants to continue the relationship. However, he feels claustrophobic and unable to do the things that he would Like to do for himself, c The father of a young child says that he and his partner (the child's mother) are having difficulty managing the child's behaviour and are arguing with each other about how to parent the child. It has emerged in the counselling process that the father's own family of origin was very easygoing and that physical punishment was never used. However, his partner's family of origin believed in the use of strict rules with physical punishment for disobedience. d A middle-aged woman is unable to work or sleep and cannot understand what the matter is'. In counselling it transpires that there have been three deaths of near relatives in recent weeks. She herself worries about whether she has bowel cancer and is avoiding seeking medical advice. e Ina time of very high unemployment a 50-year-old, who was retrenched as a senior executive nine months ago, says that he has been unable to find employment. He feels deeply depressed, has lost his motivation and feels a failure. 2 Following up after normalising After completing the previous exercise, work in your whole training group to: a discuss your normalising statements with other members of the group b for each of the statements in the first exercise, discuss in the group what issues might need to be addressed by the person seeking help after the normalising response has been used. Chapter 18: Using the here and now' experience 1 Feedback statements Working individually, write down appropriate feedback statements in place of the inappropriate statements given in examples 1, 3 and 4, on page 154-5. Also write down feedback statements for the situations a. b, c and d below. When all group members have completed their answers, discuss your feedback statements with the group. In the discussion, identify possible outcomes in each case for the person seeking help. a b c d _he person continually deflects away from what seems to be an important issue by introducing new, unrelated material The person continues to focus on blaming the behaviour of others instead of exploring their own options for addressing the situation. The person continually seeks the counsellors approval and seems unable to trust their own decisions. The person repetitively talks about past issues rather than focusing on their present situation. Chapter 19: Confrontation 1 Confrontation statements Write suitable counsellor statements of confrontation for the following examples: a The person seeking help tells the counsellor that he is very keen to receive counselling help but repeatedly arrives for appointments up to three-quarters of an hour late. b _he person seeking help has made it clear on several occasions that she is coming to counselling to address the post-traumatic effects of abuse during her childhood. However, each time she arrives for counselling she deflects away from talking about the abuse by introducing a range of other unrelated issues. c _he person seeking help admits to pushing and slapping his wife but minimises this behaviour and blames her for his behaviour, saying that she is provocative. He doesn't see that he needs to take responsibility for what he does. d When the counsellor reflects back what she sees as angry non-verbal behaviour, the person seeking help denies being angry but continues to look and sound angry, and to make statements which suggest that she is angry, e Although the person seeking help does not appear to be under any threat he is responding to others from a disempowered, victim, 'poor me' position instead of being assertive in letting others know about his needs. 2 Outcome of confrontation After completion of the previous exercise, discuss your suggested confrontation statements in your training group. In this discussion, consider the likely effect of particular confrontation statements on the person seeking help and on the counselling relationship.

Chapter 20: Challenging self-destructive beliefs 1 Practice in replacing self-destructive beliefs with more helpful beliefs Working individually, replace the self-destructive beliefs below with more helpful beliefs. After group members have finished doing this, discuss your suggestions in the group. a b c d e f Other people should always agree with me. I should be able to expect that people will be reliable and trustworthy, Other people should always respect me. I should never be seen to make mistakes. I need to be in control all the time or I will feel threatened, Other people should care about my needs. h i j k L m n o p 2 I need other people's approval to feel OK. As a result of past trauma I can't enjoy life like other people. I should do what other people want me to do. People should never be impatient. I will feel bad if other people reject me. I must work hard all the time. Things will sort themselves out if I just wait. i must always help other people when they ask me to. I must never refuse invitations. Other people should appreciate what I do. Exploring personal self-destructive beliefs Each group member is to think of a self-destructive belief that sometimes troubles them. This can be either a should, must, ought or have-to belief, or an unrealistic expectation. Then, working in pairs, their partner is to use whatever strategy they think useful to encourage them to question the usefulness of the belief and to enable them to replace it with a more helpful belief. After this, trainees are to discuss their experiences with the training group. Chapter 21: Externalising 1 Externalising practice Work in pairs, with one person acting as a person seeking help and the other as the counsellor, to practise the use of externalising. The 'person seeking help' is to choose a real problem that they may see as part of their personality (e.g. I am a procrastinator), and the 'counsellor' is to help the 'person seeking help' externalise the problem (e.g. I am troubled by procrastination). The counsellor can then ask the person seeking help a series of questions, similar to those described on page 175, where some of these questions relate to the way the problem has had success in interfering in the person's life and others focus on times when the person has had success in controlling the problem. After completing the role-play, the 'person seeking help’ and the 'counsellor' are to discuss the experience together, and then have a discussion regarding externalising in the whole training group. 2 The externalising interview (adapted from an exercise described by Roth and Epston, 1996) Find a partner to work in pairs, and take turns to play the roles of: a an externalised problem b a reporter. _he person playing the role of the externalised problem has to think of a single identifiable problem that has previously restricted their life (e.g. fear, nightmares, tardiness, alcoholism, depression, guilt or rage). Firstly, they are to give the problem a name (e.g, 'the snake') and then describe it physically (it is slippery, so difficult to catch hold of). Next they are to take on the role of the problem and speak as though they are the problem using i statements (e.g. 'I am the snake'). _he reporter then interviews the problem about its relationship with the person - this can be in a TV interview style that treats the problem as an ageing guest or a celebrity who has been influential in the persons life but is now past its prime and wonders what the future holds for it. “here are two stages to the interview. In the first stage the reporter uses questions such as those on page 176 which explore how the problem has had success in troubling the person. In the second stage the reporter uses questions such as those on page 177 which explore how the problem is having difficulty in continuing to trouble the person. After completing the exercise, trainees are to discuss their experience of this exercise with their training group, drawing attention to information that might be useful when counselling. Chapter 23: Exploring polarities See the Chapter 27 training group exercises for an exercise that explores polarities. Chapter 24: Reframing 1 Reframing practice Working individually, write down reframes for the examples below. a b c d e f 2 My teenage daughter is a great disappointment to me. I thought that when she reached this age she and I would be good friends and would spend lots of time together. All she wants now is to do her own thing. I'm just irrelevant as far as she's concerned. My husband interferes in everything I do. [just need to start doing something and he's there, taking over. I'm starting to think that I must bean incompetent idiot who isn't capable of doing anything for myself, 'Don't sniff, stand up straight, don't be late, be polite', that's all I hear from Mum. She says she loves me but I don't think that she even likes me anymore. I don't know why the manager picks on me all the time. Whenever there is a difficult job to do or a difficult customer to deal with she always gives the work to me. She's obviously trying to make my life as difficult as possible. I'm totally exhausted and realise I've been very stupid. In just a few months, I've completely redecorated my house, and written several journal articles for publication, while working full-time in a very demanding job. I've driven 200 kilometres and back to see my dying brother most weekends, and organised a group project for the Local community. I seem to be unable to stop working compulsively. I feel really depressed by my inability to relax and enjoy life. My friends tell me that I'm completely stupid because I keep going out with my girlfriend who treats me in a very offhand way. Maybe they're right! Group discussion on the effect of reframes After completing the previous exercise, discuss your suggested reframes with your training giro Up. The discussion should include consideration of the following: • • the effect the various reframes might have on the person seeking help suggestions about how the counselling process might continue if the reframe was accepted, and also if the reframe was rejected, by the person seeking help.

Chapter 25: Making decisions 1 Decision-making Sit quietly in your training group and think of a difficult decision that you have made at some time. Write down a brief summary of the way you made the decision and the outcome as a result of your choice. In particular, try to identify what it was you lost, and what you gained, when you made your decision. Was there anything that you learnt about decision-making as a result of thinking about this particular decision? When all group members have finished the task, have a group discussion on decision­ making processes - what seems to work well, and what doesn't? 2 Counselling practice with regard to decision-making Work in pairs with one person as counsellor and the other as a person seeking help. The person seeking help should preferably present a real problem that involves a choice between alternatives. The trainee counsellor can use the process described in the chapter to help the person seeking help explore their options and move towards making a decision. After the exercise, discuss the experience in your training group. Chapter 26: Facilitating action 1 Action plan Work in pairs with one person acting as counsellor and the other as a person seeking help. The person seeking help is to think of some behaviour of theirs that they would like to change but haven't succeeded in changing. The counsellor is to invite the person seeking help to prepare an action plan and to work with them in developing that plan. After all group members have finished this task, they are to discuss the experience in the training group. Chapter 27: Experiential counselling skills When doing the exercises below it will be advantageous to have an assortment of cushions available in a variety of sizes, shapes, conditions, colours and patterns. If cushions are not available, coloured sheets of paper, including those which have various patterns on them, can be used in place of cushions. 1 Dialogue with a protagonist Working in pairs, with one person acting as the person seeking help and the other as the counsellor, use an experiential process as described in this chapter to enable the person seeking help to dialogue with someone they are having relationship difficulties with. After the conclusion of this process discuss your experience, and what you have learnt, with your whole training group. 2 Exploring polarities Working individually, divide a sheet of paper into two columns. In the left-hand column write a list of your strengths and in the right hand column a list of the opposite characteristics. Use this list to discover polarities within yourself. Next, choose from your list the polarities you would like to explore in an experiential exercise. Take turns with your partner to act as the counsellor and the person seeking help to explore polarities as described in this chapter. After completing the experiential exercise, discuss your experience and anything you might have Learned from the exercise with your whole training group. 3 Making a choice between alternatives First, working individually, spend a few moments thinking about a decision you have to make, which preferably involves deciding between several alternatives. Then, working in pairs, taking it in turns for one person to act as the person seeking help and the other as counsellor, use an experiential process as described in this chapter to help the person seeking help make a choice between the alternatives available to them. After completing the experiential exercise, discuss your experience and anything you might have learned from the exercise with your training group.