(p. 67) Session 3: Relaxation Skills
Goals of the Session
■ Review homework with the aim of identifying areas of difficulty, emerging themes, and progress based on completion of logs and monitoring forms assigned at the last session.
■ Introduce “Managing the Impact” Coping.
■ Teach Relaxation Skill I: Diaphragmatic Breathing (DB).
■ Teach Relaxation Skill II: Progressive Muscle Relaxation (PMR).
■ Introduce “Thought-Changing Skills.”
Introduce “Managing the Impact” Coping
The goal of this instruction is to provide the teen with skills needed to manage the impact that their symptoms and other stressors have on their daily life, even if they cannot immediately be changed or resolved. Teens learn to cope with illness-related stressors as well as general stressors that, if overwhelming, may exacerbate symptoms. Specific strategies taught and practiced over a series of sessions include progressive muscle relaxation, diaphragmatic breathing, guided imagery, thought-changing skills, and “acceptance.” These activities are often supplemented with such strategies as mindfulness meditation training, clinical biofeedback, etc. The patient and parents are coached in adopting these skills (p. 68) as lifestyle practices rather than as merely “techniques” to employ when symptomatic. The considerable body of evidence supporting the efficacy of these interventions is emphasized throughout treatment as these may be unfamiliar to patients and require considerable coaching and correction to employ habitually and effectively.
Teach Relaxation Skills I (DB) and II (PMR)
Instruct the patient in relaxation skills involving DB and PMR. It is important to take time to actually instruct the adolescent in these skills so that they can accurately practice them between sessions. It can also be helpful to supplement these activities with aids such as viewing a video demonstration, providing a recorded relaxation script, using simple biofeedback equipment or strategies to make the relaxation more concrete, and modifying the environment to provide a more relaxing atmosphere (soothing music, dim lighting, recorded nature sounds such as ocean waves or a quiet stream, use of comfortable chair, etc.). Emphasis should be placed on daily practice (typically at least 20 minutes daily) in order to promote generalization of these skills beyond the context of the therapy session. There are also a number of useful smartphone applications that can facilitate this process. Additionally, patients should keep a simple log of their practice (refer to Worksheet 3.3: Relaxation Skills Practice Log in the Workbook) to monitor their progress and establish a link between the use of these strategies and overall reduction of stress.
Introduce Thought-Challenging and Thought-Changing Skills
For many patients, the connections between thoughts, feelings, and behavior are not clear. Worksheet 3.1: How Thoughts and Images Affect Our Emotions provides an exercise that you can employ in your session with the teen that illustrates how our thoughts/beliefs and the images we generate can drive the emotional and behavioral responses we have to life experiences.
As the Children’s Health and Illness Recovery Program (CHIRP) clinician, it is your job to facilitate a better understanding of the bidirectional (p. 69) relationships between thoughts, emotional responses, and behavioral responses in general and in particular as they pertain to the patient’s physical symptoms. Figure 3.1 in the Workbook demonstrates this relationship. As you are introducing the Thought Record homework to the teen (Worksheet 3.2: Thought Record), help the teen differentiate between thoughts, feelings, and actions. For example, in social situations, patients may report feeling “stupid” when they are actually feeling anxious based on the thought that others view them as behaving in an odd or unacceptable way. Often patients struggle with identifying the thoughts driving their reactions. This struggle provides an opportunity for you to help the teen articulate underlying beliefs that may lead to their affective reactions while also providing you with an understanding of the teen’s level of insight into the thought-feeling-behavior connection. For instance, a teen who reports thinking, “I don’t like this” when encountering a group of peers at the mall may need help extending this statement to “I don’t like feeling like this! I feel like an outsider, a misfit. I just don’t seem to fit in with them anymore.” Such a statement reveals both the potential cognitive distortions (“Since I haven’t hung out with them for weeks, I’ll have nothing to talk about and will feel out (p. 70) of place”) and the lack of understanding of the thought-feeling-behavior connection.
The patient is instructed on how to fill out a Thought Record and given homework (Worksheet 3.2) to complete before the next session, without filling in the Alternative Thoughts column, which will be explained in the next session. They should record information from at least three situations between sessions. Sidebar 3.1 shows an example of using cognitive behavioral therapy (CBT)-based skills to identify distorted automatic thoughts and subsequently engage in thought-challenging and thought-changing skills in addressing social anxiety often experienced by teens with chronic illness who have had periods of social isolation related to their health condition.
Finally, before ending the session, you should review the teen’s Sleep Log (Worksheet 1.3) and Weekly Activity and Exercise Action Plan (Worksheet I.1) and provide them with new worksheets for the coming week. Remember, addressing sleep and physical activity are an ongoing focus while the teen and family are in CHIRP.
As determined to be necessary based on previous response to homework assignment, have the teen and parent(s) complete the following homework assignments and bring to the next session:
■ Continue filling out Worksheet 1.3: Sleep Log.
■ Work on Worksheet 3.2: Thought Record. Record information from at least three situations.
■ Start filling out Worksheet 3.3: Relaxation Skills Practice Log.
■ Refine/Implement Worksheet I.1: Activity and Exercise Action Plan.