What is it?
Skills training involves carefully constructed combinations of various cognitive and behavioural strategies in a manner designed specifically to treat the particular disorder and/or the specific difficulties the person is experiencing. Training involves the development of skills needed to deal with the situation that is problematic.

Does it work? Various types of skills training are recommended for a range of disorders. The specific evidence for the various skills training approaches is discussed below.

How do you do it?
The different types of skills training (e.g., problem-solving) and how to do them is discussed below.

What is it?

Problem-solving skills training involves teaching the patient to follow a series of systematic steps to enhance their sense of control over difficulties that are encountered. Problem-solving is easy to teach and easy to learn, and can be applied to a variety of different problems such as: 'threatened-loss (e.g., of an important relationship or of personal status), actual loss, conflicts in which a person is faced with a major choice (e.g., whether or not to leave a situation, take on a new role), marital and other relationship problems, work difficulties (e.g., how to alter current working relationships), study problems, coping with boredom, difficulties concerning child care, and dealing with handicaps resulting from either physical or psychiatric illness' (Hawton & Kirk, 1989 p. 407).

Does it work?
Studies indicate that problem-solving is a useful component of treatment for patients experiencing a wide range of difficulties such as depression (Craighead et al., 1998), anxiety (Andrews et al., 1994), and adjustment disorders (Sahler et al., 2002).

How do you do it?

Before you begin, ensure that that patient's problem(s) can be clearly specified (this can take some time) and that the patient's goals seem realistic. Once this has been established, there are six main steps that you can begin to teach the patient:

Summary of steps in structured problem solving

1. Define the problem
2. List all the possible solutions
3. Evaluate advantages and disadvantages of each possibility
4. Choose the best strategy or combination of strategies
5. Plan how to implement chosen strategies
6. The chosen course of action is then implemented and the outcome reviewed.

1. Define the problem. It is important to clearly define the patient's specific problem(s). For problems that are not clearly defined (e.g., a patient reports 'financial difficulties') it is important to direct the patient to be more specific (e.g., 'how are your financial difficulties causing you problems?'). At other times, problems will occur episodically (e.g., 'difficulties with work colleagues'). In these instances, ask the patient to describe a recent situation when the problem occurred. Make sure you cover all of the patients concerns and write all of their specific problems down. Of these problems, decide with the patient which problem needs immediate attention or which problem is the easiest to solve. It is important that you only consider ONE problem at a time.
   
   
2. Generate and list all possible solutions. Then generate a list of possible solutions with the patient. This phase is often referred to as 'brainstorming', and you ask the patient to suggest as many solutions as possible, even they seem absurd or ridiculous. Encourage the patient to be creative and to remain non-judgmental at this stage. If the patient has difficulties generating possible solutions, make some suggestions to get the person started.
   
   
3. Evaluation. Briefly discuss the advantages and disadvantages of each possible solution.
   
   
4. Choose a solution. Then evaluate the potential solutions in terms of their consequences, how feasible they are for the person to implement and how well it meets the person's goals. Sometimes the patient should be encouraged to choose the solution that is most practical or that can be most easily applied, even if it is not ideal. It may also be useful to combine some of the solutions.
   
   
5. Planning. Once the action most likely to solve the problem, and which is practical for the person to carry out, is selected, it is useful to plan in detail how the solution will be carried out. This increases the likelihood that the plan will be carried out and that the problem will be resolved. (taken from MMD) The following checklist (adapted from a checklist developed by Ian Falloon) applies to any problem and will be helpful in pinpointing any pitfalls or obstacles in the solution plan. q Does the individual have the necessary resources (e.g., time, skills, equipment, money) or are you able to arrange the necessary resources, or personal or expert help?
   
   

   Does the individual have the agreement or co-operation of other people who might be involved in the plan? Does everyone in the problem solving exercise know exactly what they need to do and when they need to do it? Setting specified times or deadlines will minimise the risk of procrastination. Have all the steps been examined for possible difficulties? Has the individual planned any strategies for coping with likely difficulties? Has the individual planned any strategies for coping with any consequences that may arise? For example, if the individual applies for a job, what happens if he or she does not succeed? Or if they get a new job and have not considered what the demands of the job might entail? Have difficult parts of the plan been rehearsed? (e.g., a telephone call, conversation or interview) How will the steps of the plan be monitored? If the plan involves a number of people it will be useful to nominate a co-ordinator to monitor progress and to prompt and remind people when they need to do the things they agreed upon. Include this monitoring as part of the plan so that everyone agrees and is prepared to be reminded. Has a time and place been set for a review of the overall progress of the plan?

   
   
6. Review. The chosen course of action is then implemented and evaluated. Some modifications to the plan might need to be made and unexpected difficulties should be discussed. If it was not successful at all, another course of action might need to be selected, implemented, and the outcome again evaluated. The patient should be praised for any effort he or she has made, and where possible, successful outcomes should be rewarded.

Below is a structured problem-solving handout designed for use in the longer consultation as part of the Better Outcomes in Mental Health Care initiative.

Structured problem solving (Click here to go to a printable page)

Step 1: What is the problem?
Think about and discuss the problem or goal carefully then write down exactly what you believe to be the main problem or goal. The more time spent defining a problem that is specific, and potentially solvable, the better.

Step 2: List all possible solutions
Brainstorm and put down all ideas (generate 10 as a minimum), even bad ones. List all possible solutions without any evaluation of them at this stage.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Step 3: Discuss each possible solution
Quickly go down the list of possible solutions and assess the main advantages and disadvantages of each one.

Step 4: Choose the best or most practical solution
Choose the solution or combination of them that can be carried out most easily with your present resources (time, money, skills, etc.)

Step 5: Plan how to carry out the best solution
List, in small steps, how you intend to implement the solution. Identify the resources needed and the main problems that need to be overcome. Practise difficult steps. Take all the information needed with you (addresses, names, phone numbers).

Resources needed:

Problems to overcome:

Step 1.

Step 2.

Step 3.

Step 4.

Step 6: Record progress on the day by ticking above. Review how well the solution was carried out. Feel good about all efforts. Revise your plans if necessary. Continue the problem solving process until you have resolved your stress or achieved your goal.

References and recommended reading:

1. Andrews, G., Crino, R., Hunt, C., Lampe, L. & Page, A. (1994). The Treatment of Anxiety Disorders. Melbourne: Cambridge University Press.
2. Catalan, J., Gath, D. H., Anastasiades, P., et al., (1991). Evaluation of a brief psychological treatment for emotional disorders in primary care. Psychological Medicine, 21, 1013-1018.
3. Craighead, W. E., Miklowitz, D. J., Vajk, D. J., & Frank, E. (1998). Psychosocial Treatments for Bipolar Disorder. In P. E. Nathan & J. M. Gorman (Eds). A Guide to Treatments that Work. New York: Oxford University Press.
4. D'Zurilla T.J. & Goldfried M. R. (1971). Problem solving and behaviour modification. Journal of Abnormal Psychology, 8, 107-126.
5. Falloon, I. (Ed.). (1988). Handbook of behavioral family therapy. New York: Guildford Press.
6. Mynors-Wallis, L., Davies, I., Gray, A., et al. (1997). A randomised controlled trial and cost analysis of problem-solving treatment for emotional disorders given by community nurses in primary care. British Journal of Psychiatry, 170, 113-119.
7. Mynors-Wallis, L. M., Gath, D. H., Lloyd-Thomas, A. R., Tommlinson, D. (1995). Randomised controlled trial comparing problem-solving treatment with amitriptyline and placebo for major depression in primary care. The British Medical Journal, 310, 441-445.
   
8. Nezu, A. M. (1986). Efficacy of a social problem-solving therapy approach for unipolar depression. Journal of Consulting & Clinical Psychology, 54, 196-202.
   
9. Sahler, O. J.; Varni, J. W.; Fairclough, D. L.; Butler, R. W.; Noll, R. B.; Dolgin, M J; Phipps, Sean; Copeland, Donna R; Katz, Ernest R; Mulhern, Raymond K. (2002) Problem-solving skills training for mothers of children with newly diagnosed cancer: A randomized trial. Journal of Developmental & Behavioral Pediatrics, 23(2), 77-86.
   
10. Schulberg, H. C., Block, M.R., Madonia, M. J.. Scott, C.P., Rodriguez, E., Imber, S.D., Perel, J., Lave, J., Houck, P.R., Coulehan, J. L. (1996). Treating major depression in primary care practice. Eight-month clinical outcomes. Archives of General Psychiatry, 53, 913-919.

What is it?

As the name suggests, anger management techniques aim to help the patient to better 'manage' or regulate their anger, rather than eliminate their anger entirely. In general, the goals of treatment are to teach the patient both cognitive and behavioural skills to prevent an anger response occurring when it is not appropriate. Typically, cognitive behavioural techniques such as relaxation, cognitive restructuring, problem-solving, and stress inoculation, are used in the treatment of anger problems. One common approach to treating anger was developed by Novaco (1975). Novaco extended Meichenbaum's stress inoculation training (SIT), which was originally developed for treating anxiety, and adapted it for use with anger problems (Meichenbaum, 1975). Essentially, patients are taught coping skills and then given an opportunity to practice these skills in containable situations (e.g., using role-play). The relationship between thoughts, emotions and behaviour is also explained to the patient, with an emphasis on teaching him or her how to regulate their thoughts and emotions to prevent an inappropriate anger response.

Does it work?

In the last 20-years, the most common approach used in anger management has been cognitive-behavioral therapy (CBT). A recent meta-analysis (Beck & Fernandez, 1998) indicated that on average, people with anger problems who are treated using cognitive behavioral techniques, do better than control subjects. Importantly, this effect was significantly different from what would be expected to occur by chance. CBT is therefore considered the optimal treatment for anger problems and continues to be used widely.

How do you do it?

The approach outlined here is based on Navoco (1979) and can be supplemented with other techniques, such as problem-solving, as appropriate. Stress inoculation interventions are divided into three phases: cognitive preparation, skill acquisition, and application training and each of these will be discussed in turn (although a thorough reading of Navoco 1975 is recommended). As with all treatments, different parts of the programme will be more relevant for some patients than others, and you will need to adapt the programme to the needs of individual patients.

Cognitive preparation. This stage may take a few sessions.

1. Firstly, you need to educate the patient about anger and explain the difference between adaptive and maladaptive anger. Provide examples.
   
   
2. Then you will identify the individual's anger patterns. This is best done by asking the patient to monitor their anger during the week and ask them to record details about the situation, what happened, how they reacted, and any other information you may consider relevant. Have them tune into the physical sensations that occur when angry (muscle tension, feelings of heat etc).
   
   
3. Next, introduce anger-management techniques that can be used by the patient when faced with conflict and stress. These include relaxation, cognitive therapy and problem-solving.
   
   Skills acquisition. Again, you may need to spend a few sessions teaching and practicing the following techniques.
   
   
4. The next task is to teach the patient cognitive and behavioral skills, which will assist them to reduce their arousal levels. Standard cognitive therapy techniques, such as how to modify interpretations and expectations of anger inducing events, should be taught (refer to cognitive therapy section). It is common for patients with anger problems to have high expectations of themselves and others. It will therefore be important to challenge any irrational thoughts or beliefs and help the patient develop alternate ways of interpreting events.
   
   
5. Teaching the patient how to use self-instruction is also recommended. However, this is not simply a matter of teaching the patient to use statements such as 'don't get upset'. You need to teach the patient how to apply statements to specific situations. This is more effective than using one simple statement, as this one statement may be incongruent or inappropriate for the situation at hand, and thus serve to anger the individual further. To facilitate anger management, the patient must learn how to apply the self-instruction technique broadly. Novaco (1979) outlines a series of stages in the regulation of anger that make this process more manageable. These are:

(i) preparing for the provocation;
(ii) impact and confrontation;
( iii) coping with physical arousal;
(iv) coping with cognitive arousal
(iv) subsequent reflection;
(v) conflict unresolved;
(vi) conflict resolved.

In the first stage, explain to the patient that he or she will need to prepare for the situation at hand and modify any expectations they may have. Although not all situations can be anticipated, patients with chronic anger problems will tend to get aroused in fairly similar or predictable circumstances (you can usually get an indication of this from the patient's monitoring). In the second stage of anger regulation, the patient needs to learn how move into the 'problem-solving response mode' (p. 270) and generate statements that make them feel in control of the situation.

(Add an example that illustrates the cognitive work/coping strategies in an adult and with children)

In the next stages, the patient needs to monitor their arousal levels and implement coping strategies as necessary. Should the conflict remain unresolved, the patient should also be prepared to use self-instructions to stop themselves dwelling on the situation and use self-instruction to manage arousal levels in the face of unresolved anger.

The following table from Novaco (1979, p. 269) provides useful examples of self-instructions that the patient can use to regulate anger.

Self instructions for the regulation of anger

Preparing for a provocation
This could be a rough situation, but I know how to deal with it.
I can work out a plan to handle this.
Easy does it.
Remember, stick to the issues and don't take it personally.
There won't be any need for an argument. I know what to do.

Impact and confrontation
As long as I keep my cool, I'm in control of the situation.
You don't need to prove yourself. Don't make more out of this than you have to.
There is no point in getting mad. Think of what you have to do.
Look for positives and don't jump to conclusions

Coping with arousal
My muscles are getting tight. Relax and slow things down.
Time to take a deep breath. Let's take the issue point by point.
My anger is a signal of what I need to do. Time for problem solving.
He probably wants me to get angry, but I'm going to deal with it constructively.

Subsequent reflection

• Conflict unresolved
  • Forget about the aggravation. Thinking about it only makes you upset.
  • Try to shake it off. Don't let it interfere with your job.
  • Remember relaxation. It's a lot better than anger.
  • Don't take it personally. It's probably not so serious.
    
    
• Conflict resolved
  • I handled that one pretty well. That's doing a good job.
  • I could have gotten more upset than it was worth.
  • My pride can get me into trouble, but I'm doing better at this all the time.
  • I actually got through that without getting angry.

6. The next important step is to teach the patient anger-management skills. The goal is to teach the patient how to use skills that are incompatible with anger, such as relaxation. Progressive-muscle <relaxation> (PMR) is recommended. PMR teaches patients how to become aware of the areas where they are tense and provides a sense of control over their arousal levels.
   
   
7. Verbal communication and problem-solving skills also need to be taught to the patient, as it has been found people with anger problems tend to lack such skills. An outline of these techniques is provided elsewhere (link to communication and problem-solving) and can be incorporated into anger management training.

Application training.

This is the final stage and again, will need to be spread over a number of sessions.

8. Patient's now need to be given opportunities to apply their newly acquired repertoire of cognitive and behavioural anger-management skills. Initially, this can be done by asking the patient to imagine anger inducing scenes and have them apply their techniques imaginally. This should then progress to role-playing a variety of anger provoking situations with the patient. Then, once sufficient mastery has been achieved, the patient should move to in vivo practice. Imaginal, role-play and in vivo practice situations can be arranged in a hierarchy, from least to most anger provoking, to ensure that patient's practice these skills in a gradual manner to ensure that they do not become overwhelmed.

References and recommended reading:

1. Beck, R. & Fernandez, E. (1998). Cognitive-behavioral therapy in the treatment of anger: a meta-analysis. Cognitive Therapy and Research, 22(1), 63-4.
   
2. Novaco, R. W. (1979). The cognitive regulation of anger and stress. In P. C. Kendall & S. D. Hollon (Eds.). Cognitive-Behavioral Interventions. Theory, Research, and Procedures. New York: Academic Press.

What is it?

The aim of communication skills training is to teach individuals and families how to discuss their thoughts constructively and successfully. Sometimes it may be necessary to make a simple request, such as asking for a favour or for someone to change his or her behaviour in some way. At other times people may want to talk about very important and complicated issues without causing major arguments and hostility.

An important point to remember about interpersonal communication is that some people will react in an angry and hurt manner even when an individual has communicated politely. Inappropriate behaviour in response to polite and reasonable requests or statements is a sign that the other person may have difficulties with some aspects of their own interpersonal communication. It is important to be able to recognise inappropriate behaviour in others so that individuals do not continue to blame themselves for other people's shortcomings.

Does it work? Communication training, and variants of this training, have been used to treat a wide variety of problems and disorders. The application of communication skills has been broad and includes students with learning disabilities (e.g., Brunello-Prudencio, 2001), parent-adolescent conflict (e.g., Barkley et al., 2001), carers (Done & Thomas, 2001), alcohol and drug dependence (Monti & O'Leary, 1999) and medical students (Winefield & Chur-Hansen, 2000). Despite this variety of applications, the results tend to be favorable. However, the exact components of this training that lead to the desired changes in behaviour are unclear. Thus, training should be tailored to suit the individual based on the evidence for their particular communication skill deficit.

How do you do it?
The following guidelines, taken from the Management of Mental Disorders (2000), provide simple strategies that will help you teach your patient to improve their communication skills. The basic rule is to keep messages simple, clear, and positive.

1. Making clear, simple statements or questions. Clear and simple statements are always important. The rules for making clear, simple statements or questions are outlined below.
   • Use short statements or questions
   • Ask one question or make one request at a time
   • Be specific (e.g. Instead of saying, "I'd like you to try getting up earlier" say, "I'd like you to try and get up by 10 o'clock".)
   • Avoid strong emotional statements (e.g. "I can't stand this disgusting mess!")
     
     
2. Praising someone. Everyone needs to be appreciated and told that they are OK. Sometimes, however, people forget to express their positive feelings about other people. Explain that if you praise people for their good behaviours, nice appearance, etc., they are more likely to continue with those behaviours. Just as important, praise can help others to feel good about themselves. Rules for praising someone:
   • Look at the person
   • Say exactly what he or she did that pleased you
   • Tell the person how you feel
   • Give praise for even small accomplishments - do not wait for major change
   • Praise people immediately after they do something pleasing
   • Avoid 'back-hand' compliments (e.g. "That was a really nice thing to do, but...")
     
     
3. Asking someone to do something. Explain that if you want someone to behave in a particular way or do something for you, you are not likely to be successful if you sound like you are 'nagging', or demanding, or making the other person feel guilty in some way. Generally, if you want to ask someone to do something in particular, you should state clearly exactly what you would like that person to do. You should also tell the person how much you appreciate his or her effort. A request that is phrased in a nice way is more likely to be successful and is less likely to cause resentment. Rules for asking someone to do something:
   • Look at the person (make eye contact)
   • Say exactly what you would like that person to do (be specific)
   • Say how you feel

• You may like to use phrases such as:
  • "I would really appreciate it if you would...."
  • "It would make a big difference to me if you would help me with the ...."
  • "If you could ... I would really feel a lot more relaxed."

Remember that your tone of voice and your body language also give very strong messages. There is no point in asking someone to do something if you are standing with your hands on your hips and speaking in an angry or sarcastic manner.

Remember also that sometimes even clear and pleasant requests will be ignored. Perhaps the request was unreasonable. Or maybe the other person was feeling too troubled or too inconsiderate to help.

4. Expressing negative feelings. Negative feelings include such things as anger, frustration, disappointment, sadness, envy, and fear. If negative feelings are not expressed, other people will never know that they are doing something annoying. Also, if you do not express negative feelings as they arise, resentment is likely to build up. Resentment leads to stress and to angry outbursts at a later date. Negative feelings may be difficult to express because of fear of the other person's reaction. Alternatively, you may be able to express negative feelings very easily but your manner may be upsetting to the other person. The following rules will be helpful for expressing negative feelings in a useful way.Rules for expressing negative feelings:
   • Look at the person and speak firmly
   • Say exactly what the person did that upset you (be specific)
   • Tell the person how you feel
   • Suggest how the person may prevent this from happening in the future
   You may like to use phrases such as:
   • "I feel quite upset about... I would really appreciate it if you would ...."

Remember once again that tone of voice and body posture give strong messages. Make sure you are giving the right message!

5. Listening to others. It can be very annoying to talk to someone who does not seem to be paying attention to you. Furthermore, if you are the one not listening properly you may miss the point the other person is trying to make. Hints for becoming a good listener are outlined below.
   • Look at the person (make eye contact)
   • Look interested
   • Show that you are paying attention by nodding, etc.
   • Minimise distractions (e.g. turn off the TV, go to a quiet room, etc.)
   • Ask questions if you do not understand
   • Check that you have understood what the person said by repeating the main point of the conversation
   • Show that you care about the other person's feeling
     
     
6. In summary, the basic set of skills for clear communication are:
   • Be specific
   • Express your thought or request simply and positively
   • If necessary, suggest alternative behaviour for the future
   • Show appreciation for positive behaviours or for changes that are to be made
   • Show the person that you are listening
   • Use an appropriate tone of voice and body posture

References and recommended reading:

1. Barkley, R. A., Edwards, G., Laneri, M., Flatcher, K., & Metevia, L. (2001). The efficacy of problem-solving communication training alone, behavior management training alone, and their combination for parent-adolescent conflict in teenagers with ADHD and ODD. Journal of Consulting & Clinical Psychology, 69(6), 926-941.
   
2. Brunello-Prudencio, L. A. (2001). Knowledge and communication skills training for high school students with learning disabilities for the acquisition of self-advocacy skills. Dissertation Abstracts International, A (Humanities and Social Sciences), 62(4-A), US: University Microfilms International.
   
3. Done, D. J. & Thomas, J. A. (2001). Training in communication skills for informal carers of people suffering from dementia: A cluster randomized clinical trial comparing a therapist led workshop and booklet. International Journal of Geriatric Psychiatry, 16(8), 816-821.
   
4. Monti, P. M. & O'Leary, T. A. (1999). Coping and social skills training for alcohol and cocaine dependence. Psychiatric Clinics of North America, 22(2), 447-470.
   
5. Treatment Protocol Project (2000). Management of Mental Disorders (Third Edition). Sydney: World Health Organization Collaborating Centre for Mental Health and Substance Abuse.
   
6. Winefield, H. R. & Chur-Hansen, A. (2000). Evaluating the outcome of communication skill teaching for entry-level medical students: Does knowledge of empathy increase? Medical Education, 34(2), 90-94.
   
   
   
   
   

What is it? (reduce assertiveness expand basic social skills plus readings)

Social skills training involves the addition of further elements to communication training. These skills may include appropriate ways of approaching people, entering a group, conversation skills (how to start, maintain and close a conversation), co-operative behaviour (sharing and turn-taking), assertiveness and dealing with unpleasant reactions or rejecti ons. Rehearsal with the patient, planned practice in the patient's social settings, feedback and reinforcement is an essential part of any social skills program.

Does it work?

Social skills training has been found to be an effective component of treatment for disorders such as schizophrenia (Kopelowicz & Liberman, 1998), depression (Craighead et al., 1998), social phobia (Taylor, 1996), and child behaviour problems (Webster-Stratton & Hammnon, 1997).

How do you do it?

Assertiveness training may form one part of the social skills you teach the patient. It is envisaged that this training programme be carried out over two to three sessions. A follow-up group or support group may also be useful after the conclusion of the programme.

1. Explain that assertiveness involves being able to express needs and feelings directly. If an individual finds that his or her needs are not being met, or that other people are frequently resentful or insulted by the individual's behaviour, it may be helpful to discuss what assertiveness is. For example, you might say, 'assertiveness is the ability to communicate opinions, thoughts, needs, and feelings in a direct, honest, and appropriate manner. Assertiveness involves standing up for your rights in a manner that does not offend others or deny the rights of others. When you are assertive you have more control over your life. You also make it less likely that other people will take advantage of you. It is important to understand your own style of relating to others'. You can give the patient the following descriptions and examples about different ways of relating to others. Ask which description is most like them.

Different ways of relating to others

The passive style
People with a passive style tend to put the needs of others before their own. This may be because they do not believe they have the right to assert themselves. They may believe that they are inferior and that their needs are not important enough to make a fuss about.

Alternatively, passive people could feel that it is too difficult to be assertive or that it is much easier to let others make all the decisions. These people tend to believe that they are incompetent, weak, and too unintelligent to look after themselves or make their own decisions.

Although passive people may not always be happy with the decisions made by others, it usually seems easier to go along with the decisions and 'keep the peace' rather than make a fuss. However, given time, passive people may start to resent the fact that their needs are always overlooked. The result may be low self-esteem, depression, anger, and many other emotional or physical complaints. Also, people who are very passive often lose the respect of others if they fail to stand up for their rights.

The aggressive style
Aggression involves standing up for your rights in a way that is pushy and inappropriate. Aggression offends the rights or feelings of other people. Therefore, people who have an aggressive style believe firmly in their own rights but may not believe that others have equal rights. These people usually have a strong need to compete or prove themselves. They often feel they deserve more respect and attention than other people. Alternatively, although people with an aggressive style may agree that other people have rights, they may just be too inconsiderate to care about the rights of others.

People who have an aggressive style tend to have poor communication skills. They usually get their own way by treading on others and by being rude, pushy, and insulting. This behaviour may not be intentional but is still very hurtful and annoying. These people are offensive and unpleasant and lose the respect of others. They are also likely to have trouble developing or keeping close and affectionate relationships.

The assertive style
People who are assertive know they have rights but also remember that other people have rights as well. Assertive people care about other people's feelings and therefore phrase their requests or complaints in a polite manner. These people have a sense of 'give and take' and are co-operative at times of conflict.

Assertive people assess each situation and decide which action is most appropriate. They can bend and give in if necessary (for example, if the other person is being difficult because he or she is unwell) or they can stand up for their rights and be strong at other times. Assertive people choose the most appropriate behaviour for the situation. These people have control over their behaviour and have respect for themselves and others.

Examples of different styles
Each of the following examples shows three types of responses (passive, aggressive, and assertive) to various situations. You can see from these examples that in an assertive encounter no-one should feel put down. If people choose to react badly to your assertiveness then you can regard this as their problem and not some fault of your own. People who try to make you feel bad when you are assertive are usually trying to manipulate you without concern for your wishes. Such people would themselves benefit from an assertiveness training program.

Example 1: Mary goes to work each day and enjoys the time to herself when she gets home. Nearly every afternoon her neighbour, who stays home all day, pops in for a cup of tea. Mary does not want this to continue. How can she tell her neighbour?

Passive: I'll put the kettle on.
Aggressive: Look you've got to stop coming over every afternoon. I've got to have some time to myself.

Assertive: I often enjoy having tea in the afternoon but I need a bit of time to myself these days when I get home from work. How about making Wednesday afternoon the time when we get together?

In this case you may want to compromise (e.g., suggesting tea on Wednesdays) because you think your neighbour is lonely. You do not have to make this compromise - it is your choice.

Example 2: Waiting at the counter at Telecom, Janice is about to be served when someone starts to speak and says "It's only a quick question." There are many people waiting, for various reasons. What would you do?

Passive: OK go ahead.

Aggressive: Don't you think I've got better things to do than wait here and listen to your problem?

Assertive: I've been waiting a fair while and it's my turn now. I don't expect to be very long either.

2. Discuss which style sounds most like the patient. If you feel that they already have an assertive style then you may not need to continue with this program. However, even assertive people may learn something new.
   
   
3. The next important question to ask your patient is, 'how did you become non-assertive?'. Explain that one way to become aware of why we may be non-assertive is to examine the 'messages' (including the silent or non-verbal messages) given by our parents or other important people who told us how to behave when we were children. Since much non-assertive behaviour is an attempt to avoid conflict it is worthwhile to look back and see how our parents taught us to deal with conflict. Ask your patient to consider the following issues:
   1. How did your family handle conflict? What did they do when they disagreed with somebody or were upset with people?
   2. How did your parents teach you to deal with conflict? What were their messages? Were these messages trying to stop me from disagreeing by making me feel guilty or bad? (e.g., "Don't rock the boat", "Don't talk back", "Nice girls don't fight", "Be a good boy") or did the messages have a more threatening and argumentative tone? (e.g., "If you think that way I'll disown you", "You'll get a belting if you disagree with me again", "Shut your face, who asked you").
   3. In what ways did you learn to get what you wanted without asking for it directly? (e.g., crying, yelling, making threats, violence, etc.).
   4. Do you still use those ways today to get what you want? e. What problems are caused by your avoidance of conflict? (e.g., do you lose self-esteem?, do you start to doubt my own judgement?, or do you silently boil up inside so that even though things appear to be settled on the surface you are still suffering or angry?
      
      
4. The next step is to assist your patient with making the decision to change. Explain that to benefit from an assertiveness training program they have to be sure that there are some aspects about their normal way of responding that they wish to change - that is, they have to make a conscious decision to change. The following questions can help them make this decision. Add any other comments or dimensions which may apply to their particular situation.

What do you gain from staying non-assertive?

a. Protection from others
b. Praise for conforming to others' expectations
c. Maintenance of a familiar pattern of behaviour
d. Avoidance of responsibility for initiating or carrying out plans
e. Avoidance of possible conflict

What do you lose by being non-assertive?

a. Independence
b. The power to make decisions
c. Honesty in human relationships
d. Respect from others for my rights and wishes
e. The ability to influence the decisions, demands, and expectations of others

Do the gains of staying non-assertive outweigh the losses?

a. If so, why?
b. If not, are you willing to make the change by acting assertively?
c. Can you enlist the support, understanding, and co-operation of others involved in either the situation or in your life?

5. When the decision to change has been made it is important to begin setting goals for assertive behaviour. You can say something like, 'now that you have decided it is important for you to learn to be more assertive you will need to identify the areas in which you would like to be more assertive. Think about situations that you currently find difficult. In what kinds of situations would you like to be more assertive? Phrase these goals in a positive way. For example, instead of saying "I don't want to give in to my boyfriend and stay home every Friday night" you could rephrase this goal as, "I would like to go out with my boyfriend every (say) second Friday night but will go out without him if he refuses".
   
   It is always best to start with the easiest goals first. Therefore, write your goals on a piece of paper, order them from easiest to hardest, then write them into the spaces below.
   
   Goals:
   
   1.
   
   
   
   
   2.
   
   
   
   3.
   
   
   
   4.
   
   
   

6. The next step is to explain some of the common myths about assertiveness to your patient. You could start by saying, 'some people hold a number of beliefs that make it difficult for them to assert themselves. These beliefs are called myths because they are very rarely tested against reality. When these beliefs are tested they are usually found to be untrue. Let's go through a few examples of the most common myths that prevent people from asserting themselves. You may be able to think of some other myths that apply to you'. Read through the following:

Common myths about assertiveness


The Myth of Humility

You are following this myth if you say things to yourself like "It is good to be humble at all costs". If you believe this statement you will be unwilling to say ANYTHING good about yourself and you will feel uncomfortable when complimented by others. You will be too critical of yourself, will put yourself down in public, will have a poor image of yourself, and, not surprisingly, will often feel depressed.

The Myth of a Good Friend

You are following this myth if you say things like, "He should have known than I didn't want that" or "She should have understood why I said that". What you are really saying is "He (or she) should have been able to read my mind". The assumption (which is false) is that friends are able to know how you feel about everything at any given moment.

It is important to remember that what you believe to be important is not always important to other people. For example, you may believe that punctuality is important. If a friend is late for an appointment you may say "If he took me seriously he would have been on time". Your friend, however, may see no relationship between his punctuality and how seriously he takes you. Punctuality may simply be an unimportant factor in his life. In this case he would not understand why you would be offended. The most sensible way to resolve this type of problem is by open discussion. You will not always get your own way, of course, but at least you will let your friends know what is important to you and you will not have to rely on them 'reading your mind'.

The Myth of Anxiety

You are following this myth if you say things to yourself like "It is shameful and weak to be anxious at any time". This type of statement overlooks the fact that there are situations where everyone becomes anxious. If you believe this myth (that it is weak to be anxious at any time), you will avoid putting yourself in any situations where you are likely to become anxious and will therefore miss out on many things in life. The ironic thing is, of course, that when you end up leading a restricted life, smaller and smaller things make you anxious so you do not really avoid feelings of anxiety. In many situations where you may be asserting yourself, especially for the first time, it is normal to experience some anxiety.

The Myth of Obligation

You believe in this myth if you say to yourself "If my friend asks me for a favour, I have to agree if I am a true friend". Also, you are likely to place the same demands on your friends; that is, if you ask a friend for a favour, you expect that person to agree if he or she is a true friend. If you believe in this myth you will never feel comfortable about asking or giving favours because you will not see that there is a choice involved. That is, when someone asks you to do something you may feel resentful because you will not be able to say no. Also, you will not be able to ask anyone to do anything because you will believe that they cannot say no!

The Myth of Sex Roles

You will be following this myth if you say things like "I shouldn't do that because it's not feminine (or masculine)". You will confuse what you truly want to do, say, or feel with what is the current social view of what females or males should do. Remember, sex roles rarely represent the true nature of males or females but represent the view society currently has of these genders. This view varies from decade to decade and from country to country. You will have more peace of mind if you decide what is right for you, rather than what is expected of you. Do not fall into the trap of letting people use your gender to make you behave the way they want you to behave. For example, you may be told that you are a nagging wife when what you are really trying to do is give an opinion or stand up for yourself. Of course, you need to be honest with yourself here. When someone verbally attacks you, take note of whether they are simply using sexist jargon to put you down. Just because someone expects a female or male to behave in a certain way does not mean that you have to go along with their expectations.

7. You can then explain the 'bill of assertive rights' to your patient. This is a list of personal rights that is relevant to your patient and to everyone else. You can ask him or her to practise repeating their personal rights, especially those rights that seem hardest to accept.
   • I have the right to be the judge of what I do and what I think.
   • I have the right to offer no reasons and excuses for my behaviour.
   • I have the right to refuse to be responsible for finding solutions to other people's problems.
   • I have the right to change my mind.
   • I have the right to make mistakes.
   • I have the right to say "I don't know".
   • I have the right to make my own decisions.
   • I have the right to say "I don't understand".
   • I have the right to say "I don't care".
   • I have the right to say "no" - without feeling guilty
     
     
8. The next step is to help your patient identify their personal rights in difficult situations. Choose a difficult situation they have experienced and, 'using the Bill of Assertive Rights listed above, try to identify which rights are applicable to your goals or to other difficult situations. Ask yourself the following questions:
   
   • What are my rights in this situation?
   • Are my rights being violated? If so, how?
     
     
9. Then you need to help facilitate the process of putting these techniques into action. You can introduce this step by saying something like, 'for each of your goals, think about how you can assert yourself most effectively. Practise useful responses or assertive statements until they feel more natural. It may be useful to read the examples below and think about the different ways of responding in each situation'.

Practise examples
Example 1: You are just about to answer a question that your brother has asked you but your father answers for you. He has always done this since you were young. You want to answer for yourself. Your response to your father is:

Passive:

Aggressive

Assertive

Example 2: You are just leaving a party when a friend asks if she can have a lift home because she cannot afford to catch a taxi and does not want to catch public transport late at night. Your friend makes a habit of asking people for lifts. She does not live near you and you are tired and want to go to bed. Your response to your friend is:

Passive:

Aggressive

Assertive

10. You can also help your patient develop 'protective skills'. Explain that, 'in some situations it is impossible to assert yourself in a healthy way. Perhaps someone is persistently criticising you unfairly. Or maybe they are behaving irrationally and will not respond to reasonable behaviour on your part. In these situations you may need to use protective skills. These skills are less than ideal in that they rarely resolve a situation in a manner which is satisfactory to both parties. However, these skills help you to deal with impossible situations. Protective skills should only be used where more constructive solutions are not going to work.'

Protection 1: Broken record
This technique involves repeating your answer over and over again until the other person gets the message. For example, this technique may involve saying no without explanation over and over again to a pushy salesman, or may involve refusing an inappropriate request from a friend over and over again. The most common mistake that people make at this stage is that they give explanations or answer questions that the other person raises. If it is clear that the other person is not prepared to let you assert yourself by saying no (or whatever) gracefully, then it is time to give up on explanations, stop answering questions, and simply repeat your answer over and over again.

Protection 2: Selective ignoring
This technique involves refusing to respond to inappropriate conversation or requests until the other person gives up. For example, someone may continue to harp about some past event despite a clear message from you that you no longer wish to discuss this event with them. When you fail to respond to their criticism, while continuing to respond to other aspects of their conversation, they will eventually get tired of trying to criticise. Of course, it is often hard to ignore criticism, especially if the criticism is unfair or if 'punishment' of some kind has already been received. Sometimes it helps to say once and for all: "I can hear what you are saying but I am not going to respond to it from now on. We have discussed this before, you know my views. If you bring this topic up again I will ignore it. This doesn't mean that I'm not prepared to talk to you about other issues". Then make sure you do ignore this topic.

Protection 3: Disarming anger
This technique involves a trade-off. When someone is being inappropriately aggressive towards you it is sometimes possible to disarm his or her anger by refusing to carry on the conversation until the anger dies down. For example, you can say, "I will talk about whatever you want, but I can't talk while you're angry. Calm down first and then we'll talk". Be prepared to listen if they do calm down.

Protection 4: Separating important issues
Often people will mix up issues in order to persuade you to act the way they want you to act. Do not let them confuse you. You can concentrate on the issue that is important to you and refuse to be put off. For example, someone close to you might say "Since you won't lend me the money it is clear that you don't really care for me". It is important to sort out the issues here: e.g., "It is not that I don't care for you, it is just that I don't wish to lend money". You may need to combine the broken record technique with this technique to get maximum effectiveness.

Protection 5: Dealing with guilt
Some persons find it easy to get others to do what they want by making them feel guilty. For example, some children can give off messages to their parents such as "You would be a perfect parent if only you wouldn't stop me playing in the park". Because of our irrational desire to appear perfect we feel guilty if we are less than perfect. If you find yourself feeling guilty the first thing to do is ask yourself who is making you feel guilty. What are they expecting you to be perfect at? The words "I am sorry" are frequently over-used. Often these words are not genuinely meant. The person who is always saying he is sorry feels guilty when there is no need. He (or she) fails to recognise his right to his own opinions and his own life. It is useful to avoid using the words "I am sorry" unless you genuinely feel there are good reasons to apologise.

Protection 6: Apologies
There are circumstances in which apologies are appropriate. For instance it may be that in a social interaction you have been thoughtless of the other person. The other person complains about your behaviour but extends his or her complaint to a criticism of everything about you. Although you can recognise the other person's right to be hurt by your thoughtlessness, you should make it quite clear that in apologising for the thoughtlessness you do not accept everything else that is said about you.

Protection 7: Agreement
When faced with unfair criticism there are times when you simply want to turn the criticism off with minimum effort. You can do this by seeming to agree with your critic while not really doing so. You can use phrases such as "You may be right", "That's probably so", "Really?".

The final step is to encourage your patient to practise what he or she has learned. Explain that:

'you cannot expect to become assertive overnight. It will take time and practise to learn these new skills and to apply them consistently. It will also take time for your family and friends to adjust to your new behaviour. If you are usually aggressive people will probably be pleased with your new behaviour. On the other hand, if you are normally quite passive some people may feel threatened when you start to assert yourself. Remember though that this fear is their problem, not yours. You are simply reclaiming your assertive rights. Give yourself time and make any changes gradually. As your assertive behaviour starts to feel more natural you should begin to feel more confident and happy with yourself.'

References and recommended reading:

1. Alberti, R. & Emmons, M (1998). Your Perfect Right. A Guide to Assertive Living. California: Impact Publishers.
   
2. Butler, P. (1981). Self-assertion for women. Harper and Row.
   
3. Craighead, W. E., Miklowitz, D. J., Vajk, D. J., & Frank, E. (1998). Psychosocial Treatments for Bipolar Disorder. In P. E. Nathan & J. M. Gorman (Eds). A Guide to Treatments that Work. New York: Oxford University Press.
   
4. Fensterheim, H. and Baer, J. (1975). Don't say yes when you want to say no : how assertiveness training can change your life. New York : McKay.
   
5. Kopelowicz, A. & Liberman, R. P. (1998). Psychosocial Treatments for Schizophrenia. . In P. E. Nathan & J. M. Gorman (Eds). A Guide to Treatments that Work. New York: Oxford University Press.
   
6. Smith, M. J. (1981). When I Say No I Feel Guilty. New York : Bantam.
   
7. Taylor, S. (1996). Meta-analysis of cognitive behavioural treatments for social phobia. Journal of Behavior Therapy and Experimental Psychiatry, 27, 1-9.
   
8. Treatment Protocol Project (2000). Management of Mental Disorders (Third Edition). Sydney: World Health Organization Collaborating Centre for Mental Health and Substance Abuse.
   
9. Trower, P., Bryant, B., & Argyle, M. (1978). Social Skills & Mental Health. London: Methuen & Co Ltd.
   
10. Webster-Stratton, C., Reid J., & Hammond, M. (2001). Social skills and problem-solving training for children with early-onset conduct problems: who benefits?. Journal of Child Psychology & Psychiatry & Allied Disciplines, 42(7), 943-52.
    
    

What is it?

Parent Management Training is based on social learning theory (behaviour is learnt and modelled from others) including principles of operant conditioning (behaviour is shaped as a result of the responses of others). Parent Management Training involves understanding children's needs and developing realistic expectations of their behaviour and aims to provide parents with techniques to manage their child's behavioural problems. Behaviour modification aims to change problematic behaviour through the use of positive and negative reinforcement and/or extinction and inhibitory strategies. These techniques may be used to alter parent-child interactions, to promote pro-social behaviour in children, and to decrease difficult or oppositional behaviour.

What is it used for?

Parent Management Training can be an effective intervention for cases when a change in children's behaviour is required. This includes treating children with Anxiety, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, Conduct Disorder, Sleep Disorders, the development of social skills, as well as other behavioural problems.

(Special section for ADHD, Conduct type disorders, enuresis, encopresis to be added)

How do you do it?

Parent Management Training involves:

• Psycho-education
• Improving communication skills
• Setting appropriate expectations and rules
• Developing appropriate and consistent patterns when applying consequences for violating rules
• Acknowledging and rewarding positive behaviour
• Promoting positive interactions between parents and children
• Practice, evaluating outcomes, modifying strategies when required
• Parents working together

Psycho-education
Parents may be unaware of what constitutes 'normal' behaviour at particular stages of development and may have trouble adapting to changes in their child's behaviour. Psycho-education involves providing information about child and adolescent development and what to expect at different ages and stages. Parents are also given information regarding appropriate expectations, rules, and effective ways to enforce rules and to administer consequences when these rules are broken.

Initially parents are asked to identify and monitor inappropriate behaviour (e.g., non-compliance, fighting and arguing) in order to gain a better understanding of the triggers that lead to the problem behaviour. An easy to follow model for doing this is known as the A-B-C model, which is described below:

A = Antecedent.
Identifying the triggers that lead to the problematic behaviour, including information about when, where, who with, and what was happening.

B = Behaviour
The problem behaviour itself including, type of behaviour, duration, and intensity of the behaviour are monitored.

C = Consequences
What is the outcome of the problem behaviour? This section must include looking at how parents respond and how this then impacts on the child's behaviour.

Apart from gaining knowledge about the current situation, monitoring of child and parent behaviour and interactions provides feedback on the effectiveness of intervention strategies applied, and hence should continue throughout treatment.

Improving communication skills

Improving communication skills between parents and children will often be called for. Parents may need to learn to develop better listening skills as well as clear communication ability aimed at the child's level of understanding. Parents-child discussions should involve appropriate negotiation. If children believe that they are being listened to and feel that some of their suggestions are taken on board, they will be more likely to forego some of the demands parents view as unacceptable.

Setting appropriate expectations and rules

Parents are asked to develop lists of appropriate behaviour and rules that they expect children to abide by. These should be negotiated between the parents given the information provided by the general practitioner. However, the general practitioner may feel the need to challenge parents in order to raise discussion over inappropriate parental beliefs. Once expectations and rules are developed, parents can use these as a guide to assess children's behaviour. These rules should be discussed with children so that they are aware of the expectations placed on them.

Developing appropriate and consistent forms of administering consequences
An important parent management technique is the enforcement of appropriate and consistent discipline. This involves setting logical consequences, which are applied consistently if rules are broken. Parent management training relies on principles of operant conditioning, which have been shown to be successful in altering parent and child behaviour. Operant conditioning involves providing reinforcement (reward/punishment), which is contingent on the child's behaviour. Intervening with a suitable punishment (e.g., time out, loss of privileges) when negative behaviour is displayed is important if a reduction of unacceptable behaviour is to occur. The punishment must fit the situation and the severity of the misconduct. It may be useful to negotiate appropriate punishments and rewards with the child when rules are discussed.

There may be times when it is more appropriate for parents to learn to ignore some of the more minor inappropriate behaviours. Ignoring in itself may lead to the extinction of these behaviours and reduces conflict between parent and child.

Acknowledging and rewarding positive behaviour

As well as identifying inappropriate behaviour, parents should recognise positive behaviour and highlight this by responding with positive reinforcement (praise, rewards). This reinforcement provides a balanced approach to the demands parents make in terms of expectations and rules and promotes valued behaviour in children. An increase in positive reinforcement will result in an increase in positive child/parent interactions. A reward should be something that the child likes and values. Rather than parents' nominating rewards, it is preferable that the child proposes appropriate rewards as part of setting up expectations and rules.

Promoting positive interactions between parents and children

Parents should be encouraged to take an interest in their children's activities and when appropriate to include children in parent activities. Children generally thrive on positive attention and an increase in this will promote better family relationships. Taking part in activities selected and led by children will result in good quality interactions that often impact on other aspects of family life. These interactions need not take up long periods of time; rather, an effort should be made to aim for a realistic amount of daily quality time with children.

Practice, evaluating outcomes, and modifying strategies when required

In sessions, techniques are taught using extensive demonstration and modelling for parents when necessary. Skills are practised in the session in a role-play situation and direct practice with the child may occur both in the training setting and applied at home. New ways of communicating or disciplining children should be practised with the general practitioner prior to administering them in a difficult situation in the home. This practice serves to both, permit parents the opportunity to investigate appropriate wording and responses, or identify any difficulties they may be experiencing. This trial run allows these problems to be addressed so that parents may be confident when using approaches with children.

The aim of treatment should be identified as the shaping (the gradual changing) of parent and child behaviour rather than an expectation of immediate significant change. Small changes should be seen to be important and a step towards reaching greater goals.

Strategies continue to be monitored in order to evaluate their effectiveness and problems that may arise for the parents both in the administration of these, or in their outcome, are raised with the general practitioner and are addressed in sessions. The general practitioner provides the parent/s with consultation and assists in the development of alternative approaches when strategies don't work. For example, if a punishment or reward is not proving effective, an alternative one must be sought that will represent a loss/gain in something that the child values.

Parents working together

Parents must be seen to be working unitedly and to share values and beliefs about childrearing. Hence, they must be clear on rules and expectations and abide by these in providing consistent consequences to the child and reliable support to each other.

Recommended Reading:

1. Briesmeister, J. M. & Schaefer, C. E. (1997). Handbook of Parent Training: Parents as co-therapists for Children's Behavior Problems - Second edition. London: John Wiley & Sons Ltd.

Stress management involves addressing an individual's feeling of inability to manage the everyday demands of life. While everyone experiences some level of life stress, it is when this stress is perceived as too difficult for the individual to cope with that interventions are needed. It is generally accepted that stress management must address both the cause and the symptoms of stress. Initially, it involves identifying the stressful situation or event, and establishing whether it can be altered or has to be lived with. Psychological interventions are aimed at developing strategies to increase coping skills for dealing with the physical and emotional symptoms of stress. These can include psychosomatic symptoms of anxiety and depression such as difficulty breathing, heart palpitations and sweating, as well as feelings of worthlessness, and negative thinking.

What is it used for?

Stress management training is useful for any situation in which the individual feels that he or she is not coping with the demands of everyday life. It may be used following the difficulties that accompany a change in a life situation (e.g., loss of employment, relationship breakdown) or to better manage the increasing demands of lifestyle.

How do you do it?

Stress Management involves:

• Time Management
• Problem-solving
• Relaxation
• Behaviour Modification
• Cognitive Therapy

1. Time Management Appropriate time management involves being able to prioritise, schedule, and execute tasks in a feasible manner. It may be required to address aspects of personal or professional life. The three processes identified, prioritising, scheduling and executing, make up the steps to accomplishing good time management habits.

Prioritisation: Prioritisation means ranking tasks and responsibilities in order of importance. Before doing this a list must be made of tasks to be done and assigning these tasks an importance rating. One way to do this is to use an ABC rank order method. In this technique you assign an A for the highest order priorities (must do immediately), a B for second order priority tasks (should get to pretty soon) and a C for low-priority activities (can wait). Complete the tasks in this order.

Scheduling: Scheduling is the allocation of time for prioritised activities, which may include using a clock for shorter time period tasks or a calendar for long-term responsibilities. Several methods exist to help schedule activities appropriately including boxing (breaking the day into 3 -4 hour chunks (morning, afternoon, evening) and scheduling activities that are achievable in these time frames, and clustering (tasks listed or mapped out by location allowing you to perform activities that are in close proximity to one another). The general practioner and patient may develop alternative strategies that are more suited to the individual's daily activities.

Execution: Execution is the implementation of the agreed schedule. The most effective way to ensure execution of tasks is to establish goals that are feasible. Several steps may help in making certain these goals are met. These include assigning a deadline to each goal, breaking goals down into small tasks that are achievable, rewarding accomplishments when goals are completed and not before.

2. Problem-Solving Instruction in problem solving is aimed at introducing new or more structured ways to resolve problems. Several steps that are important when tackling a problem are taught to patients. To begin with, a good description of the problem must be developed. Then possible options for dealing with it need to be generated. The idea is to think of as many options as possible and then to select realistic choices from this list. The selected options could then be ranked in terms of degree of feasibility, or it may be that one or two ideas to solve the problem may stand out above the others and may be combined. The final choice or choices should be discussed with regard to the best possible outcome. The final solution chosen should be refined and a check made to see what resources would be required so that the patient is adequately prepared. The idea is implemented and then evaluated. Not all ideas will work well the first time and persistence may be required. Alternatively, if not successful, the patient may want to draw on one of the substitute solutions.
   
   
3. Relaxation Another component of stress management is the use of techniques to relax the body and mind. Relaxation involves voluntarily releasing tension and reducing arousal which can be an effective way to reduce the physical symptoms of stress. Various relaxation techniques exist and individuals may find that they prefer one specific relaxation style. Relaxation techniques include progressive muscle relaxation, isometric relaxation, guided imagery and controlled breathing. For instruction on relaxation techniques see Relaxation
   
   
4. Behaviour Modification Behaviour modification may be used to alter problematic patterns of behaviour. Problem behaviour must initially be recognised (e.g., turning to alcohol as a way of coping with stress; violent outbursts; anxiety in work situations). Cognitive restructuring often accompanies behaviour modification. Hence, dysfunctional cognitions that go along with the problem behaviour need to be identified and challenged. Once the general practitioner and client have developed an understanding of the pattern of the problem behaviour, behaviour modification techniques are applied to alter this behaviour. For example, if a patient reports that they are avoiding a particular work demand (e.g., taking part in formal presentations), steps may be developed to enable the patient to practice this task - initially they might practice the task on their own, then in the therapy session, then presenting to a friend, and continuing this process until they are able to attempt the presentation in a work setting. In this instance behaviour modification would only be part of the intervention as relaxation strategies and cognitive therapy would be also be required to tackle the anxiety associated with this task. For more detailed instruction on behaviour modification techniques see Behaviour Modification

Cognitive therapy involves identifying and modifying the dysfunctional thoughts that lead to unwanted emotions and behaviour. These problematic thought patterns include expectations, perceptions, attributions, and appraisals. Unhelpful thought patterns need to be challenged and replaced with more functional thoughts which allow better coping with life situations. In brief, this involves identifying and acknowledging dysfunctional thoughts, generating alternative thought patterns, adopting and implementing these new views, and evaluating the effectiveness of new thought patterns, then redefining if necessary. When experiencing stress an individual may be using negative thinking such as, "Things are getting worse. I can't manage. I'm hopeless at presenting ". Once this thought is acknowledged as unhelpful, alternative, more realistic thought patterns need to be developed (e.g. "If I just read the talk for a while, my nerves will settle and I'll be okay"). This new thought is adopted alongside the behavioural changes that the patient is making to alter the situation. Ideally, a selection of more helpful thoughts that can be applied to various situations should be developed. For more detailed instructions on implementing cognitive therapy please see Cognitive Therapy

References and recommended reading:

1. 1. Meichenbaum, D. (1985). New York: Pergamon.
2. 2. Lazarus, R. S. & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer.

What is it?

Interpersonal psychotherapy (IPT) is described as a useful approach for patients in the 'midst of recent conflicts with significant others and for those having difficulty adjusting to an altered career or social role or other life transition' (Karasu, et al., 1993, p.6). IPT was originally developed as a time-limited (12-16 sessions) approach, to be used weekly with patient's diagnosed with unipolar, nonpsychotic depression (Klerman, Weissman, Rounsaville, & Chevron, 1984). IPT is based on the theory that interpersonal relationships play a significant role in both causing and maintaining depression. IPT aims to identify and resolve current interpersonal difficulties that are thought to be related to the patient's depression. These difficulties may include: conflict with others, role disputes or role transitions, social isolation, and prolonged grief following loss. IPT builds skills - mainly in the communication and interpersonal domains. This therapy should not be used with inpatients or patients who are psychotic, suicidal or have substance use problems (Gillies, 2001).

Does it work?

There are two randomised controlled trials (RCTs) of IPT for the acute treatment of major depressive disorder (Weissman et al., 1979; Elkin et al., 1989). The outcomes of these studies were favorable and indicate that this approach is effective, particularly for moderate symptoms. IPT has also been trialled in the treatment of other disorders such as bulimia, drug abuse, bipolar disorder, dysthymia and patients with human immunodeficiency virus (HIV). Again, while the results from treatment trials are promising, IPT is still not fully tested and research continues into this treatment's effectiveness.

How do you do it?

Special training and continuing supervision is required.

References and recommended reading:

1. Elkin, I., Shea, M. T., Watkins, J. T., Imber, S. D., Sotsky, S. M., Collins, J. F, Glass, D. R., Pilkonis, P. A., Leber, W. R., Docherty, J. P., Fiester, S. J., & Parloff, M. B. (1989). National Institute of Mental Health Treatment of Depression Collaborative Research Program: General effectiveness of treatments. Archives of General Psychiatry, 46, 971-982.
   
2. Gillies, L. A. (2001). Interpersonal psychotherapy for depression and other disorders. In Barlow, D. H. (Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (3rd ed.). (pp. 309-331). New York: Guilford Press.
3. Karasu, T.B., Docherty, J. P., Gelenberg, A., Kupfer, D.J., Merriam, A.E., Shadoan, R. (1993). Practice guideline for major depressive disorder in adults. American Journal of Psychiatry, 150 (suppl.), 1-26.
   
4. Klerman, G.L. & Weissman, M.M. (1993). Applications of Interpersonal Psychotherapy. Washington, DC: American Psychiatric Press.
   
5. Klerman, G.L., Weissman, M.M., Rounsaville, B. J., & Chevron, E.S. (1984). Interpersonal Psychotherapy of Depression. New York, NY: Basic Books Inc Publishers.
   
6. Weissman, M. M. & Markowitz, J. C. (1994), Interpersonal psychotherapy: Current status. Archives of General Psychiatry, 51(8), 599-606.
   
7. Weissman, M. M., Prusoff, B. A., DiMascio, A., Neu, C., Goklaney, M., & Klerman, G. L. (1979). The efficacy of drugs and psychotherapy in the treatment of acute depressive episodes. American Journal of Psychiatry, 136(4B), 555-558.