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1. Simple measures like practising slow diaphramatic breathing during panic attacks, getting sufficient exercise and giving attention to good nutrition and adequate social contact. Mental (cognitive) rehearsal: (a) Ask the client to divide a desirable response into a number of steps or stages. (b) Have the client imagine actually performing each desirable step leading to the complete satisfactory response. (c) Set a homework assignment of actually experimenting and practicing in "real world" some or all of the steps drawing upon the imaginary practice for confidence. 2. Client's journal: A diary can be divided into time slots, smaller than a day if necessary. Or the diary can focus on just the significant events. Some headings: (a)The time, (b)what happened, (c)how I actually behaved including what I said, and (d)what I felt. (e)What should have I done/will do next time? Over time the diary or journal can be a valuable learning tool and source of confidence and inspiration for mental rehearsal. 3. Modelling: This is what I call "monkey see monkey do." In its purist form it involves learning by observing and receiving encouragement and useful feedback from someone who is expert in the desired behaviour. Practice and competence banishes anxiety. This is how all vital skills are learned, from surgery and aviation to panel beating. I once sent a timid youth out night-clubbing with another young man who was expert at approaching strangers of the opposite sex, and totally devoid of social fear. Training videos can provide a useful and convenient form of modelling. For example there was a time when South Australia's Mental Health service's Cerema Clinic made use of videos modelling sexual behaviour for sex therapy. Videos on various topics can be helpful to corporate persons with anxieties related to their performances (e.g. speaking up at meetings, or speaking to high status persons - "executive phobia".). Modelling can involve joining a special interest training group, e.g. Toastmasters or the Penguins as part of the homework. 4. Relaxation techniques. These can involve the techniques commonly used with hypnotherapy. The relaxation procedure itself follows closely the format of yoga relaxation. Once a pleasant state of relaxation or trance like state is achieved systematic desentisation can be attempted and so too methods such as encouraging clients to construct or their own mental place of refuge to which they can retreat any time they choose for mental refreshment - it can be simply a room or a castle or whatever pleases the client. A variation or addition to this technique can be the invention by the client of a fictitious guru or teacher. Some religious people are already using this technique in the form of a belief in guardian angels. But literal belief is not necessary. 4. Systematic desensitisation: E.g. for a spider phobia. The patient is guided through a relaxation routine similar or identical to yoga relation and perhaps then asked to visualise a tiny little spider down the end of a long hall, so far away it is hard to see it. When the patient can visualise this without rising tension (patient can indicate tension by raising index finger) the image is made slightly more threatening. With spider phobias I make use of a children's book with the artists' friendly stylised pretty spiders being held up at a distance, and moving up to a documentary book with clear photography, the book eventually being held on lap by the client and browsed. Finally the client keeps and feeds a spider in a jar at home at the bedside, brings it to sessions and in my presence opens the jar and releases the spider. I always try to introduce real-world practice. I have spent nearly 2 hours riding up and down an elevator in Adelaide's David Jones store in Rundle Mall with an elderly lady clinging to my shirt. We were getting strange looks from the store detectives! She was after about 2 hours, able to do it alone while I had coffee in a totally different store 100 metres away. 5. Self talk: Get the patients to identify what they are saying to themselves during episodes of say anxiety or depression and to document the precipitating stimuli. This where the journal or diary mentioned above can be useful. Then the patients are asked to write a better script, more uplifting or productive things to say to themselves during such times. This is where Albert Ellis' (mentioned above) ideas can be useful. He points out we make ourselves miserable by catastrophising, and by expecting too much of the world. It is not reasonable to expect to be liked by everyone. A failed dinner party is a trivial matter not genuinely "ghastly", "horrible", or "terrible"! We should do what we can to make a bad situation better, but worrying beyond that is wasted emotional energy. Again he argues that the patient's realities get ignored. But one does not have to totally discard all the concepts of analytical therapies. Throwing the baby out with the bathwater would be a big mistake. For example it would be a massive mistake to dismiss the importance of symbolism just because symbolism is a feature of Freudian and Jungian psychology. We are symbol using animals. These very words are symbols. The psychology of symbolism is not alien to stimulus-response psychology because it is precisely via the processes of reinforcement that things and events acquire their symbolic value. If you look at books on CBT you will see that it is recommended that patients keep a journal with many headings. A great many of patients suffer depression. Depression patients lack energy and are procrastinators so about 30-40% of them never get as far as even buying a little book to write in. Others don't bother because they are quick to see that the CBT procedures or "homework" being recommended are irrelevant to their situation. For example some of my depression and panic patients are women who are trapped in a marriage with a husband they despise but at the same time are dependent on. There often seems to be a passive-aggressive lose-lose aspect to their behaviour as refusing to drive a car, or spending husband's entire pay packet or credit card limit on the "pokies" in hotel gaming rooms, or getting arrested for shoplifting.
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