To most of us, calling a near relative on the phone is no big deal. For Maria it is a serious challenge.
“I am going to call my grandma. That’s my Personal Plan of Action for the next week,” Maria says.
She, Anette, Linda and Karina are the four the course participants that meets this autumn morning in a municipal building in Solroed 25 kilometers outside of Copenhagen, Denmark. Learning to set realistic goals for yourself and to make the effort to achieve it – is a central element of the course.
“I used to be very close to my grandma, but something has gone wrong. Why doesn’t she call me? Did I do something wrong that offended her? I make all kinds of speculations now. But I want to visit her, and so I need to call her. It’s difficult,” Maria says.
At the beginning of this day’s session, everybody explains how they managed their Personal Plan of Action from last week. Closing the session, two and half hour later, they present their next plan, and they make it very concrete, answering questions like “is it something you feel like doing”, “how often”, “when”, and they estimate how realistic it is to actually get it done on a scale from 1 to 10.
“I will do it the day, I really feel up to it, and I am pretty sure, I will do it, So, I give an 8,” Maria says.
Nicolaj Faber works for the Danish Committee for Health Education, and he is the national organizer of the “Learn to tackle” courses that deal with both psychiatric diagnosis and physical diseases.
I spoke to him before going to the session in Solroed. About the Personal Plan of Actions, he explained:
“For these people, suffering from depression or anxiety, it may be a problem to get out of bed in the morning or face other people when entering a shop. They have lost their ability to make decisions, define goals for themselves and to act. That is what we want them to relearn. We call it self-efficacy.”
Another important concept of the course is the Circle of Symptoms
The Circle defines all kinds of symptoms that psychiatric patients may experience: tension and tightening of muscles, psychical and physical pain, stress, difficult feelings, grief and loss, shortness of breath and fatigue. Topping the circle is “general condition” indicating that all these symptoms can aggravate each other, and all of them influences the general condition.
Not only the participants present their Plan of Action, also Lise Olesen and Susanne Hviid, the two instructors. As most other “Learn to tackle” instructors they suffer or have suffered themselves from some of the problems that the course deals with.
Five years ago, Lise met with a social worker because she suffered from stress, depression, anxiety and even chronic pain from a slipped disc. The social worker recommended a “Learn to tackle” course.
The course worked very well for Lise, and her instructor recruited her for the obligatory four-day instructor course. After being an instructor on a volunteer basis for several years, she now also works in a part time job at the municipality to take care of administrative tasks in relation to the courses.
Susanne Hviid is a retired teacher. She attended a “Learn to tackle chronic pain” course, when the instructor recruited her to be a voluntary instructor herself. Her background for co-instructing this course is a son with a psychiatric disease.
“I am about to move to another part of the country. I have already told my new municipality that I will like to go on instructing courses there,” Susanne tells.
“Having suffered from the same problems, the instructors relate much better to the participants, and they serve as role models in a way that no professional could ever do,” Nicolaj Faber explains.
Obviously, Lise Olesen and Susanne Hviid are very aware about this. All through the session they refer to their own experiences and feelings, for example with handling medicine or alcohol problems.
All must be written down
Next on the agenda is “fatigue and sleeping problems”. Susanne presents the topic, based on the 150 pages course book. She asks each participant to name potential reasons for sleeping problems. Meanwhile, Lise Olesen writes the input on the whiteboard. Not everybody has this problem, but they all have input for the board: unhealthy diet, too many tasks, drug abuse, loneliness are some of them.
After a little debate on this, Susanne quickly moves on to tips and ideas on how to cope with sleeplessness. No lack of ideas here, either. Make your bed and bedroom comfortable, avoid electronic media immediately before going to sleep, take a warm bath before going to bed. And much more.
Using the same method, Susanne and Lise deals with drug abuse and handling medicine. Another point on the agenda is how to detect the signs that an attack of anxiety or deeper depression is on its way and how to react to it.
Susanne ask if relatives can be of any help in detecting danger signals. “Yes, my husband notes that I put my hand to the face, and then he asks me if I am all right. That is clear sign,” Linda tells.
The main point today is how to react to these signs in order to cope with an attack of anxiety and avoid going into a deeper depression.
Anette intervenes: “We must learn to stop ourselves. That is why we need to have our Action Plan.” She refers to a special Action Plan on how to react, when you detect the signals.
Such action plans for different situations are central tools of this course. The instructor returns to these kind of plans whatever problem is up for debate. All the time, Lise and Susanne stresses that they must write it down. First, because they remember it much better later, if they write it down. Secondly, when on paper, it always there to grab in a crisis situation when thoughts and feelings are confused.
“You can write on a piece of paper. Even better is a poster. Place it on the inside of your wardrobe. If it is hidden in a book, you may not be able to find it when you need it,” Susanne explains.
Quickly on to next topic
Just before the coffee break comes “The Fantasy Journey”, a kind of meditation session. A taped voice with smooth background music asks everybody to take a couple of deep breaths and close their eyes. The voice then take the participants to a long road, passed a big box where they can leave all their worries, into a garden and further on into the woods and back again in 10-15 minutes
Afterwards, I ask Anette why she opened her eyes after a couple of minutes and started drawing instead.
“I don’t like it. It is too fast. I don’t want to move into that feeling, just to be brought back after a few minutes. I accomplished the same by drawing.
According to Anette, it is a general problem of the course.
It is just like another session when they asked us to think about bad things for two minutes and then about good things for a minute. If I really do go into the bad things of my life, I need to use much more time to deal with it. I cannot just jump directly to the good things in seconds. Much of this course moves too fast from one topic to another,” she says.
Later, I talk with Lise Olesen and Susanne Hviid about the way they handle the course. The speed with which they move from one subject to another and the way they interrupt participants who talk for too long, and why they don’t allocate more time for the Fantasy Journey.
Lise Hviid explains: “It is important to understand that this is not group therapy. We want to teach them tools to handle their situation. For example, we introduce the Fantasy Journey today, so that they know about this, and they can use such methods at home for as a long a period as they like. We do not want to lead them through a therapeutic experience.”
For the instructors, it is a major challenge to make the group work, when some participants talk a lot, and others cannot get their voice heard.
At the first sessions, the main problem usually is to make participants comfortable enough to talk at all. This, certainly, is no longer the case for this group, attending their sixth and next-to-last session. Everybody is very open and talking.
Sometimes, we as instructors, must make an effort to move on, when it ends up in too much small-talk. Of course, they need to talk to other people who can relate to their situation. They need to go into detail about their personal situation and they need network. That is why we ask to them to “mate” with another participant and call each other once between each session, and we encourage them to meet as a group when the course is over,” Lise Olesen explains.
Anxious to be first-in-line
During the session, I notice a lot of inside joking about Karina wanting to be first-in-line at the rounds of reporting about and presenting Personal Plans of Action.
“At the first sessions, I was so scared about talking about myself to the group. I insisted on being first-in-line, because I wanted to get it over. The more I listened to the others and thought about my turn, the more scared I became. Now, I promised to be second in line at the next session,” Karina explains to me after the session is finished.
She has a long history of complex anxieties. She has passed through other self-help groups, but this time she wanted something local in Solroed, because she needs a local network.
“I suffer also from social phobia, and it is extremely difficult to learn new people and say Hello, I am Karina, and I suffer from a psychiatric disease. It is much easier when you start out with other people who understands your situation,” Karina says.
Judging from today’s session, Karina seems now quite comfortable with this group of people. Anyway, she is very happy about it.
“I have learned some of these tools before, but it is very good to refresh it. What I really like about this course is that is so concrete, so hands-on. Like “write a list”, “make an action plan” and so on.
Also, it is so much different, because the instructors are like “patients” themselves. Some years ago, I attended sessions at a psychiatric hospital. A professional psychologist taught us tools like these, according to cognitive methods. But he didn’t have a real feeling for our situation and our problems. There was a distance between us.
Lise and Susanne are different. They know intuitively what I think and feel. We are on the same wavelengths. I don’t have to explain so much,” Karina says.
Karina hope that she can keep seeing the other participants afterwards.
“Of course, that is also my own responsibility,” Karina concludes.
Facts about “Learn to tackle” course
- consists of 7 modules, each 2 ½ hour long, once a week.
- courses are the Danish implementation of Chronic Disease Self-Management Programs, based on development work at Stanford University, California, USA and National Health Service, England.
- In Denmark, the Danish Committee for Health Education develops curriculum, produces materials, educates the instructors and supervises them. The local municipality recruits participants and organizes the courses.
- Since 2003 these courses has taken place in Denmark. Danish development work has been funded by private foundations and public funds. 65 out of 98 municipalities offers “Learn to tackle” courses
- An evaluation report showed that participants had less symptoms afterwards than a control group. Participants showed increased belief in own capacity.
- The Committee now offers special “Learn to tackle” courses for young people and an on-line version. The Committee is in the process of developing courses with migrants as target group.
Chronic Disease Self-Management Programs in Europe and the US
Chronic Disease Self-Management Program (CDSMP) is the name for the method behind the “Learn to tackle” courses. Here you will find links to institutions that use this method.
- INSEA (Initiative für Selbstmanagement und Aktives Leben).