Controlling Anger – An NHS Self help guide
What is it like to be angry?
Jim is travelling to work by bus and is jolted, when the car in front stops suddenly at traffic lights. Some time goes by and the lights turn from red to green and back again, but the car in front doesn’t move. Jim starts to feel tension rising and a tight feeling in his stomach. He begins to curse the driver in his mind “Stupid, lazy, selfishly holding everyone up, he’ll make me late”. The feeling builds up, he begins to feel hot. Someone brushes against him by accident; he turns on them, swears and pushes them away roughly.
Michelle is feeling tired and she has a headache so she sends the children out of doors to play, telling them not to disturb her. After half an hour, she hears a loud noise and shouting so she goes out to see what is happening. The youngest child is sitting on the path and crying with a small cut on her chin and the older ones are just looking on and doing nothing. She feels relief that nothing more serious appears wrong, and then a sudden surge of fury takes hold. She thinks “why can’t they do as they are told?” and “why do they always let me down?” She gets angrier and feels a pounding in her head. Her legs start to tremble, and things seem to look misty or unreal, as though a curtain has come down. All she can think about is grabbing the nearest of the older children. She thinks “I’ll teach you not to do it again”.
After work, you go to pick up a newspaper from your local shop. You’re waiting to pay when a couple pushes in front of you as though you weren’t there. You try and keep your temper and not say anything, telling yourself it is not worth getting upset about. They take their time, and finally as they reach the door, one of them looks back and catches your eye for a few seconds. Then she turns around and says something to her friend and they both laugh as they leave the shop.
You feel angry and think “they’ve made a fool of me”. The rest of your day is spoilt, you can’t relax and you feel irritable.
You may have been in situations like these and had some of the feelings and thoughts which are described. Or you may have been in other situations which have left you feeling angry. Everyone feels angry at times, this is often due to life stresses such as money or housing problems or difficulties in relationships. A certain level of anger is normal. For some people the problem becomes much worse and gets in the way of normal life. Anger is a problem when it becomes too strong, happens too often and lasts too long. It can spoil relationships or work and if it leads to violence or aggression, can get you into trouble with the law. Anger can also be a signal that something is wrong in your life.
How can this guide help me?
You may feel that you can do little to control your anger – but there are things that you can do to make a difference. This guide aims to help you cope with anger. There are exercises in the guide to help you begin to understand and deal with your anger in practical ways. You may find it helpful to complete these exercises.
There are two sections to the guide:
Understanding anger and its causes
- Do I have problems with anger?
- What is anger?
- What causes anger?
- Angry thoughts
- Controlling the physical symptoms of anger
- Controlling angry behaviours
- Problem solving
- Long-term beliefs
There is a lot of information in this guide, and it may help to listen to a section at a time.
If you find that you are unable to use this guide, but you know anger is a real problem for you, it may be worth contacting your GP to ask for a referral for help and support from a health professional.
Understanding anger and its causes
Do I have problems with anger?
If you have a problem with anger you may already know it, although it is often those around you who are most aware. These are some of the most common signs of difficulty in controlling anger. Write down those you experience regularly:
How you feel
- Anger or agitation
- Irritable at the slightest thing
- Restless, on edge, uptight
- Flashes of rage
- ‘Red mist’ comes down
How you think
- Poor concentration
- Mind goes blank when angry
- Thinking the worst of people
- Everything seems like a big problem
- Life seems unfair
- Others seem unreasonable
- Spending time thinking over past events that have led to anger, shame or hurt.
- Hating yourself
- “You/they have ruined everything”
- “You/they have made a fool of me”
- “I’ll explode”
- “You/they deserve this”
- “You/they let me down”
- “I can’t trust anyone”
- “You are never there for me”
- “I’m an idiot”
- “I/you shouldn’t have done that”
What happens to your body
- Heart pounds, races, skips a beat
- Chest feels tight
- Stomach churns
- Legs go weak
- Tense muscles
- Go very hot
- Having to go to the toilet
- Head buzzing, pounding
What you do
- Snappy and irritable behaviour
- Shout and argue
- Hit out
- Leave the situation
- Throw/hit an object, slam door, etc.
- Attack someone
- Be violent and aggressive
- Say something unkind or sarcastic
- Push someone
- Do nothing, bottle it up
- Sulk or ignore someone
- Get drunk/smoke/take drugs
- Hurt yourself
All of the above can be warning signs that you are angry. Some are outward signs, such as violent and aggressive behaviours, others are more inward and passive, like sulking or being sarcastic.
If you are regularly experiencing some or all of these signs then you may have a difficulty with anger control. The following sections may help you to tackle this problem.
What is anger?
Anger is a natural human response and part of the fight or flight safety system which can help us to stay safe and defend ourselves in dangerous situations. It can become a problem when: it is happening frequently; feels out of control; is ‘over the top’ for the situation and leads to you or those around you being hurt either emotionally or physically.
Often when we are angry, the main thing that we are aware of is our angry mood. Our mood can vary in strength from a mild irritation to intense fury and rage. When it reaches its strongest, it is unlikely that we will be aware of much else. However, when we look for causes of our anger, we most often direct our attention outwards, to events or people in our immediate world or surroundings. For instance, the motorist holding up traffic in the first example at the beginning of this guide, the careless children in the second, or the rude behaviour of the people in the shop.
Anger can have physical effects such as increasing the heart rate, blood pressure and causing changes in the body’s chemistry.
The psychological explanation of anger recognises that our mood is a key part of the anger, but it is not the only part. In order to understand the causes of anger better, we need to look at the other parts in detail and see how they fit together and affect each other. It is helpful to separate our anger into mood, thoughts, bodily reactions and behaviour. The other part we need to consider is the outside world or our surroundings. We need to look at how changes in this affect us, and how we in turn may make changes in our behaviour that affect our environment.
You may feel yourself trapped in a vicious circle of anger.
It starts with the outside world and can include:
- Problems with others
- Debts and practical problems
- Frustrating events or situations
- Stress – no time for yourself
In your inner world you have thoughts, ‘hot thoughts’, for example “he is putting me down”. Your mood becomes irritable or angry. You feel bodily symptoms, your heart races, you become tense, hot or breathless. You become enraged, your angry behaviour comes to the surface, you attack, argue, run away or damage things
All of these parts of anger can affect each other and anger can spiral out of control. Angry behaviour can also cause an angry response from others. Bodily signs of anger can lead us to feel out of control and this can make our mood worse. Angry hot thoughts can make us feel more enraged. The angry thoughts can lead to ‘rumination’ where we mull over and brood on things that made us angry.
Does a similar vicious circle of anger happen to you? Try and draw it out
What causes anger?
Anger can vary from mild irritation to intense fury and rage. As with all emotion, bodily changes go with it – heart rate goes up, blood pressure goes up as our body is prepared for fight or flight.
It can be caused by reacting to things outside us such as other people or events (such as the traffic jam in the first example) or by worrying over our own personal problems. Upsetting memories from the past can lead to angry thoughts and feelings. It is important to note that it is not people or events that make you angry, it is your reaction to them that makes you angry.
Write down what things tend to trigger your anger?
First of all the outside things like other people or events
And then what goes on inside you (thoughts, worries and memories).
Some people tend to be more angry than others. Research has shown that they have a low tolerance for frustration. They can’t take things in their stride. It may be that some people are naturally more like this from birth, but it may also be that they have not learned to handle anger and to express their feelings in other ways.
Some people come from families that are poor at handling emotion and talking things through calmly, families where levels of anger are high. These people are more likely to have difficulties with anger. People are more likely to feel anger where they have experienced situations in the past that have hurt them or made them feel ashamed but were unable to express the anger at that time.
Sometimes anger can start to be a problem when it never has been in the past. This can be a sign of stress, or can be related to chronic illness or pain. Some people who are angry also have high levels of anxiety. Learning to manage your anger may help you to begin to manage anxiety and low mood if you also have those emotions.
Although feeling angry from time to time is normal and sometimes justified, getting very angry is rarely helpful and the belief that ‘getting it all out’ can make you feel better is not true. Research has found that if you vent your anger frequently you are likely to get more rather than less angry and also that this can badly affect your health. It is best to begin to understand your anger, find solutions if possible and gain control over it. This way you are likely to learn ways of handling situations that make you angry.
Anger is a natural human response which becomes a problem when it is too strong, happens too often and lasts too long. Anger affects the way we feel, think and behave. It causes a number of symptoms in our body. It can be caused by our reactions to things happening around us or by our own thoughts and worries. We may be more likely to be angry by nature or may never have learned to control our anger and express our feelings more helpfully.
We have seen that thoughts can make us feel angry, but often people who have a problem with anger do not notice these angry thoughts. It is important in trying to gain control over anger that you begin to recognise and challenge thoughts.
‘Hot thoughts’ are angry thoughts that flash into your mind and make you feel worse. People tend to have similar thoughts happening again and again, for example:
- “He is so stupid”
- “You’re making a fool of me”
- “You’re selfish”
- “I want to hurt you”
- “I hate this place”
Do you have similar angry thoughts? jot them down
These hot thoughts are often backed up by ways of negative thinking. It may help you to decide if you have any of the following unhelpful thinking styles.
Unhelpful thinking styles
Taking things personally
People who are angry often take things personally and feel hurt by it. They look for and expect criticism from other people. If, for example, someone doesn’t speak to them in a shop, they may feel that person dislikes them, when in fact it may be that he or she is just shy or worried. If someone looks over at them they may think “he thinks I’m stupid”, when in fact the person is just glancing over without any such thought.
Do you think you sometimes take things personally and feel hurt or angry, when it may have little to do with you? jot down some recent examples
Ignoring the positive
People who get angry tend to focus their thinking on negative or bad events and ignore positive or good events. In the examples at the beginning of the guide Michelle thought about one small accident that had happened but did not think about the half hour of quiet play before it.
This is often a problem for people who get angry with those close to them.
Do you sometimes ignore the positive? – jot down some recent examples
People who become angry often expect too much from themselves or those around them. If these standards are not met, then they feel badly let down and hurt. This hurt becomes anger. For example, Mary has a friend who had agreed to go on holiday with her but let her down at the last minute. Mary felt the friend had failed her and decided that she did not want to see her again. This was despite the fact that the friend was good to her on many other occasions.
Do you sometimes expect perfection from yourself or others? – jot down some examples
Black and white thinking
Thinking in black and white, all or nothing terms is common in people who get very angry.
This is particularly a problem when it comes to knowing how firm to be with people. For example, John has a friend Paul who had borrowed money from him. John was quite happy to offer this loan and thought, “Paul is a good mate; I know I can trust him”. Paul has not offered to repay it after two weeks and John, who didn’t like to mention it, has begun to think, “He is taking a lend, he thinks I’m a soft touch, an idiot”. He becomes angry and the next time he sees Paul he begins to shout and make threats about what he will do if the money is not repaid immediately. He thinks: “If I don’t show him, he’ll take me for a ride”. It might have been better for both, if John had taken a middle approach and firmly asked Paul to repay the money earlier, rather than saying nothing or becoming very angry in response to the thought, “He’s taking a lend”.
Do you sometimes think in black and white, all or nothing terms? – jot down any recent examples
If you find yourself with unhelpful thinking styles like those already mentioned it can help to try and think more balanced thoughts. One way of doing this is to write two columns, one for angry thoughts and the other for a more balanced thought.
Here are some examples:
“He is looking over here at me and thinks I’m stupid”
He is looking over here but I don’t know what he is really thinking.
“They always let me down”
“They sometimes behave badly but at times they are really OK”
She just doesn’t care about me, she is selfish”
“I know she let me down, but she does care, she usually tries to be kind”
Write down some of your thoughts now and write as many answers or balanced thoughts as you can. The aim is to get faster at catching these hot thoughts when they come into your head and answering back straight away. It takes a lot of practice but really does work. Notice any habit you may have of only focusing on things that previously made you angry. This rumination tends to be unhelpful and will increase feelings of anger.
Beliefs about anger that can be unhelpful
Some people hold beliefs that make it harder for them to bring their anger under control. The beliefs sometimes excuse anger or make it seem the only response. The beliefs are sometimes held because of life experiences or personal values. People may have lived with these beliefs for so long that they accept them without question, but it is important to question them to help overcome anger.
Here are some examples of these unhelpful beliefs and ideas on how to challenge and question them.
I can’t control my anger, my father was angry and it is something I inherited from him.
This is the idea that anger is something you can’t change – that it’s in your make-up, something you were born with. This is an excuse that lets you off the hook in controlling your anger. We know that some people are born with tendencies to be more emotional, fearful, angry or sad. The way we react to these emotions however is learned, and we can tackle our own angry behaviour by changing the way we respond to events and people.
If I don’t let my anger out I’ll explode.
It has long been a popular belief that some emotions build up, like steam in a pressure cooker and need some way out or else they become harmful. If you hold this point of view losing your temper could be seen as something healthy. But we know from research that people are often left feeling much worse after losing control of anger. Shouting, hitting, slamming doors can all increase and strengthen feelings of anger.
If you don’t show anger you’re either a saint or a wimp.
This is an example of black and white thinking. You think that if you’re not angry and aggressive then you’re a hopeless wimp. But the best way to deal with situations, both for yourself and those around you, is not to be angry and out of control, but to be firm, sure and in control – to be assertive.
My anger is something people fear and it stops them taking advantage of me.
This belief sees anger as a protector and other people as dangerous. It may be that this belief was correct at a particular time of your life, but if you continue to think this way it can cause problems. Good friendships are not formed on fear. You will be unlikely to have good friendships and relationships if your behaviour is angry. It is also likely to backfire, where others with problems of anger will see you as threatening and possibly pick fights with you.
If I get angry it takes my anxiety away.
This belief is often found in people who have been the victims of violence or aggression. It is better to try and tackle your anxiety by other ways rather than exchanging one unpleasant emotion for another. Anxiety can only be overcome by facing what you fear and finding ways of overcoming it.
I have good reason to be angry because of things other people have done to me.
Anger is a natural reaction when we are mistreated or taken advantage of. But if this anger continues into all areas of your life then it will cause difficulties for you. If the mistreatment took place a long time ago and the people who did it are no longer in your life it may help to ask “where does this anger get me now”? Do not let yourself go over and over in your mind things that have led you to feel angry.
It can be helpful to become more mindful of how your angry thoughts affect you and how you typically react. It is important to focus on the here and now and notice if your thoughts are frequently moving to pictures of events that have made you angry, notice how this makes you feel. Try to bring your thoughts back to the here and now. You can accept that you tend to have these angry thoughts but that this does not mean these thoughts have to control what you feel and do. Try and distance yourself from the thought rather than focusing on it.
Mindfulness meditation courses are now widely available and can further help you to learn to cope with anger. Becoming serene, relaxed and gaining a state of inner peace can be helped by mindfulness and relaxation training. This can in turn help you to reduce focus on anger and reduce distress. (Visit the Mental Health Foundation’s website for an online mindfulness course or details of mindfulness teachers in your area.) There are also examples of websites where you can find free relaxation and mindfulness downloads.
We need to look carefully at the angry hot thoughts we have and try to see if unhelpful thinking affects the way we view situations. It can help to try and have more balanced thoughts. We also need to examine long-held beliefs about our anger and challenge those which are not helpful. It can be helpful to be mindful of angry thoughts and the effects they have on us. Remember, logic can defeat anger!
Controlling the physical symptoms of anger
Relaxation and calming methods can help to reduce angry feelings. If you are with a partner who also becomes angry, it may help if you both learn these relaxation techniques. You need to learn to use the following approaches automatically if you are in a difficult situation. Look out for the warning signs of anger that you have identified earlier.
Reducing physical symptoms
In order to reduce the severity of physical symptoms it is useful to nip them in the bud, by recognising the early signs of tension and anger.
Once you have noticed early signs of tension you can prevent anger from becoming too severe by using relaxation techniques. Some people can relax through exercise, listening to music, watching TV, or reading a book. Picturing a pleasant scene in your mind can also help.
For others it is more helpful to have a set of exercises to follow. Some people might find relaxation or yoga classes most helpful, others find online recordings, courses or apps useful.
Suggestions of some free to download relaxation resources are available on-line. Other guides in this series also describe how to use relaxation, for example, Anxiety, Stress.
Remember relaxation is a skill like any other and takes time to learn. Keep a note of how angry you feel before and after relaxation, rating your anger 1-10.
It is very common when someone becomes angry for changes to occur in their breathing. They can begin to gulp air, thinking that they are going to suffocate, or can begin to breathe really quickly. This is called over-breathing; it has the effect of making them feel dizzy and therefore more tense. It can lead to unpleasant feelings but is not dangerous.
Try to recognise if you are doing this and slow your breathing down. Getting into a regular rhythm of “in two-three and out two-three” will soon return your breathing to normal.
Controlling angry behaviours
If we look back to the vicious circle of anger on page six, it becomes clear that if we can challenge our angry thoughts and reduce the physical symptoms of anger then we should not get to the point where we begin to behave angrily. No-one is perfect however! If we do not manage the previous stages it helps to have ideas on how to tackle the angry behaviours we might normally show. We can do this in three stages:
Be very clear what your angry behaviours are – what comes before them and what happens afterwards. It can help to keep a diary over a short period to help you understand this.
For example, Alex continually blows his top in home, work and social situations. He has tried to understand this by keeping a diary of what happens on these occasions. These are two examples of what he has found:
Monday 12th May
Before my anger.
My partner asked me to let her know what time I’d be in
My initial thoughts and feelings were angry ones and I thought “she doesn’t trust me”
I stormed out and slammed the door
What happened afterwards was that she wouldn’t speak to me for the rest of the day
Tuesday 13th May
Before my anger
At work someone says our section has less to do than theirs
My initial thoughts and feelings were “I feel angry”. I think “who does he think he is, what does he know”?
I shouted “shut your face” and walked off
What happened afterwards was that everyone was staring at me – people were looking at me late in the canteen as I passed by.
It is clear from his notes collected over the week that Alex deals with conflict and angry thoughts and feelings by angry behaviours and leaving the situation.
Make a list of all the other things you can do instead of behaving angrily. When you have done this choose the best new approach to try in difficult situations. Here is Alex’s list as an example:
- Excuse myself and leave the situation for a minute, “I’ll be back in a minute”, return when calmer.
- Take a deep breath and relax for a second.
- Ask the other person to let me know why they have said something, try and understand then ask, “Why do you want me to let you know when I’ll be in”? “Why do you say our section is doing less”?
- Ask the other person to sit down and talk about i Say, “Let’s get a cup of tea and talk about it…”
Alex decided to try and use numbers two and three to tackle the difficult situations.
Try to adopt the new behaviour in situations where you feel angry. Keep a diary of how it went. This is Alex’s dairy of this stage.
Monday 23 June
Before my anger
My partner asked me to help out with the shopping on Thursday
My initial thoughts and feelings were angry ones. I thought “she knows I always meet the lads on Thursday nights, she is trying to control me”.
I tried a new behaviour. I took a deep breath – relaxed and said “why have you asked me that”?
What happened afterwards
She said that week she was doing an extra shift and if I couldn’t help we’d have no food in for the weekend. I said “Ok, I’ll go out later than usual on Thursday”.
As you can see for Alex this new behaviour helped to avoid an argument, which is what would usually have happened.
Helpful ideas for changing angry behaviours can be:
- Use a quick relaxation and/or breathing exercise.
- Timing – if you tend to get angry at certain times when you talk to someone e.g. at night, try and talk to them calmly at different times of the day.
- If particular things make you angry, it may be you can avoid them, e.g. don’t travel to the shops when you know you’ll get stuck in traffic for ages. If you hate to sit in when your partner watches sport, plan something else at that time. If you hate his friend don’t be around when the friend is there.
- Count to ten before responding.
- Go for a quick walk.
- Ask yourself at the time “Why is this making me angry”?
- Ask yourself at the time, “Is this worth getting angry about”?
- Use calming self statements in your head, e.g. “calm down”, “getting mad won’t help”, “just forget it”.
- It can be helpful to become more mindful of how your angry behaviours affect you and how you typically react. Notice how you feel what are your thoughts and what are you doing right now.
In order to control angry behaviours you need to:
- Know what your angry behaviours are.
- Decide what other behaviours might take the place of your angry behaviour.
- Think of the best new ways of dealing with your anger and what the good results of that will be.
- Try out these new behaviours.
Sometimes real worries and stress can make us more irritable and angry. A problem solving approach may help in this.
A good way to begin is to write down a problem. Describe it as clearly as you can, for example “I never have any money”, is too vague, something like “I owe £3000 to different credit card companies”, is more helpful. Next, write down as many possible solutions as you can. It doesn’t matter how silly you may think the solutions are, the point is to think of as many as you can. Try to think how you have solved similar problems in the past. Ask a friend what they might do. Think to yourself what you might advise a friend to do if they had the same problems, e.g. possible solutions:
- Get all debts on one loan with less interest.
- Agree on affordable payments.
- See a debt counsellor.
- Get a part-time job.
- Sell car.
If you have a problem that may be making you stressed try writing it down.
Now list as many possible solutions as you can.
Choose what seems like the best solution and write down all the steps it would take to achieve the solution. Who might help? what might go wrong? often it is helpful to think “what is the worst thing that could happen”? If you can think of a plan to cope with this, your anxiety might reduce.
If you are trying to come up with a plan to tackle a problem that has been worrying you for some time, it is often helpful to discuss this with a friend or even your doctor.
Stressful lifestyle – general tips
Nowadays life is often stressful, and it is easy for pressures to build up. We can’t always control the stress that comes from outside but we can find ways to reduce the pressure we put on ourselves:
- Try to identify situations you find stressful by noticing the beginnings of tension.
- Take steps to tackle what it is about these situations that you find stressful.
- Make sure you have time for things you enjoy.
- Take up a relaxing hobby.
- Make sure you get enough sleep.
- Eat a well-balanced diet.
- Take regular exercise.
- Learn to relax or use mindfulness.
We have learned in the section of this book on unhelpful thinking styles that angry people tend to take things personally and will often jump to conclusions. It is therefore important to try and improve communication skills so that misunderstandings that lead to anger are less likely to happen. You need to move to a calm and assertive communication style that is neither angry nor passive. Here are a few tips on improving communication skills:
- Slow down and listen carefully to the other person – don’t rush in and say the first thing that comes to mind.
- Don’t jump to conclusions about what the other person is saying or thinking; ask them to tell you more about what they are trying to say.
- Don’t try to mind-.
- If someone is sounding defensive or critical, don’t immediately fight back.
- It is ok for someone to have a different opinion.
- Try and understand the feelings behind what is being said. Try and distance yourself in your mind to understand what is going on.
- It may be that the person feels afraid, hurt or unloved.
- If you can keep calm and try and find out more about how the other is feeling, then a row or fight can be avoided.
- Stop and think about the bigger picture.
- Try and express or talk about what your feelings really are, rather than going into angry words. Most often what is behind anger is fear, hurt or frustration. Of course you need to try and be clear in your own mind first why you feel angry.
Long term beliefs
Sometimes people have long held views about themselves that are very self-critical – for example “I’m not a very lovable person” or “I’m not a very clever person”. These beliefs are often because of past experiences, especially if there has been a lot of anger, criticism or violence in our lives. The beliefs hold no truth for the present time and it helps to stop this self-criticism. These beliefs can make you more sensitive and this in turn may lead to anger towards yourself or others. Try not to knock yourself down, look at the good things about yourself, not the bad, don’t stick with negative beliefs that are there because of unhappy times in your past.
How can I help myself overcome anger and aggression?
- Recognise your angry thoughts and begin to challenge them.
- Challenge any unhelpful thoughts or beliefs that don’t allow you to let go of anger.
- Think of the best ways of dealing with your anger and what the good results of that will be.
- Do not let yourself ruminate on situations that have led you to feel angry.
- Use relaxation and other ways to control the physical symptoms of anger.
- Understand and control angry behaviour, try new calmer actions.
- Improve communication and problem solving skills.
- Do not allow yourself to continue with long-term critical beliefs about yourself.
Where can I get further help?
We hope you will use the exercises suggested in this guide which may help you overcome anger and aggression on your own. If you feel you are making little progress or feel things are getting worse, then seek help in overcoming your problem. Your GP is the best person to talk to first, or perhaps your health visitor/ practice nurse if you see one. Your GP may suggest a talking treatment or tablets, or both. They may suggest you see a mental health worker who can offer expert help with your problems. They may also suggest classes for anger management. You may also have other problems with your mental health. There are more guides in this series that may help or talk to your GP about any symptoms such as low mood.
If you feel so distressed that you have thoughts of harming yourself or you feel you are at risk of harming others, then visit your doctor as soon as possible and explain to him or her how you are feeling.
A list of useful contacts, books and references are available in the written version of this guide.
- Dr Lesley Maunder and Lorna Cameron, Consultant Clinical Psychologists.
- Frank Charlton, Clinical Psychologist, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust has developed this resource with the support of NHS healthcare staff, service users and local voluntary sector groups.