Professional Documents
Culture Documents
(David H. Barlow, Kristen K. Ellard, Christopher P PDF
(David H. Barlow, Kristen K. Ellard, Christopher P PDF
of Emotional Disorders
editor-in-chief
scientific
advisory board
Jack M. Gorman, MD
1
2011
1
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v
found in unified, transdiagnostic interventions for disorders that
share common features and respond to common therapeutic proce-
dures. Deepening understanding of the nature of psychological dis-
orders reveals that many groups of related disorders share important
causes, and look very similar in terms of behavioral problems and
brain function. Thinking of these disorders or problems as related,
or on a “spectrum,” is the approach now taken by leading therapists
and researchers as well as by committees writing the next version
of the diagnostic manual for psychological disorders, the DSM-5.
This is because most people with one disorder or problem also have
another problem or disorder (referred to as comorbidity). If someone
has panic disorder, they may also have social anxiety as well as depres-
sion; these are all emotional disorders. If someone abuses drugs, they
may also abuse alcohol or cigarettes; these are all addictive disorders.
Treatment programs in this series are “unified” because they share a
common, unified set of therapeutic procedures that are effective
with a whole class of disorders, such as emotional disorders or addic-
tive disorders. Treatment programs are “transdiagnostic” because
they are designed to be effective with all of the disorders in that class
(emotional or addictive or eating disorders) that somebody might
have, rather than just one disorder. Working with one set of thera-
peutic principles makes it easier and more efficient for you and your
therapist, and should address all of the problems you may have in a
more comprehensive and effective way.
vi
fun out of life and keep you from doing the things you want. This
program is not generally recommended for a specific phobia, if that
is the only problem you are experiencing at this time. Other books
in this series can deal more efficiently with that problem (visit www.
oup.com/us/ttw for a list of books). Only your healthcare profes-
sional can tell you for sure which disorders you have and which you
may not have; and only your healthcare professional can decide on
the most appropriate treatments for you.
vii
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Contents
ix
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Chapter 1 What are Emotional Disorders?
Goals
1
applicable to all emotional disorders, even if you have more than
one, or a disorder that doesn’t quite fit the definition of one of the
major disorders previously mentioned and described later in the
chapter. This is why the program is called the Unified Protocol for
Transdiagnostic Treatment of Emotional Disorders.
To begin to see if this program is right for you, take a look at these
examples from cases we have treated at our clinic:
Sarah
2
In addition to anxiety about speaking in front of others, Sarah said
she had always been anxious in social situations or in group
situations. She recalled that she had been this way since high school,
but that in recent years her social anxiety had gotten even worse.
Although she had always had a small but steady group of close friends,
Sarah noticed that her social network had been getting smaller and
smaller as her close friends got married and had children, or moved
away for work. She had a great deal of anxiety about meeting new
people, and felt that her anxiety was definitely holding her back from
making new friends. Sarah was single and had not been on a date in
a number of years. Although very interested in dating, she felt her
anxiety was preventing her from going out on dates. ■
Linda
3
replace him with someone younger, if the company decided to lay
him off, or if the company folded. She described always feeling like
the rug might be pulled out from underneath her and her family,
and that something terrible might happen at any moment. Linda
described feeling tense and restless much of the time. She found it
very difficult to fall asleep, often lying awake with her thoughts
racing. She would also frequently wake during the night and begin
worrying about things she needed to do the next day. She also
described feeling a “wave of panic” wash over her at certain points
in the day, particularly when she felt overwhelmed. Her heart
would begin to race, her palms would get sweaty, and she would
find it difficult to breathe. She stated this happened mostly when
she worried about many different things at the same time, when
she thought about something really terrible happening, or when her
thoughts felt out of control.
Kevin
4
pulled off to the side of the road and got out of his car. Kevin had
never experienced anything like this before and he was terrified that
he would lose control as a result of these attacks. He called his wife
to pick him up to take him to work, and had his car towed, telling
his wife it had broken down. He had been experiencing increased
stress at work and had been having some marital problems. The
night before, he and his wife had talked about separating for the
first time. Following this first attack, Kevin began having
additional panic attacks that occurred in a variety of situations.
Most felt like they were coming from “out of the blue,” but he felt
that he was especially likely to have them in situations where he was
unable to escape or where he felt trapped. Kevin was almost
constantly worried about having another panic attack and felt tense
and anxious for most of the day due to this concern. Since this first
attack, Kevin no longer drove on the highway. Instead, he took
surface roads to work, which added another 30–45 minutes to his
commute. In addition to avoiding the highway, Kevin noticed that
he began to avoid traffic or driving on busy roads. In fact, he had
begun leaving for work an hour earlier than before and leaving an
hour later, in order to avoid rush-hour traffic. He also began
avoiding other situations and places, such as airplanes, elevators,
stores, shopping malls, theaters, and crowds, where he feared being
trapped and embarrassed if he had a panic attack. Wherever he
went, Kevin carried his cell phone (so he could call for help if
anything happened to him) and his medication bottle with him.
Although the medication bottle was empty, he said looking at it
made him feel more comfortable and better able to cope. Kevin had
tried a number of different things to “get rid of ” his panic,
including relaxation, hypnosis, and even medication that his doctor
had prescribed. However, none of these things had helped. ■
Brian
■ Brian is a 34-year-old male who lives with his wife and 4-year-old
child. Starting about three months ago, after beginning a new job,
Brian noticed he was becoming increasingly concerned about the
possibility of getting sick from touching items such as doorknobs and
money, and when interacting with others in public. Recently, he
experienced an increase in these symptoms. In response to these fears,
5
he has been washing his hands frequently throughout the day and
avoids touching things he believes may be dirty. For instance, he
opens doors with his shirtsleeve or with a tissue, and on one
occasion, even wore a pair of latex gloves when using public
transportation. Currently, he washes his hands about 30 times
per day, under hot water, and uses nearly one bottle of liquid soap
every couple of days. He generally avoids public places where germs
may “congregate,” including movie theatres, restaurants, and the
mall. He tries to reduce direct contact with others as much as
possible, and refuses to shake hands with business colleagues. In
addition, he is overly cautious around his son, out of fear that he
came into contact with someone who was sick at preschool. Usually,
he asks both his wife and son to change their clothes immediately
when they get home each day, and has even asked his wife to take
an extra shower, all in an attempt to reduce his exposure to germs
and potential illness. His showers typically last about 45 minutes.
He usually showers about twice per day, but has showered up to
four times in a single day. Taken together, his washing behaviors
require at least two hours per day and have been causing significant
tension between him and his wife. He is also struggling at his job
because he is so focused on staying clean (as opposed to completing
daily activities) that he is falling behind in his work. On one
occasion, Brian “got stuck” washing his hands in the bathroom at
work for over 20 minutes straight. As a result, he was very late for
an important meeting. Brian is concerned about these symptoms
but has been unable to stop obsessing about the possibility that he
may be contaminated. He noted that the more he washes, and tries
to “get clean,” the worse his fears become. Brian remembers having
similar concerns when he was in high school, but feels that these
symptoms have now gotten “out of control.” ■
6
Is this Treatment Right for My Symptoms?
You may notice that in each of the cases presented each person is
experiencing slightly different symptoms. Sarah is experiencing
intense anxiety about speaking in public and social situations, which
is getting in the way of earning a possible promotion at work and
limiting her social life. Linda is overwhelmed by worries and con-
cerns about something terrible happening to her and her family, and
often feels down and worthless, all of which is getting in the way of
her finding a job and doing things she enjoys. Kevin is experiencing
“out of the blue” panic attacks and constant worry about having
more attacks, which is causing him to avoid highway driving and
spend a considerable amount of extra time commuting to work.
Brian is so afraid of germs and getting sick that he spends almost
two hours each day showering and washing his hands. Even though
each individual experience is different, they all have one thing in
common—intense, strong, and/or unwanted emotions are getting
in the way of living their lives.
To help you think about how your own symptoms might relate to
the experiences described here, ask yourself the following questions
and record your responses in the space provided.
________________________________________________________
________________________________________________________
_________________________________________________________
________________________________________________________
________________________________________________________
_________________________________________________________
________________________________________________________
________________________________________________________
_________________________________________________________
7
What Types of Disorders is this Program Intended for?
Panic Disorder
1
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (4th ed., text revision). Washington, DC.
8
in any real danger or can’t figure out why. When a person starts to
experience panic attacks, they become very worried about having
another panic attack, and may begin to change their lifestyle or to
avoid certain situations as a result.
Obsessive-Compulsive Disorder
Many people have fleeting thoughts that don’t make sense to them
and that seem to come out of nowhere, or may have idiosyncratic
behaviors or habits like keeping things in a certain order or doing
things a certain way. For someone to be diagnosed with obsessive-
compulsive disorder, however, these intrusive thoughts and/or com-
pulsive behaviors must take up a great deal of time in the person’s
day, happening for at least an hour or more, and must be very inter-
fering and/or distressing for the person.
9
project or meeting expectations; their family and friends’ health and
well-being; their own health and well-being; their finances; how they
are getting along with others; or even community or world issues.
Someone with generalized anxiety disorder doesn’t just worry about
one of these things; they worry about several of these different things.
Most importantly, they find it very, very difficult to “turn off ” these
worries, even when they are trying to do other things. These worries
come with physical sensations as well. They may feel restless, wound
up, irritable, and/or distracted. They may experience muscle ten-
sion, and have trouble sleeping. Just as with obsessive-compulsive
disorder, it is not uncommon for people to worry about things in
their life, and quite often worrying about something can act as a
powerful motivator to get something done, making worry quite
helpful. To receive a diagnosis of generalized anxiety disorder, a
person must be worrying about a number of these different things
more days than not, for at least six months, find these worries diffi-
cult to control, and experience at least three of the symptoms that go
along with worry (e.g. restlessness, muscle tension, difficulty sleep-
ing). In addition, these worries must be getting in the way of the
person’s life and/or be very distressing to them.
10
Major Depressive Disorder
11
These are just some of the diagnoses people can receive through an
assessment by a health professional using the DSM, and some of the
more common ones. Even though we have listed these separately
here, it is important to note that at our clinic it is not uncommon
for people to be experiencing many of these symptoms at the same
time. In fact, it is probably more common at our clinic for people to
receive two, or even three or four diagnoses at the same time, or to
have symptoms that don’t quite meet the definitions for one disorder
or another. This is another important reason why we developed the
treatment program here: we want to help you to address all of the
symptoms you are experiencing, regardless of the disorder, instead
of looking at them one at a time.
Summary
12
the category of emotional disorders. Emotional disorders are charac-
terized by a tendency to experience strong, intense, and/or uncom-
fortable emotions that seem to “take over” the person’s life. These
aversive experiences may cause people to change their behavior or
avoid situations, in ways that begin to interfere in their lives in
important ways. In this chapter, we presented four different case
examples demonstrating how emotions might interfere in a person’s
life. We also reviewed the symptoms and criteria for meeting a diag-
nosis of a range of disorders, including generalized anxiety disorder,
obsessive-compulsive disorder, panic disorder, social anxiety disor-
der or social phobia, and depression. Research has shown that indi-
viduals with these disorders tend to experience emotions more
frequently, more intensely, and as more distressing than individuals
without these disorders. Further, even though individual diagnoses
exist, more often than not individuals suffer from more than one
disorder at the same time. Therefore, this treatment program is
designed to directly address the aversive emotional experiences at the
core of all these disorders.
13
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Chapter 2 Is This Treatment Right for You?
Goals
Now that you have read about the types of problems this treatment
was designed for, and thought about how your own emotional expe-
riences might be getting in the way of living your life, let’s explore
whether this treatment program is right for you.
15
This program is designed for you to go through at your own pace, but
we do recommend spending enough time on each chapter in order to
really understand and practice the skills presented. Each chapter con-
tains exercises designed to help you put the concepts into practice.
Each chapter ends with a self-assessment quiz, enabling you to test
how well you have understood the concepts and strategies introduced
in the chapter. If you find yourself struggling with the answers to
these quizzes, go back and read through the chapter again.
16
Chapter 9: Understanding Behaviors 1: Avoiding Your Emotions
Chapter 10: Understanding Behaviors 2: Emotion-Driven
Behaviors
Chapter 11: Understanding and Confronting Physical Sensations
Chapter 12: Putting it into Practice: Facing Your Emotions in the
Situations in which They Occur
Chapter 13: Medications for Anxiety, Depression, and Related
Emotional Disorders
Chapter 14: Moving on From Here: Recognizing Your
Accomplishments and Looking to Your Future
17
Ideally, you will be working through this program with the help of
your health care provider or mental health professional. However,
this program can also be done on your own.
This treatment was developed at the Center for Anxiety and Related
Disorders (CARD) in Boston, Massachusetts, where several other
highly regarded and successful treatments have been developed, such
as treatments for panic disorder, specific phobias, and generalized
anxiety disorder (also available as “Mastery of Your Anxiety and
Panic,” “Mastery of Your Specific Phobia,” and “Mastery of Your
Anxiety and Worry” in the TreatmentsThatWork™ series). The pur-
pose of the research conducted at CARD is to understand how anx-
iety and mood disorders develop, what maintains them, and how
best to treat them. The Center has received longstanding funding
through the National Institutes of Health (NIH), and is one of the
largest research clinics of its kind in the world. We have now used
this treatment program to treat hundreds of patients, with over 70%
of patients experiencing significant improvement in their symptoms
and a return to a more functional way of life. Of course, we cannot
promise that these techniques will work for everyone. As with many
of our programs designed to treat anxiety and mood problems, one
of the biggest predictors of success is the amount of practice one
does. This treatment is essentially a learning program, and it requires
quite a bit of work and dedication. However, once something is
learned, it becomes a natural part of your life and therefore is carried
with you even after the program ends.
The benefit you will receive by going through this treatment pro-
gram, then, is a chance to gain a part of your life back that may be
missing now because of your symptoms. Everyone has their own
individual goals for treatment, and Chapter 4 will allow you to
explore your goals in great detail. The important point is, by giving
this treatment program a chance you may be able to get closer to
living the life you want to live.
18
What are the Costs of this Program?
Like anything you may strive for in life, this program takes work.
Probably the biggest cost of engaging in this program is time and
effort. As we said before, the success of this program rests largely on
the amount of effort you put into it. You should be prepared to
commit the next 9 to 18 weeks to this program, trying to stay con-
sistent and continue moving through the concepts and exercises
without long interruptions. To put this in perspective, think of it
like signing up for a course in school. The typical college course lasts
about 15 weeks (although some courses are condensed and more
intense). For those 15 weeks, you are learning new concepts, and
doing homework and other exercises to really practice what you have
learned, so that by the end of the course the concepts and skills stay
with you. The same is true here: you should be willing to devote one
whole “semester” to yourself, allowing yourself the time to really
learn and practice the skills in this program. If you are unable to
make this type of commitment at this time, it may not be the right
time to try this program. In order to really give this program a chance
to work, you have to be willing to see it through from beginning to
end. Only then will you see the potential for real, lasting change. As
a summary of what we have discussed in this chapter, work through
the Decision Tree provided to help you determine if this program is
right for you at this time.
Chapter 4 will help you explore the benefits and costs of doing this
program in more detail, allowing you to assess your own commit-
ment, motivation, and willingness for change.
19
Decision Tree
YES
NO
YES
20
Chapter 3 Learning to Record Your Experiences
Goals
Key Concepts
21
you on your way toward gaining a better understanding of them.
Through recordkeeping, you will learn to observe when, where, and
under what circumstances uncomfortable emotional situations
occur. As a result, you will gain an understanding of the factors that
cause anxiety, mood difficulties, or other uncomfortable experiences
to increase and continue, which in turn will make you feel more in
control of your experiences and less like a victim of them.
Second, you will learn to recognize how what you think, what you
feel, and what you do, can contribute to uncomfortable or distress-
ing emotional experiences like anxiety or depression. This is very
important because the treatment in this program is designed specifi-
cally to help you identify which aspects of what you think, do, and
feel are contributing to your distress, and to teach you new, more
helpful ways of coping with your experiences. This, of course, is very
difficult to do if you don’t know what you are thinking, doing, and
feeling in the first place. Ongoing recordkeeping can help you begin
to recognize and identify these parts of your experience.
22
You may be particularly concerned about this if you are distressed
about feeling distressed, or if you feel like your distress is out of your
control. It is important to realize, however, that there is more than
one way to observe and monitor your experiences: a subjective way
and an objective way.
23
triggers and situations will lessen the sense of being out of
control of your emotional experiences. It is easy to lose track of
the specific triggers, partly because they can be very subtle and
hard to identify, and partly because you may start to respond to
triggers out of habit, without even knowing consciously what it
is you are responding to. Recordkeeping will help you to
identify the triggers of your distress.
What Do I Record?
24
as you move through the program, allowing you to see the impact of
the changes you make on your overall experience.
1
Norman, S. B., Cissell, S. H., Means-Christensen, A. J., & Stein, M. B. (2006).
Development and validation of an overall severity and impairment scale (OASIS). Depression
and Anxiety, 23, 245–249.
25
26
20 + 20
19 19
18 + + + 18
Score on the
Score on the
12 12
x x
11 11
x x +
10 10
x + +
9 9
x
8 x 8
7 x + 7
6 x + 6
x
5 x + 5
4 4
3 3
2 2
1 1
0 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Week
Figure 3.1
Sample Progress Record
likely will experience similar peaks and valleys along the way, and
quite often a rough week can be followed by a much better one.
The Progress Record graph will help you to keep everything in per-
spective. It may be helpful to place the Progress Record in a very visible
place, such as on your bathroom mirror or refrigerator (or, somewhere
where it is not visible to others but very noticeable to you), so that you
will be reminded of the positive changes you are making. You may
photocopy the Progress Record from this book.
Summary
In the next chapter, we will present two more important concepts that
will help prepare you to start this treatment program—maintaining
your motivation to engage in treatment, and setting your treatment
goals.
Homework
27
✎ Use the Progress Record to begin charting your progress
through the program, recording the total scores from the
OASIS and ODSIS week by week.
Self-Assessment Quiz
Answer each of the following by circling true (T) or false (F). Answers
can be found in the appendix.
28
Overall Anxiety Severity and Impairment Scale (OASIS)
The following items ask about anxiety and fear. For each item, circle the number for the answer that best
describes your experience over the past week.
1. In the past week, how often have you felt anxious?
0 = No anxiety in the past week.
1 = Infrequent anxiety. Felt anxious a few times.
2 = Occasional anxiety. Felt anxious as much of the time as not. It was hard to relax.
3 = Frequent anxiety. Felt anxious most of the time. It was very difficult to relax.
4 = Constant anxiety. Felt anxious all of the time and never really relaxed.
2. In the past week, when you have felt anxious, how intense or severe was your anxiety?
0 = Little or None: Anxiety was absent or barely noticeable.
1 = Mild: Anxiety was at a low level. It was possible to relax when I tried. Physical symptoms were
only slightly uncomfortable.
2 = Moderate: Anxiety was distressing at times. It was hard to relax or concentrate, but I could do it
if I tried. Physical symptoms were uncomfortable.
3 = Severe: Anxiety was intense much of the time. It was very difficult to relax or focus on anything
else. Physical symptoms were extremely uncomfortable.
4 = Extreme: Anxiety was overwhelming. It was impossible to relax at all. Physical symptoms were
unbearable.
3. In the past week, how often did you avoid situations, places, objects, or activities because of anxiety
or fear?
0 = None: I do not avoid places, situations, activities, or things because of fear.
1 = Infrequent: I avoid something once in a while, but will usually face the situation or confront the
object. My lifestyle is not affected.
2 = Occasional: I have some fear of certain situations, places, or objects, but it is still manageable.
My lifestyle has only changed in minor ways. I always or almost always avoid the things I fear
when I’m alone, but can handle them if someone comes with me.
3 = Frequent: I have considerable fear and really try to avoid the things that frighten me. I have
made significant changes in my lifestyle to avoid the object, situation, activity, or place.
4 = All the Time: Avoiding objects, situations, activities, or places has taken over my life.
My lifestyle has been extensively affected and I no longer do things that I used to enjoy.
4. In the past week, how much did your anxiety interfere with your ability to do the things you needed
to do at work, at school, or at home?
0 = None: No interference at work/home/school from anxiety
1 = Mild: My anxiety has caused some interference at work/home/school. Things are more difficult,
but everything that needs to be done is still getting done.
2 = Moderate: My anxiety definitely interferes with tasks. Most things are still getting done, but few
things are being done as well as in the past.
3 = Severe: My anxiety has really changed my ability to get things done. Some tasks are still being
done, but many things are not. My performance has definitely suffered.
4 = Extreme: My anxiety has become incapacitating. I am unable to complete tasks and have had to
leave school, have quit or been fired from my job, or have been unable to complete tasks at
home and have faced consequences like bill collectors, eviction, etc.
29
5. In the past week, how much has anxiety interfered with your social life and relationships?
0 = None: My anxiety doesn’t affect my relationships.
1 = Mild: My anxiety slightly interferes with my relationships. Some of my friendships and other
relationships have suffered, but, overall, my social life is still fulfilling.
2 = Moderate: I have experienced some interference with my social life, but I still have a few
close relationships. I don’t spend as much time with others as in the past, but I still socialize
sometimes.
3 = Severe: My friendships and other relationships have suffered a lot because of anxiety. I do not
enjoy social activities. I socialize very little.
4 = Extreme: My anxiety has completely disrupted my social activities. All of my relationships have
suffered or ended. My family life is extremely strained.
TOTAL: ______________
30
Overall Depression Severity and Impairment Scale (ODSIS)
The following items ask about depression. For each item, circle the number for the answer that best
describes your experience over the past week.
1. In the past week, how often have you felt depressed?
0 = No depression in the past week.
1 = Infrequent depression. Felt depressed a few times.
2 = Occasional depression. Felt depressed as much of the time as not.
3 = Frequent depression. Felt depressed most of the time.
4 = Constant depression. Felt depressed all of the time.
2. In the past week, when you have felt depressed, how intense or severe was your depression?
0 = Little or None: Depression was absent or barely noticeable.
1 = Mild: Depression was at a low level.
2 = Moderate: Depression was intense at times.
3 = Severe: Depression was intense much of the time.
4 = Extreme: Depression was overwhelming.
3. In the past week, how often did you have difficulty engaging in or being interested in activities you
normally enjoy because of depression?
0 = None: I had no difficulty engaging in or being interested in activities that I normally enjoy
because of depression.
1 = Infrequent: A few times I had difficulty engaging in or being interested in activities that
I normally enjoy, because of depression. My lifestyle was not affected.
2 = Occasional: I had some difficulty engaging in or being interested in activities that I normally
enjoy, because of depression. My lifestyle has only changed in minor ways.
3 = Frequent: I have considerable difficulty engaging in or being interested in activities that
I normally enjoy, because of depression. I have made significant changes in my lifestyle because
of being unable to become interested in activities I used to enjoy.
4 = All the Time: I have been unable to participate in or be interested in activities that I normally
enjoy, because of depression. My lifestyle has been extensively affected and I no longer do things
that I used to enjoy.
4. In the past week, how much did your depression interfere with your ability to do the things you
needed to do at work, at school, or at home?
0 = None: No interference at work/home/school from depression
1 = Mild: My depression has caused some interference at work/home/school. Things are more
difficult, but everything that needs to be done is still getting done.
2 = Moderate: My depression definitely interferes with tasks. Most things are still getting done, but
few things are being done as well as in the past.
3 = Severe: My depression has really changed my ability to get things done. Some tasks are still being
done, but many things are not. My performance has definitely suffered.
4 = Extreme: My depression has become incapacitating. I am unable to complete tasks and have had
to leave school, have quit or been fired from my job, or have been unable to complete tasks at
home and have faced consequences like bill collectors, eviction, etc.
31
5. In the past week, how much has depression interfered with your social life and relationships?
0 = None: My depression doesn’t affect my relationships.
1 = Mild: My depression slightly interferes with my relationships. Some of my friendships and other
relationships have suffered, but, overall, my social life is still fulfilling.
2 = Moderate: I have experienced some interference with my social life, but I still have a few close
relationships. I don’t spend as much time with others as in the past, but I still socialize sometimes.
3 = Severe: My friendships and other relationships have suffered a lot because of depression. I do not
enjoy social activities. I socialize very little.
4 = Extreme: My depression has completely disrupted my social activities. All of my relationships
have suffered or ended. My family life is extremely strained.
TOTAL: ______________
32
Progress Record
20 20
19 19
18 18
Score on the
12 12
11 11
10 10
9 9
8 8
7 7
6 6
5 5
4 4
3 3
2 2
1 1
0 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Week
33
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Chapter 4 Maintaining Motivation and
Setting Goals for Treatment
Goals
Homework Review
Did you complete your OASIS and ODSIS for the previous week?
Did you plot your total scores on the Progress Record chart? If you
did not do the recordkeeping this past week, think of what may have
kept you from recording your experiences, and ways you might
ensure you stick to it. Is there a time of day you can devote 10 minutes
to recording? Can you leave forms somewhere that will remind you
to complete your recordkeeping, like next to your bed (reminding
you to record at the end of the day), or next to your coffee maker (to
remind you to record at the start of the day)? Remember, as explained
in the previous chapter, recordkeeping enables you to develop a more
objective level of self-awareness, and will help you to track your
progress throughout this program. Keeping objective records will
help you to feel more in control of your distressing experiences. In
addition, monitoring and recording is essential for obtaining detailed
information about the way in which you experience distressing or
35
uncomfortable emotions—what you physically feel, what you think,
and what you do. If you have not completed the monitoring for this
past week using the OASIS and ODSIS, we recommend you com-
plete these before continuing on.
If you have completed the monitoring, well done! You can refer
back to these first records as your starting point, and to begin to get
into the habit of regular recordkeeping. As mentioned, in the chap-
ters that follow you will be introduced to more forms to be used
daily to record your experiences, so it is good to get in the habit of
recording now.
Motivation
36
even feel like you don’t want to change, or it is not worth the time
and effort. This is completely normal, and is a natural part of
the change process. It is important to allow yourself to have these
moments. Recognizing that external factors can affect your motiva-
tion, and allowing yourself to occasionally have these doubts, is
important. Remember, it is all part of the change process.
Were you able to come up with reasons for each of the boxes? If not,
please take a moment to go back and fill in some reasons for any
boxes you might have left blank.
37
Pros/Benefits Cons/Costs
Figure 4.1
Sarah’s Decisional Balance Worksheet
Sarah came in for treatment mainly for help with excessive anxiety in social situations. She would become
anxious anytime she was in a group situation, or around new people. She had been avoiding interacting
with new people, as well as people she didn’t know very well, ever since high school. Over the years, her
life has become increasingly restricted and she has recently noticed that her social circle consists of only a
few close friends. She hasn’t dated much at all, and would like to begin to be more comfortable around
others so that she can start dating, as well as increase her circle of friends.
Now that you’ve filled out the Decisional Balance Worksheet, let’s
take a look at your reasons for staying the same. We can use Sarah’s
Decisional Balance Worksheet shown in Figure 4.1 as an example to
help our discussion. Sarah noted that staying the same would be
easier. This is a very common response, and she’s at least somewhat
correct. In some ways, it is easier to stay the same. You wouldn’t have
to spend time reading this workbook, and you wouldn’t be filling
out these forms. However, think about how much time and effort it
takes to avoid your uncomfortable emotions. It might feel easier
because it is what you are used to doing, but it takes a lot of time and
energy to continue avoiding your emotions. Sarah also noted that
it was comfortable to stay the same. While there is some amount
of comfort that comes with doing what we’re used to doing, how
comfortable are your emotional experiences currently? Most people
38
Decisional Balance Worksheet
Pros/Benefits Cons/Costs
Change
Stay the
Same
39
seek treatment or help precisely because their emotions and their
lives have become so uncomfortable!
Another common reason that people cite for not changing is that if
treatment doesn’t work, they will somehow be worse off than before.
This is a difficult spot to be in, and can make people feel that their
emotions are out of control, or perhaps even that they are helpless.
However, in completing this program you are taking steps forward.
You are learning more about how emotional difficulties develop and
how they are maintained. We cannot guarantee that this treatment
will work for everyone, and not everyone progresses at the same rate.
However, it is important to note that no matter what, you will be
better off than when you started. You will have a better understand-
ing of how emotions become problematic, and you will have a strong
set of skills to help break this cycle and prevent emotions from inter-
fering in your life in the future. Looking at your Decisional Balance
Worksheet, how can you respond to the reasons that you recorded
under the cons to changing, and the pros of staying the same? Record
any responses you come up with, in either the Pros of Changing or
Cons of Staying the Same boxes.
Now let’s look at some of Sarah’s cons for staying the same. One of
the most common reasons people place in this box is that they will
continue to feel this way and continue to be limited in their daily
lives. Think about all the different ways in which your symptoms
have gotten in the way of you living the life you want to be living.
Now take out a piece of paper and record some of the ways in which
these symptoms have been interfering in your life.
How many of these things would change if you were able to success-
fully engage in treatment? What things jump to your mind when
40
you think about successfully addressing these difficulties in treat-
ment? If you have not already recorded them in the Pros of Changing
box, then do so now. Now look over the reasons you have recorded
in the Pros of Changing box. These reasons are probably a large part
of why you sought help for these difficulties. People often find it
helpful to have these recorded and written in one place. Treatment
can be difficult. And we know that your motivation is going to
change (both increase and decrease) over the course of treatment,
due to any number of external factors. This is normal and does not
mean that you are “failing” or that the treatment is not working.
This worksheet will be very helpful to you whenever you notice your
motivation might be lower than normal. Reviewing this worksheet
can help you to push yourself through this brief period of reduced
motivation. Remember, these decreases in motivation are only tem-
porary, and they will pass. Using this worksheet to review some of
the pros and cons for changing and staying the same can help you
renew your motivation and continue down the path toward the life
you want to be living.
Now that we’ve discussed some of your reasons for changing, let’s
discuss how you can make these changes happen.
Research has consistently shown that one of the most effective ways to
achieve successful behavior change is through goal setting. When we
talk about goals, we are referring to future states or events that we are
interested in making happen, or hoping to prevent from happening.
These can include more immediate things, such as “going to the gym
tonight” or “finishing my treatment homework” and more distant
things, such as “making more friends” and “feeling happier.”
41
“going to the gym tonight” is much more likely to lead to successful
behavior change than the goal of “feeling happier.” Before starting
treatment, it is helpful to identify the larger goals you have for your-
self over the course of treatment, such as “making more friends” and
“feeling happier” and then come up with more concrete manageable
steps to achieving those goals.
Although you might have a general sense of what your goals for
treatment are, it will be helpful to explicitly record these goals in
your workbook. Take a look at Sarah’s completed Treatment Goal
Setting Worksheet shown in Figure 4.2. A blank copy for your use is
provided on page 45.
Sarah’s number one treatment goal was “to make more friends.” This
is a common treatment goal for people who have concerns similar to
Sarah’s. The next step in setting manageable goals for treatment is to
identify specific behaviors that would let Sarah know she had
achieved her goal—what we call Making it More Concrete. For Sarah,
having more friends meant that she would be able to meet friends
after work, go to see new movies in the theaters, have dinner parties,
and call friends when having a bad day. It also meant that she
wouldn’t stay home alone on Saturday nights anymore. These new
goals are all more concrete than her original goal “to make more
friends,” and Sarah will be able to more easily evaluate whether she
has achieved her goals. For instance, if she goes to see a movie with
someone, talks to someone on the phone after having a bad day, or
goes out with someone on Saturday night, Sarah will know she is
achieving her goal. After Sarah had set some more specific and con-
crete goals, she next outlined the necessary steps to achieve those
goals. Starting with one of her concrete goals she listed in the Making
it More Concrete section as Step 5, Sarah was able to identify some
manageable steps that would move her toward her concrete treat-
ment goal of “going to see new movies with friends.”
Now, take some time to fill out the Treatment Goal-Setting Worksheet
for yourself. Sometimes, it can be difficult to complete this work-
sheet, as it might feel like the steps necessary to meeting your goal are
not manageable. It might even be hard to see yourself actually doing
some of these things. This is a natural response, and it is common to
feel this way. When completing the Taking the Necessary Steps
section, it will be helpful to ask yourself whether the steps you are
42
My #1 goal for treatment is: To make more friends
Making it More Concrete
Now, let's take a moment to make this goal more concrete. What would it look like once
you have achieved this goal? What things would you be doing, or not doing? What
behaviors would you be engaging in? What behaviors would you not be engaging in?
Meeting friends after work, going to see new movies with friends, having
friends over for dinner parties, calling friends to cheer me up when I have
a bad day, and not staying home alone on Saturday nights anymore.
Taking the Necessary Steps
Next, think about some small manageable steps that you can take towards reaching the
specific treatment goals you've listed above. These steps should take anywhere from a
few days or a week up to a month to achieve. What steps will you need to take? It can
be helpful to work backwards from your goal to help identify specific steps you will need
to take to get there. Use the behaviors you listed above to help come up with your steps
43
writing down are specific behaviors that can be completed in a lim-
ited time period, rather than whether you believe you are capable of
completing them currently. Remember, our emotions can make us
feel like we are unable to change, and our fear of failing can make it
difficult to start the change process. As you go through treatment,
you will learn skills for responding to these emotions in ways that
will be more helpful, and will ultimately make the emotions begin
to feel more manageable; although it might be hard to believe this
100% now. Keep in mind that the goal of this section is to come up
with specific behaviors that can be completed in a brief timeframe,
such as “Get phone number from acquaintance” and “Call person to
invite them to a movie on Saturday night,” as opposed to simply
listing, “Go see a movie with a friend.” As long each of these steps
are specific behaviors that can be individually accomplished in a
brief timeframe, then you can get there.
44
Treatment Goal-Setting Worksheet
_________________________________________________________________________________
Now, let’s take a moment to make this goal more concrete. What
would it look like once you have achieved this goal? What things
would you be doing, or not doing? What behaviors would you be
engaging in? What behaviors would you not be engaging in? Try to
be as concrete as possible here.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Next, think about some small, manageable steps that you can take
toward reaching the specific treatment goals you’ve listed above.
These steps should take anywhere from a few days or a week, up to
a month to achieve. What steps will you need to take? It can be help-
ful to work backwards from your goal to identify specific steps you
will need to take to get there. Use the behaviors you listed above to
help come up with your steps to achieving your treatment goal.
Step 5:
_________________________________________________________
Step 4:
_________________________________________________________
Step 3:
_________________________________________________________
45
Step 2:
_________________________________________________________
Step 1:
_________________________________________________________
46
People often have at least a few goals for treatment. Let’s take a
moment to list at least two more treatment goals you have. You might
find it helpful to repeat this process for additional goals as well.
My 2nd goal for treatment is: __________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Next, think about some small, manageable steps that you can take
toward reaching the specific treatment goals you’ve listed above.
These steps should take anywhere from a few days or a week, up to
a month to achieve. What steps will you need to take? It can be help-
ful to work backwards from your goal to identify specific steps you
will need to take to get there. Use the behaviors you listed above to
help come up with your steps to achieving your treatment goal.
Step 5:
_________________________________________________________
Step 4:
_________________________________________________________
Step 3:
_________________________________________________________
47
Step 2:
_________________________________________________________
Step 1:
_________________________________________________________
48
My 3rd goal for treatment is: __________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Next, think about some small, manageable steps that you can take
towards reaching the specific treatment goals you’ve listed above.
These steps should take anywhere from a few days or a week, up to a
month to achieve. What steps will you need to take? It can be helpful
to work backwards from your goal to help identify specific steps you
will need to take to get there. Use the behaviors you listed above to
help come up with your steps to achieving your treatment goal.
Step 5:
________________________________________________________
Step 4:
________________________________________________________
Step 3:
________________________________________________________
Step 2:
________________________________________________________
Step 1:
________________________________________________________
49
Summary
Homework
Self-Assessment Quiz
Answer each of the following by circling true (T) or false (F). Answers
can be found in the appendix.
1. Feeling both that you want to change, and that you might not
be ready to change, is a natural part of the process of any
behavior change.
T F
50
2. Having doubts about your ability to change means you will
fail.
T F
51
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Chapter 5 Understanding Your Emotions
Goals
Key Concepts
In this chapter, you will learn about the adaptive nature of emotions,
and how emotions function to help us in our daily lives. You will
learn what makes up an emotional experience, and how to begin to
recognize what makes up your own emotional experiences.
Homework Review
Did you complete the OASIS and ODSIS for this past week? Did
you plot your total scores on these forms on your Progress Record
chart? If so, congratulations and well done! If not, continue to
explore what might be keeping you from recordkeeping. Make
recordkeeping a priority while you are going through this program.
If it helps, reread Chapter 3 to help remind you of the importance
of recordkeeping, and why we are encouraging you to do it in the
first place. Find a regular time that works for you each day to com-
plete your recordkeeping, helping you to get into the habit more
quickly. As you go through the next few chapters, you will begin to
gain more and more important information from your records, and
will begin to see the benefits of making recordkeeping a habit!
53
Why Are We Focusing on Emotions?
54
In the next two chapters, we will explore the purpose emotions serve
in our lives, and what makes up an emotional experience. You will
be introduced to ways in which you can begin monitoring your own
emotional experiences as they unfold, as well as the ways in which
you respond to these experiences. Finally, you will see how we learn
from our emotional experiences, and how this can influence how we
respond to experiences the next time around.
Fear
55
In this situation, it is clear that fear motivated you to escape from the
situation more quickly than you otherwise could have if you stopped
to think about it, and it is fear that kept you and your friend alive.
These are natural reactions, and they often happen outside of aware-
ness. That is, humans do not consciously think about moving out
of the way—it just happens. Imagine what would have happened
without the sensation of fear, or the automatic response to it. You
might not have registered that you and your friend were in any
danger at all. Or, without that automatic EDB, you would be left to
debate over what to do next, ultimately being run over before you
had a chance to make a decision. So, as we can see, the uncomfort-
able or “bad” emotion of fear is actually a protective mechanism to
keep us from getting hurt.
Sadness/Depression
56
Again, our emotions are telling us something about our situation
and helping us to do something useful. Sadness signals us to narrow
our focus onto something that is important to us, giving us time to
shut out the rest of the world so that we can “come to grips” with a
loss and gather our strength to move on. Sadness also signals to
others that we may need support and comfort, so that we may have
time to heal. So, here again, the uncomfortable or “bad” emotion of
sadness serves an important function in our lives.
Anxiety
Anger
57
mobilize efforts to defend oneself or a loved one. Anger is often
directed at the perceived source or cause of this threat (or feeling).
Imagine that you discover your utility company has been charging you extra fees for
services you aren’t using. When you call the utility company for an explanation, you are
told by the customer service representative that these “hidden” extra charges have begun to
incur late fees, and you now are expected to pay the utility a large amount of money—
money you not only don’t have, but also is needed to pay for food and rent for your
family. You angrily demand to speak to the customer service manager, demand an
explanation, and demand the charges be reversed.
58
are important to have in our lives, that we need all of our emotions,
and that we don’t necessarily want them to go away.
What Is an Emotion?
________________________________________________________
________________________________________________________
59
What thoughts might someone have when they are afraid?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
60
identify the physiological sensations that might accompany the
following states:
What physical sensations come with feeling excited?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
61
your experience, to remind you to pay attention to your thoughts,
feelings, and behaviors as interacting components of what might
otherwise seem like an overwhelming or confusing experience.
A sample, completed model is shown in Figure 5.1.
Summary
Homework
62
Physical sensation/Feelings
(What I’m feeling)
ANXIOUS, SCARED
FRUSTRATED, NAUSEOUS
TENSE
Figure 5.1
Sample Three-Component Model of Emotions
63
64
Three-Component Model of Emotions
Physical sensation/Feelings
(What I’m feeling)
Self-Assessment Quiz
Answer each of the following by circling true (T) or false (F). Answers
can be found in the appendix.
65
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Chapter 6 Recognizing and Tracking Your
Emotional Responses
Goals
Homework Review
Did you complete your OASIS and ODSIS for this week? Did you
plot your scores on the Progress Record chart? In the previous chapter,
we added a new recordkeeping form—the Three-Component Model
of Emotions form. What did you notice when you broke down an
emotional experience this past week? Were you able to identify what
you were thinking? What you were doing? What you were feeling? If
you did not complete the Three-Component Model of Emotions
form, go back and complete the form using a recent emotional experi-
ence before reading further. What did you notice when you broke
down your experience in this way? Did you notice ways in which your
thoughts may have led to certain behaviors, or affected the way you
felt, which in turn may have contributed to more thoughts? See if you
can begin to identify a cycle—how does each circle (thoughts, feel-
ings, and behaviors) influence the others, and vice versa?
Key Concepts
67
to these emotions, and what the consequences are of these responses.
You will also see how we learn from our emotional experiences, and
how these experiences can influence our behaviors and actions.
68
Example of the ARC of Emotions
In this imaginary scenario, the “A” is the presentation. The “R” is all
of the components of the emotion you experienced, such as the per-
fectionistic behaviors prior to the talk, as well as the physical sensa-
tions, thoughts of inadequacy and failure, and negative evaluations
of the audience’s response during the talk. The “C” is concluding
that you are incapable of making a good presentation, and finding
excuses to avoid giving future presentations.
The ARC you identify in any given situation may vary depending
upon what causes you as an individual the most discomfort or dis-
tress. Let’s look at this example in another way.
Let’s say the biggest source of distress for you personally is the poten-
tial for being negatively evaluated by others. Your ARC might look
something like this:
69
delivering a perfect talk, and therefore avoid attempting again
in the future (a long-term consequence)
Alternatively, let’s say your biggest source of distress is the fear of
having a panic attack and not being able to escape the situation.
Your ARC might look something like this:
70
As you can see, the As in these different scenarios did not change,
but depending upon what is most salient, distressing, or important
to you, your response might be very different from someone else’s in
the same situation. Beginning to monitor what triggers emotional
experiences, as well as how you respond to these experiences and the
consequences of those responses, will aid you in understanding why
your emotional experiences end up the way they do (be they intense,
overwhelming, distressing, etc.). It will also start you on the way to
identifying where things might be going wrong, and what you might
do differently to be able to manage and cope better. As mentioned,
as you move through this program we will guide you toward exam-
ining your experiences more closely, but for now the most important
thing for you to do is to begin paying attention and monitoring
the ARC of your experiences. The Monitoring Emotions and EDBs
in Context form on page 79 is a helpful way to begin recording
the ARC of your experiences. Use this form along with the Three-
Component Model of Emotion form, challenging yourself to record
at least one or two emotional experiences, identifying the triggers,
responses, and consequences of your responses. A sample Monitoring
Emotions and EDBs in Context form is shown in Figure 6.1.
71
72
R
A C
Response
Antecedents Consequences
Date/
Situation, Triggers Thoughts Feelings Behaviors What happened next?
Time
Late to doctor They’re going to Anxious, frustrated Gave up and drove I was mad at myself for
Mon appointment think I’m so back home; drove missing the appointment
incompetent, why fast and cursed at
can’t I get my act other drivers
together
Husband quiet after work He’s tired of being Sad, scared, Kept asking him if Husband got irritated at me,
Tues with me; he’s mad anxious he was ok I got upset
that I am not
working
Wed Looked through want-ads I can’t do this, I’ll Anxious, sad, Stopped looking Got mad at myself for not
never find another frustrated and cleaned the looking for a job
job, no one is going house instead
to want to hire me
Thurs Sister called sounding She isn’t happy, I’m Helpless, anxious, Tried to fix it for Couldn’t fall asleep, mind
upset not a good sister, sad, agitated her, paced around was racing
I’ve failed her
Fri Dinner party with friends I hope everyone is Anxious, stressed Couldn’t stop Feel like I didn’t even talk to
going to get along, out fussing, kept asking anyone because I was so busy
what if they don’t everyone if they worrying about everyone
like the food, what were ok
if the food isn’t
ready on time
Figure 6.1
Monitoring Emotions and EDBs in Context—The ARC of Emotions
experiences in this way, the better you will become at identifying the
what, when, and where of your emotional experiences.
See if you can identify the ARC of a recent emotional experience you
have encountered:
2. R – What was your response? What thoughts did you have? What
physical sensations or feelings did you notice? What did you do?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
_________________________________________________________
73
Learned Behaviors
74
grabbing the handle of the pot that burned you before, but also
hesitate before grabbing other pans off the stove. Even further, it’s
not just pans on your own stove you hesitate to touch, but pans on
any other stove you may come across, like the stove at a friend’s or
relative’s house.
You may be thinking, this is great, but what does this have to do
with my symptoms? The important thing to understand here is that
we have the ability to quickly learn and alter our behavior in response
to unpleasant emotional experiences. For the most part this is adap-
tive, such as avoiding getting burned again by touching something
hot on a stove—but this might not always be the case. What about
giving in to the EDB of escape by leaving a crowded event every
time we feel panicky, even if being at the event itself is important to
us? What about altering our behavior to avoid the possibility of an
unpleasant experience like contracting germs on a train by refusing
to take public transportation? Or how about altering our behavior to
avoid the unpleasant emotion of embarrassment by avoiding all
social gatherings? Sometimes we interpret our emotions as guiding
us away from a threatening situation that might not even be there,
and our responses in turn become maladaptive instead of adaptive.
Part of the aim of this program is to help you make the distinction
between what is a real threat and what is a perceived threat, allowing
you to better understand when and how emotions should guide you.
We will discuss all of this in more detail in upcoming chapters, but
for now the important thing is to begin paying attention to how we
learn from our emotional experiences.
75
weekday afternoon instead. If you are trying to write an essay and
you don’t want to face the possibility that you can’t think of what to
say, you may clean the house or watch TV rather than starting to
write. Similarly, if you don’t want to experience a panic attack, you
may walk to work instead of riding the train.
76
What about something you have learned to do to experience
something good? What was the experience that influenced you
in this case?
_____________________________________________________
_____________________________________________________
______________________________________________________
Summary
Homework
77
Self-Assessment Quiz
Answer each of the following by circling true (T) or false (F). Answers
can be found in the appendix.
78
Monitoring Emotions and EDBs in Context—The ARC of Emotions
R
A C
Response
Antecedents Consequences
Date/
Situation, Triggers Thoughts Feelings Behaviors What happened next?
Time
79
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Chapter 7 Learning to Observe Your Emotions and
Your Reactions to Your Emotions
Goals
Homework Review
Did you complete your OASIS and ODSIS for this week? Did you
plot your total scores on your Progress Record chart? In the previous
chapter, you were also introduced to the Monitoring Emotions and
EDBs in Context form. Did you record your experiences over the
past week? Once again, remember that it is vital for your success in
this program that you continue to monitor your experiences in the
ways described. This helps you to develop an objective understand-
ing of the triggers of your distressing or uncomfortable emotional
experiences, the symptoms, thoughts, and behaviors that are most
typical during these experiences, and the cycles that might be esca-
lating your distress. As we pointed out in Chapter 3, it helps to stand
outside the bowl of gelatin rather than wallow in the middle of it.
If you have not completed your records, we recommend that you
spend at least a couple of days completing them and rereading the
previous chapter before continuing on.
81
If you did complete your records, look to see if you notice any
patterns. What seem to be typical events that trigger uncomfortable
or distressing experiences for you? What are typical thoughts and
behaviors you noticed when distressed? Do you notice any common
themes in your thoughts or common behaviors when you’re anxious,
depressed, or upset? Continuing to ask yourself these types of ques-
tions will help you gain a full and objective understanding of the
nature of your reactions.
Key Concepts
The key concepts of this chapter are learning ways to become more
aware of emotional experiences as they unfold, and to see how these
experiences fit with what is going on in the present moment. You
will learn strategies for increasing your awareness of how thoughts,
physical sensations/feelings, and behaviors work together to make
up emotional experiences. You will also learn how to identify your
reactions to emotions, or judgments about emotional experiences,
and ways in which these reactions might play a role in your symp-
toms. You will also learn and practice skills to help you step out of
your emotional experiences in order to look at them as if you were
an outside observer, to identify what aspects of your experience are
core, adaptive emotions that are there to convey important informa-
tion, and what aspects are judgments or negative reactions to your
experience. Finally, you will learn how to see whether your experi-
ence actually fits with what is happening in the current moment.
82
how to look at your experience from the outside. Emotion awareness
does not simply mean focusing on your emotions. You may feel right
now that you are keenly aware of your emotions, that you already
know you are anxious or depressed or even frustrated. You might feel
like being aware of your emotions is not the issue, but rather that
your emotions are overwhelming to you, or they seem confusing, or
that you don’t have any control of your emotions, or that they seem
to just “happen” automatically. What you might not be aware of,
however, is that your emotional experiences evolve out of the ongo-
ing interaction of your thoughts, physical sensations/feelings, and
behaviors, and that this interaction can influence the intensity, the
duration, even the overall emotional tone of your experience, and
can play a large part in both generating and maintaining your symp-
toms. When we speak of emotion awareness in this treatment, we
are referring to the skill of stepping out of the cycle of interacting
thoughts, feelings, and behaviors, in order to view your experience
objectively. Only in this way are you able to disentangle what part
of your experience really fits the situation you are currently in, and
what part of your experience is the result of less-than-helpful pro-
cesses like catastrophic thinking or maladaptive behaviors (concepts
we will discuss in more depth in Chapters 8 and 9).
You can think of it this way: When you have an emotional response,
such as fear, in reaction to something happening around you, or
even something happening internally like a physical sensation, this
initial emotional response is not in and of itself problematic. As we
have discussed, emotions are there to serve a purpose, and at their
core they are adaptive. This initial emotion of fear is there to alert
your attention to something potentially threatening to you. However,
your emotional experience does not end at this initial triggered emo-
tion of “fear.” Rather, a whole host of associated and interacting
thoughts, feelings, and behaviors come about as a result of this ini-
tial emotion. These responses are the reactions to your emotions and
play a large role in the lives of people with emotional disorders.
Basically, these reactions are there to help you evaluate the initial
message and decide what to do about it, and as such are intended to
be helpful and useful. For example, when we experience fear, we
are being alerted to something that may be potentially threatening.
We can evaluate this message, and if we determine that the current
83
context does not actually present a threat, we recognize this initial
fear response as a false alarm, at which point the fear will begin to
fade. Alternatively, our fear may motivate us to act quickly, preserv-
ing our safety in a threatening situation (and thus serving a very
important function). We can evaluate this message and, after deter-
mining that the threat is no longer present (we are safely out of
harm’s way), recognize the emotional response as having been help-
ful but no longer necessary, at which point the fear will also begin to
fade. We may also see that the accompanying sensations like our
racing heart and sweaty palms were all a part of the response that
helped us get out of the way, and therefore also served a purpose that
is no longer needed, at which point the sensations will also begin to
fade. However, whereas these secondary reactions are intended to be
adaptive, they can become problematic and maladaptive, particu-
larly if these evaluations become critical, catastrophic, or judgment-
laden (e.g., “I can’t cope” ), or are not accurate reflections of what
is actually happening in the current context. Whereas we may be
keenly aware of our initial emotional responses, such as fear, we may
be less aware of these secondary reactions to the fear, or when these
reactions cross the line from being helpful to extremely unhelpful.
84
you that you feel you need to leave the area. The next day, instead of
crossing this same street again and risking the experience reoccurring,
you walk a different way, even if it will take much longer to meet your
destination. Figure 7.1 illustrates how these reactions might unfold.
85
86
Feeling (what I’m feeling)
FEAR
RACING HEART, SWEATY PALMS
HEART BEATING FASTER,
SHORTNESS OF BREATH
ANXIETY, PANIC
MORE ANXIETY
Figure 7.1
Sample Three-Component Model of Emotions
be important to us, we become able to stop the vicious cycle of inter-
acting thoughts, feelings, and behaviors, before it has a chance to
run away with us.
See if you can identify some of your own reactions to a recent emo-
tion-provoking experience you’ve had:
87
and letting reactions to them come and go without trying to reduce
them, change them, or deem them good or bad, and without trying
to run away from them.
88
actually going on right now. Instead, our reactions to our emotions
are oftentimes rooted in what has happened in the past, or what we
think might happen in the future. Emotions may trigger memories
about what happened the last time we felt this way and/or may start
us speculating about what is in store for us or what lies ahead. Pretty
soon, we’ve lost all touch with what is going on right in front of us, in
the here and now, and are instead somewhere far away in the past or
future (“This is what happened the last time” or “This is what is
coming next”). We no longer see the emotional experience for what it
truly is—thoughts, feelings, and behaviors unfolding in the here and
now. We may have learned something from our experiences in the
past, but what happens in this moment will never be exactly identical
to what has happened before. Similarly, we may have ideas about
what might happen in the future, but we can never be 100%
certain—and, therefore, the information right in front of us is the
only accurate information we have. Importantly, if we are focused on
the past and/or the future, we tend to miss out on very important
information that is right in front of us. In order to understand our
emotions and what they are trying to tell us, we need to become more
aware of our emotional experiences as they are happening right now.
To put our emotions in the proper context, we need to get out of the
past and the future, and anchor ourselves in the present moment.
For example, suppose the last time you rode on a train you had a
panic attack. As we have discussed previously, you learn from your
experiences, and particularly from experiences that bring up intense
emotions. You may have experienced a great deal of anxiety and fear
as a result of the panic attack in the past. You remember that when
that panic attack occurred, the train was very crowded and you felt
like you couldn’t breathe.
Now let’s say you are riding the train in the present moment. The
train stops at a busy station and several people begin to crowd
onboard. You remember that the last time this happened you had a
panic attack. You feel a sharp twinge of fear race through your body
and your heart begins to beat stronger. Your mind begins to race and
your anxiety begins to build. You become convinced that you are
going to have another panic attack, and tell yourself that this time it
will be even worse than before, and worry that this time you might
even pass out.
89
At this moment in time, your fear is triggering memories of a past,
distressing situation in which you had a panic attack. Your fear is
also triggering catastrophic thoughts about the future, in which you
imagine having an even worse experience, one you are not sure you
can cope with. What you are not aware of is that at this moment,
your fear is only associating, or matching a present situation with a
past memory. There is no real and present danger at this moment,
and in fact it is actually a false alarm. By staying in the past and the
future, you miss out on the reality of the present moment, in which
you are not actually having a panic attack, are not in any real or pres-
ent danger, and in fact are nearing your destination. Importantly,
when you reach your destination, if your mind is still stuck in the
past and the future, you may think that you narrowly escaped the
inevitable panic attack this time, but it is sure to happen the next
time. A more accurate reflection on your current situation however,
is that you successfully rode a packed train to your destination with-
out having a panic attack.
90
at this very moment. When we pay attention in this way, we become
fully rooted in present reality, and the choices that are available to us
right now. Only then can we allow new learning and new reactions
to uncomfortable emotions (e.g. “I can cope with this”) to occur.
Being mindfully aware of the present moment does not come natu-
rally to many of us. In can be particularly difficult to anchor our-
selves in the present in this way when we are feeling agitated or
distressed. Learning to pay attention to our experiences, observe
them objectively, nonjudgmentally, and with acceptance and under-
standing as they are in the moment, is not something that happens
overnight. You can think of this skill as developing a new muscle,
and developing muscles takes practice. If you want to run the Boston
Marathon, you don’t just enter—you train and practice, struggling
a bit at first, until running long distances comes naturally to you.
The same holds true here. Learning to observe your experiences as
they are unfolding in the present moment, evaluating what aspects
are helpful and what aspects are not so helpful, and making changes
accordingly, takes a bit of practice before it can become automatic.
It is a skill that should be practiced throughout this treatment, and
used to help you as you move through each subsequent treatment
chapter, looking more closely at how your patterns of responding
within each of the domains of thoughts, behaviors, and physical
sensations/feelings might be contributing to your symptoms.
91
used to observing your experience. Use the Nonjudgmental, Present-
Focused Emotion Awareness form at the end of the chapter to help
you chart your progress and stay on track with your practice.
A sample completed form is shown in Figure 7.2.
Figure 7.2
Sample Nonjudgmental, Present-Focused Emotional Awareness Form
92
Nonjudgmental Emotion Awareness Exercise
The first time you go through this exercise (adapted from Segal,
Williams and Teasdale, 20021), pause between sections and record
what you notice. This will help you get a better sense of how this exer-
cise works. After you have gone through the exercise from start to
finish at least once, try practicing the whole exercise without interrup-
tion, recording what you notice only at the very end of the exercise.
Close your eyes and get settled in your chair. For a moment now, turn your attention to
yourself in the room. Picture the room—imagine what the room looks like, what is in the
room, where the furniture is laid out. Now picture yourself sitting inside the room and exactly
where you are. Notice how it feels to be sitting in the chair. Begin to observe how your body
feels, and any sensations that are there. Notice any physical reactions you may be having in
this moment. Pause for a moment, and just allow yourself to observe your physical sensations.
________________________________________________
________________________________________________
________________________________________________
________________________________________________
Slowly bring your attention to your own breathing. Notice yourself breathing in and
breathing out. Focus on your breathing as it is happening right now, in this moment, using
your breath to help anchor yourself to the present moment. Focus on the sensation of your
breath entering your body, then leaving your body. Your breath is always with you, and
your breathing is always happening in the here and now. Use your breath to remind you to
pay attention and observe what is happening right now. Pause for a moment, and just
allow yourself to notice your breath.
________________________________________________
________________________________________________
________________________________________________
________________________________________________
1
Segal, Z.V., Williams, J.M.G., & Teasdale, J.D. (2002). Mindfulness-based cognitive
therapy for depression: A new approach to preventing relapse. New York: Guilford Press.
93
As you stay focused on your breath, bring your attention inward towards your own
thoughts. Notice how your thoughts are constantly changing. Sometimes you think one
way, sometimes you think another. Some thoughts just pass by, others may distract you,
some of them may be hard to let go of. Simply notice what you’re thinking. If you notice
yourself getting caught up in or carried away by a thought, just acknowledge it, without
judgment, and gently try to bring your attention back to observing your thoughts as they
occur, using your breath to help anchor you. Allow yourself to watch your thoughts for a
few moments—and, as you do, notice how they come and go.
________________________________________________
________________________________________________
________________________________________________
________________________________________________
As you take note of these thoughts, start to shift and explore how you’re feeling. Emotions,
just like thoughts, are constantly changing. Sometimes you feel love and sometimes hatred,
sometimes calm and then tense, joyful—sorrowful, happy—sad. Sometimes emotions
come in waves, sometimes they linger; sometimes they are brought on by certain thoughts,
other times they seem to come out of nowhere. Simply acknowledge how you’re feeling in
this very moment. Allow yourself to observe your emotions, without judgment. Notice
how they ebb and flow. Pause for a moment, and just allow yourself to observe your
emotions.
________________________________________________
________________________________________________
________________________________________________
________________________________________________
Continuing to use your breath to anchor you, begin to take note of your entire
experience— how your body feels, what you are thinking, what emotions you are
experiencing. If you notice that you are trying to change your experience in some way,
take note of that, and gently guide yourself back to your experience. Notice whatever
you’re experiencing in this very moment.
94
First time only: What did you notice?
________________________________________________
________________________________________________
________________________________________________
________________________________________________
Using your breath to anchor you, allow your awareness to shift so you can take in what’s
going on around you. Notice the temperature of the room. Notice any sounds occurring
outside the room. Notice any sounds occurring inside the room.
________________________________________________
________________________________________________
________________________________________________
________________________________________________
And, when you are ready, start to bring yourself back into the room. Picture yourself
sitting in this room, picture the way the room looks, how the room is laid out. When you
are ready, come back into the room and open your eyes.
LINDA: I notice that made me really uncomfortable! I don’t like just sitting
still—it makes me feel too anxious.
THERAPIST: So being still and focusing on the present brings up some distress for
you?
95
THERAPIST: So it sounds like some thoughts came into your mind, and you had
some reactions to those thoughts, like you didn’t want them to be
there?
LINDA: Yes, definitely, but I think I was focusing more on trying not to
think about them.
LINDA: Well, at first I just felt sort of silly, and then I felt sort of tense when
I started thinking about things.
THERAPIST: So you noticed some behaviors that went along with this, as well—
some fidgeting.
96
As you can see by this example, doing this exercise the first time
around may feel a little strange, or you may feel like you are not
doing it right. Remember that the goal of this exercise is not to do it
perfectly—the goal is to begin to learn how to observe and be aware
of your own experience, to understand how the whole process
unfolds for you. This will help you to begin to see where your emo-
tional experiences might be changing from something adaptive and
helpful, to something maladaptive and unhelpful.
97
your own breath. Your breath is with you wherever you go, and is
always happening in the present moment. Whether you use your
breath or some other type of cue, make sure it is something you can
use easily and quickly to remind you to anchor in the present. Once
you have identified something that works for you as your reminder
cue, practice pairing this with something sensory that brings your
attention to the present, something that is going on around you.
This can be a sound that you hear, something that you see, or some-
thing you can physically feel (like a chair, a computer keyboard, a
dish sponge). So, for example, at any given point in the day you
might take a deep breath (your cue) and listen to the sounds from
the street outside, or the sounds in the room. Or, you might take a
deep breath and turn your attention to the way the keys of your
computer keyboard feel under your fingertips. The goal of this exer-
cise is not to think about the meaning of what you notice, nor is it
to try to understand your reaction to it. The first purpose of this
exercise is simply to practice paying attention to what is going on
around you at that moment, bringing yourself “out of your head”
and into the present.
98
How effective were you at
anchoring yourself in the present?
What did you notice?
0 – 10
(not at all) (extremely)
Mon
Sound of wind blowing leaves on the 6
trees
Wed
Feeling of the keys on the keyboard 6
while I was typing an email
Figure 7.3
Sample Anchoring in the Present Form
To help you learn this skill, practice anchoring yourself to the pres-
ent at least once per day by noticing at least one thing going on
around you. Record what you notice on the Anchoring in the Present
form provided at the end of the chapter. This form should be used
to track your success at anchoring in the present, and to get you in
the habit of using this strategy every day. Remember, the goal of this
exercise is not to think about the meaning of what you notice, nor
is it to try to understand your reaction to it. The purpose of this
exercise is simply to practice paying attention to what is going on
99
around you at this moment. Also record any thoughts, feelings (phys-
ical sensations), or behaviors that you may have noticed. A sample
completed Anchoring in the Present form is shown in Figure 7.3.
Summary
Homework
100
yourself to become more familiar with observing your
experience. Use the Nonjudgmental Present-Focused Emotion
Awareness form to record your experience.
101
Self-Assessment Quiz
Answer each of the following by circling true (T) or false (F). Answers
can be found in the appendix.
102
Nonjudgmental, Present-Focused Emotional Awareness Form
Set aside a time, at least once (or even twice) per day, to deliberately practice nonjudgmental present-
focused awareness. The goal of this exercise is to get used to paying attention to what is happening inside
and around you in the moment, observing your thoughts, physical sensations/feelings, and behaviors.
Practice acknowledging thoughts and feelings just as they are, letting go of the need to critically judge,
change, or avoid your inner experience. With increased practice, these techniques will become more auto-
matic and eventually can become a skill used at any time throughout the day and in any situation.
Physical Sensations/ 0 – 10
Practice Thoughts Behaviors
Feelings (not at all) (extremely)
1.
Sun
2.
1.
Mon
2.
1.
Tues
2.
1.
Wed
2.
1.
Thurs
2.
1.
Fri
2.
1.
Sat
2.
103
104
Mood Induction Recording Form
The purpose of this exercise is to practice noticing the thoughts, physical sensations/feelings, and behaviors that come up during an emotional
experience. Try to find music and/or songs that bring up strong emotions for you. As you listen, note your reactions to the music and/or the songs
you have selected. Use this form to record what you noticed after listening to each piece. What was your first emotional response? How strongly
did you feel these initial emotions? What was your reaction to this initial emotional response—what thoughts, sensations, or feelings did you
experience? Rate the intensity of your emotional experience using the 0–10 point scale below:
0 1 2 3 4 5 6 7 8 9 10
Not at all A Little Moderately Quite a Bit Extremely
Intensity of
Initial Emotional
Emotional Reaction to Emotional Response
Response
Response
Rate how
Describe behaviors
Describe emotions you strongly you Describe sensations or
Song Name Describe thoughts (e.g., fidgeting,
experienced felt these feelings
pacing, sighing)
emotions
Feeling (what I’m feeling)
At least once per day, practice anchoring yourself to the present by noticing at least one thing going on
around you. This can be a sound you hear, something you see, or something you can physically feel (like
your chair, a computer keyboard, a dish sponge). You can use your breath to help anchor yourself to the
present moment. The goal of this exercise is not to think about the meaning of what you notice, nor is it
to try to understand your reaction to it. The purpose of this exercise is simply to practice paying attention
to what is going on around you right now. Also record any thoughts, feelings (physical sensations), or
behaviors that you may have noticed.
Sun
Mon
Tues
Wed
Thurs
Fri
Sat
106
Chapter 8 Understanding Thoughts: Thinking the Worst
and Overestimating the Risk
Goals
Homework Review
Did you complete your recordkeeping for this week? Did you
plot your OASIS and ODSIS scores on your Progress Record chart?
In the previous chapter, we introduced three new forms—the
Nonjudgmental Present Focused Emotion Awareness form, the
Mood Induction Recording Form, and the Anchoring in the Present
form. Did you try formally practicing nonjudgmental, present-
focused awareness this week? Remember, even if this exercise feels
difficult or awkward at first, practicing it a few times will allow you
to become more comfortable with the idea of observing your
thoughts, feelings, and behaviors, in an objective way. The point is
not to do it perfectly, but to try it enough times to allow yourself to
become more comfortable with observing your experience, without
trying to solve your problems, control your thoughts, or do any-
thing beyond noticing in an objective way. If you did not practice
this at least three times over the past week, go back and try again
before moving on to this chapter.
Did you try anchoring in the present this past week? What did
you notice? What seemed to bring your attention to the present
107
the best? Sounds? The way something felt? Tastes? Did you take a
breath, or do something else to help remind you to anchor in the
present? Practicing anchoring yourself to the present at least once
per day is important for making this skill more automatic. If you did
not try this exercise, spend the next few days practicing anchoring
in the present, at least once per day, before moving forward with
the program. Remember, you are trying to get better at stepping
outside the gelatin instead of wallowing in it. These skills will help
you to do this.
Key Concepts
Cognitive Appraisal
108
you interpret or appraise a situation can vary—from which particu-
lar aspects of a situation you focus on, to how much meaning you
assign to events or experiences. The different ways you interpret or
appraise situations have important consequences for how you feel.
There are also a number of different ways in which the aspect you
focused on can be interpreted or appraised. For instance, you might
interpret your boss or teacher pointing out something you could
improve on as indicating failure (e.g., “Because my boss pointed out
I need to improve my eye contact, I really blew that talk”), or you
might interpret the feedback as constructive criticism (e.g., “The
talk went really well. Next time I can make it even better by improv-
ing my eye contact”).
109
experiences from the past to help us interpret or appraise current
situations, and will often use these interpretations and appraisals to
project what might happen in the future. Importantly, as we will
discuss in greater detail later, these different appraisals will all have
quite different consequences for our emotions, including what we
do and how we feel.
110
Figure 8.1
Ambiguous Picture
111
Looking At Your Interpretations
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
What factors contributed to your automatic interpretations (e.g., past experiences, memories, specific
aspects you focused on in the picture, etc.)?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Generate some alternative interpretations about what the picture might mean (come up with at least 3
alternatives). If your first, automatic interpretation was a negative one, see if you can come up with a
positive interpretation. Conversely, if your first, automatic interpretation was positive, see if you can come
up with a negative interpretation. Practice being flexible with your interpretations.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
112
Notice how different interpretations, or appraisals, are associated
with different emotions and even different behavioral responses.
This illustrates a really important concept—that our appraisals can
actually influence our emotional experience. Our appraisals can even
influence how we respond behaviorally to the event, or in the situa-
tion itself. For people experiencing emotional disorders, this process
can become problematic.
Now, how might you interpret the picture if you were feeling really
sad or down? What about if you were feeling excited or happy? Just
as your appraisals can influence your emotions, how you are feeling
can also influence how you interpret or appraise situations or events
in your daily life. This fact is part of what helps maintain some of
the difficulties that people with emotional disorders experience, as
we will discuss.
During this exercise, people are often surprised at how many addi-
tional interpretations they can come up with, despite the fact that
their initial interpretation came so quickly. This is just what we do
in our daily life. Events that occur, or situations we find ourselves in,
are immediately and often automatically (without our awareness)
interpreted. These initial interpretations, or automatic appraisals, can
play a key role in determining our emotional experiences.
Automatic Appraisal
113
such threats. However, this natural adaptive process can become
problematic.
THERAPIST: So, you were invited to a party by some of your friends at the
office?
SARAH: Yeah, and I told them that I would go. I went shopping earlier in the
week and bought a new outfit for the party and everything. But
then, right before the party, when I was getting ready to go, I started
to freak out.
THERAPIST: What did you notice while you were getting ready for the party?
SARAH: I began to feel a little nauseated, and I noticed that my heart was
beating fast. I was starting to sweat while I was putting on my
makeup.
114
THERAPIST: Okay, so you noticed some physical sensations associated with your
anxiety. What thoughts did you notice while you were getting ready
for the party?
SARAH: Well, I guess I was worrying about how the party would go.
I was worried that I wouldn’t have anything to say. It got so bad, that
I called my friends and told them I couldn’t make it.
THERAPIST: You were so worried about not having anything to say that you called
your friends to cancel?
SARAH: Yeah. I was so anxious, I couldn’t bear it. I didn’t really feel any better
staying home, though. I felt horrible. I just sat on the couch and got
angry at myself for not going.
THERAPIST: It sounds like you were quite anxious about not having anything to
say while you were at the party. I’m curious, what would happen (or
what would it mean about you) if you didn’t have anything to say?
SARAH: Well, I guess if I didn’t have anything to say, people would think I
am boring.
THERAPIST: And what would happen if people thought you were boring?
THERAPIST: Ok, so you are concerned that your friends will think you are boring,
and then you won’t get invited to parties in the future. If that were
true, what would happen next?
SARAH: I would lose all my friends and then I would be alone forever.
In the preceding example, Sarah initially identified that she was con-
cerned she would not have anything to say while at the party, which
she felt led her to end up calling her friend and not going to the
party. However, Sarah’s behavior seems like a quite extreme reaction
to the fear of not having anything to say. In discussing it further with
the therapist, Sarah was able to identify her core automatic appraisal
that was driving the intensity of her emotional response. Namely,
that people would think she is boring and she would lose all of her
friends and be alone forever. It is important to recognize that this
appraisal would make almost anyone anxious, and would make it
very difficult to actually attend the party.
115
As discussed earlier, we are not always aware of what we are telling
ourselves. Sometimes our appraisals can become so well learned that
they can actually occur automatically, without our full awareness. It
is important to identify exactly what we are telling ourselves about a
situation, which we call our core automatic appraisal, in order to
understand our emotional response and react in a way that will be
more helpful for us in the long term, instead of reacting in direct
response to the intensity of our emotions. One technique that can
be helpful for identifying our core automatic appraisal is the
Downward Arrow Technique. In order to do this, it can be helpful
to ask ourselves questions, similar to those the therapist asked Sarah:
“What would happen if X were true?”; “What would happen next?”;
“If X were true, what would it mean about me?”
Now, let’s practice this new skill. First, choose a few examples from
your Monitoring Emotions and EDBs in Context forms from the
previous weeks. Think back to those events and look at the thoughts
that you were able to identify at the time. Do you notice any discon-
nects between your behavior in the situation (e.g., avoidance) and
the automatic appraisal you identified (e.g., “I won’t have anything
to say to people”)? Oftentimes the initial, automatic appraisals we
identify tell us only part of the story. Try using the Downward Arrow
Technique worksheet to identify some of your core automatic
appraisals from your previous homework forms. A sample completed
worksheet is shown in Figure 8.2.
116
Automatic Appraisal: I won't have anything to say.
If this were true, what would it mean about me? Why does this matter to me?
What would happen if this were true? What would happen next?
If this were true, what would it mean about me? Why does this matter to me?
What would happen if this were true? What would happen next?
Underlying Appraisal: If I don't have anything to say, I won't get invited to parties anymore.
If this were true, what would it mean about me? Why does this matter to me?
What would happen if this were true? What would happen next?
Underlying Appraisal: If I don't get invited to parties anymore, I will lose all my friends.
If this were true, what would it mean about me? Why does this matter to me?
What would happen if this were true? What would happen next?
Underlying Appraisal: I will lose all my friends and I will be alone forever.
Figure 8.2
Sarah’s Downward Arrow Technique
117
Downward Arrow Technique
If this were true, what would it mean about me? Why does this matter to me?
What would happen if this were true? What would happen next?
Underlying Appraisal: _______________________________________________________________
If this were true, what would it mean about me? Why does this matter to me?
What would happen if this were true? What would happen next?
Underlying Appraisal: _______________________________________________________________
If this were true, what would it mean about me? Why does this matter to me?
What would happen if this were true? What would happen next?
Underlying Appraisal: _______________________________________________________________
Thinking Traps
118
feed into emotions such as fear, anxiety, depression, or anger, often
making our emotions feel more intense, or perhaps even “out of
control.” To illustrate this, it might be helpful to go back to the
imaginary scenario from the beginning of the chapter, in which you
receive feedback from your boss or teacher on a presentation you’ve
made. Of course, if you do poorly on an assignment at work or
school, it is often useful to use feedback from a supervisor or teacher
to help focus on where you went wrong (rather than other aspects of
your performance), in order to help improve your performance in
the future. This is an example of how filtering out information can
be adaptive and helpful. However, this becomes a problem when
you continue to filter out additional information and exclude other
possible appraisals of a situation, such as all the things you did right,
the fact that your overall performance was very good, or that the
mistake you made was a very understandable error. In such instances,
focusing only on what you did wrong excludes other important and
meaningful information concerning your positive accomplishments.
Such filtering may lead to feelings of sadness or helplessness and, in
turn, thoughts like “I’ll never do anything right.” Thus, both our auto-
matic appraisals and our feelings maintain the cycle of emotions—
our appraisals influence how we feel, and our feelings influence the
future appraisals we make.
119
or no evidence to support that interpretation. Similarly, you
may ignore evidence that would suggest another, perhaps more
likely outcome.
120
of common thinking traps on page 119 to help, try to identify any
examples of probability overestimation from your homework.
121
However, before we get there, it will be helpful for you to first prac-
tice identifying the different kinds of automatic appraisals that you
are making in your daily life. In order to do this, we are going to
begin tracking your automatic appraisals using the Identifying and
Evaluating Automatic Appraisals form at the end of this chapter. For
now, fill in the first four columns only (up to the “Generate Alternate
Appraisal(s)” column). You will be coming back to fill in this last
column a little later, once you have read through the next section.
Cognitive Reappraisal
One way out of these thinking traps is to pay attention to the apprais-
als we have, and evaluate them not as “truths” but rather as one pos-
sible interpretation of the situation. Instead of automatically thinking
Getting ready, about I will have a panic attack, lose Anxiety, Probability
to drive to work control of the car and crash apprehension Overestimation
Figure 8.3
Kevin’s Identifying & Evaluating Automatic Appraisals form
122
that the worst scenario is going to happen, and that when it does we
will be unable to cope, it is important to begin to recognize other
interpretations. Thoughts about the worst-case scenario can still be
there, but they can coexist with other possible assessments of the
situation. Research has shown that being able to identify your think-
ing traps before you encounter situations or events can help make
your emotions feel more manageable and less intense. Before con-
fronting these emotionally provocative situations, it can be helpful
to consider your automatic appraisals within the context of the pres-
ent situation. We call this cognitive reappraisal.
Importance of Nonjudgment
You might notice that you often judge or blame yourself for the
automatic interpretations you make. This is common, but it is also a
barrier to generating flexibility in appraisals because the more you
blame yourself, the more you try to control or eliminate those
thoughts and the more rigid your thought patterns become. It is also
important to practice being aware of automatic appraisals in a non-
judgmental way, noticing the appraisal and allowing it to enter and
pass through your mind, rather than grabbing onto it as the only way
of considering the situation and running with that interpretation.
The point is not to think, “I am so stupid for falling into this trap,”
or to punish yourself for having that thought. Rather, the point is to
be aware of the trap and consider the trap within the context of
the emotion being experienced, as one way of thinking about the
situation. This will allow for increased flexibility in thinking.
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emotion-provoking situations, helps us regulate our emotions, making
them less intense and helping them feel more manageable.
Based on the thinking traps discussed earlier, two strategies are help-
ful in learning to reevaluate automatic appraisals and to generate
alternative appraisals: countering probability overestimation, and
decatastrophizing.
THERAPIST: What are you concerned will happen as a result of having a panic
attack?
KEVIN: Well, they are just so intense and uncomfortable. When they happen,
I’m afraid that they are going to keep going and going, getting more
and more intense until I just drop dead from the panic.
THERAPIST: How many panic attacks have you had in the past?
KEVIN: Ever? Gosh, I’m not sure. That would have to be in the hundreds.
THERAPIST: Ok, so let’s say you’ve had one hundred panic attacks up to now.
How many of those panic attacks have you died from?
KEVIN: Well, none yet. But I just know that if I don’t do something to stop
it, they’re going to kill me!
THERAPIST: How likely do you think it is that your next panic attack will actually
kill you?
KEVIN: I don’t know. I guess it’s a 50–50 chance that I will die as a result of
my next panic attack.
THERAPIST: Ok, so that would mean that for every two panic attacks you have,
one would kill you. Based on your past experience, can you think of
some alternative possibilities for this automatic appraisal?
KEVIN: Well, I guess I’ve had over one hundred panic attacks before, and
some of them have been pretty intense, and I haven’t died yet. So, it
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is possible that I won’t die from the panic attack and it will pass on
its own.
Figure 8.4
Kevin’s Identifying & Evaluating Automatic Appraisals form
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Countering Probability Overestimation—Learning to
Reevaluate Jumping to Conclusions
________________________________________________________________________________
________________________________________________________________________________
THERAPIST: You mentioned that you are afraid that upon meeting someone new
you will become so embarrassed that you will begin to blush
noticeably. What are you concerned will happen if you blush
noticeably?
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SARAH: If I blush, the other person will see how anxious I am and will
completely reject me and devastate me.
THERAPIST: So your core automatic appraisal is that you will blush noticeably and
the other person will completely reject you, which will leave you
devastated and unable to cope. Is this correct?
THERAPIST: Ok. Have you been rejected before? I mean, have other people you’ve
met not hit it off with you?
SARAH: Yeah, I suppose so. Not too often, but it has happened on occasion.
THERAPIST: How have you coped with that in the past when you didn’t hit it off
with someone?
SARAH: Well, I guess I haven’t been too upset. I mean, if we didn’t hit it off, I
wasn’t too upset to not maintain contact with the person. So maybe,
if I don’t hit it off with someone, it’s not such a horrible thing.
THERAPIST: Has there been a time when you were upset or disappointed that you
didn’t hit it off with someone?
SARAH: Yeah. There was this guy that I went on a date with and I really liked
him, but I was so nervous, he never called me again after our date.
THERAPIST: That must have been difficult. How did you feel after that?
SARAH: Well, I was really sad because I liked him and I was a little angry at
myself because I thought that I must have done something wrong.
THERAPIST: Of course you felt sad. That is difficult when we really like someone
and our feelings are not reciprocated, we can feel like it was a missed
opportunity. So when did this happen?
THERAPIST: Last month? So, how would you say you were able to cope with this
situation then?
SARAH: Hmm…well, I guess I was able to cope with it pretty well. I mean, I
hadn’t really thought about it in a while, until you brought it up just
now.
127
THERAPIST: So despite feeling rejected by someone whose company you did enjoy,
you were able to cope with it quite well. In fact, it really wasn’t on your
mind anymore. Perhaps even if you were rejected by the other person,
it wouldn’t be as devastating as you had initially assumed.
SARAH: Yeah, I guess not. I mean, it’s happened before and I’m still standing.
3. So what? _________________________________________
________________________________________________________________________________
________________________________________________________________________________
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Evaluating Obsessive, Intrusive, Nonsensical Thoughts
CLIENT: Well, for example, if I ask myself if I’m 100% sure I’ll molest a child,
I just can’t answer that. I don’t want to, but how can I be sure
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I won’t? And if I ask myself how bad it would be if
I molested a child, or if it would really be so terrible, well of course
it would be terrible!
THERAPIST: Yes, molesting a child would be terrible. But let me ask you this, how
does having these thoughts make you feel?
THERAPIST: And what do you think when you have these thoughts?
CLIENT: That I must be some sort of a monster! That I’m a terrible person,
and that my family should be ashamed of me.
THERAPIST: So, your automatic appraisal is that by having these thoughts, even
though they are offensive to you and go against your own beliefs, you
are a monster? I’m wondering, does having these thoughts also mean
you want to be a child molester?
THERAPIST: So, it sounds like you can have these thoughts, and find the whole
idea incredibly offensive. I’m wondering, would you call someone a
monster who thinks that molesting a child is a horrible thing to do?
130
that, intrusive, and having no real meaning about who that person is
or what that person might do. Others, however, can have the same
thought and interpret the thought as meaning something terrible
about themselves, and as something they will inevitably act on. It is
the interpretation of what these thoughts mean that is the source of
distress, and it is here that the strategies discussed in this chapter
should be used. If you are having these types of intrusive thoughts,
see if you can identify your automatic appraisals about these intru-
sive thoughts, and see if you can generate some alternate appraisals
using the skills discussed earlier.
Summary
In this chapter, we have looked more closely at one of the main three
components of emotional experiences—thoughts. We explored how
thoughts influence emotions, and how emotions influence thoughts,
such that how you think about or appraise a situation will have an
impact on how you feel, and how you feel will have an impact on the
way in which you interpret or appraise a situation. We also discussed
how appraisals can become automatic and can lead to “thinking
traps.” Two common, core thinking traps are thinking the worst
(or catastrophizing) and jumping to conclusions (or overestimating
the probability of a negative outcome). Finally, we discussed ways in
which these automatic appraisals and thinking traps might be ques-
tioned and challenged, allowing for new, alternative interpretations
to arise and increasing flexibility in the way situations are appraised
or interpreted.
131
emotional response and maintain the habitual cycle of emotional
responding that has become problematic for you.
Over the next two chapters, we will look closely at another of the
three components of emotional experiences—behaviors. Specifically,
we will explore maladaptive strategies often used to avoid emotional
experiences in Chapter 9, and discuss emotion-driven behaviors
(EDBs) in Chapter 10.
Homework
Self-Assessment Quiz
Answer each of the following by circling true (T) or false (F). Answers
can be found in the appendix.
132
1. How you interpret or appraise a situation has no effect on your
emotions.
T F
2. Thinking traps become problematic when they are applied
automatically and are not appropriate to current the situation.
T F
3. Our current emotions affect the types of appraisals we make.
T F
4. The goal of cognitive reappraisal is to eliminate incorrect ways
of thinking.
T F
133
134
Goals
Homework Review
Review your scores on the OASIS and ODSIS from the previous
week, and add your data to your Progress Record. Did you monitor
and were you able to identify your automatic appraisals associated
with your emotional experiences this past week? Were you able
to question the evidence and evaluate your ability to cope with
negative events? Remember the goal of evaluating your automatic
appraisals is not to correct “faulty” or “incorrect” ways of thinking,
but to increase flexibility in how you appraise different situations.
If you have not done so, spend the next week closely monitoring and
challenging your automatic appraisals.
Remember, as you go through this treatment each new chapter
builds on the previous chapters. It is important that you give your-
self some time to practice each of the skills before moving on to the
next chapter, as cognitive reappraisal is a very important skill that
will be very helpful for you as you proceed through the rest of this
treatment. Increasing your flexibility in appraising situations by
identifying and then reappraising your automatic appraisals takes a lot
of effort, and might be difficult and even feel artificial or less believ-
able at first. As we discussed before, your current ways of appraising
135
situations are so well practiced that they have become automatic.
This can make them difficult to change. Increasing your flexibility
in appraising situations is like learning a new language. Both require
a good deal of practice. However, over time and with repeated
practice, generating alternative appraisals will become more second
nature, and then you will no longer need to exert the same amount
of effort to alter your anxious thoughts. It will happen naturally.
Key Concepts
Emotion Avoidance
136
might potentially happen. Some people suffering from depression
also report difficulty in allowing themselves to feel positive emo-
tions, seeing themselves as unworthy of the positive experience, or
telling themselves something might be enjoyable now, but will
undoubtedly be followed by some disappointment. Therefore,
people may experience a whole range of emotions, negative and pos-
itive, as uncomfortable or unwanted, and they may develop specific
strategies that enable them to avoid having these experiences.
137
is distressing. Some common examples of cognitive avoidance
strategies are distraction (e.g., reading a book, listening to
music, watching television) and “tuning out” (e.g., pretending
you are not in the situation or not fully engaging in the
experience of being in the situation). Distraction might seem
useful because it keeps our minds from “running away” with
us. But this can also be a form of emotion avoidance. For
example, someone who worries about the safety of loved ones
may watch television or keep busy when loved ones go out
at night. The person is fearful that if they do not distract
themselves and prevent negative thoughts and feelings, they
will become overwhelmed by their anxiety and worry.
Rationalization of problems can also be a form of avoidance
(different from the cognitive reappraisal techniques discussed
previously) if the rationalization is used as an attempt to “push
away” or quickly diminish emotions as they happen. For
example, a person who worries about getting a bad grade on
a paper may desperately try to provide reasons why a bad
grade would not matter, etc. If this strategy is done with the
intention of pushing away or avoiding emotions, then it is an
emotion avoidance strategy.
3. Using “safety signals.” When someone is unable to directly
avoid an emotionally provoking situation, and cognitive
avoidance strategies are not sufficient, they may come to rely
on “safety signals” to keep emotions from becoming
overwhelming. Safety signals are any items that people
carry with them that make them feel more comfortable or help
calm them in times of extreme distress, despite the fact that
these items usually lack any real usefulness in dealing with a
potentially threatening experience. Thus, safety signals can
have almost a magical or superstitious quality to them, and
function sort of like a “talisman.” Some common examples
of safety signals are water bottles, medication (or empty
medication bottles), cell phones, prayer books, pets, or even
small dolls or teddy bears. Sometimes the safety signal can be
another person, or a “safety person.” In this case, someone
who is anxious or distressed may be able to enter distressing
situations as long as their safety person is with them.
138
While using safety signals may seem perfectly harmless, this is
not the case. Relying on safety signals can prevent you from
learning that the situation is not dangerous, as you might
attribute your ability to manage your emotions to the presence
of the safety signal. Furthermore, the presence of the object
(or person) reinforces the idea that uncomfortable, unexpected
emotional experiences are unmanageable and overwhelming,
by sending the message that the only way you can cope with
these experiences is by having your safety signal with you.
So what does this mean? It means it may be time to ditch
your lucky socks, clean out your bag or briefcase, and work
toward facing situations, and their accompanying emotions,
head-on.
For homework, you will use the List of Emotion Avoidance Strategies
form at the end of the chapter to begin identifying the ways you
attempt to avoid uncomfortable emotions. A sample completed
form is shown in Figure 9.1.
For about one minute, try and think about a white bear.
Okay, now for another minute, think about anything you want to,
but absolutely DO NOT think about a white bear.
Again, how successful (or unsuccessful) were you at not thinking
about a white bear?
How frequent and intense were your thoughts when you tried not to
think about a white bear, as compared to when you allowed yourself
to think about it?
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Subtle Behavioral Avoidance Cognitive Avoidance Safety Signals
Keep hands in my pockets in public Tell myself that I’m clean Carry hand sanitizer and
places baby wipes
Cover my mouth and nose with my Carefully replay scenarios to
sleeve generate evidence that I’m
Don’t eat prepared foods unless I not contaminated
can see it being made After getting home, I remind myself
Use plastic utensils at restaurants of how often I washed my hands
Avoid being near people who appear
“dirty” or disheveled
Open doors with tissue
Turn off bathroom faucets with
paper towel
Use extra detergent when washing
clothes
Figure 9.1
List of Emotion Avoidance Strategies
How might this be similar to how you deal with your own thoughts
and emotions related to personal events? Have you ever found
1
Dostoevsky, F. (1988) Winter Notes on Summer Impressions (D. Patterson, Trans.).
Evanston, IL: Northwestern University Press. (Original work published 1863)
140
yourself trying not to think about something distressing? Write
some examples in the space provided:
_________________________________________________________
_________________________________________________________
_________________________________________________________
Now that you can’t get the white bear off your mind, let’s try another
exercise to help with understanding the paradoxical nature of emo-
tion avoidance.
First, pick one of the examples you just wrote down that is difficult
for you to think about. Try to take note of the specific details of the
situation or experience, including any parts of it that may have been
especially emotional. What were you doing? Thinking? Feeling?
Try to remember everything just as it happened. Don’t do anything
to avoid. Just let yourself think about it, holding the memory in
your mind.
Now you get to do it all again. But this time, you should try not to
think about this memory or situation, using any strategies you can
think of. Try as hard as possible not to think about the event for a
short period of time.
141
Summary
Homework
142
Self-Assessment Quiz
Answer each of the following by circling true (T) or false (F). Answers
can be found in the appendix.
143
List of Emotion Avoidance Strategies
The purpose of this list is to begin to identify some of the subtle ways that you may attempt to avoid
uncomfortable emotions. The list will help you later in treatment when you engage in emotion exposures,
so that you can eliminate these counterproductive strategies and ensure that the exposures are as effective
as possible. In the “subtle behavioral avoidance” column, list behaviors that you do that help you feel
better when you are experiencing intense emotions. These include taking medication, doing deep breath-
ing exercises, etc. In the “cognitive avoidance strategies” column, list any techniques you use to feel better
when you are in a situation you cannot physically escape. Some of these strategies include distracting
yourself (by watching TV or listening to the radio), “tuning out” of a conversation with another person,
or trying to force yourself to think of something other than the situation at hand. Finally, in the “safety
signals” column, list anything that you carry with you, or that you do before going out, that makes you
feel more comfortable. This could include carrying a water bottle or medication, having your cell phone
with you, carrying the names of your doctor or other important people, etc. If you have trouble figuring
out which column to put a strategy in, that’s okay. The most important part is that you begin to record
the variety of emotion avoidance strategies you are engaging in currently.
144
Chapter 10 Understanding Behaviors 2: Emotion-Driven
Behaviors
Goals
Homework Review
Did you remember to complete your OASIS and ODSIS this week,
and to plot your scores on the Progress Record chart? In the previous
chapter, we introduced the List of Emotion Avoidance Strategies
form. What strategies did you notice? What are some of the things
you do to avoid your emotions? Do you distract yourself with music
or TV? Seek reassurance from others? Avoid eye contact? Stay away
from crowded places? If you did not complete the List of Emotion
Avoidance Strategies form, take some time now to fill it in. Review
the examples in the last chapter—what are some behaviors you
might use to avoid uncomfortable emotions? What about cognitive
strategies like rationalizing or distraction? What are some safety
signals you have, like only going places with a certain person, or
always making sure you have a bottle of water with you?
Key Concepts
145
emotional experiences. Emotions are closely linked to behavior.
Strong emotions can tell us or “drive” us to engage in specific behav-
iors, sometimes before we even have a chance to think about it. This
is often helpful and adaptive, for instance when we are in immediate
danger (e.g., seeing a car coming straight at us). However, some-
times our EDBs are not consistent with the situation at hand (e.g.,
having the same response when giving a presentation, as we would
seeing a car coming towards us) and these same behaviors, while
relieving us from the experience of intense or uncomfortable emo-
tions in the short term, can actually limit our lives in important
ways, or even be harmful. In this chapter, you will first learn to iden-
tify your own EDBs, and then you will develop new behavioral
responses to your emotions that will be more helpful to the situation
at hand.
146
coming up that you need to prepare for, you might experience
some anxiety that prompts you to prepare for the interview. In this
case, most people would agree that the behavior of preparing for the
interview is adaptive and helpful in managing this situation.
However, if you were to engage in a similar level of preparation for
a social interaction with friends, you could see how this might be a
problem. In the first case, the preparatory behavior would be much
more adaptive than in the second. To take another example, some-
times tennis players or golfers throw or break their racquet or club as
an EDB in response to anger at a bad shot, (and many at least feel
like doing this). While this EDB might relieve or reduce the anger
somewhat, it is clearly not adaptive and always regretted. The ability
to recognize when, and under what circumstances, a behavior should
be considered adaptive or non-adaptive is essential to behavioral
change.
Examples of EDBs
Anxiety
147
Sadness
■ Someone who feels down and depressed stays home for several
days in a row to sleep instead of going to work, even though
they know that there are sympathetic friends at work.
Fear
Anger
148
Coming back to our example of Brian, let’s look at how the therapist
worked with him to identify his emotion-driven behaviors.
THERAPIST: I’m wondering if you can recall a recent event in which you felt
contaminated.
BRIAN: Definitely. In fact, I can give you one that happened while coming
to the session today. While I was in the elevator, this woman standing
next to me started to cough. I immediately turned away from her
and covered my mouth.
BRIAN: Yes. As soon as she started coughing, I noticed myself getting anxious.
My heart started beating fast. Immediately, I had this sudden urge to
get out off the elevator. I felt trapped…I was surrounded by sickness.
I know it sounds stupid but in that moment all I can think of is that
this person has some disease that I’m going to get.
BRIAN: Probably nothing. Hell, it could’ve even been allergies. But in that
moment when she’s coughing, all I can think about is how to get out
of that situation. I guess I worry she might have a bad virus or
something…for a while I was worried about the swine flu. Sometimes
I worry I might even get AIDS, even though I know you can’t get it
that way.
THERAPIST: So, looking back, what behaviors did you notice occurring in response
to your emotions? What behaviors did your anxiety prompt you to
do?
THERAPIST: I see. So your anxiety, or maybe even fear in that situation, prompted
you to escape.
BRIAN: Definitely. We were going to the same floor, so I started watching the
display to see how long it would be before the doors would open and
I could get away from her. In the meantime, all I could do was cover
my mouth with my arm. Actually, I even tried to hold my breath for
a while but eventually I had to breathe.
149
THERAPIST: Okay. Well these are all good examples of emotion-driven behaviors.
The fear you experienced in response to this woman coughing
prompted you to escape form the situation. But because you couldn’t
get out of the elevator immediately, you covered your mouth, turned
away from her, and even tried to hold your breath. You also looked
at the display to see how long the situation would last. It’s almost like
you were just trying to hold on until the situation was over.
BRIAN: That’s how it felt. All I wanted to do was get out of there. And then
when I finally got off of the elevator, I immediately went to the
bathroom and scrubbed my hands. I even put some soap around my
mouth, thinking that somehow this would keep me from getting
sick.
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It is important to understand the function of our behaviors and to
identify both the short- and long-term consequences of engaging in
EDBs. In order to understand the function of your behaviors, includ-
ing whether they are adaptive or not, it can be helpful to reflect back
on situations that elicited strong emotions and closely examine how
you responded behaviorally. Take a recent situation in which you
were feeling strong emotions. What was the situation? What emo-
tions were you experiencing? Take a moment to identify in the space
provided the specific behaviors that were prompted or “driven” by
the emotion itself. Remember to include even more subtle behav-
iors, such as facial expressions, gestures, and even the positioning of
your body.
Situation: ________________________________________________________________________
________________________________________________________________________________
Emotions: ________________________________________________________________________
EDBs: ___________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Now take a close look at the behaviors. What was the purpose or
function of the EDBs? Do they seem reasonable and adaptive, given
the nature of the situation? How did engaging in these behaviors
make you feel? What were the short-term and long-term conse-
quences of these behaviors? Would you have liked to act differently
in response to your emotions? If so, how?
151
it…chances are we’ll be as afraid, if not more afraid than we
were before.
152
is about learning how to fully experience, accept, and tolerate the
full range of emotions, and to learn to respond to your emotional
experiences more adaptively.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Research has found that one of the most effective ways to break the
cycle of emotions, and actually change the way emotions are experi-
enced, is to do something that is completely different than what you
would normally do in response to your emotion. So, for example,
smiling instead of frowning when feeling down has been shown to
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change the way emotions are experienced at that moment. We would
refer to this as choosing an alternative action, or an action that is
opposite or counter to what you’ve done in the past in response to
your emotions. For example, sadness or depression tends to make
people want to withdraw from others, or not do things they nor-
mally enjoy. In this case, adopting an alternative action might involve
talking with friends and going out and doing things. Alternative
action doesn’t always mean that you have to do something big; it can
be something like sitting up straight instead of slouching or trying
to smile a bit when depressed. Some other examples are talking with
someone even though it makes you anxious, or staying on a bus
when you want to escape. Changing how you behave can, over time,
also change how you feel. This concept is not new, and has appeared
in sayings, folk wisdom, and the arts over the ages (for example, the
song “Whistle a Happy Tune” from The King and I, in which the
lyrics suggest whistling whenever you feel afraid).
154
Table 10.1
of the EDBs you would like to change as part of your treatment and
then develop some clear alternative actions that you believe will be a
more adaptive way of responding to your emotions long term.
Summary
Homework
✎ Use the Changing EDBs form at the end of the chapter to help
modify your maladaptive emotion-driven behaviors (a completed
sample is shown in Figure 10.1).
155
✎ Continue to practice the skills you’ve learned up to this
point. For example, it can be helpful to continue practicing
present-moment awareness (refer back to Chapter 7) by using
the Anchoring in the Present form. Similarly, it may be helpful
for you to continuing practicing using flexible cognitive
appraisal strategies (see Chapter 8) using the Identifying and
Evaluating Automatic Appraisals form.
Self-Assessment Quiz
Answer each of the following by circling true (T) or false (F). Answers
can be found in the appendix.
156
New (incompatible)
Situation / Trigger Emotion EDB Consequence
Response
My daughter came to a
Talking with daughter Anxiety, concern for Gave daughter “advice” Tried to listen without similar conclusion on how
about her job my daughter about how I would handle offering advice
the situation. to handle the situation.
Thanked me for listening.
Ask husband for reassurance Tried to be understanding. Husband was much more
Husband expressed Anxiety regarding his job security. Tried to do something positive about his job later
frustration about his job Worry about him losing his active following the that day. Felt good about
job. conversation, rather than being able to shift my
simply worry. attention to other things.
It felt good not to “fight”
Woke up early and was Lie in bed thinking about Got out of bed and went my anxiety and force myself
unable to get back to Anxiety to go back to bed. Enjoyed
things. for a long walk.
sleep. getting some exercise in the
morning and had a
productive day.
Daughter didn’t call me Call to make sure she was She called later that night.
Anxiety Wait until she calls me Nothing bad happened – she
when she said she would okay.
was just too busy to call.
Figure 10.1
Sample Changing EDBs form
157
158
Changing EDBs
New (incompatible)
Situation / Trigger Emotion EDB Consequence
Response
Chapter 11 Understanding and Confronting
Physical Sensations
Goals
Homework Review
Before you start this chapter, review your records from the previous
chapter – the Changing EDBs form, the Identifying and Evaluating
Automatic Thoughts form, and the Anchoring in the Present form.
If you have stopped keeping your records, remember that recording
your experiences is an essential part of this program. Without the
records, you will not be able to evaluate your own reactions or tailor
the strategies you are learning here to your own particular experi-
ence. So, it is really to your benefit to continue the recordkeeping.
You may have noticed this is a point we keep making chapter after
chapter. This is because we know that sticking to any regimen like
recordkeeping can be hard, and being reminded of why you are
doing it can help you to keep at it. If you are still finding it difficult,
see if you can identify what might be standing in the way of your
recordkeeping, and try to make it as easy on yourself as possible.
Find a time each day that works for you, make a commitment to
yourself to use this time to invest in yourself. Make sure you have all
the materials you need (forms, pens, pencils, etc). Tape reminders to
your mirror or set an alarm for yourself every day.
159
In addition, we recommend that you do not continue until you fully
understand all of the material presented in the previous chapters.
If you have questions, either reread the section or ask your mental
health professional for clarification. Since so much of this program
is based on learning new things, it is very important that you fully
understand the reason for everything you will be asked to do.
If you have completed your records, what do you notice about the
previous week? What patterns do you see emerging? Do you see any
relationship between some of your thoughts and some of your behav-
iors? How are your thoughts influencing what you do, and how is
what you do influencing your thoughts? And how are your thoughts
and behaviors influencing the way you feel? Are you able to bring
attention and awareness to the present moment, to get “out of your
head” in order to help you observe your thoughts and behaviors
more objectively?
Key Concepts
The key concept for this chapter is the role that physical sensations
play in emotional experiences. Physical sensations refers to any physi-
cal symptoms that you might experience during strong emotions.
For instance, when you are frightened or really excited, your heart
might beat more quickly. Just like how we think and how we behave
in a situation can influence our emotional experience, so can how we
feel physically. Our internal physical sensations can become “signs”
that our emotions are more intense than they really are, and can
influence the intensity of our emotional response and what we do in
response to our emotions. In this chapter you will work toward con-
fronting the internal physical sensations associated with intense or
uncomfortable emotions.
160
experience to explore—how we feel. How we feel refers to the inter-
nal physical sensations we experience, or our physical responses
during emotions. Our emotions influence how we feel physically,
and our physical feelings influence our emotions (just like our
thoughts are influenced by our emotions and can also influence our
emotions—see Chapter 8). It is important to be aware of how we feel
during an emotional experience, just as it is important to recognize
what we think and what we do.
161
you to begin to identify physical sensations as just that—physical
sensations, separate from being part of a distressing emotional
experience. Although physical sensations are a big part of emotional
experiences, in isolation they are not necessarily something bad or
aversive in and of themselves. Oftentimes our appraisals of physical
sensations can make them seem much worse than they are.
It might be useful to consider this. When you were a child, did you
ever visit a playground? What are most playgrounds designed to
do? They are there to provide fun and excitement for children. They
are a place where kids can release their energy and run wild. But let’s
look closer at what kids experience at the playground. When a kid
goes down a slide, his stomach might drop, and he might feel dizzy
and lightheaded when he lands at the bottom and stands back up.
What about the swings? Did you ever swing really high on a swing
and throw your head back, so the world was rushing past you quickly
upside down? This brings butterflies to the stomach, a sense of unre-
ality, and maybe again some more dizziness and lightheadedness.
What about those merry-go-rounds on playgrounds? Their whole
purpose is to make kids really, really dizzy; so dizzy they can’t stand
up when they get off (that’s the “best” part, if you are a kid). What
about roly-poly’s down a hillside? The point of these again is more
dizziness, disorientation, even a little nausea. All of these activities
are undoubtedly accompanied by some vigorous running around,
which brings on a pounding heart and accelerated heart rate. All
of these physical sensations—dizziness, stomach distress, feelings of
unreality, lightheadedness, pounding heart, accelerated heart rate—
when they occur in the context of childhood and the playground,
are good sensations, something kids purposely bring on! But these
same, exact sensations, experienced as an adult in a room full of
people, suddenly become threatening, representative of impending
doom, and a sign of not being able to cope. What makes these
experiences so different? Is it the physical sensations themselves?
Or is it the interpretation of what having these physical sensations
might mean?
162
evaluate your interpretation of the sensations and, using the skills
you learned in Chapter 8, be able to determine if this physical sensa-
tion represents a true and present danger, or is just a passing auto-
nomic response. The more you can allow yourself to get used to
feeling these sensations within a safe context (e.g., in the privacy of
your own home rather than in the middle of a mall), the easier it will
be to break the association with these sensations as something threat-
ening or signaling danger.
Try engaging in these exercises over the next few weeks. During the
exercises, try to pay close attention to how you feel physically, as well
as any emotions or thoughts you might have during the exercise.
To get the most benefit from these exercises, it is important to repeat
them at least two or three times in a row each time you do them. You
may notice the first time that they feel very aversive, the second time
maybe not quite as bad, and by the third time they might become
much easier. Even if it takes longer and requires more repetitions,
you will likely find after several repetitions that you have become
more and more used to the physical sensations, and in turn they
have become less and less aversive.
163
3. Spin in circles
4. Run in place
After each exercise, use the Symptom Induction Test Form provided,
to take note of the following:
164
Symptom Induction Test Form
Please complete each of the exercises (as described) below. Be sure to engage
in each exercise fully, and try to produce at least moderate symptom inten-
sity. After the exercise, please note:
1. the physical symptoms you experienced
2. the intensity of the symptoms (0–8 scale; 0 = no intensity, 8 =
extreme intensity)
3. the level of distress you experienced during the task (0–8 scale; 0 =
no distress, 8 = extreme distress)
3. the degree of similarity to your naturally occurring symptoms
(0–8 scale; 0 = not at all similar,
8 = extremely similar)
Wait until the symptoms have mostly subsided before attempting the next
exercise. Use the other spaces provided to be creative and come up with
additional exercises that are specific to you. When you are done, pick three
of the exercises that produced the most anxiety for you. Put a star next to
those exercises. You will repeat those exercises that you rated as most dis-
tressing.
165
Even if you are not distressed by the physical sensations, some people
find it helpful to use this experience as an opportunity to practice
nonjudgmental awareness. Remember, physical sensations (similar
to those produced by these exercises) are one of the three compo-
nents of emotions. So becoming more aware of them can be helpful,
regardless of whether they elicit distress or are accompanied by other
emotions.
It’s worth noting that some people don’t experience much distress
when completing these exercises, while other people may find them
more difficult. If you did not experience distress during these exer-
cises, it is worth considering a number of possible reasons why. First,
these exercises may not bring up sensations that are consistent with
what you naturally experience during strong emotions. Thinking
about your own symptoms, you can develop exercises to elicit phys-
ical sensations that you currently find distressing. For instance, if
visual sensations bother you, you could stare in a mirror for two
minutes, or look at a bright light for 30 seconds before looking away,
or stare at the pattern on a wood grain door for 30 seconds. Certain
visual patterns (such as those on carpets or wallpaper, or graphic
visualizers on MP3 players) can also elicit feelings of unreality.
Feelings of weakness, or tingling sensations, could be elicited by
tensing all the muscles in your body at the same time, for about
30–60 seconds. Or, if you are bothered by feeling hot, you might
wear a heavy winter coat while sitting in a stuffy room, or in front of
a space heater. Remember, the goal of these exercises is to deliber-
ately bring on the sensations that cause distress. So identify the phys-
ical sensations that cause distress and then develop your own exercise
to bring them on. So as long as it’s safe to do, you can be creative.
Make a list of the exercises you can try and write them in the space
provided. Remember, be creative!
1._______________________________________________________________________________
2._______________________________________________________________________________
3._______________________________________________________________________________
4._______________________________________________________________________________
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The second reason you may not have experienced much distress
when completing these exercises is that you may have stopped the
exercises before experiencing significant sensations, possibly in antic-
ipation that the sensations would be distressing or become too
intense. If you believe you may have stopped the exercises too early,
try again. This time try to continue with the exercises for the full
amount of time recommended above.
Now that you’ve identified the exercises that bring on the physical
sensations that you find the most distressing, you will practice by
engaging in the exercises repeatedly, so you can begin to notice how
your distress about the symptoms decreases the more you are willing
to confront them. Be sure to engage in each exercise fully, and try to
produce at least moderate symptom intensity each time. Try not to
avoid by engaging in the exercises halfheartedly or by “tiptoeing”
through them. Rather, approach the exercises without hesitation and
challenge yourself to elicit the physical sensations. By fully eliciting
the physical sensations, you will provide yourself with an opportunity
to learn that the symptoms are not dangerous, and that they will
return back to normal on their own after a short period of time.
167
Engage in the exercises over and over again, only waiting long enough
in between trials for your symptoms to mostly subside. Continue
to repeat the exercise until your distress reaches a 2 or less. If your
distress never reaches above a 2, do anything you can to make the
exercise more difficult (e.g., combining the exercises, doing them in
front of other people, trying to induce symptoms when you already
feel anxious, sad, or upset). You should do at least one set of each
exercise every day over the next week.
Summary
You now have all of the core concepts and skills to begin confront-
ing, accepting, and tolerating uncomfortable emotional experiences.
You have learned how to observe your emotional experiences in an
objective way; how to identify and reappraise maladaptive automatic
thoughts and interpretations; how to identify and counter emotion
avoidance strategies and maladaptive EDBs; and how to better toler-
ate physical sensations as just physical sensations, recognizing their
role in emotional experiences. In the next chapter, all of these skills,
strategies and concepts discussed thus far will be brought together
through emotional exposures, through which you will have the
opportunity to really learn these skills by applying them to your real
life experiences.
168
Homework
Self-Assessment Quiz
Answer each of the following by circling true (T) or false (F). Answers
can be found in the appendix.
169
170
Symptom Induction Practice Form
DAY 1:__________________________ DAY 2: ___________________________ DAY 3: ________________________________
Trial Intensity Distress Similarity Trial Intensity Distress Similarity Trial Intensity Distress Similarity
Trial Intensity Distress Similarity Trial Intensity Distress Similarity Trial Intensity Distress Similarity
Goals
Homework Review
Did you complete your recordkeeping for the previous week? Have
you plotted your OASIS and ODSIS scores on your Progress Record
chart? Have you noted any changes in your responses?
If you did complete the exercises, what did you notice? Did you
notice any thoughts or behaviors that may have occurred in response
to the physical sensations? How did these interact, and how did they
affect your experience? If you had a negative thought in response
to a physical sensation, did the sensation get better or worse?
171
Were you doing anything to avoid fully experiencing the sensations?
What happened when you allowed the sensations to occur, without
trying to control them? Did they get better or worse?
Key Concepts
The key concept for this chapter is emotion exposure. During this
part of treatment, you will gradually confront specific situations,
images, and/or activities that may produce strong or intense emo-
tional reactions. This is an opportunity to put the skills learned so
far into practice and, in doing so, gain confidence that you can
handle your emotional experiences as they unfold. It is very impor-
tant that you commit to making time and effort during this last part
of treatment, because this is the chance for the greatest, longest-
lasting changes to occur.
The way we get you out “on the bike,” learning by doing, is through
emotion exposures. Emotion exposures are exercises that are specifically
172
designed to provoke strong emotional responses, the exact responses
that have led to your symptoms of distress, and for which we have
provided you with all of the skills necessary to allow you to cope
in more adaptive ways. As we will discuss, there are a number of
different kinds of emotion exposures, or different contexts in which
emotions can be provoked. Emotion exposures can occur in the
context of internal situations, such as thoughts, memories, or even
the physical sensations we discussed in Chapter 11. Emotion
exposures can also occur in external situations that might produce
emotions, such as places or situations that make you uncomfortable,
or that you might avoid currently (such as riding in an elevator,
meeting new people, or touching “contaminated” objects). During
this chapter you will gradually confront situations that produce
strong emotions and modify your responses to those emotions. All
of the skills you’ve learned so far (present-focused nonjudgmental
awareness, cognitive reappraisal, countering avoidance and EDBs,
confronting physical sensations) will help you to practice conduct-
ing emotion exposures. This is your chance to put these new skills
into action. These skills will also help you to eliminate any emotion
avoidance during these emotion exposures. Remember, engaging in
emotion avoidance during these exposures will interfere with your
progress during treatment, because emotion avoidance strategies not
only prevent you from fully experiencing your emotions, but also
prevent you from learning new information about the experiences,
such as your ability to cope with these experiences. In order to learn
new ways of responding to emotionally intense situations, it is nec-
essary to conduct exercises to intentionally bring on these types of
emotional experiences. Reactions to emotions cannot be changed
until emotions are fully experienced and EDBs are identified and
modified. This part of treatment can be hard for people at first. But
remember, you have come this far in this treatment; therefore you
owe it to yourself to try and “get on the bike” to really put these new
skills to work for you.
173
exercises you can use to bring on strong, uncomfortable emotions
and practice the skills you have learned so far.
174
3. Avoidance, and subsequent impairment, begins to be reversed.
4. EDBs are recognized and modified.
175
Use the Emotional and Situational Avoidance Hierarchy form pro-
vided, to get an idea of the types of situations that trigger uncom-
fortable emotions for you, and situations that you most often
avoid. Over time, you will gradually and systematically work your
way up your hierarchy. Remember that the purpose of these
exercises is to elicit strong, uncomfortable emotions, so choosing
exposures that are too “easy” may not be as helpful. Try to begin with
an exposure that you believe will evoke at least a moderate degree
of emotion (activities toward the middle of your hierarchy), but
that you are relatively confident about completing successfully.
This allows an opportunity for you to experience mastery over an
aversive experience early on, while simultaneously challenging
yourself.
176
Do Not Hesitate To Enter Usually Always
Avoid But Rarely Avoid Sometimes Avoid Avoid Avoid
0 1 2 3 4 5 6 7 8
No Slight Definite Strong Extreme
Distress Distress Distress Distress Distress
2 Flying 8 8
3 Taking a bus 7 7
4 Elevators 6 7
5 Eating at a restaurant 6 6
8 Going to a movie 4 4
Figure 12.1
Kevin’s Emotional and Situational Avoidance Hierarchy
177
Emotional and Situational Avoidance Hierarchy
Describe situations you are currently avoiding in order to prevent uncomfortable emotions from
occurring, starting with the worst or most distressing situation. Rate the degree to which you avoid each
of the situations you describe, and the degree of distress they cause. For each, write the applicable number
in the space provided.
1
WORST
10
178
When designing exposures, it is important to consider that uncom-
fortable emotions can be negative or positive. For example, some
people find it difficult to fully engage in a pleasurable activity that
would force them to “leave their worries behind.” The experience of
positive emotions may evoke anxiety about “being off guard.”
Therefore, it may be particularly important to design exposures
around both negative and positive emotional experiences. In looking
back over your hierarchy, have you considered pleasurable activities
that may bring up uncomfortable emotions?
You can use the Record of Emotion Exposure Practice form at the
end of the chapter to record your emotion exposures. You should
spend time processing the exposures you complete, paying particu-
lar attention to any patterns of emotion avoidance or obstacles that
may have stood in the way of successful completion of exposures.
Take a look at how Kevin filled out the Record of Emotion Exposure
Practice form (Figure 12.2). Notice how he focused on examining
his thoughts, feelings, and behaviors both before and after he
completed the task.
SARAH: It was a bit easier now that I’ve started to challenge my thoughts, but
I was still really anxious beforehand and wanted to cancel like I’ve
done before.
SARAH: I noticed a lot of physical sensations and just wanted to get out of
there. But as I stayed longer it wasn’t so bad. I got more comfortable
179
Exposure Task: Driving on the expressway for at least 15 minutes
Behaviors: None
Behaviors: Gripped the wheel tightly, maintained a rigid posture, and kept checking the
mirror to make sure no one could prevent me from pulling the car over to the side of the
road. I had trouble maintaining a constant speed.
Number of minutes you did the task: 20 min.
Maximum distress during the task (0 – 8): 7
Distress at the end of the task (0 – 8): 5
Any attempts to avoid your emotions (distraction, safety signals, etc.)?
At one point, when I was feeling panicky, I turned the radio on and turned up the volume.
I also found myself trying to regulate my breathing to prevent myself from having an
attack. I did not go into the passing lane.
What did you take away from this exposure task? Did your feared outcomes occur?
If so, how were you able to cope with them?
When I felt panicky, I got pretty scared. I told myself that I was in control of the car and
that I could pull over to the side of the road if the feelings got too bad. But I stayed in the
situation and actually tried to loosen my grip on the wheel and adjust my posture so I
was driving in a more relaxed position. My anxiety stayed pretty high throughout the
exposure, but I never lost control of the car. It stared to come down near the end of the
exposure.
Next time, I’ll make the exposure more difficult by driving in the passing lane. Also, I
think the exposure needs to be a little longer to allow the anxiety to really come down
before I get off the expressway. There are a number of EDBs I will need to address as
well, such as staying at a constant speed and not looking in the mirror so much, but I
definitely made some progress.
Figure 12.2
Kevin’s Record of Emotion Exposure Practice
180
and talked to some people, even people I didn’t know. I actually had
a pretty good time.
SARAH: It got better, yeah. Especially after people seemed interested in what
I had to say. That was one of my main fears. I thought I’d be boring
and have nothing to say, but I made conversation.
THERAPIST: So you were able to test your fears. Did you avoid your emotions at all?
SARAH: I tried not to, but I think I did some subtle things like not make eye
contact or really introduce myself to groups of people.
THERAPIST: Are there other exposures you can do around that avoidance?
181
a moment to review the Decisional Balance Worksheet you com-
pleted with Chapter 4, reminding yourself of the potential benefits
of making a change, relative to the costs of continuing on in the
same way. For many people, emotion exposures represent the
“moment of truth.” This is the point where you bring all your skills
together and work toward making changes happen in your life.
Sometimes you might set an exposure that evokes emotions that you
have difficulty experiencing, and you may even escape as a result. Try
not to get too discouraged or frustrated with yourself. Compassion is
key here. Understand that some of these patterns may be a little more
ingrained and, as a result, may take a little while to work out. If you
escape from the situation, give yourself a moment, use the cognitive
reappraisal skills, and then get back in there. If you need to move a
step down on the hierarchy, or modify the exposure to make it less
provoking, go ahead. But make a note of the original exposure so you
can repeat it at a later point in time. Some people benefit from really
easing into exposures, while others seem to do better with a “jump in
the deep end” type of attitude. You’ll need to find what works for
you, but as long as you’re confronting situations that you’ve avoided
in the past, and the accompanying emotions, you are most likely
making progress in overcoming your emotional difficulties.
182
be important. Are you conducting your exposures with trepidation
and reluctance, or with courage and acceptance? Treat each exposure
as an opportunity to take one step closer to your goals.
Summary
In this chapter, you have had the opportunity to take all the skills,
strategies, and concepts you have learned in this program and apply
them to your real life situations. This is the best way to learn any
new skill—we can read about something, or be told or lectured
about something, and feel like we know it quite well intellectually.
But in order to truly understand any new skill, the best approach
is learning by doing. Emotion exposures allow you to do just that.
They are intended to provoke the same distress you have been strug-
gling against, the same distress that brought you to this program in
the first place, in order to give yourself the opportunity to practice
these new skills.
Homework
183
✎ Repeatedly engage in physical sensation exposures following
the instructions in Chapter 11.
Self-Assessment Quiz
Answer each of the following by circling true (T) or false (F). Answers
can be found in the appendix.
184
Record of Emotion Exposure Practice
________________________________________________________________________________
Prior to the task:
Anticipatory Distress (0–8): _______
Thoughts, Feelings, and Behaviors you noticed before the task:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Reevaluate your automatic appraisals about the task:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
After completing the task:
Thoughts, Feelings, and Behaviors you noticed during the task:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Number of minutes you did the task: _______
Maximum distress during the task (0–8): _______
Distress at the end of the task (0–8): _______
Any attempts to avoid your emotions (distraction, safety signals, etc.)?
________________________________________________________________________________
________________________________________________________________________________
What did you take away from this exposure task? Did your feared outcomes occur? If so, how were you
able to cope with them?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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Chapter 13 Medications for Anxiety, Depression, and
Related Emotional Disorders
Goals
In any case, almost 60% of the people who come to our clinic for
psychological treatment are taking some kind of medication for their
anxiety and mood symptoms. Some have been taking it for quite
some time. For others, their physician has given them a prescription
to get them through the next couple of weeks but told them to come
to our clinic as soon as possible.
187
As we mentioned in Chapter 2, it is not at all necessary to stop
taking medications in order to do this program, and we do not
recommend that you stop taking your medication before starting
the program. Eventually, you may wish to stop on your own. About
half of the people stop taking medications by the time they finish
this program, and others stop sometime during the first year after
finishing. In the sections that follow, we describe ways to stop taking
medications if you want to.
At this point the evidence seems clear that some types of medica-
tions, if prescribed at the right dosage, can be effective for at least the
short-term relief of anxiety or depression for some people. Many of
these medications, however, are not effective in the long term unless
you continue to take them. Even then, they may lose some of their
effectiveness unless you learn some new, more helpful methods of
coping with your emotions while you are on the medication.
Nevertheless, there are some people who begin a course of medica-
tion therapy and stop several months later without any need to go
through a program such as this. For all of these reasons it seems
useful to review the ways in which medications work, and the differ-
ent types of medications prescribed for emotional disorders, as well
as the best times to use them based on current knowledge.
Antidepressant Drugs
188
symptoms, headaches and other side effects, particularly sexual
dysfunction, with these medications. In addition, there may be some
initial worsening of anxiety, although this can be decreased by
starting with lower doses (such as 5mg of Prozac). The most effective
doses for controlling panic and anxiety for drugs most often prescribed
are 20–40 mg of Prozac, 75–150 mg of Luvox, 20–40 mg of Paxil,
and 100–200 mg of Zoloft.
189
For example, you can’t eat cheese, chocolate, or other foods contain-
ing tyramine, nor drink red wine or beer. If you do, you risk danger-
ous symptoms including high blood pressure.
190
Benzodiazepines
High potency medications have stronger effects per dose than lower
potency medications. High potency benzodiazepines alleviate anxiety
without causing the side effects of extreme sleepiness that is seen with
higher doses of lower potency benzodiazepines (e.g., Valium). These
medications work very quickly—their effects are usually noticeable
within 20 minutes of ingestion and are the most frequently prescribed
medications for anxiety. The best-known high potency benzodiaz-
epines are alprazolam (Xanax) and clonazepam (Klonopin). To give
you an idea of how strong Xanax is, 1 mg of Xanax equals approxi-
mately 10 mg of Valium. The therapeutic dose of Xanax for anxiety
varies from person to person, and can depend on the nature of the
anxiety. One to four mg per day is the best dosage for anxiety, but
more than 4 mg is sometimes required for severe anxiety. The appro-
priate dose of Klonopin is 1.5 to 4 mg per day.
191
It is important to realize that the side effects decrease over time and
are not dangerous.
192
with the types of strategies described below, dramatically reduce with-
drawal and relapse when benzodiazepines are discontinued.
Now that you have finished this program, you should be ready to
stop your medication if you wish. Be very sure that you stop your
medication under the supervision of your physician; only he or she
can decide how quickly it will be safe for you to taper your medica-
tion to the point where you stop it altogether. This will be particu-
larly true for medications like Xanax, which are best tapered very
slowly. If withdrawal from benzodiazepines or other medications is
posing a particular problem in your life, and is something you have
tried before, unsuccessfully, while working with your physician, then
another book in the TreatmentsThatWork™ series from Oxford
University Press, Stopping Anxiety Medication Workbook, 2e, may be
useful for you. That particular program is designed specifically for
panic attacks, as well as symptoms of very severe anxiety and panic
that one feels when attempting to withdraw from benzodiazepines
or other drugs.
With what you have learned from this program you should have
little trouble stopping your medication if you follow these general
guidelines.
3. Use the principles and coping skills that you have learned in
this workbook as you withdraw from the medication.
193
The reason that we have not addressed this topic until now is because
it is important for you to learn how to manage your emotions before
successfully stopping medication. One reason for this is that you
may begin to experience emotions at more intense levels as you come
off the medication. If you are on medication, the principles you have
learned during this treatment may need to be applied again to deal
with some increased intensity of emotions as you come off medica-
tion. Once again, most people do not find this a problem and grad-
ually reduce their medication as they become more comfortable in
dealing with their emotions. If your emotions seem to be increasing
as you decrease your medication dose, it is most likely due to mild
withdrawal symptoms. The symptoms simply reflect your body
readjusting to the changes of having the medication withdrawn. The
withdrawal symptoms do not mean that you must go back on the
medication, and do not mean that something is seriously wrong
with you. Instead, the withdrawal symptoms mean a period of
adjustment, and should last only a week or two (in rare cases a little
longer) until the medication clears from your system. In addition,
you now have the skills to handle these symptoms.
Summary
194
this process. The Stopping Anxiety Medication Workbook, 2e might
also be useful in helping you to manage this change.
Homework
✎ Plan how you will deal with any of the anxiety-inducing effects
of drug withdrawal by using the Stopping Anxiety Medication
Workbook, 2e from Oxford University Press.
Self-Assessment Quiz
2. You are unlikely to feel any different when you withdraw from
your medication.
T F
195
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Chapter 14 Moving On From Here—Recognizing Your
Accomplishments and Looking to Your Future
Goals
Key Concepts
1. Use your breath or other chosen cue to help bring you out
of your head and into the present moment. Do a quick
“three-point check”—what am I thinking right now? What am
197
I doing? What am I feeling, emotionally and physically?
Try and objectively observe your experience, without trying to
judge, “manage” or “control” it.
It is time to consider the kind of changes you have made since you
first began this program. There are several ways to do this. First, take
198
a look at your Progress Record. If you’ve completed the OASIS
and ODSIS from week to week, and logged the data into your
Progress Record, you should have a good sense of how some of your
symptoms have changed over the course of this program. There
may be ups and downs, but compare your scores at the beginning
of the program to now. Has there been a decrease in your overall
levels of anxiety and feelings of depression? Circle the appropriate
answer (yes or no) on the Progress Evaluation Form provided on
page 200.
Finally, think about changes in your behaviors. Are you avoiding less
than you used to? How are you doing with the emotion exposures?
199
Progress Evaluation Form
Are you moving up the Fear and Avoidance Hierarchy? Have certain
items become less frightening? Are you doing things that you were
too afraid to do before? If there has been a significant reduction in
your emotion avoidance, check YES next to the item labeled
Avoidance. If not, check NO. Also, look at your completed Changing
EDBs forms. Are you beginning to adopt alternative actions, rather
than what you used to do in response to your emotions? If so, circle
YES next to the item labeled Emotion Driven Behaviors. If not,
circle NO.
200
Practice Plan
you learned in this program. Use the Practice Plan provided here to
list all of the things to be practiced over the next few weeks.
At the end of each week, revise your Practice Plan according to your
progress and the next steps to take. You might find it helpful to actu-
ally schedule “treatment sessions” into your weekly schedule, setting
aside time to review your progress and revise your plan. This also
201
gives you an opportunity to notice any changes in your symptoms
and implement strategies before any maladaptive cycles of emotions
develop. Taking stock in what you have accomplished each week can
be a good way to stay on top of your emotional life and to prevent
any problems from arising. For instance, if you notice any problem-
atic patterns of avoidance or EDBs, you can “nip it in the bud”
before things start to head in a bad direction. You can also use this
time to simply consider what worked, and what didn’t. This may
continue for six months or more, or for as long as you want.
Long-Term Goals
Now that you’ve completed this program, and hopefully seen some
improvement in your symptoms, take a moment to revisit your
long-term goals and then, in the space provided, consider your new
long-term goals and the specific steps needed to make them a reality.
Your goals might include things such as going back to school, chang-
ing jobs, meeting someone new, taking up a new hobby, or maybe
even flying to a tropical island for a much-deserved vacation.
Remember, it can be helpful to work backwards from your goal to
help identify specific steps you will need to take to get there.
Long-Term Goals
Long-Term Goal Steps to Achieve Long-Term Goal
5.
4.
3.
2.
1.
Long-Term Goal Steps to Achieve Long-Term Goal
5.
4.
3.
2.
1.
202
How to Maintain Progress
There are several ways to maintain the progress you have made in
this program so far.
203
you could use the cognitive reappraisal techniques to cope with
particularly strong reactions to stressors, or the inevitable symptom
fluctuations that are part of everyday life.
Concluding Remarks
Changing the way we respond to situations can be hard, and takes both
time and effort to accomplish. Your maladaptive patterns of emotional
responding didn’t happen overnight. So you probably shouldn’t expect
them to change overnight, either. Give it a little bit of time. Also,
change never occurs in a straight line. Expect bumps in the road.
Self-Assessment Quiz
Answer each of the following by circling true (T) or false (F). Answers
can be found in the appendix.
204
3. It is usually a good idea to simply tackle problems as they arise,
and generate emotion exposures “as needed,” rather than
develop a plan for completing exposures that are in line with
short-term and long-term goals.
T F
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Appendix
Self-Assessment Answers
Chapter 3
1. T 2. F
3. F 4. T
Chapter 4
1. T 2. F
3. T 4. F
Chapter 5
1. F 2. T
3. F 4. T
Chapter 6
1. T 2. F
3. T 4. F
Chapter 7
1. F 2. T 3. F
4. F 5. F
207
Chapter 8
1. F 2. T
3. T 4. F
Chapter 9
1. T 2. F
3. T 4. T
Chapter 10
1. F 2. T
3. T 4. F
Chapter 11
1. T 2. T
3. F 4. T
Chapter 12
1. T 2. F
3. T 4. F
Chapter 13
1. T 2. F 3. F
4. F 5. T
Chapter 14
1. T 2. T 3. F
208