That Work'"

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1a ostic
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nal isorde

David I-I. Barlow

l(risten K.. Ellard Christopher P. Fairholme

Todd]. Farchione . Christina L. Boisseau

Laura B. Allen Jill T. Ehrenreich-May

EDITOR-IN-CHIEF

David H. Barlow, PhD

SCIENTIFIC

ADVISORY BOARD

Anne Marie Albano, PhD

Gillian Buder, PhD

David M. Clark, PhD

Edna B. Foa, PhD

Paul J. Frick, PhD

Jack M. Gorman, MD

Kirk Heilbrun, PhD

Robert J. McMahon, PhD

Peter E. Nathan, PhD

Christine Magurh Nezu, PhD

Matthew K. Nock, PhD

Paul Salkovskis, PhD

Bonnie Spring, PhD

Gail Steketee, PhD

John R. Weisz, PhD

G. Terence Wilson, PhD

 Elli.zalbeili. Angel De G!i'ciff. M.Ps.a.
Psicologa Clmka
R.M.S. JP§ 712
era. 13 #93-85 (303)
·reu. (571)617°1011

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David H. Barlow ® Kristen K. Ellard e Christopher P. Fairholme

Todd J. Farchione @Christina L. Boisseau (!)Laura B. Allen
Jill T. Ehrenreich-May

Elizabl'I · · -,
i ".:..ll
Rl\1::
Cra. 13 #93-8.; ,.>!l3)
Tel (571)617-1011
J,~I

OXFORD
UNIVERSITY PRESS

2011
 f;:·:·.'1/'·

OXFORD
UNIVERSITY PRESS

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ISBN-13 978-0-19-977267-4 Paper

9 876 54 3 2 1

Printed in the United Srates of America

on acid-free paper
 One of the most difficult problems confronting patients with various
disorders and diseases is finding the best help available. Everyone is
aware of friends or family who have sought treatment from a seem-
ingly reputable practitioner, only to find out later from another doctor
that the original diagnosis was wrong, or the treatments recom-
mended were inappropriate or perhaps even harmful. Most patients,
or family members, address this problem by reading everything they
can about their symptoms, seeking out information on the Internet,
or aggressively "asking around" to tap knowledge from friends and
acquaintances. Governments and healthcare policymakers are also
aware that people in need don't always get the best treatments-
something they refer to as "variability in healthcare practices."

Now, healthcare systems around the world are attempting to correct

this variability by introducing "evidence-based practice." This simply
means that it is in everyone's interest that patients get the most
up-to-date and effective care for a particular problem. Healthcare
policymakers have also recognized that it is very useful to give con-
sumers of healthcare as much information as possible, so that they
can make intelligent decisions in a collaborative effort to improve
health and mental health. This series, TreatmemsThat Work™ is
designed to accomplish just that. Only the latest and most effective
interventions for particular problems are described in user-friendly
language. To be included in this series, each treatment program must
pass the highest standards of evidence available, as determined by a
scientific advisory board. Thus, when individuals suffering from
these p:oblems or their family members seek out an expert clinician
who is familiar with these interventions and decides that they are
appropriate, they will have confidence that they are receiving the
best care available.

The latest development m evidence-based treatment programs,

based on the most up-to-date research and clinical evaluation, is

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 comorbidiry). 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.

This particular workbook is designed for your use as you work

together with a therapist to address your emotional disorders.
Generally, this group of disorders includes all of the anxiety and
mood (depressive) disorders such as panic disorder with or without
agoraphobia, social anxiety disorder, generalized anxiety disorder,
post-traumatic stress disorder, obsessive-compulsive disorder, and
depression. The program is also designed to address closely related
emotional disorders such as hypochondriasis, and other problems
associated with excessive anxiety focused on health concerns, as well
as problems with experiencing dissociation (feelings of unreality).
What all of these disorders have in common is excessive or inappro-
priate emotional responding that is interfering with your ability to
lead a happy and normal life-such as excessive anxiety or fear about
certain situations or people, or feelings of depression that take all the

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.

David H. Barlow, Editor-in-Chief

Unified Transdiagnostic TreatmentsThatWork™
Boston, MA

vii
 Chapter 1 What are Emotional Disorders? 1

Chapter 2 Is This Treatment Right for You? 15

Chapter 3 Learning to Record Your Experiences 21

Chapter 4 Maintaining Motivation and Setting

Goals for Treatment 35

Chapter 5 Understanding Your Emotions 53

Chapter 6 Recognizing and Tracking Your Emotional

Responses 67

Chapter 7 Learning to Observe Your Emotions and

Your Reactions to Your Emotions 81

Chapter 8 Understanding Thoughts: Thinking the Worst

and Overestimating the Risk 107

Chapter 9 Understanding Behaviors 1: Avoiding

Your Emotions 135

Chapter 10 Understanding Behaviors 2: Emotion-Driven

Behaviors 145

Chapter 11 Understanding and Confronting Physical

Sensations 159

Chapter 12 Putting It into Practice: Facing Your Emotions in

the Situations in which They Occur 171

Chapter 1.3 Medications for Anxiety, Depression, and

Related Emotional Disorders 187

Chapter 14 Moving On From Here: Recognizing

Your Accomplishments and Looking
to Your Future 197

Appendix Self-Assessment Answers 207

ix
 What are Emotional Disorders?

iii I ! ii I : 11
1
1i1 ! i ! Ii t , 1:
J 1! J; ; l ! l j; !

~iJ To learn what "emotional disorders" are

r~'l To learn about symptoms of common diagnoses and how this

treatment aims to address these symptoms

What are Emotional Disorders?

This treatment workbook is designed to help people suffering from

"emotional disorders." Disorders in this group include social anxiety
disorder, depression, panic disorder (and agoraphobia), generalized
anxiety disorder, obsessive-compulsive disorder, and other anxiety,
depressive, and related disorders such as anxiety focused on health
(hypochondriasis). In all of these emotional disorders you experi-
ence strong, intense, and/or uncomfortable emotions like anxiety,
panic, depression, or fear that are getting in the way of living your
life and compelling you to do things you may not want to do. These
emotions tend to be so uncomfortable that you might start to do
things, or avoid certain situations, just so you won't have to experi-
ence these intense feelings. The problem is, by avoiding these experi-
ences, your life may become very limited, and you may find it
difficult to go about day-to-day activities like going to work, spend-
ing time with friends, or just doing something leisurely or enjoyable.
In addition, avoiding these intense experiences may be causing you
to put off pursuing meaningful goals, to miss important events, or
to change important plans. The main problem is that these intense,
strong, and/or uncomfortable experiences have become the focus
of your existence, and are preventing you from living the life you
want-and this may be why you have picked up this book in the
first place. The program described in this workbook is new, and
integrates the most powerful psychological techniques and strategies

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 ofEmotional 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

~ Sarah is a 35-year old, single woman who works as an investment

manager at a bank. At work, Sarah was given increased
responsibilities and was even being considered for a promotion.
One ofher new responsibilities involved giving a briefpresentation
at a weekly staffmeeting. Sarah had never liked speaking in front
ofothers, but had largely been able to avoid doing so over the years.
During her first presentation, she became increasingly anxious and
actually left the room before she had finished. Later; Sarah
described feeling "unable" to finish the talk, and noted that she had
experienced "intense" and "scary" physical sensations during the
presentation, such as increased heart rate, sweating, and dizziness.
She was concerned that she was going to pass out, and felt that she
"had to get out" ofthe room to prevent herselffrom fainting.
Shortly after this incident, Sarah contacted our center for help
controlling her anxiety, so that "something like this would never
happen again. "

Sarah had always been anxious about speaking in front ofother

people. Growing up, she had rarely spoken in class and her teachers
would often comment on her report cards that she wqs very quiet.
This anxiery persisted through high school, although Sarah always
did well in school. She was q.ble to get by without doing any oral
presentations using a variety ~fexcuses or by "staying home sick" on
days when she was scheduled to give a presentation. In college,
Sarah found it was more difficult to get out ofor avoid giving
presentations. Prior to taking a particular class, she would always
check the syllabus and drop classes that required her to give a
presentation. Despite these difficulties, Sarah was able to graduate
college and get a good job after graduation.

2
 Jn addition to anxiety about speaking in ftont ofothers, Sarah said
she had always been an,"<ious 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 grozp ofclose.friends,
Sarah noticed that her social network had been getting smaller and
smaller as her close foends got married and had children, or moved
away for work. She had a great deal ofanxiety about meeting new
people, and felt that her anxiety was d~finitely holding her back ftom
making new.friends. Sarah was single and had not been on a date in
a nwnber ofyears. Although very interested in dating, she felt her
anxiety was preventing herftom going out on dates.

Umla
[(g Linda is a 53-year-o!d, married, mother oftwo and grandmother of
three. She had workedfor several years as a school teacher, but had
stopped working two yearsprior in order to care for her ill father,
who had passed away six months b~fore she came to our center. Linda
came to our center saying she felt anxious "all the time" and was
having difficulty sleeping. She wanted to go back to work now that
she was able, butfelt like her anxiety was holding her back. She
described her.rel/as feeling "stuck. "She wasn't enjoying things she used
to, like spending time with foends or going to the gym., and.found
herselffeeling tired and overwhelmed all ofthe time. She was having
.fequent arguments with her husband, andfelt more irritable than
usual She told us she wanted to 'get rid ofthis dark cloud and
uneasy.feeling" she was carrying around with her every day.

Linda said she often felt overwhelmed by "worries and concerns. "
She ftequently worried about her two grown children, even though
they both were happily married, doing well financially, and had
started families oftheir own. She worried about their happiness,
their health, whether th~y would have enough money to survive,
~fher grandchildren were developing okay, and ifshe was doing
enough/or them. She often found herselfimagining something
terrible happening to them, like their house burning down, or
having a fatal car accident. Linda afro worried about her
husband's.fob, even though he had been at the samejob for
22 years. She worried about what would happen ifthey decided to

3
 replace him with someone younger, ifthe 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 ofthe 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 ofpanic" 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 ofcontrol.

Linda very much wanted to return to work, but wasfinding it

difficult to go about finding a new job. As soon as she would begin
to look through job postings, she would start to worry about not
being good enough, not fi'nding the right job, being too old, or her
new coworkers not liking her. Once these thoughts started, she
would find herselflooking for other things she ''needed" to be
doing, like cleaning the house, which would take her away from
her job search. She would later feel bad about herselffor not
looking for a job, and would end up feeling "blue" and depressed.
She stated she often felt ''helpless" and ''worthless, "and sometimes
felt so heavy she couldn't motivate herselfto do anything at all.
Linda stated she had had similar struggles and worries that
something bad was going to happen for as long as she could
remember, and was tired offeeling this way.

Kevin

~ Kevin is a 51-year-old married male, who lives with his wife of

20 years and their two children, aged 12 and 16 He works as a
lawyer, which he has been doing for the past 25 years. Kevin came
to our center experiencing intense panic attacks that consisted of
heart palpitations, shortness ofbreath, dizziness, a lump in his
throat, nausea, and sweating. He had his first panic attack while he
was on the highway driving to work one day. Kevin immediately

4
 pulled offto the side ofthe road and got out ofhis car. Kevin had
never experienced anything like this before and he was terrified that
he would lose control as a result ofthese attacks. He called his wife
to pick him up to take him to work, and had his car towed, telling
his w~fe 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 ofsituations.
Most felt like they were coming from "out ofthe blue, "but he felt
that he was especial(y likely to have them in situations where he was
unable to escape or where he felt trapped. Kevin was almost
constant(y worried about having another panic attack and felt tense
and anxious for most ofthe 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 bu~y roads. In .fact, he had
begun leaving for work an hour earlier than b~fore and leaving an
hour later, in order to avoid rush-hour rraffic. 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 ifhe 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 ofdifferent things to "get rid of" his panic,
including relaxation, hypnosis, and even medication that his doctor
had prescribed. However, none ofthese things had helped

Brian

i7i3 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 ofgetting sick from touching items such ar 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 ftequently 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 oflatex gloves when using public
transportation. Currently, he washes his hands about 30 times
per day, under hot water, and uses nearly one bottle ofliquid soap
every couple ofdays. 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 offear 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 srruggling 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 fate 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 hisfears become. Brian remembers having
similar concerns when he was in high school, but feels that these
symptoms have now gotten "out ofcontrol. "

In each of these cases, strong, intense, and/or uncomfortable emo- I

tional experiences are getting in the way of these individuals' ability
to live the life they want, and driving them to do things they don't
want to do. You may recognize your own experience in these cases,
or you may find you have a very different experience than the ones
presented here. The important question to ask yourself is: Am
I having similarly intense or uncomfortable experiences that are
getting in the way of my life?

6
is this Treatmemt Right for My Svm!Jltoms?

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.

ff~ What symptoms do I feel I need help with?

g.J What emotions seem to go hand and hand with these

symptoms? Fear? Anxiety? Depression?

ci How are these experiences getting in the way of my life?

7
 The treatment program described in this book is designed to help
people like Sarah, Linda, Kevin and Brian, and people like you,
regardless of the specific emotional problem they might have. Each
of the experiences just described would meet a diagnosis for separate
anxiety or mood disorders; however, each has at its core intense emo-
tional experiences that are beginning to "take over" the person's life.
We designed this program to address these common experiences
and, as such, to be able to help with a range of disorders including
panic disorder, generalized anxiety disorder (GAD), social phobia,
obsessive-compulsive disorder (OCD), depression, or any other dis-
order in which strong, intense emotional experiences are the main
symptoms a person experiences.

To help you figure out where you fit in to this treatment program,
let's look a little closer at these diagnoses. To diagnose a person with
an anxiety, mood, or any other disorder, mental health professionals
rely on the Diagnostic and Statistical Manual of Mental Disorders
or "DSM," published by the American Psychiatric Association.
(DSM-IV; APA, 1994 1). In this manual, certain symptoms experi-
enced by individuals "go together" to make up a specific disorder.
Here are some examples of what these disorders might look like:

Panic Disorder
In panic disorder, people experience intense panic attacks, or a wave
of fear that washes over them, which causes uncomfortable sensa-
tions including some combination of the following: a racing, pound-
ing heart; shortness of breath or smothering sensations; hot or cold
Rashes; a feeling of choking; sweaty palms; nausea or stomach dis-
tress; dizziness, lightheadedness, or faintness; feelings of unreality or
being detached from oneself; a fear of dying; a fear of going crazy;
or a fear of doing something uncontrolled. These panic attacks seem
to come from nowhere, and last around ten minutes or less at their
peak. People who experience panic attacks often describe a sense
of feeling trapped and needing to escape, even though they are not

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 Dis1miler
People with obsessive-compulsive disorder experience frequent and
recurring unwanted, irrational thoughts, images, or impulses that
don't make sense to them. For example, someone might find himself
having horrific or aggressive images pop into his mind that he finds
very disturbing, or someone may be plagued by doubt about whether
she turned something off, or filled out a form correctly; even though
she has already checked several times. These intrusive thoughts cause
the person a great deal of anxiety and distress, and the person tries to
suppress them or neutralize them in some way in order to get rid of
them. The person may also feel driven to repeat some behavior, or
repeat some phrase or word over and over, in order to feel less uncom-
fortable. For example, someone with intrusive thoughts about getting
germs from everything he touches may find himself driven to wash his
hands repeatedly. Or, someone who keeps having unwanted or non-
sensical blasphemous thoughts may find herself saying a prayer over
and over in her head. Or, someone who feels intense anxiety when
things are out of place may feel driven to put things back in order.

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.

Generalized Anxiety Disorder

People with generalized anxiety disorder experience excessive worry

and concern over a number of different areas of their life. They may
worry about minor matters, such as getting errands done or getting
places on time; issues related to work or school, such as finishing a

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 ofren 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.

Social Anxiety Disorder

People with social anxiety disorder or social phobia experience intense
fear of social or performance situations in which they are around
unfamiliar people, are being evaluated or possibly scrutinized by
others, or may do something that will embarrass or humiliate them,
such as going to a party, or giving a presentation at work. When they
are in one of these situations they experience intense, overwhelming
anxiety, and may even have a panic attack. The person knows the fear
is likely unreasonable, or at least excessive, but can't control it. As a
result, the person either starts to avoid social and/ or performance
situations, or finds himself enduring them with a great deal of
distress. As with other disorders, it is not uncommon for people to
get nervous or anxious when meeting new people or speaking or
performing in front of a group of people. However, to receive a diag-
nosis of social anxiety disorder or social phobia, this fear has to be so
intense and the avoidance so great that it interferes in the person's
social life, work, and/or ability to go about her daily routine.

10
Major i!Je;masshrn Discmiler
People with major depressive disorder, or what we commonly refer
to as depression, find themselves more days than not feeling very
down, blue, or depressed. They may find themselves losing interest
in things that used to interest them, like playing sports, reading
books, or going out to dinner with friends. They may feel like they've
lost their appetite, or they may find themselves overeating. They
might have trouble sleeping, or feel like they can't get enough sleep
or can't get our of bed. They may feel tired all the time, unmotivated
to do much of anything. They may have difficulty concentrating, or
find their minds going blank. They may feel restless and agitated, or
they may feel very sluggish and slowed down. They may have a sense
of worthlessness or feel guilty. Some people even have thoughts
about hurting or even killing themselves. As with all of the disorders
we have discussed, it is not uncommon for people to have days when
they feel down or unmotivated, or even restless and agitated. To
receive a diagnosis of major depression, the person needs to have
been feeling this way more days than not, for at least two weeks or
more. Along with feeling sad, blue or depressed, and/or feeling like
he has lost interest in things, the person also must be experiencing at
least three or four of these other symptoms at the same time:

~ill loss of appetite or overeating

&'.!2 sleeping too little or too much

~i feeling unmotivated or tired all the time

~ feeling restless or agitated, or sluggish and slowed down

~ finding it hard to concentrate

iW feeling worthless or guilty

i~ having thoughts of hurting or killing oneself

An important note: If you are feeling so down and depressed

that you have thoughts of hurting or killing yourself, we urge
you to please go to your nearest emergency room right away, or
at the very least telephone a suicide support hotline. There, you
can find someone to help you through this period before you
do something you regret that cannot be changed.

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.

How Cam You Treat Several Disorders at the Same Time?

This treatment was developed following several decades of research

into how anxiety and mood disorders develop, what makes someone
experience symptoms of anxiety and mood disorders, and what causes
the symptoms to stay around and get worse. Our research draws from
the science of psychopathology, the science of emotion, neuroscience
or the science of the brain, and the science of human behavior. Through
this research we have learned that the disorders just discussed actually
have much more in common than their separate diagnostic labels might
lead you to think. At their core, all of these disorders arise out of a ten-
dency to experience emotions more frequently, more intensely, and
as more distressing than someone without these disorders. Because of
this, people tend to do certain things and behave in certain ways in
order to try and manage or control these experiences, but these strate-
gies tend to backfire. Therefore, this treatment program focuses on
allowing you to understand your emotional experiences better, identify
what you may be doing that actually causes your symptoms to worsen,
and what you can do to start feeling better and live the life you want.

Summary

This treatment program is designed to help individuals suffering

from a variety of anxiety and depressive disorders, which all fall into

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 rime. Therefore, this treatment program is
designed to directly address the aversive emotional experiences at the
core of all these disorders.

In the next chapter, we will provide an overview of the treatment

program, giving you an idea of what this program entails, and allow-
ing you the opportunity to decide if this treatment is right for you.

13
 Is This Treat1nent Right for You?

:I!! II! III! i I

!

Goals

~!il To understand how this treatment program works and what it

entails

!£:~ To understand the importance of completing exercises

2 To understand how this treatment works in combination with

other treatments such as drugs or psychotherapy

fif~ To determine if this treatment is right for you

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.

Outline of the Trnatmen~

In each chapter of this book, we will introduce you to ideas and

strategies that will teach you new skills for managing your emotional
experiences and your symptoms of anxiety, mood, or other emo-
tional disorders. The book is designed such that each chapter builds
on the one that precedes it, allowing you to continually practice each
skill you learn while being introduced to the next new skill. We will
begin by providing you with a deeper understanding of why we have
emotions in the first place, how they are adaptive, and how they
become maladaptive. You will learn strategies for becoming more
aware of your own experiences, and will learn how your thoughts,
feelings, and behaviors all contribute to your experiences. You will
learn specific strategies that, when put into practice, will help you
to change less helpful ways of coping you may have developed over
time, and replace these with more helpful ways of managing your
expenences.

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 selfassessment 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.

The importance of doing the exercises in each chapter can't be

emphasized enough. This is not the kind of treatment that you can
sit back and read and hope for results. The success of this program is
based largely on the amount of effort you put into it. The best way
to understand the concepts presented here is through "learning by
doing." The more you practice the skills, the more automatic the
skills become. Think of it as deciding to enter a marathon. You can't
just decide to do it and expect to be able to run 26 miles with ease.
You have to start several months before, exercising a bit more every
day, until eventually you build the muscles and the stamina neces-
sary to carry you through. In Chapter 4, we will discuss ways to help
you decide your own level of motivation to put in the work and
effort in order to make your treatment a success. But for now, realize
that the best way to use this treatment program is by not just reading
the concepts, but practicing them through the exercises provided as
well. Remember: Learning Comes By Doing!

Here is an outline of the treatment program and the remammg

chapters in this book:

Chapter 3: Learning to Record Your Experiences

Chapter 4: Maintaining Motivation and Setting Goals for

Treatment

Chapter 5: Understanding Your Emotions

Chapter 6: Recognizing and Tracking Your Emotional Responses

Chapter '7: Learning to Observe Your Emotions and Your

Reactions to Your Emotions

Chapter 8: Understanding Thoughts: Thinking the Worst and

Overestimating the Risk

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

Can I [))o this Treatment at the Same Time as mher Treatments?

If you are involved in another psychotherapy treatment program

that specifically focuses on treating anxiety or mood symptoms, it
may be best to wait until that program is finished before starting
this one. Oftentimes different treatment programs offer slightly
different and sometimes conflicting strategies for coping with emo-
tional difficulties. This can sometimes lead to mixed or confusing
messages about what you should be doing to manage your symp-
toms. If you have just started a program and have not yet seen results,
and are turning to this maimal hoping to speed up the process, you
might want to allow your current program to run its full course to
see if you get results. If, at the end, you are still struggling with your
symptoms, you can give this program a try. On the other hand, if
you are seeing a mental health professional for other issues not
focused on your symptoms, such as supportive counseling or marital
counseling, there is no reason why you can't do both at the same
time.

If you are currently taking medications for your symptoms you may
be able to continue medications while going through this program.
Keep in mind, however, that certain drugs, such as anti-anxiety
medications like Xanax® or Klonopin®, taken regularly (every day)
can dampen your emotions, making it difficult to reap the full
benefit of this program.

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.

What are the Benefits of this Program?

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 Treatments That Work™ 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
 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
!Oecision Tree

Are you struggling with strong,

intense, and/or uncomfortable If NO, consult with your doctor
emotions like anxiety, panic, ----> or mental health professional
depression or fear? Is this getting about alternative treatments.
in the way of your life?

YES
I
I
I
t
Are you involved in other
If YES, wait until the other
psychological treatments that -----»· treatment is over to decide
might interfere with this
about this one.
program?

NO
I
I
I
t
Do you think the benefits of this
program outweigh the costs? ----l> If NO, wait until you are ready.
Are you motivated to give this
program priority right now?

YES
I
I
I
t
Then this program is right for
you!

20
 Learning to Record Your Experiences

Goals

ID:i To learn the importance of recordkeeping

t~ To introduce you to the Overall Anxiety Severity and

Interference Scale (OASIS), the Overall Depression Severity
and Interference Scale (ODSIS), and the Progress Record

§l To learn how to monitor your experiences for one week

~ To complete the self-assessment

Key Concepts

In this chapter, we will help you to understand the importance of

monitoring and recording your experience. For the rest of this pro-
gram, you will be asked to keep ongoing records of your emotional
experiences, and your progress week by week. Keeping ongoing records
of your experience is a crucial part of the success of this program.

Why Take the Time to Record?

There are many reasons why it is important to keep records of your

experiences on a regular, ongoing basis. First, intense or chronic
anxiety, mood difficulties, or other uncomfortable emotional experi-
ences typically feel out of your control, as if they have a life of their
own. You probably feel as if sometimes you are a victim of your own
uncomfortable or distressing experiences. Learning to be an observer,
as opposed to a victim, of your own experience is a first step toward
gaining control. You will be learning specific skills that will help you
to learn to observe your emotional experiences in Chapter 7, but
even the simple act of recording your experiences will begin to help

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.

Another important reason for regular, ongoing recordkeeping is that

this type of monitoring provides much more accurate information
than you get by simply asking yourself, "How have I been feeling
lately?" If you were asked to describe the last week, you may judge it
to have been very bad, when in fact there may have been several times
when you felt relatively good. When you are focusing so much on the
times you felt anxious, depressed, or generally distressed, it is easy to
forget about the times you did not feel that way. Not only that, but
thinking about the previous week as very "bad," while overlooking
relatively "okay" times during the week, is likely to make you feel
even worse. In fact, such negative judgments about how you've been
doing in general may be contributing to your ongoing feelings of
anxiety; depression, or other distressing emotions. Keeping ongoing
records of your emotional experiences forces you to recognize that
your mood state fluctuates, and that there are times when you feel less
distressed than at other times. By keeping ongoing records, you will
begin to get a more realistic picture of what is really going on for you,
enabling you to feel more in control and less distressed.

Sometimes people are concerned that continually recording their

levels of anxiety, depression, or distress will make them feel even worse.

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. Jr is important to realize, however, that there is more than
one way to observe and monitor your experiences: a subjective way
and an o~jective way.

Subjective monitoring means monitoring "how bad you feel," how

severe the anxiety is, how much it is interfering in your life, or how
helpless you feel to control it. It's like being in the middle of a giant
bowl of gelatin and feeling as if there is no way out. You probably already
do a lot of subjective monitoring, thinking about how bad you feel and
how powerless you feel to make it stop. You might even try to avoid
monitoring your experiences because it just makes you feel worse.

Objective monitoring, on the other hand, is quite different-and is

what we are asking you to do in this program. Objective monitoring
means monitoring the features of your distress in a more "scientific"
way. This is more like standing outside the giant bowl of gelatin
and noting exactly what color it is, and how many times it shakes.
In this program, you will learn to record things such as how many
times over the course of the week you felt a certain way, what was
happening right before you felt distressed, and how you responded
(what you were thinking, doing, and feeling). In other words, you
will be recording just the facts and evidence, not your judgments
or evaluations of how good or bad the experience may have been
for you.

At first, it may be difficult to switch from subjective to objective

monitoring, and as you start to use the records, you may even notice
an increase in your distress because you are focusing on your feelings
in the old, subjective way. However, with practice, you will begin to
find that switching into the objective mode becomes easier and easier.
To help you do this, we have inch1ded very specific forms in this pro-
gram that have been designed to record very specific objective infor-
mation, which you will find throughout the remaining chapters.

Let's review all of the benefits of ongoing monitoring and recording,

as well as the reasons why it is crucial to the success of this program:

~ To identify specific triggers of episodes of anxiety, depression,

or other distressing emotional experiences. Knowledge of these

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.

1:11 To identify the specific ways in which you experience anxiety in

an objective way. These include your thoughts, physical feelings,
and behaviors.

~ To evaluate the success of your attempts to change. Remember,

when you are anxious, depressed, or distressed in some way, it
is easy to dismiss gains and focus instead on how terrible you
feel. Objective monitoring will help you to appreciate your
progress and gains. When an episode of distress makes you foel
as if you've failed or taken a step backward, the records will
show the changes that you've made, so that the one incident of
distress does not overshadow your progress. So, keep all of your
forms so you can look at them again later. It's a good idea to
get a folder where you can keep all of your forms and records.

~:'1 To become an objective observer of yourself so that you can

begin to stand outside the bowl of gelatin. This is an important
step m your progress.

What Do I Record?

As you go through each chapter in this book, you will be introduced

to specific records and forms that have been developed to help you
learn and practice each new skill. However, there are two records
that you will use throughout the entire program. These records will
allow you to objectively record how often over the past week you
experienced the types of general anxiety and depression common to
all emotional disorders, at least to some extent, how severe the anxi-
ety and depression was, and how much these feelings interfered in
your daily life. These forms will also allow you to chal't your progress

24
 as you move through the program, allowing you to see the impact of
the changes you make on your overall experience.

The first is called the Overall Anxiety Severity and Interference

Scale, or OASIS 1 • This form has five questions asking about anxiety
and fear. The second form is called the Overall Depression Severity
and Interference Scale, or ODSIS. This form is nearly identical to
the OASIS, but asks specifically about experiences with depression.
On both scales, for each item you are asked to circle the number
for the answer that best describes your experience over the past week.
At the bottom of the form, you can record the total of all the num-
bers you have circled, which is your total score on the form for that
week. These total scores will be the numbers you use to chart your
progress, which will be described next. Blank forms are provided at
the end of the chapter.

Keeping a record of your improvement is an important way to help

keep yourself moving forward, especially during those times when
you might feel frustrated or discouraged. Use the information gath-
ered from the OASIS and the ODSIS to chart your progress week by
week on the Progress Record. The Progress Record is designed to
summarize your progress so that you can easily view changes over
the course of the entire program. A blank copy of the Progress Record
is provided at the end of the chapter. On the bottom of the scale,
you will see one number for each week you use this program. Use
the numbers on the left side of the scale to plot your total score on
the OASIS for each week. Use the numbers on the right side of scale
to plot your total score on the ODSIS for each week. You may want
to use a different colored pen for each scale, or a pen for one and a
pencil for the other, in order to tell the two scales apart.

Here is an example of how a Progress Record might look (Figure 3.1).

Notice that progress does not occur in a straight line, but instead
there are some peaks and valleys along the way. This is typical for
most people, and you may find a similar pattern emerges for your
own progress. If you find your own experience seems to be worse one
week than the week before, challenge yourself to keep going-you

1 Norman, S. B., Cissell, S. H., Means-Christensen, A. ]., & Stein, M. B. (2006).

Development and validation of an overall severity and impairment scale (OASIS). Depression
and Anxiety, 23, 245-249.

25
N
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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

We cannot emphasize enough the importance of recordkeeping.

Monitoring and recording your experiences using the forms in this
workbook should be done daily to get the full benefit of the program.
Remember, there is a difference between su~jective monitoring, or
focusing on how bad you feel or how bad your anxiety might be, and
objective monitoring, or looking at the features of your experience in
a more "scientific" way. Completing the OASIS, ODSIS, and Progress
Record weekly will help keep you on track and keep your progress in
perspective. At first, you may have to push yourself to keep these
records, but it will become easier, and even rewarding, as you con-
tinue. These records not only will help you to give yourself feedback,
but are also very helpful to your mental health professional.

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

~ Begin to monitor your weekly experiences using the OASIS

and ODSIS. Use these forms to get into the habit of objectively
recording how often you experienced anxiety and depression
over the past week, how severely, and how much these feelings
interfered in your daily life.

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.

I
Self-Assessment Quiz

Answer each of the following by circling true (T) or false (F). Answers
can be found in the appendix.

r. Recordkeeping helps you learn to observe when, where, and under

what circumstances uncomfortable emotional situations occur.

T F

2. Objective monitoring and recordkeeping means focusing on

how bad you feel.

T F

3. You should be able to easily switch from subjective to objective

monitoring without practicing it, and if you can't you must be
doing it wrong.

T F

4. Objective monitoring and recordkeeping helps give you more

accurate information about your experiences; for example,
allowing you to see there may actually have been some good
moments in a week you judged as all bad.

T F

28
 Overall Anxiety Severity and Impairment Scale (OASIS)

The following items ask abour anxiety and fear. For each item, circle the number for the answer that best
describes your experience over the past week.

r. In the past week, how ofren 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?

O = Little or None: Anxiety was absent or barely noticeable.

l = 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, bur 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 ofren 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 an..'Ciety 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, bur, overall, my social life is still fulfilling.
2 = Moderate: I have experienced some interference with my social life, bur 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.

I. In the past week, how often have you felt depressed?

O = No depression in the past week.

1 = Infrequent depression. Felt depressed a few rimes.
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?

O = 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.

+ 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 rhe 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 dose
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

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19 19
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17 17 Q)
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3 3
2 2
1
o, IO
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
~I Week
 11 l
111
Il 1
I! I
111 Maintaining Motivation and
Ii
1

r 11 i1
Setting Goals for Treatment
11 ! i!
i Ii iI
iI IiJ

Goals

;1si1 To discuss the importance of motivation

~ To explore the costs and benefits of changing

~ To explore the costs and benefits of remaining the same

~ To set specific goals you hope to achieve during treatment

~ To set manageable steps to reach 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 recordk.eeping 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 thi:
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 refei
back to these first records as your starting point, and to begin to ge1
into the habit of regular recordkeeping. As mentioned, in the chap-
ters that follow you will be introduced to more forms to be usec
daily to record your experiences, so it is good to get in the habit oJ
recording now.

Motivation

Motivation and commitment are important for anyone who is think-

ing about changing their behavior to improve their life. Research has
consistently shown that two factors strongly influence how well
people do at the end of treatment. First and foremost, how much a
person engages in the treatment (completing all homework assign-
ments, conducting all of the exercises, repeating exposures, etc.) pre-
dicts how well they will do after treatment. Second, how motivated
and committed a person is to changing predicts how well they do
after treatment is finished. The more motivated and committed you
are, the more likely you are to engage in the treatment procedures.
Knowing how important your motivation and commitment are for
getting the most out of treatment, we have developed some proce-
dures to help maximize and maintain your level of motivation over
the course of treatment.

First, keep in mind that motivation is not fixed. It changes over

time. Some days your motivation will be high, and completing all
of the treatment procedures will be relatively effortless. However,
some days it might be more difficult to get yourself to complete the
homework or exercises. It is on these days that it is most important
to push yourself and complete the assignments. It is important to
recognize that external factors can affect your motivation. Increased
stress at work, feeling particularly tired or sick, or having more than
usual on your plate one week, can all reduce your motivation for
engaging in the treatment procedures. At some points, you might

36
 even feel like you don't want to change, or it is not worth the rime
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.

During times of low motivation it can be helpful to revisit the

reasons for and against making a change, as well as the reasons for
and against staying the same. So let's start with an exercise to help
you record all the reasons you have for and against both changing
and staying the same.

Decisional Balance !Exercise

Thinking about changing or coming into treatment can be scary.

This can make a person feel somewhat ambivalent about changing.
When people think about changing, they often don't consider "all
"sides" in a complete way. Instead, they do what they think they
"should" do and avoid doing things they don't feel like doing. Some
people might even feel confused or overwhelmed and give up think-
ing about it at all. Thinking through the pros and cons of both
changing and staying the same is one way to help you fully consider
a possible change and help the process feel more manageable. This
can also help you cope with difficult times that might arise along the
way. Write all the pros and cons you can think of for both changing and
staying the same on the Decisional Balance Worksheet provided on
page 39. A completed sample of the worksheet is shown in Figure 4.1.
Take your time and really explore the pros and cons for both chang-
ing and staying the same. Sometimes it can be difficult to recognize
reasons for staying the same, and sometimes you may not want to
admit those reasons to yourself However, it is important to be
honest with yourself and recognize all the reasons for and against
both changing and staying the same.

Were you able to come up with reasons for each of the boxes? If not,
please tak.e a moment to go back and fill in some reasons for any
boxes you might have left blank.

37
 \
Pros/Benefits Cons/Costs

I won't h;~v'e- to <;vffev ;m~mov-e-. C-h<inB~ i<; diff101lt <ind will be

h<iv-d wov-k~
I will be <ib/e- to live <i fvll life- <iB'in.
Thie; i<; p<ivf of who I <im, I'm <i <;h~
Change I will be- <iblc. to mc.e-t ne-w people-, <ind pc.v-<;on.
hope-fvl/~ m<ifce. <;omc. ne-w fvic.nd<;.
If I f<iil, then thi~ <ive- ve-<il/~
I c..<in c;favt d<itiY!ffe hope-le.<;<; fov- me. I migit nc.v'e-v- f?t
bdfov-.

It wovld be c.<i<;iev- ta not h<iv'& to fY I will umtinve ta fc.e-1 thic; Wd~.

thv-ovgi <ii/ of thic;.
M~ life. will e-ontinvc. to be. limifod.
Stay the It ic; e-omfornble; it'c; wh<it I'm v<;c.d
Same to doiY!ffe I <;till won't be- <ible- to mc.e-t ne-w
pe-oph
I won't be. <ib/e- to bc.8n d;:iti~

Figure 4.1
Sarah's Decisional Balance Worksheet
Sarah came in for treatment mainly for help with excessive anxiety in social situations. She would becor
anxious anytime she was in a group situation, or around new people. She had been avoiding interacti
with new people, as well as people she didn't know very well, ever since high school. Over the years, !-
life has become increasingly restricted and she has recently noticed that her social circle consists of onlJ
few close friends. She hasn't dated much at all, and would like to begin to be more comfortable arou1
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, le

take a look at your reasons for staying the same. We can use Saral
Decisional Balance Worksheet shown in Figure 4.1 as an example
help our discussion. Sarah noted that staying the same would I
easier. This is a very common response, and she's at least somewh
correct. In some ways, it is easier to stay the same. You wouldn't ha'
to spend time reading this workbook, and you wouldn't be fillir
out these forms. However, think about how much time and effort
takes to avoid your uncomfortable emotions. It might feel easi·
because it is what you are used to doing, but it takes a lot of time an
energy to continue avoiding your emotions. Sarah also noted th:
it was comfortable to stay the same. While there is some amou1
of comfort that comes with doing what we're used to doing, ho
comfortable are your emotional experiences currently? Most peop

38
Decisional IBalam:e Worksheet

Pros/Benefits Cons/Costs

Change

Stay the
Same

39
 seek treatment or help precisely because their emotions and thei1
lives have become so uncomfortable!

Ok, now let's explore some of Sarah's reasons against changing. A~

we discussed earlier, changing is difficult and will require a lot ol
time and effort on your part. However, staying the same has taken a
lot of time and effort as well, and it continues to do so. Change
might feel like it requires even more effort and time, but this is
largely because you have practiced "staying the same" for so long. In
time, once you have successfully completed treatment, your new
way of behaving and interacting with the world wil! become second
nature and will feel just as "easy" as staying the same does now.

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 wil! 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 ~ontinue 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 jllf1p 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 reas-ons 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.

Setting Manageable Goals

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 "malung more friends" and "feeling happier."

We might achieve some of these goals in a matter of hours ("going

to the gym tonight"), while others might take longer to accomplish
("making more friends"), and some we might always be working
toward (e.g., "feeling happier"). We all have goals that are achievable
in these different timeframes. Research has shown that setting spe-
cific, concrete, and manageable goals for behavior change greatly
improves our chances of successfully changing. Thus, the goal of

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 #i goal for treatment is: To Make- mov-e.- fv-ie;,nds
Mal<ing 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?

Try to be as concrete as possible here.

Me;,e-fin
fv-ia1ds ol/e;,v- fov- dinne;,v- parf-ie;,<;, c..-alli~ fv-ie;,nds to c..-he;,e;,v- Me;, vp whe;,n I have;,
a bad da~, and no+ sfa~i~ hoYVle;, alone;, on Satvv-da~ ni§kits oin~Mov-e;,.

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

to achieving your treatment goal.

Steps: C-oil/ pe-v-<;on to invite- the:-m to &° <;e;,e;, oi Movie- on Satvv-dci~; ni§kit
Step 4: (:Jle;,t phone;, VJVYVlbe;,v- fv-om ac..-lfJ'cilnfanc..-e;,
Step 3: Mcike- mov-e;, fve;,lfJ'e;,VJf ciVJd e;,xfe;,nde;,d vonve;,v-<;cifion with aVlfJ'ciinfanc..-e;,<;
Step 2: Make- <;mt:J/I tt:Jlk- with t:Jvqvt:Jinfanve;,<;
v
Step 1: f:.nfe;,v- t:Jnd v-e;,mt:Jin in <;itvcitions whe;,v-e;, ofhe;,y pe;,op/e;, ave;, pv-e;,<;e;,nf
(e;,ffe' at wov-k-, at the;, 8JrY1)
Figure 4.2
Sarah's Treatment Goal Setting Worksheet

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
Treaftment Goai~SeUi11g Worksheet

Mv, #1 booal for treatment is:------------------------~-

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? Try to
be as concrete as possible here.

Taking the Necessary Steps

Next, think about some small, manageable steps that you can tal<e
toward reaching the specific treatment goals you've listed above.
These steps should tal<.e 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 rake 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: - - - - - - - - - - - - - - - - - - - - - - - - - - -

Making it More Concrete

Tal<:e 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
or not engaging in? Again, be as concrete as possible here, try to list
specific behaviors.

Taking the Necessary Steps

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 I:

48
My 3rd goal for treatment i s : - - - - - - - - - - - - - - - - - - - - - - - - - -

Making it More C1mcrnte

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
or not engaging in? Again, be as concrete as possible here, try to list
specific behaviors.

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? Ir 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 l:

49
Summary

Keeping your motivation high is important for successfolly chang-

ing any behavior, especially how you respond to your emotions.
Remember, motivation is not fixed, and your own motivation will
change (both increase and decrease) over time and as you progress
through this program. This is a natural and normal part of the
behavior change process. The two steps that we discussed in this
chapter are extremely helpful in keeping your motivation high as
you go through this program. Revisiting the reasons for and against
both changing and staying the same (Decisional Balance Worksheet)
can be helpful in strengthening and even building your motivation
at times when your level of ambivalence (feeling both that you want
and don't want to change) has increased. Similarly, setting concrete,
manageable goals for you to work toward behavior change (Treatment
Goal Setting Worksheet) is an important step to help make the
change feel more manageable and less overwhelming. Revisiting
these two steps over the course of the program can help you to keep
your motivation high and increase your chances for success!

Homework

~ Continue monitoring your weekly experiences using the

OASIS and ODSIS.

~ Remember to use the Progress Record to record the total scores

from the OASIS and ODSIS week by week.

Seif-Assessment Quiz

Answer each of the following by circling true (T) or false (F). Answers
can be found in the appendix.

I. 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

3. Goals are more effective when they are concrete.

T F

+ Once I start the program, my motivation will remain as strong

as it is now.

T F

5'1
 Understanding Your En2otions

Goals

~ To learn about the important function of emotions in

everyday life

ifi''ll To learn what makes up an emotional experience

iii] To begin to gain a greater awareness of your own emotional

expenences

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 rbis 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 recordk.eeping, 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 cm Emotlloms?

As we discussed in the first chapter, many of the symptoms of anxi-

ety and/or depressive disorders stem from difficulties coping with
uncomfortable or distressing emotions or emotional experiences.
For example, someone with social anxiety may find that the intense
fear they feel in social interactions, or the intense anxiety they expe-
rience anticipating a social event, severely limits their ability to do
their job or lead a full social life. Someone with generalized anxiety
disorder may find that anxiety about the future outcome of some-
thing important to them, such as their performance at work or the
health of their family, is so overwhelming that they can't think about
anything else. Someone with depression may feel so paralyzed by
sadness and feelings of worthlessness that they cannot motivate
themselves to do much of anything. These emotional experiences,
and the distress they cause, play important roles in keeping symp-
toms of emotional disorders going. In fact, oftentimes people seek
treatment specifically to try and get rid of uncomfortable emotions,
such as anxiety, fear, anger, or sadness. They want the therapist to
"take away" or "stop" the negative emotions, or "shut off the switch"
to the fear circuit in their brain. However, as you will learn, getting
rid of these uncomfortable emotions would not be very helpfol or
adaptive, and in fact would actually work against you. The truth is
that all emotions, even the uncomfortable ones, play very important
roles in our lives and provide us with a lot of important information.

The goal of this treatment is not to eliminate uncomfortable emo-

tions like fear, anxiety, sadness, or anger, etc. Instead, this treatment
is designed to help you learn how to better understand and tolerate
uncomfortable emotions, to see how your responses to your emo-
tions are driving your symptoms, and to ground your emotional
experiences within the current context in which they are occurring,
rather than in associations with what may have happened the last
time you felt a certain way, or fears about what your experience
might mean for the future. All of this will help you to counter mal-
adaptive strategies you have developed over time to manage uncom-
fortable or distressing emotional experiences, and begin to build
new experiences, ones in which you find you are able to cope with a
foll range of experiences and lead the life you want.

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.

Why Do We Have Emotions?

It is important to understand that emotions are not necessarily "bad"

or "dangerous," although they can sometimes feel that way. We need
the full range of emotions, the "good" ones and the "bad" ones, in
order to function in the world. Imagine for a moment what it would
be like if we had no emotions. We would have no ups and downs, but
we would be like robots, automatons drifting through our days. Now
imagine what it would be like if we only had the "good" emotions.
How would we know if our lives were suddenly in danger, without a
sense of fear, or stand up for ourselves when we are be;ing wronged,
without a sense of anger? The fact is that all of our emotions, the
good, the bad, and the "ugly;" tell us very important things about
what is going on in our lives. They help us to navigate our world, and
to motivate us to do things that are helpful or useful for our survival.
Our emotions signal us to engage in specific behaviors, which we call
"emotion-driven behaviors" or EDBs, which are often automatic and
adaptive. As such, nature has given us a highly coordinated and
orchestrated way to function in the world-we feel something, we do
something in response. Let's take a look at some examples of how this
system works, looking at the definition and function of some of what
we might traditionally think of as the "bad" emotions.

Fear
Fear is nature's alarm system. It is a basic response to danger, and
signals the need for immediate action and/or attention. Let's tal{e a
look at how fear might be helpful.

Imagine you are crossing the street with a friend Suddenly, a car come.s screeching and
careening straight toward you. Without thinking, you Jump on to the sidewalk and pull
your friend to safety away from the oncoming car.

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 foar that kept you and your friend alive.
These are natural reactions, and they ofren 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 foar, 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/Deprassioin
Sadness or depression is one of the most shunned of our emotions.
How many times have you heard someone say "cheer up" or "don't
be sad"? However, sadness also serves an important function in our
lives. Sadness or depression is extreme dejection, melancholy, and a
sense of hopelessness and/or inability to cope on one's own, which is
a natural response to what we perceive as an uncontrollable situation
or loss, such as the loss of a loved one, or a personal setback for
which no solutions are obvious. It signals the need for withdrawal
and reduction of activity so that mourning may take place, resources
can be gathered, and the event can be processed appropriately. It also
functions as an important social cue, eliciting help and support from
others. Let's take a look at another example to see how sadness might
be helpful:

Imagine you find out that a very close friend or family member has passed away. You will
probably feel intense sadness and a great sense ofloss. You are also likely to feel as ifyou
have no energy, and find it difficult to focus on anything except for disorganized thoughts
ofyour loved one and how you will cope. You may also feel numb, and that the loss hasn't
really 'hmk in. "These are typical responses to experiencing a tragedy or traumatic event.
As a result, you might find that you are unable to do much ofanything other than focus
on the loss and try to find ways to cope with it. Others may pick up on your sadness, loss
ofenergy, and disorganization, and come forward to help you manage during your time
ofneed. Theil· support can in turn help you to heal and get back to managing your own
life more quickly.

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
Anxiety, like sadness or depression, is another emotion we are often
told not to feel. However, anxiety also has an important place in our
lives and serves a very important function. Anxiety is a future-oriented
state. It's purpose is to allow us to be ready to cope with potentially
negative or dangerous events. It signals the need to reduce activity and
refocus attention on possible sources of future threat or danger
(assumedly for self-preservation purposes). When we feel anxious, our
bodies and minds go into a state of vigilance and "preparation" so that
we aren't caught off guard if something bad happens.

Imagine that you have a big presentation coming up at work or school, which is going to
be very importantforyourjob or grade. Naturally, you start to think about it more often
as the date approaches, and you might even start to feel anxious. So, you start doing some
research on the topic-maybe you even work late to make sure you have gathered all of
the in.formation you need. You prepare the presentation and practice it several times (you
might even ask a ftiend or family member to give you feedback on it). You'll even
anticipate some ofthe questions people might ask, so that you know how you might
respond. On the day ofthe presentation, you may get up earlier than usual, put on your
best clothes, and go over the presentation again.

Yet again, we see the uncomfortable emotion of anxiety ser\red a very

dear purpose here. It motivated you to anticipate possible negative
events (e.g., difficult questions from the audience) so you could get
prepared and be ready to respond to them, and to focus your atten-
tion on the topic that was causing you anxiety. Let's look at one
more emotion.

Anger
Anger is a natural response to perceived intentional injury, mistreat-
ment, or victimization. It signals the need to increase activity and

57
 mobilize efforts to defend oneself or a loved one. Anger is ofter
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 tG
incur late fees, and you now are expected to pay the utility a large amount ofmoney-
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

Here, the emotion of anger is an adaptive way of signaling to the

other person that they have frustrated or "wronged" you in some
way. Speaking forcefully to the customer service representative is ~
way of communicating this anger, so that (hopefo.lly) the representa·
tive recognizes that you have been wronged and fixes the problem
thereby ending the utility company's transgression against you. Even
though we don't always express anger by yelling, anger is a very
important emotion to pay attention to, as it is sig~aling you to take
steps to defend something of value that you feel is being threatened,
or to prevent someone from mistreating you or some situation from
causing you harm.

As these examples illustrate, emotions serve a very important func-

tion in our lives and, at their core, are adaptive experiences to have
However, as we have also noted, these emotions can also get in the
way, cause a great deal of distress, and cause someone to limit the
degree to which they are truly living their lives. You may be saying tc
yourself, "I can see fear is adaptive, but what about the fear I seem tc
feel for no reason when I have a panic attack?" or, "anxiety might be
useful to some people, but I can't turn it off-I feel it all the time!'
The truth is, whereas these emotions are all adaptive in the norma
course of anyone's life, sometimes we can experience these emotiorn
as too intense, too uncontrollable, and as happening in the wronE
situation or at the wrong time. As you go through this treatment
you will learn how and why this occurs, and ways that you can brea.1
the cycle of intense, overwhelming emotions. However, before we
can start to understand where emotions become maladaptive, it ii
important in the beginning to understand that emotions, even the
ones that seem uncomfortable and feel like you could do without

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.

So how do our emotions go from being useful, functional and adap-

tive to being overwhelming, intense, and even crippling? In order
to begin to explore how this process unfolds, let's first break down
what it is we are talking about in the first place, when we refer to
an "emotional experience."

What is an !Emotion?

W'hat exactly is an emotional experience? We have discussed how

emotions are useful, how they inform us, and how they motivate our
behavior (EDBs). However, you may experience your own emotions
like a big "cloud" of intense feelings, and it might seem difficult for
you to identify anything useful about your emotional experiences or
be able to understand what your emotions are trying to tell you. One
way to make something that feels overwhelming less so, is to brealc it
down into its main parts. Every emotional experience can actually be
broken down into three main parts-what we think, what we do, and
how we physically feel. By identifying each of these parts of your expe-
rience, your emotions can begin to feel a bit less overwhelming.

The three components of emotional experiences are:

I. Cognitive (\'qhat I Think): These are the d1oughts often

triggered by or linked with emotional states. For example,
someone who is feeling sadness may have thoughts about a
situation being hopeless, or being inadequate ("I always mess
everything up.") Someone who is feeling pride may have
thoughts of being capable or of being able to conquer something
difficult ("I know I can do this!"). See if you can come up with
some thoughts that might accompany the following states:

W'hat types of thoughts might someone have when they are anxious?

\V'hat about when someone is happy?

59
 What thoughts might someone have when they are afraid?

2. Behavioral (What I Do): These are actions a person does or has

the urge to do as a response to the emotional state. Often,
someone will respond to a feeling without thinking about it.
This is because it seems like our bodies just "know" the best
way to deal with these situations. These experiences are what we
call emotion-driven behaviors or "EDBs." We discussed some
examples of adaptive EDBs (e.g., jumping out of the way of an
oncoming car in response to fear), but EDBs are also present in
emotional experiences that may not feel useful or adaptive. For
example, someone who is depressed may stay in bed all day or
just watch television, because the thought of getting out and
"confronting" the day is too overwhelming. Or, someone who is
anxious in social settings but suddenly finds herself in a crowd
of people where she is expected to interact, mayi avoid eye
contact or even exit the situation entirely in order to escape this
frightening social encou~ter. Someone who is anxious may also
pace around the room, or start mindlessly eating snack foods.
See if you can come up with examples of EDBs that might
occur in the following states:

What might someone do when they feel scared or panicky?

What about if someone were really angry?

What might someone do if they felt ashamed or embarrassed?

3. Physiological (How I Feel): These are the physiological

responses attached to emotional states, or the way your body
physically responds to emotions. For example, fear is often
accompanied by a racing heart, a tensing of the muscles, maybe
even shortness of breath. Anxiety may be accompanied by
sweaty palms, a knot in the stomach. Sadness may be accompa-
nied by a sensation of heaviness in the limbs. See if you can

60
 identify the physiological sensations that might accompany the
following stares:

What physical sensations come with feeling excited?

What about when experiencing panic?

What sensations come with anger?

What about when you are feeling happy?

As you can see, these three components-thoughts, physical sensa-

tions/feelings, and behaviors-are identifiable in every type of emo-
tional experience, although some aspects may be more readily
identified than others in any given situation. For example, you may
be keenly aware of physical sensations in a given situation, but less
aware of your behaviors or thoughts. Conversely, you may be aware
of your thoughts, but less aware of accompanying physical sensa-
tions and behaviors. It is important to begin to identify all three of
these components of your experience, as they tend to interact and
feed off of each other, influencing and changing your ongoing expe-
riences. As you proceed through this treatment, we will look closer
at each of these components separately, identifying ways in which
our responses to our emotions within each of these components
change from being adaptive to being maladaptive, and discussing
new strategies for better regulating our responses in mor~ adaptive
and self-supportive ways. For now, however, it is a good idea to start
practicing identifying your own thoughts, feelings, and behaviors in
response to emotional situations.

The Three-Component Model of Emotions form is a good place to

begin monitoring your experience in each of these three domains.
Use this form to record at least one emotional situation over the next
few days, reflecting on the experience and breaking it out into
thoughts, physical sensations/feelings, and behaviors. You might
even want to try to visualize these three circles when reflecting upon

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 confosing experience.
A sample, completed model is shown in Figure 5 .1.

Monitoring and recording the three components of your emotional

experiences will help you to better understand and begin to break
down these experiences. Another goal is to begin monitoring when,
where, and why your emotional experiences are occurring in the first
place. In the next chapter, we will discuss ways to help you begin
paying attention to what triggers emotional experiences for you, as
well as how you respond to these experiences and the consequences
of those responses.

Summary

In this chapter, we have discussed the ways in which all emotions,

even the ones we traditionally think of as "bad," serve important and
adaptive functions in our lives, and can motivate our behavior in
important and helpful ways. We saw how emotional experiences can
be broken down into three main components-thoughts, physical
sensations/feelings, and behaviors-and how beginning to pay
attention to these three domains may help to make emotional expe-
riences feel less overwhelming. In the next chapter, we will begin to
explore how emotional experiences unfold, and how our experiences
influence the way we behave in, and experience, similar situations in
the future.

Homework

~ Complete the Three-Component Model form by selecting at

least one emotional experience that occurs during the course of
the week and breaking it down into thoughts, physical
sensations/feelings, and behaviors. This form will help you to
build awareness of your emotional experiences, breaking down
experiences in order to help them foel less overwhelming and
unmanageable.

62
 Physical sensation/Feelings
(What I'm feeling)

ANXIOUS, SC-AKW
'F"IZUSTRATf.P NAUS~US
T6-NS6-

Thoughts (what I'm thinking) Behaviors(what I'm doing)

WH-AT 1-F" I CAN'T flNP A JOB? \

C-~N ltOUS6-
NO ON6- WIU-- ltlR&- Mft !'M
NOT d?UAl.-lflw -roiz ANY1lt1N0i
INST~P orl.-OOKIN0! AT
PAPf-IZ( ~T JUNK -roop
l'M SUC-lt A -F"All.-UR&-

Figure 5.1
en
c.:i
Sample Three-Component Model of Emotions
Three-Component Model of !Emotions

Physical sensation/Feelings
(What I'm feeling)

Thoughts (what I'm thinking) Behaviors(what I'm doing)

(
\
 ~ Continue monitoring your weekly experiences using the
OASIS and ODSIS.

~ Remember to use the Progress Record to record the total scores

from the OASIS and ODSIS week by week.

Self-Assessme111ft Quiz

Answer each of the following by circling true (T) or false (F). Answers
can be found in the appendix.

I. The goal of this treatment is to eliminate uncomfortable or

distressing emotions like fear, anxiety, and depression.

T F

2. .All emotions, even ones we consider "negative," are essentially

adaptive, and serve important functions in our lives.

T F

3. Anxiety is never helpful or useful.

T F

4. Emotional experiences are made up of three main parts: what

you think, what you feel, and what you do.

T F

65
 Recognizing and Tracking Your
Emotional Responses

Goals

ITfi To learn how emotional experiences unfold

fE] To learn the ways emotions influence our actions and behaviors

[~ij To learn skills to help you begin monitoring your own

emotional experiences

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

In this chapter, you will learn how emotional experiences unfold,

skills for identifying what triggers your emotions, how you respond

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.

Monitoring IEmotil:mal Experiences-The ARC of !Emotions

An important first step toward helping you understand your own

emotional experiences, and toward making your emotional experi-
ences less intense or uncomfortable and more manageable, is gaining
a better understanding of when, where, and why they are occurring.
This means beginning to look more closely at your experiences,
monitoring what is happening at the very moment they occur, and
taking note of what happened before and what comes after. The
ARC of emotions is meant to introduce you to the process of moni-
toring your experiences with the goal of gaining a better understand-
ing ofthem, enabling you to respond more adaptively and realistically.
It is not important yet to record specific aspects of your experiences,
such as strategies you might be using to manage your experiences or
avoid your emotions. Rather, at this stage in the treatment, the goal
is to simply monitor your emotional experiences and to become
more aware of the whole context in which these experiences occur.

It is important to understand that emotions don't just come out of

nowhere, even though sometimes it might feel like they do. Every
I "
emotional experience we have is triggered by some event or situa-
tion, which causes us to react and respond, and these responses in
turn have consequences. This is known as the ARC of emotional
experiences:

f§.l1 A- The antecedents, or triggers, that precede our emotional

experiences

!1lill R - The response to the antecedents, including all of our

emotional behaviors, thoughts, and feelings

~ C - The consequences of our responses

Every emotional experience we have has an ARC. Through monitor-

ing the ARC of your emotional experiences, you will begin to gain a
better understanding of them.

68
!Example of the ARC of IEmofticms

To illustrate the ARC of emotional expenences, let's look at an

example:

Imagine that you have a series ofimportant presentations in dass or at work, at the
request ofyour boss/teacher, over the next several days. You work hard to prepare the
presentation but you can't get it out ofyour mind that you are not as well prepared as you
like to be, so you work even harder to get it ready and make it "perfect. "As the
presentation begins your stomach is tied in knots, your heart is racing, and you're
trembling a bit. During the presentation people seem bored and inattentive and you feel
it is going badly. Youi·e sure everyone cmz see how anxious you are. V:7hen it is ove;; )'OU
immediate(y start thinking about the next presentation and what excuses you can make,
such as calling in sick, to get out ofit.

In this imaginary scenario, the "AZ' 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:

A = Presentation for class or work

R = Expectations that presentation must be nothing less than

perfect; anticipatory anxiety; physical sensations like trembling,
sweaty palms, dry mouth; hyperawareness of the audience's
reactions; thoughts of your own personal inadequacy

C =After the speech, you experience feelings of failure or of being

"less than perfect" (a short-term consequence); you prepare
longer and harder for the next talk to avoid a repeat of your
perceived failure, and/or you decide that you are unable to
meet the (self-imposed) expectation of constructing and

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:

A = Presentation for class or work

R =Your palms get sweaty, your heart starts beating, you find it
harder to breathe; you have thoughts about having a panic
attack, passing out, being unable to escape the situation; you
begin to rush through the presentation in order to get through
it before the impending panic attack begins

C = You finish the presentation quickly and therefore "successfully"

avert having a full-blown panic attack (a short-term conse-
quence); you decide you were lucky this time, but should avoid
giving speeches in the future because you fear that next time you
won't be so "successful" and will end up having a full-blown panic
attack in front of the audience (a long-term consequence)

Let's look at one final example. Imagine your biggest source of

distress is the presence of nagging doubts about whether you have
been thorough enough or done something correctly, even perfectly.
In this case, your ARC might look something like this:

A = Presentation for class or work

R = You notice (or perceive) inattention and boredom in the

audience, and begin to have thoughts that you may have
forgotten to relay important parts of the speech, doubts about
whether you adequately covered specific topics, and doubts
about whether you may have repeated certain phrases by
accident; you feel increasingly agitated, tense; begin to stutter
slightly, lose your train of thought

C = Uncertainty about whether or not the speech went well, and if

you were able to present the speech well enough (short-term
consequences); avoid giving speeches in future because you
perceive your ability as inadequate (a long-term consequence).

70
 As you can see, the As in these different scenarios did nor 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.

As you begin to identify events or situations that trigger your

emotions (the As), it is also important to recognize that these triggers
can be either something that has just happened or something that
happened much earlier in the day, or even last week. For example, if
you get into an argument or are rejected by a loved one in the morn-
ing, it may influence the way you approach an interaction or situa-
tion, like giving a presentation, later in the day. You may have more
difficulty concentrating on the task at hand or become more easily
upset when, for example, the audience seems inattentive. In the imag-
inary scenario presented earlier, you may have reacted to the situation
in a very different way if it hadn't been for that argument you had
earlier in the morning. The A in that case would have included not
only giving a presentation, but also having a fight with your loved one .
.Alternatively, if you had a terrible night's sleep the night before the
presentation, your fatigue would also serve as a trigger, perhaps malring
you feel more jittery or more sensitive to criticism. The more practice
you have at paying attention to and monitoring the ARC of your

71
-.I
N
R
A
Response
c
Antecedent c
~= -=~

Date/
Situation, Triggers Thoughts Feelings Behaviors What happened neJCt?
Time

l-;ife;. to dodov lhe.~'ve. gi~ to Anxiovs1 fY\/stv;ite.d 0i;ive. vp ;ind dvove. I w;it; m;id ;it M~t;e.lf fov
Mon ;ippointme.nt think. I'm so l:m.-k. home.; dvove. mic;c;i~ the. ;ippo1ntme.nt
inc-ompe.fe.nt1 wh~ f ;ic;t ;ind c.-vvse.d cit
c.-;m't I g-t M~ aC.-t othe.v dvive.vt;
tog-the.v
ltvc;band CC'ie.t ;iffov wovk- lte.'t; tive.d of be.ij- Sad1 t;c.-ave.d, Ke.pt ac;k.l~him if ltvc;b;ind gt iVYifdte.d cit me.,
Iv~ with me.; he.' s M<l anxiovc; he. Welt; o/::: I gt vpc;e.t
that ! am not
wovk-i~

We-d L-oo/ce,d thvou@i wcint-cidc; I c.-;ivi't do thic;, I'll Anxiovc;, c;ad1 Stoppe.d look-I~ 0iot mad cit M~t;e;,lf fov not
ne.ve.v f nd cinothe.v fY\/c;mte.d cind de.ane.cl the. look-i~ fov ci JOD
~ 001 no one. ic; gi~
1 w;int to hive. me.
to
hout;e. lnc;focid

lhvr-~ Siste.v c.-;i/le:,.d soundi~ She. ic;n't h;ipp~, I'm lte.lple.c;c;, anxiovc;, lvie.d to f x it fov Couldn't f;il/ ;it;/e.e.p, mind
vpse.t not ci god c;ic;fov, c;ad, "gtate.d he.v; p;ic.-e.d avound wac; y;ic.-i~
I've. f°iiile.d he.v
frl Pinne.v p;i~ with fvie.ndc; I hope. e.ve.v~one. is Anxiouc;, c;tve.Sc;e.d Couldn't c;top f"e.e.I li/ce, I didn't e.ve.n tci/k. to
gin5- to ~f a/ol'l§r out fvc;c;i~ /ce,pt ;ic;k.i~ an~one. be.c.-;ivt;e. I wat; c;o out;~
wh;it if the.~ don't e;,ve.Y~OVIC- if the;,~ woVY~i~abovt e.ve.v~ovie.
li/ce, the. food, wh;it we.Ye. ok.
if the;, food isn't
Ye.cidj_ on ti Me.

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:

r. A- What triggered your emotional experience? Were there other

things that may have happened either earlier in the day, or even
earlier in the week that may have also influenced how you felt?

2. R - What was your response? What thoughts did you have? What
physical sensations or feelings did you notice? What did you do?

3. C - What were the consequences of your response? What were

the short-term consequences? Long-term consequences?

Just as we have emphasized the importance of considering the pos-

sible triggers for your emotional experiences, be they occurring
immediately prior or hours before, it is also important to pay atten-
tion to what you may have learned as a consequence of these emo-
tional responses. \Ve will discuss this important aspect next.

73
 Understanding what comes before our emotions are triggered helps
us to better understand our emotions and our emotional response.
But it is also important to understand the consequences (Cs) of our
responses to emotional experiences, and in particular our emotion-
driven behaviors, or EDBs. We are designed to learn from our expe-
riences. The only way for us to know what is good and what is bad
is through our experiences, and our emotions help to guide us in
making this distinction. Ifwe want to ensure our survival, we should
move toward things that are good for us and away from things that
are bad. More ofi:en than not, it is our emotions that are telling us
what is good and what is bad.

If you think about it, this serves a very adaptive purpose in nature.
For example, if a rabbit in the forest comes across a fox lurking in the
bushes near its favorite watering hole, the intense emotion of fear
the rabbit experiences helps the rabbit to learn that it should stay
away from this potentially life-threatening situation in the future.
The rabbit learns very quickly from this experience of fear that in
order to ensure its survival, it should probably avoid this area, and
would be better off finding itself a new watering hole. This type of
learning takes place in nature all the time, and just goes to show that
even if we don't necessarily like fear, fear definitely has its place and
is a very adaptive emotion.

This type of learning from uncomfortable emotions is not only for

animals in the wild. It is something people share, and has been passed
down through evolution. As humans, we too are designed to learn
quickly from our experiences. For example, if you are cooking on a
stove and accidentally grab a pot handle that is very hot, you experi-
ence pain and immediately pull your hand away. When you reach
for a pot handle the next time, you may stop yourself and grab a
potholder instead, in order to avoid the unpleasant experience of
being burned again. You have learned that in order to avoid pain,
you should think twice before grabbing something on the stove.
What's more, we are also designed to quickly apply what we have
learned, not only to the immediate situation but to other, similar
situations as well. For example, you not only stop yourself from

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.

When we experience strong emotions, they leave lasting impres-

sions. What triggers our emotions, and what happens when we have
them, stays with us and influences how we experience similar situa-
tions in the future. As humans, we also learn to repeat things that
make us feel good, and to avoid things that make us feel bad.
However, as humans we also have the gift of reasoning and foresight,
and therefore we also may learn to do certain things in order to keep
ourselves from potentially feeling bad. For example, if spicy foods
give you heartburn, you may avoid spicy foods. Similarly, if large
social gatherings make you uncomfortable, you may avoid going to
large social gatherings. If you don't want to wait in long lines at the
supermarket, you may do your shopping late at night or during a

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.

In addition to learning to avoid strong emotions, engaging in the

behavior the strong emotion is driving us to do (the EDB)-such as
running when afraid, even if there is nothing to be afraid of; as in a
panic attack-actually forces us to learn some inappropriate, poten-
tially damaging responses. Engaging in the EDB does serve to relieve
the distress associated with the emotion, even if it is for just a short
time, and helps us to avoid feeling worse. Because of this relief; we
learn to repeat this same EDB when experiencing the strong emo-
tion in the future. For example, we might avoid eye contact during
conversations, or quickly exit a crowded area when feeling panicky,
or stay in bed all day when feeling down. Over time, we learn to
do this same EDB over and over again in an attempt to relieve the
emotion and the possibility of feeling worse. The problem is that
repeatedly doing these EDBs can result in a vicious cycle in which
the EDBs become automatic, counterproductive, and insensitive to
the true context in which our behavior is occurring. Because these
EDBs relieve uncomfortable emotions in the short term, we may
think they are useful for us. However, they may actually be interfer-
ing in important ways in our ability to live our lives. These learned
strategies for coping with intense emotions, such as avoiding situa-
tions that trigger emotions, comprise the "C," or consequences phase
of the ARC model. By avoiding these strong and intense feelings,
we never have the chance to find out what these feelings might really
be telling us, or to see that these feelings will pass. And, by avoiding
intense emotions, we may actually be depriving ourselves of impor-
tant, valued aspects of our lives.

Can you think of something you have learned to do to avoid

experiencing something bad? What was the experience that
influenced you?

76
 What about something you have learned to do to experience
something good? What was the experience that influenced you
in this case?

>ummary

In this chapter, we learned an important strategy for beginning to

understand the where, when, and how of our emotional experiences,
by monitoring the ARC of our experiences. Identifying the ARC
of emotions helps us to note triggers that may have come immedi-
ately prior to an emotional experience, as well as to identify more
distant triggers that may influence the way we respond to emotional
situations or events. Finally, we learned how our emotional experi-
ences can influence the ways in which we approach or avoid similar
situations in the future. In the next chapter, you will learn some
specific strategies to help you become better able to observe your
own experience, allowing you to become even more aware of how
your emotional experiences and your reactions to these experiences
unfold.

-llomiework

~Use the Monitoring Emotions and EDBs in Context form

to begin monitoring the ARC of your emotional experiences.
Be sure to consider both immediate and distant triggers and
consequences.

~ Continue monitoring your weekly experiences using the

OASIS and ODSIS.

~ Remember to use the Progress Record to record the total scores

from the OASIS and ODSIS week by week.

77
SeU~Assessment Quiz

Answer each of the following by circling true (T) or false (F). Answers
can be found in the appendix.

r. In the ''.ARC" of emotional experiences, "A" stands for what

triggered the experience, "R" stands for how you respond, and
"C" stands for the consequences of how you responded.

T F

2. Triggers for emotional experiences only include events or

situations that just happened, and can never include events
from earlier in the day.

T F

3. Our emotions help us to learn to approach or repeat things

that make us feel good, and avoid things that make us foel bad.

T F

4. There are usually only short-term consequences for how we

respond to an emotional experience.

T F

78
Monitoring !Emotions and lEDBs in Context-The ARC of !Emotions

R
A
Response
c
..,,.~
...._

Date/
Situation, Triggers Thoughts Feelings Behaviors What happened ne}{t?
Time
 Learning to Observe Your Emotions and
Your Reactions to Your Emotions

Goals

ru'.i To learn about how reactions to emotions affect emotional

expenences

imJ To learn the concept of non-judgmental emotion awareness

and how to look at your emotional experiences like an outside
observer

~1 To learn about the importance of present-focused awareness

~ To practice present-focused awareness using mindfulness

exercises and musical mood inductions

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.

What Do We Mean by Emotion Awareness?

Previously, we discussed the ways in which emotions can be adap-

tive; how to begin to monitor your emotional experiences, identify-
in~ triggers, responses, and the consequences of your responses (the
ARC of emotional experiences); and how to break down an emo-
tional experience into its three main component parts (thoughts,
physical sensations/feelings, and behaviors). In this chapter, we will
take these concepts one step further, giving you skills to help you
gain a greater objective awareness of your emotions. You will learn

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 our 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 adaptiv:e. 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 fonction). 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 foar, we may
be less aware of these secondary reactions to the fear, or when these
reactions cross the line from being helpfol to extremely unhelpful.

To understand this concept, let's look at an example, staying with

the emotion of fear. Remember the scenario from Chapter 5, where
you learned that the fear elicited when a car comes careening toward
you while you are crossing the street is adaptive, functional, and
could even save your life by ensuring that you jump out of the way
quickly, even before you have time to think about it? In this scenario,
the emotion of fear has motivated you to act in the moment in a life
preserving way, and is dearly not problematic. However, let's say this
emotion of fear has also caused your heart to race and your palms to
sweat, and you are aware that these sensations are still present after
the danger has passed. You begin to feel anxious in response to these
sensations and start worrying that they are getting worse, or that you
can't calm down. Maybe you even react to your beating heart by
thinking you might be having a heart attack. You begin to panic,
and start worrying that you are going to pass out. Or maybe you
begin to feel the world is not safe, and that you got a lucky break this
time but something bad still might happen, or is even bound to
happen. This entire experience may become so overwhelming for

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.

In this imaginary scenario, fear has brought up uncomfortable and

unwanted feelings (a racing heart and sweaty palms), setting off a
cascade of negative thoughts and behaviors, causing a great deal of
anxiety that lasts long after the situation has passed. The fear you
initially experienced is viewed as something that is threatening to
you, rather than as a naturally occurring emotion that alerted you to
something important about what was happening in the world around
you at a particular moment (i.e., "get out of the way if a car is coming
toward you").

To use another example presented previously, the intense sadness,

numbness, and great sense ofloss you might feel following the death
of a loved one are not, in and of themselves, problematic. These
emotions, again, are there for a purpose, allowing you to focus on
coping with the loss and allowing a period of grieving. However, if
your reaction to your sadness is a stream of negative thoughts, such
as your sadness being a sign that you are unable to cope, or that you
will never be able to have a normal life or experience happiness again
in the future because of your inadequacies, these thoughts may serve
to intensify your feelings of sadness and isolation, leaving you feel-
ing heavy, unmotivated, and alone. Instead of viewing your sadness
as a signal to tak.e needed time to care for yourself right at that
moment, you view your experience of sadness as a sign of failure and
hopelessness.

These examples show us how our secondary reactions can become

problematic and even serve to intensify and prolong uncomfortable
emotions. The more we view our emotions as threatening and
unwanted, and the more we tell ourselves that our feelings are "bad"
or that we are "bad" for feeling a certain way, the more we tend to
fuel a vicious cycle of thoughts, physical sensations/feelings, and
behaviors that serve to intensify emotional experiences. In contrast,
by learning to observe how our emotional experiences are unfolding,
accepting without judgment that our initial emotional reactions are
sending us a signal that something is occurring that may or may not

85
co
en

lt~KI B~nN01 "fASle:.R.

SltOKTNe:.ss or B~nt'~

Thoughts (what I'm thinking)

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WltAI l"f i 01e:.11tll Ne:.x-r nMe:.? 11 BUSYS~IS

Figure 7.1
Sam pie 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:

What triggered the emotional experience?

What was your initial emotional response (i.e. fear, anxiety,

sadness, elation)?

Use the Three-Component of Model of Emotions form provided at

the end of this chapter, to map out how your experience emerged.
Use arrows to show how your thoughts, physical sensations/feelings,
and behaviors interacted to influence your experience.

Nonjudgmental !Emotion Awareness: Distinguishing !Emotions

from Your Reactions to !Emotions

By becoming fixated on our reactions to an initial emotion, fueling

our emotional experiences through negative thoughts, actions
(EDBs), and avoidant reactions, we prevent our initial emotional
response from following its natural course, which is to ebb and Row
and gradually decrease. Further, we never get the chance to see how
our emotions come and go, or to learn what they might be telling us.
By contrast, letting go of our reactions-which often take the form
of judgments about our emotions-allows us to move through and
let go of our emotional experiences more easily. This is referred to as
nonjudgmental awareness.

Nonjudgmental awareness means staying in touch with our experi-

ences even when they are uncomfortable, and accepting them as
they are, learning how to just let emotions happen when they happen,

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.

Accepting our experiences in this way does not mean resignation-it

is not the same thing as saying you must "just live with your anxiety"
or uncomfortable emotions and "just deal with it," or "grin and bear
it." Instead, accepting our experiences as they are in the present
moment, recognizing that our emotions, even uncomfortable ones,
are trying to tell us something, and therefore it is actually ok that
they are there, allows us to begin to respond to our experiences in a
more thoughtful, realistic way, rather than through knee-jerk reac-
tions. Only then can we begin to distinguish between what is an
accurate reflection of what is going on in our world at that moment
and is something we need to act upon or do something about, and
what is a "false alarm" or something we can let go. And by accepting
our experiences as they are in the present moment, not as threaten-
ing but as just uncomfortable, they begin to lose a little of the power
they may have over us.

importance of Focusing on the Present

In the last section, we discussed the importance of evaluating and

accepting our emotional experiences as they are occurring in the
present moment. But what is so important about the present
moment? What about what we have learned from past experiences?
What about being prepared for the future? Learning from experi-
ence and planning for the future are both very important processes,
and do indeed inform us to some degree about how we might
respond to situations that are confronting us. However, the only way
we can determine whether ongoing emotional responses are an accu-
rate reflection of current situational demands or needs, is to anchor
our awareness within the present context. Living entirely in the past
or the future, without regard to what is right in front of us, does not
help us to accurately understand what we need to do in response to
the situation we are faced with at any given moment.

The fact is that our moment-to-moment judgments about, and

responses to, our emotions often have very little to do with what is

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
foture ("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 foture, 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 understan.d 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, i11 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.

As you can see, if we do not anchor ourselves in the present moment,

using the current context from which to evaluate our experience,
recognizing which of our secondary reactions are accurately reflect-
ing current reality and which are missing out on the current context
entirely, we are unable to learn from our current situations and,
instead, hold on to memories of past distress or worries of future
catastrophe. You can think of this skill as using a time-lapse camera
to better understand how your emotional responses unfold: by step-
ping out of your experience and observing your responses as they
are happening moment by moment, you get a much better sense
of where you might be leading yourself astray, where you are cross-
ing over from evaluating an emotion to determine how you should
respond given the current circumstances, to engaging in a vicious
cycle of interacting negative thoughts, behaviors, and feelings
that are serving to intensify, heighten, or even worsen your experi-
ence. This focus on the present moment also allows you to take new
information in, and learn new associations with your emotions (e.g.,
feeling fear does not always mean you are in danger).

Paying attention to our experiences in this way is called being

mindful. Mindfulness is the awareness that comes through paying
attention, on purpose and nonjudgmentally, to things as they are

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.

»rncticing Present-focused, Ncmjm:igmental Awareness

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. lf 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, arid
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.

In order to master this skill, it is first important to get used to what

it feels like to observe your experience as it is occurring in the pres-
ent moment. It can be very surprising to discover how much of the
time we are not aware of the present moment at all! To get used to
this, we recommend setting aside at least five minutes, once a day for
at least one week, to formally practice present-focused awareness.
An exercise is provided in the next section (an audio version can
be downloaded from the Treatments That Work TM Web site at www.
oup.com/uslttw). You may decide to continue practicing this exer-
cise as part of your daily routine, or you may not. The important
thing at this point is to practice for at least a week, in order to get

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 .

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Figure 7.2
Sample Nonjudgmental, Present-Focused Emotional Awareness Form

92
 The first time you go through this exercise (adapted from Segal,
Williams and Teasdale, 2002 1), 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
yourselfin the room. Picture the room-imagine what the room looks like, what is in the
room, where the.fi1rniture is laid out. Now picture yourselfsitting 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 sensatiom that are there. Notice any physical reactiom you may be having in
this moment. Pause for a moment, andjust allow yourseifto observe yourphysical sematiom.

First time only: What did you notice?

Slowly bring your attention to your own breathing. Notice yourselfbreathing in and
breathing out. Focus on your breathing as it is happening right now, in this moment, using
your breath to help ttnchoryourse/fto thepresent moment. Focus on the sensation ofyour
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, andjust
allow yourselfto notice your breath.

First time only: What did you notice?

1 Segal, Z.V., Williams, J.M.G., & Teasdale, J.D. (2002). Mindfalness-based cognitive
therapy far 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 ofthem may be hard to let go of Simply notice what you're thinking. Jfyou notice
yourselfgetting 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
Jew moments-and, as you do, notice how they come and go.

First time only: What did you notice?

As you take note ofthese 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 ofnowhere. Simply acknowledge how you're feeling in
this very moment. Allow yourselfto observe your emotions, without judgment. Notice
how they ebb and flow. Pause for a moment, and just allow yourself to observe your
emotions.

First time only: What did you notice?

Continuing to use your breath to anchoryou, begin to take note ofyour entire
experience- how your body feels, what you are thinking, what emotions you are
experiencing. Ifyou notice that you are trying to change your experience in some way,
take note ofthat, 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 anchoryou, allow your awareness to shift so you can take in what's
going on around you, Notice the temperature ofthe room. Notice any sounds occurring
outside the room. Notice any sounds occurring inside the room.

First time only: What did you notice?

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.

To get an idea of how this exercise might look, let's look at an

example of an exchange between "Linda'' and her therapist:

THERAPIST: So, what did you notice?

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?

LINDA: Definitely. I don't know, it just makes me think about things

I don't want to think about, like how this treatment better work,
that I wiU be a complete failure if it doesn't, that I shouldn't be
sitting here I should be working instead, the usual stuff. Then I was
trying to stop thinking about them. I don't know ...

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.

THERAPIST: So you were focusing on your reaction to them.

LINDA: Yes, I suppose I was!

THERAPIST: What about physical sensations-did you notice anything about

how you felt?

LINDA: Well, at first I just fdt sort of silly, and then I felt sort of tense when
I started thinking about things.

THERAPIST: You noticed some physical reactions to your thoughts?

LINDA: Yes, whenever I think about what I should be doing, my shoulders

start to feel tense and I feel fidgety.

THERAPIST: So you noticed some behaviors that went along with this, as well-
some fidgeting.

LINDA: Yes. I don't know, maybe I'm not doing it right.

THERAPIST: Remember, the goal is to let go of judgments about your experience

and to just practice being an observer of your own experience or
reactions. In this sense, there is no "right" or "wrong" way; just getting
more used to observing how your thoughts, feelings/physical
sensations, and behaviors unfold and influence each other. Ir sounds
like this time starting the exercise triggered a little bit of distress for
you, and brought up some negative thoughts that you struggled with
a bit. It also sounds like some physical sensations of tension came up,
too, as well as some behaviors like fidgeting. So you actually noticed
quire a bit about your experience this first time around. Let's practice
again, only this time see if you can just observe any negative thoughts
that come up, noting them as just thoughts, not allowing yourself to
struggle with them, and noticing what physical sensations and/or
behaviors also arise. Remember, you are practicing becoming a
curious observer of your experience, rather than approaching your
experience as a judge and jury, like you might be used to doing. This
is a new perspective, and it takes time to get comfortable with it.

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.

Once you begin to get more comfortable observing your experience,

and the thoughts, feelings/physical sensations, and behaviors that
make up your experience, try practicing this same form of observa-
tion while in an emotional state. This can be done by choosing music
or songs that are particularly meaningful to you, ones that might
bring up strong emotions for you. If you have difficulty choosing a
piece of music, you may want to try some of the selections on the
suggested list available on the TreatmentsThatWork™ Web site at
www.oup.com/us/ttw. Listen to each piece of music and practice
observing how your thoughts, feelings, and behaviors interact in
response to the emotions brought up by the music. Use the Mood
Induction Recording Form at the end of the chapter to practice
identifying emotions triggered by the music, as well as your reac-
tions to the emotions. 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 included on the form.

Daily Practice Anchoring in the Present

Once you have formally practiced observing your experience for at

least a week, it is important to begin incorporating this skill into
your daily life by informally practicing present-focused awareness
at least once per day, in order to allow this skill to become more
automatic. This can be accomplished very easily and without much
effort. First, it is important to identify one thing you can use easily
in your daily life to remind yourself to bring your awareness to the
present moment. One of the best and most readily available cues is

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 presen't. 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 foel 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.

The second purpose of this exercise is to begin associating your

chosen cue with the experience of being anchored and observing the
present moment. By repeatedly pairing your cue with awareness of
what is going on around you (a sound, sight, or sensation), you will
begin to quickly associate the cue with present-focused awareness.
This will allow you to eventually anchor yourself in the present more
automatically while in an emotionally distressed state. For example,
when you are feeling overwhelmed and anxious, taking a deep breath
(your cue) will remind you to step out of the cycle of thoughts, feel-
ings, and behaviors, and observe your experience, allowing you to
r
quickly identify and change maladaptive responses (something you
will be learning more about in subsequent chapters).

It is important to understand that your chosen cue is not intended

to be used to distract you from feeling emotional. Rather, your
cue is intended to give you a portable aid to quickly remind you to
bring your attention and awareness to the present moment during
times of distress, allowing yourself to do a quick "three-point check"
of thoughts, feelings and behaviors you are experiencing at that
moment, and determine whether your responses in these three

98
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figure 7 .3
Sample Anchoring in the Present Form

domains are an accurate reflection of what is going on at that specific

moment in time. As you go through this treatment, you will learn
strategies to help you determine if your responses in these domains
are helpful or appropriate, and strategies for bringing you back on
course when your responses are maladaptive. For now, your goal is
to learn how to observe your experience and anchor in the present,
in preparation for learning these additional skills later in treatment.

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

In this chapter we have looked more closely at how emotional expe-

riences unfold, discussing the importance of being aware not only of
initial emotions that might be triggered, but also secondary reac-
tions to these emotions. We have discussed how secondary thoughts,
physical sensations and feelings, and behaviors can influence the
intensity, duration, and emotional tone of our experience, causing
an initial, adaptive emotional response to become a maladaptive
response. We have also discussed the importance of learning how to
objectively and nonjudgmentally observe both our emotions and
our reactions to our emotions, in order to identify ways in which
our thoughts, feelings and/or behaviors are becoming maladaptive.
We talked about the importance of anchoring our awareness
within the present context in order to determine whether our ongoing
emotional responses are an accurate reflection of current situational
demands or needs. Finally, we discussed the importance of practicing
observing thoughts, feelings, and behaviors as they are occurring in
the present moment, and introduced strategies to help you practice
this skill.

In the next four chapters, we will be looking more closely at the

domains of thoughts, behaviors, and physical sensations/feelings,
helping you to distinguish which strategies that you are currently
employing within these three domains may actually be maladaptive
and contribute to your symptoms, and ways in which you can
employ more adaptive strategies that break the cycle of maladaptive
responding, and alleviate your symptoms.

Homework

~ Set aside time to deliberately practice nonjudgmental, present-

focused awareness at least once a day for one week, to allow

100
 yourself to become more familiar with observing your
experience. Use the Nonjudgmental Present-Focused Emotion
Awareness form to record your experience.

~ Use the Mood Induction Recording Form to begin monitoring

your emotions in response to certain music, and to practice being
aware of emotional experiences in a nonjudgmental way. Note on
the recording form your reactions to the songs and/or music you
listen to, exploring what thoughts, physical sensations/feelings,
and behaviors emerge in response to the music. Do this exercise
multiple times on separate days, and see if you notice how
emotional reactions may differ, depending on how you were
feeling beforehand. Use the Three-Component Model of
Emotion form to explore your reactions further.

~ Use the Anchoring in the Present form to informally practice

present-focused awareness several times throughout the day,
using your chosen cue such as breathing, to help anchor
yourself to the present. Practice anchoring yourself to the
present once per day by noticing at least one thing going on
around you and recording this on the form.

~Continue to use the Monitoring Emotions and EDBs in Context

form to identify emotional triggers and your responses to these
triggers. Include as many examples as possible, and start
practicing noticing EDBs in your daily life. In addition, you
should purposely engage in at least two activities over the week
that bring up emotions, positive or negative, observe your
reactions and responses, and record your experiences on the
form. This may involve beginning to enter into some situations
or engage in some activities that might be slightly uncomfortable.
This may be difficult at first, bur it is important in order to begin
building awareness of emotional experiences, both positive and
negative.

~ Continue monitoring your weekly experiences using the

OASIS and ODSIS.

~ Remember to use the Progress Record to record the total scores

from the OASIS and ODSIS week by week.

101
SeiH\ssessment Cluiz

Answer each of the following by circling true (T) or false (F). Answers
can be found in the appendix.

r. In this treatment, "emotion awareness" means focusing on your

emotions and how bad they might feel.

T F

2. In this treatment, "emotion awareness" means learning to step

outside of your experience in order to observe your interacting
thoughts, feelings, and behaviors in a more objective way.

T F

3. Accepting your emotions means resigning yourself to "grin and

bear it."

T F

4. Most of the time we are focused on the present moment,

instead of thinking about the past or worrying about the
future.

T F

5. Learning to be mindful is easy and doesn't rake much practice.

T F

102
Set aside a rime, 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.

1.
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103
.~ I Mood Induction Recording Form

The purpose of this exercise is ro practice noticing the thoughts, physical sensations/feelings, and behaviors that come up during an emotional
experience. Try ro find music and/or songs that bring up strong emotions for you. As you listen, note your reactions ro 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 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)
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105
 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

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Wed

Thurs

Fri

Sat

\
106
 Understanding Thoughts: Thinking the Worst
and Overestimating the Risk

Goals

f@ To understand how thoughts influence emotions

:8 To learn about cognitive appraisal

@ To learn about and identify common thinking traps

~ To learn about and implement cognitive reappraisal to increase

flexibility in thinking

Homework Review

Did you complete your record.keeping 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.

Did you continue to monitor your emotional experiences this past

week? What triggers did you notice? Do you see any patterns begin-
ning to emerge? What sorts of situations seem to trigger anxiety,
depression, distress, or other uncomfortable emotions? Are you
noticing typical thoughts or behaviors in response? What new, objec-
tive information did you learn about yourself this week?

Key Concepts

The key concepts for this chapter include a discussion of cognitive

appraisal, or how we understand, interpret, and make meaning of
the world around us and things that happen to us. You will develop
a greater awareness of the ways in which you interpret or appraise
situations, and learn how such appraisals influence emotional expe-
riences, including how you feel and how you respond to emotionally
provocative situations. You will work to develop greater flexibility in
your appraisals by first identifying unhelpful "automatic" appraisals,
and then learning to generate alternative appraisals or interpreta-
tions, which we call cognitive reappraisal.

Cognitive Appraisal

This part of treatment addresses one very important aspect of

the emotional experience-thoughts. You will explore how your
thoughts-particularly, how you interpret or appraise situations-
affect your emotions, and also how your emotions can influence
your thoughts. There are a number of different ways in which how

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.

What am Cognitive Apprnisa~s?

In any given situation, there are a large number of different things

or aspects that you can focus on. To illustrate this point, let's go back
to the imaginary scenario from chapter 6, in which you are asked
to give a presentation at work or in class. Imagine that after the
presentation, you meet with your boss or teacher to discuss your
performance. During the conversation, your boss or teacher begins
by praising you for doing well on the presentation. Imagine that
later in the conversation, your boss or teacher also tells you about
an aspect of your performance where you could improve. Perhaps
she says you could work on making greater eye contact with the
audience while presenting. Many times in this situation, people walk
away focusing mostly on either the praise or the criticism offered by
their boss or reacher.

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").

Your appraisals can also vary in how much importance or meaning

you assign to the event or situation. For example, you might take
this perceived failure to mean something about you as a person (e.g.,
"I really blew that talk, I am such a failure"), or as a single bad event
(e.g., "This talk didn't go well, bur I will do better next time").

This is the way that the human mind works-serving as a filter

by focusing on certain aspects of a situation and assigning meaning
to those aspects, in order to increase the efficiency and speed
with which we can respond to a given situation. This can be helpful,
as we will discuss in more detail. \\Te also tend to draw upon our

109
 experiences from the past to help us interpret or appraise current
situations, and will ofi:en use these interpretations and appraisals to
project what might happen in the foture. 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.

Cognitive Appraisal !Exercise #i: Making Meaming

Let's try an exercise now to help illustrate how a number of different

appraisals of the same situation are possible.

Please take a moment to look at the picture in Figure 8.1 and to

think about what might be happening in the picture. Now, using the
Looking at Your Interpretations form, record your first or ini~ial
appraisal of what is happening in the picture. Be sure to record
the first thing that jumped into your mind when you looked at the
picture. Next, record what factors led you to that interpretation
(e.g., what specific aspects in the picture did you focus on that led
you to this initial interpretation?).

What are some other possible interpretations of what might be hap-

pening in this picture? Take a few minutes to record as many other
possible interpretations as you can come up with on the Looking at
Your Interpretations form. This can be difficult at first, but over time
and with practice, this can become second nature. Remember, there
is no "right answer," even if some of the appraisals might not be as
believable as your initial appraisal.

How would your initial interpretation about what is happening in

the picture make you feel? What if you were actually in this picture,
what kinds of behaviors would you engage in related to this initial
interpretation? Is there another appraisal that you were able to come
up with that would be associated with a different emotional response?
What kinds of behaviors might you engage in if you made this inter-
pretation instead?

110
Figure 8.1
Ambiguous Picture

111
What were your automatic interpretations about the picture?

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-thar 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 appraisais can influence your emotions, how you are reeling
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

What are Automatic Appraisals?

Many thoughts and appraisals pass through our mind. We automati-
cally latch onto certain ways of appraising things to help us filter our
experience and respond to situations quickly and efficiently. This
commonly happens and is natural. It is adaptive for us, in some situ-
ations, to focus on a few key, salient pieces of information and
exclude additional information or evidence. For instance, if there is
immediate threat or danger, such as a car coming down the street
toward us, we focus on the speed the car is traveling and its distance
from us, instead of what color the car is, or what state the license
plate is from. This is helpful, as it helps us to process potential threat
and danger quickly, and allows us to respond more efficiently to

113
 such threats. However, this natural adaptive process can become
problematic.

Over time, individuals often develop a particular way or style of

appraising situations or events. Research has found that individuals
with emotional disorders are more likely to latch on to negative,
more pessimistic appraisals or interpretations. And, as mentioned
before, these negative interpretations can affect the way we feel and
behave.

Identifying Core Automatic Appraisals

Sometimes it can be hard to identify automatic appraisals, because

we often do not even realize we are making them. Thus, it can be
helpful to practice identifying these appraisals in relation to emo-
tionally provoking situations in our own lives.

Let's start with an example to illustrate. The following is a descrip-

tion of an exchange between a therapist and Sarah. Earlier in the
week, Sarah was invited to a party with friends from work. As the
night of the party drew closer, Sarah became increasingly anxious
about attending. About 20 minutes before she was supposed to leave
for the party, Sarah called her coworker who was hosting the party
to apologize and say she was unable to attend.

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?

SARAH: Then I wouldn't get invited to parties anymore.

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. Ir 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 ifX 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
Tech.r:iique 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 h;ive- :m1thif'l§= to i:;a"i"

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 h;ive- nothif'l§- to i:;;i1, I'm bov-lf'l§=

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 §f't lnvlfod to p;iirtle-i:; ;in1mov-e-, I will /oi:;e- ;ii/ m1 fv-ie-ndi:;.

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 /oi:;e- ;ii/ m1 fv-ie-ndi:; ;ind I will be- ci/one- fov-e-ve-v-.

igure 8.2
arah's Downward Arrow Technique

'117
 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 A p p r a i s a l : - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

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 A p p r a i s a l : - - - - - - - - - - - - - - - - - - - - - - - - - - - -

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 A p p r a i s a l : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
I".
I
These appraisals (e.g., thoughts of threat or failure) are often not
very helpfol. If they occur inappropriately, at the wrong time, or too
frequently, they tend to make us feel worse and can get in the way of
living a foll life. Now, let's discuss some specific examples of auto-
matic appraisals that people commonly make. We call these unhelp-
ful automatic appraisals thinking traps.

Thinking Traps

What are Thinking Traps?

When we latch onto a single interpretation about a situation repeat-

edly, it becomes powerful and starts to exclude other ways of
thinking about an event. The thought may become a "trap" that can

118
 feed into emotions such as fear, anxiety, depression, or anger, often
making our emotions feel more intense, or perhaps even "our 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.

Common Thinking Traps

Identifying the automatic appraisals you are makjng in emotionally
provocative situations (which can then lead to experiencing the emo-
tions as overwhelming) is the first step in correcting unhelpful think-
ing patterns. Sometimes it is easier to identify automatic appraisals
when they can be broken down and "labeled." To help in this process,
research has identified two common "thinking traps" often found
among individuals who experience emotional disorders like anxiety
and depression. These thinking traps are not "bad" or "·wrong," but
they do reduce our flexibility when we encounter certain situations,
which can serve to maintain the negative emotional response cycle.

The two common thinking traps are:

'j~ Probability Overestimation (a.k.a., jumping to conclusions):

This is when you overestimate the likelihood of negative events
happening. You interpret things negatively when there is little

"119
 or no evidence to support that interpretation. Similarly, you
may ignore evidence that would suggest another, perhaps more
likely outcome.

lli:l Catastrophizing (a.k.a., thinking the worst): This is when

you automatically predict that the worst possible scenario is
going to happen, without considering other possible outcomes.
YOu also tend to underestimate your ability to cope with this
outcome if it does occur.

Probability Overestimation (or Jumping to Conclusions)

People with emotional disorders will often overestimate the likeli-

hood that something bad will happen, such as failing a test, that
others will reject them, that the plane they are on will crash, or that
they will contract an illness. In the event of real threat or danger, this
might be helpful, because it helps us to prepare for the threat or even
to avoid something dangerous. Sometimes, it can even be helpful
for emotions to "drive" our thoughts to overestimate threat or danger
so that we are prepared and do not get hurt (or fail, or embarrass
ourselves). However, it becomes a trap when one frequently and
indiscriminately overestimates the chance that an unpleasant event
or feared outcome will happen. For instance, imagine Kevin is expe-
riencing repeated panic attacks that appear to come from out of the
blue. When Kevin has a panic attack, he becomes terrified that he
will die as a result of the panic attack. The problem with such a
thinking trap is that by overestimating the likelihood of the feared
event (e.g., dying as a result of a panic attack, even though it has
never happened before) and only focusing on that one possible inter-
pretation, Kevin is missing the alternate possibilities (e.g., it is a
panic attack and will pass shortly), or evidence that dying as a result
of panic is unlikely to happen.

Again, it is important to note that the problem with these thinking

traps is not that they are "wrong" or "bad." Rather, these traps make
our appraisals more rigid (less flexible), which, when combined with
our mood, can keep us stuck in the cycle of strong emotions. In order
to begin to practice identifying these thinking traps as they might be

happening in your daily life, take out your Monitoring Emotions and
EDBs in Context forms from the past few weeks. Using the descriptions

120
 of common thinking traps on page 119 to help, try to identify any
examples of probability overestimation from your homework.

Caiastrnphizing (or Thinld11g the Worst)

This thinking trap refers to the tendency of people with emotional

disorders to think that the worst possible outcome is going to happen
and, when it does, that they will be unable to cope with it. For
example, Sarah might believe that if she introduces herself to some-
one new she will become embarrassed and begin to blush. As a result,
she assumes the other person will be completely rejecting and even
scornful toward her, which she would find devastating. In this sce-
nario, the results would be catastrophic (e.g., other person will reject
her), even though a much less disastrous outcome is likely. There is
also an assumption that Sarah would be unable to cope with this
catastrophic outcome, should it occur (e.g., it would be devastat-
ing). The problem with this trap is that by assuming the worst pos-
sible outcome is going to occur, and that when. it does we will be
unable to cope with it (e.g., the other person will reject me, which
will be devastating), and only focusing on that one possible interpre-
tation, we miss alternate possibilities (e.g., the other person might
not reject me) or evidence that we have coped with similar events in
the past (e.g., I have been rejected before and survived). This think-
ing trap can keep us stuck on one particular interpretation, fueling
the intensity of our emotional response and preventing us from
adopting a more flexible, realistic perspective.

Again, using the Monitoring Emotions and EDBs in Context forms

from the past few weeks, practice identifying examples of catastro-
phizing as they are happening currently in your daily life. Use the
descriptions of common thinking traps to help identify examples of
catastrophizing from your homework. You will notice that some of
your automatic appraisals can be considered both probability over-
estimation and catastrophizing. This is normal and very common.
It is not important to be able to pinpoint the appraisal as being one
versus the other. Rather, the purpose is to begin to recognize when
you are falling into these rigid ways of appraising situations, so that
you rake the next step in treatment: increasing flexibility in your
thinking.

121
 However, before we get there, it will be helpfol for you to first prac-
tice identifying the different kinds of automatic appraisals that you
are making in your daily lite. 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.

A sample, partially completed form is shown in Figure 8.3.

Cognitive Reappraisal

Allowing Other Interpretations

Thinking traps maintain the negative emotional response cycle by

decreasing our flexibility in thinking, preventing us from acknowl-
edging a range of different possible interpretations, or from suffi-
ciently considering the context in which something occurs.

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 ofautomatically thinking

SITUATION/ AUTOMATIC IDENTIFY GENERATE ALTERNATIVE

EMOTION(s)
TRIGGER APPRAISAL(s) "THINKING TRAP" APPRAISAL(s)

&reAtl ng- l'"-ad~, abovt I will hav"' a panic.. •me-le, lo<;e Anxlef.t, Pl'ob;ibi/i-~i
to dnve to woYk e-on-IYol of fhe <All' ;ind c..l'd<;h appl'ehen<;/on OVel'""TIMil 'on

" " " C-ata<;-IYophiz1ng-

The panic.. will e-ontlnve to

5~n fedi"&-panic..foi /¥.+ wol'"<;e and woK"-, vntil Anxie.f.t, fe:-aY P!'obabi lif.t
ik at fhe. movi"" I c.,;in't ta~ It and I die. OV"-Y<:.<;timation

" " " C..m<;-IYophi z1"&-

kf+ hoM"- wifhovf M~

If I have. a panic.. arne-lc, I
won'+ be abk to f,,,.t he.Ip Anx/,,.f.t, fe:-•Y" C...ta<;-IYophiz1"&-
c..e.ll phone
and I will '"'

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.

The goal of cognitive reappraisal is to increase flexibility in your

thoughts and allow for alternate appraisals of emotionally provoca-
tive situations that are anchored in the present situation, and take
the current context into consideration.

Importance of Nonjudgment
You might notice that you often judge or blame yourself for the
automatic interpretations you mal<:.:e. This is common, but it is also a
barrier to generating flexibility in appraisals because the more you
blame yoursel£ 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.

Cognitive Reappraisal Strategies

Cognitive reappraisal is a useful skill for helping to break the habitual
cycle of emotions. Research has identified it as a highly effective strat-
egy for changing the way an emotion or event is experienced. Learning
to develop a more flexible approach to interpreting situations, and
recognizing more realistic and evidence-based reinterpretations of

123
 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.

The first cognitive reappraisal skill is countering probability overesti-

mation, or learning how to reevaluate jumping to conclusions. Afi:er
identifying the core automatic appraisal, the next step is to realisti-
cally examine the probability of that outcome actually happening.
Let's start with an example to illustrate. The following is a descrip-
tion of an exchange between a therapist and Kevin. Kevin is con-
cerned that he will die as a result of having a panic attack.

THERAPIST: What are you concerned will happen as a result of having a panic
attack?

KEVTN: 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?

KEVTN: 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?

KEVTN: Well, none yet. But I just know that: ifl 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?

KEVTN: 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?

KEVTN: 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

124
 is possible that I won't die from the panic attack and it will pass on
its own.

In the preceding example, the therapist was able to help Kevin to

identify the thinking trap he was falling into (e.g., 50% chance he
would die as a result of the panic attack) and to generate alternative
appraisals or interpretations of the situation that were more consis-
tent with the evidence and his experience so far (e.g., he has had
100+ panic attacks and none have killed him).

Now, let's start practicing using this cognitive reappraisal skill on

examples from your daily life. Look back at the Identifying and
Evaluating Automatic Appraisals form you filled out earlier. Using the
questions in the next section to help, begin filling out the last column
by generating alternate appraisals for any appraisals you identified as
examples of probability overestimation. Figure 8.4 shows Kevin's
completed Identifying and Evaluating Automatic Appraisals form.

SITUATION/ AUTOMATIC IDENTIFY GENERATE ALTERNATIVE

EMOTION(s)
TRIGGER APPRAISAL(s) "THINKING TRAP" APPRAISAL(s)

I mi€,M not h;ive, ;i p;mic.-

0i&tfi~ V&<Jcl~, ;ibovt I will h;ive, ;i p;inic.- ;itt;idc.,
to clvi v'& to wovk. lo<:& c.-onfvol of th& c.-•v
•ncl c.-v;i<;h
" "
The, p•nic.- wi II c.-ontinve, ta
6&~n fcdins-p•nic;*1 1¥,t wov<;& ;incl wov<;&, vnti I Anxie-ti-1 fe,•v
w 1k ;it the- mav1e-<; I c.-;in't faF::.e, it ;incl I cli&
" "
I h@v'e- P.•nic.- ;imc.-k., I
f-e-ft ham& withavt M~ Ifwon't d
be, ;ib/e, to ~t he,/p
c,e,ll phone,
•ncl I will 1&
Anxi&fi], Pvob;ibi/i,_ ;it/-;ic.- I've, clviv'&n P,f&nt~ of
•ppve,he,n<;ion Ov'&V&<;tim;i ion
tim&t;; withavt h;ivins-one,
r;::.ve,n if I h;ive, ;i p•nic.- ;itfadc.,
" C-;ihc;T-vophiuns- I c.-;in <;/-ill c.-on+Yol the- c.-;iv
clviv'& thvavgi th& f=li~
I h;iv'e, h;icl ov'&V 100 r.•nic.
Pvob;ibili,_ ;itfac.-k.<; ;incl h;iv'e,n't cli&Ci fvol'll
1
Ov'&ve-<;tim;i ion
one- ~e-t
-~n If m~ p;in1c.- c.-ant1nve,<; to
C-;it..;T-vophiz..ins- r¥'t wov<;&, I c.-;in faf;::.e, it,
" /!e,c,;ivt;;e, I /<:.now it wi II C.-OIYI&
clown &V&ntv•ll'I"
r;::.ve,n if I cla h•v'& ;i p•nic.-
;ittadc., I c.-•n h;incll& it It will
An,1ie,fi],f&•v c..t..;T-vophiz..ins-
p•<:<: •ncl I won't n&&cl to c.-;i/I
_fEv he,JL

figure 8.4
Kevin's Identifying & Evaluating Auromatic Appraisals form

125
 Cmrntering Probabimy Overns~imation-learning to
Reevaim11fte Jumping to Conclusions

Questions to ask when evaluating automatic appraisals:

r. Do I know for certain that -----~----- will

happen?

2. Am I 100% sure these awful consequences will occur?

3. What evidence do I have for this fear or belief?

4. What happened in the past in this situation?

5. Do I have a crystal ball? How can I be sure that I know the answer?

6. Could there be any other explanations?

7. How much does it feel like _ _ _ _ _ _ _ _ will happen?

What is the true likelihood that will
happen?

8. Is my negative prediction driven by the intense emotions I'm

experiencing?

9. Is _ _ _ _ _ _ _ _ really so important or consequential?

Given the answers to these questions, what is an alternative way oflooking at this situation?

The second cognitive reappraisal skill is decatastrophizing, or learn-·

ing to reevaluate thinking the worst. Once you have identified the
core automatic appraisal, the next step is to realistically examine the
evidence, based on how you have coped in the past. Let's start with
an example to illustrate. The following is a description of another
exchange between a therapist and Sarah. As previously mentioned,
Sarah is concerned that upon meeting someone new, sb.e will blush
and the other person will respond scornfully and reject her.

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?
.

126
 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?

SARAH: Yeah, that's what I'm afraid will happen.

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,
ifl 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?

SARAH: This was last month actually.

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.

In the preceding example, the therapist was able to help Sarah to

identify the thinking trap she was falling into (e.g., people will reject
me and I will be devastated) and to generate alternative appraisals or
interpretations of the situation that were more consistent with the
evidence and her experience so far (e.g., she might not want to con-
tinue contact with the person either, and even if she did want to and
they did not, she has coped with similar circumstances in the past).

Let's practice using this cognitive reappraisal skill on some of your

examples from your Identifying Automatic Appraisals form you
filled out earlier. Using the questions provided in the next section,
begin to generate alternate appraisals for any appraisals you identi-
fied as examples of catastrophizing from your homework.

[lecatastrnpilizing-learning to Reevaluate Thinking the Worst

L What is the worst that could happen? How bad is that?

2. If ________ happened, could I cope with it? How

would I handle it?

3. So w h a t ? - - - - - - - - - - - - - - - - - - - -
4. Even if happens, can I live through it?

5. Have I been able to cope with in the past?

6. Is _ _ _ _ _ _ _ _ _ really so terrible?

Given the answers to these questions, what is an alternative way of looking at this situation?

128
 Sometimes people have thoughts that seem to "come into their
mind" and don't make sense. This is quite common, and happens
to most people. However, whereas most people are able to let
these sorts of "strange" thoughts go, maybe by telling themselves,
"That was weird!" and then forgetting about them, others might
get "stuck" in the thoughts. For some, the thoughts are intrusive
and distressing, and they can't seem to block them out of their mind.
For example, someone might be bothered by an intrusive thought
that they will harm someone they love, or that they might do some-
thing terrible like molest a child. Or, someone might have intrusive
thoughts that go against their religious or moral beliefs, such as
Satanic thoughts or unwanted sexual thoughts. These types of
intrusive thoughts are also experienced as "automatic," but they are
a little different from what we have been discussing so far. So far
in this chapter we have been discussing automatic appraisals or
interpretations a person might make of situations and events, and
these types of thoughts can usually be reappraised using the two
strategies just described. The types of thoughts we are discussing
here however, do not make sense and can be very difficult to
challenge. For example, if you are challenging the thought "I am a
child molester" with the questions, "What is the worse that can
happen? How bad is that?" it can be very hard to come up with a
satisfying answer!

The reality is that the obsessive, intrusive, nonsensical thought is

not what needs to be reappraised. Instead, what needs to be evalu-
ated is your interpretation of what having this thought might mean.
To illustrate this point, take a look at this exchange between a man
having intrusive thoughts about being a child molester and his
therapist:

CLIENT: I tried to use the questions to reappraise my thoughts, but it just

doesn't work. All I can come up with are reasons why the thoughts
are really bad.

THERAPIST: Can you give me an example?

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

129
 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?

CLIENT: Awful! I feel sick to my stomach, and I get really anxious.

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?

CLIENT: No! Absolutely not! The whole idea is so disgusting! It mal<:es me so

angry that anyone could do such a horrible thing!

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?

CLIENT: No, that wouldn't make sense.

THERAPIST: So I guess it is possible that you could have a horrible intrusive

thought about being a child molester and not be a monster
yourself?

CLIENT: I guess so.

As you can see here, trying to challenge an intrusive, nonsensical

thought can be very difficult, and often does not work. However,
something else occurs when people have these sorts of thoughts-
they usually are part of an emotional experience, and bring up strong
emotional reactions. If you are having these types of thoughts,
ask yourself; "How does having this thought make me feel? What do
I think having this thought means?" The thoughts a person has
about intrusive, nonsensical thoughts is what makes these thoughts
distressing to one person and not to another. One person might have
horrible intrusive thoughts and be able to "shake them off" as just

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 wjll 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.

Keep in mind that it can be difficult to acknowledge some of the

core automatic appraisals that you have been trying to avoid for such
a long time. You might even feel a bit discouraged by the sheer
number of thinking traps you notice yourself falling into. You
are not alone. This is a common response. Remember, though, the
purpose of cognitive reappraisal is not to eliminate all negative
appraisals or thoughts, nor is it to "punish" yourself for having
negative interpretations. Cognitive reappraisal is a skill designed to
help you gain some perspective on your thoughts, so that the nega-
tive, automatic appraisals do not further feed the intensity of your

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

~ Begin using the Identifying and Evaluating Automatic Appraisals

form at the end of the chapter to monitor your appraisals and
emotions (first four columns only). Note the situation or trigger
for the interpretation, the interpretation or automatic appraisal
itself, the emotion, and then evaluate whether the appraisal
represents either of the thinking traps we discussed.

~ Once you have identified your automatic appraisals, begin the

reappraisal process. Generate at least one alternative appraisal
for every automatic appraisal (although generating more than
one alternative can be helpful, as well) and write it down in the
last column of the Identifying and Evaluating Automatic
Appraisals form. Remember, the goal is not to entirely believe a
new interpretation, but rather to allow it to coexist with the
automatic negative appraisal. Neither of the interpretations is
necessarily correct-they are each examples of a range of
possible interpretations.

~ Continue monitoring your weekly experiences using the

OASIS and ODSIS.

~ Remember to use the Progress Record to record 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.

132
I. How you interpret or appraise a situation has no effect on your
emot10ns.

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 mal<e.

T F

4. The goal of cognitive reappraisal is to eliminate incorrect ways

of thinking.

T F

133
......
w
""'

Identifying and Evaluating Automatic Appraisalsldentifying and !Evaluating Automatic Appraisals

SITUATION/ AUTOMATIC iDIENTllFY "THINKING GIENIERATE AlTlERNATIVIE

EMOTION(s)
TRIGGER APPRAISAl(s) TRAP" APPRAISAl(s)
 Understanding Behaviors 1: Avoiding
Your Emotions

3oais

~i~;,J To learn about emotion avoidance

"'" To learn how emotion avoidance influences emotional

expenences

&.::J To identify different types of emotion avoidance strategies

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 Bexibility
in appraising situations is like learning a new language. Both require
a good deal of practice. However, over rime 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

The key concept for this chapter is emotion avoidance. Emotion

avoidance refers to any strategies we might use to avoid feeling strong
emotions, or to prevent our emotions from becoming more intense.
Although these responses may be useful in some situations, they
rarely work well in the long term and they can even increase the
intensity of your emotions when you encounter a similar situation
in the future. In this chapter you will develop greater awareness of
your own patterns of emotion avoidance, and you will work toward
challenging these responses through emotion exposures. Over time,
you will develop an understanding of how avoidance of emotions
maintains current patterns of emotional responding in the long
term, and this will allow you to develop new, more helpful behav-
ioral responses to intense emotions.

Emotion Avoidance

What is Emotion Avoidance?

One way people attempt to control their emotional experiences is
through emotion avoidance. Emotion avoidance is when we engage
in behaviors designed to prevent ourselves from experiencing strong,
and ofrentimes unwanted, emotions. Emotion avoidance most often
occurs with regard to negative emotions, but can occur for positive
emotions as well. For instance, some people suffering from anxiety
find it difficult to feel calm and peaceful. Allowing themselves to
experience these positive emotions makes them feel like they've let
their guard down, leaving them vulnerable to something bad that

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.

rypes of Emotion Avoidance Strategies

Some types of emotion avoidance are more "obvious," such as when

someone refuses to enter a situation that is likely to produce emo-
tional distress. But there are also other, less obvious things people do
to avoid their emotions. These more subtle emotion avoidance strat-
egies can be broken down into three main types: subtle behavioral
avoidance, cognitive avoidance, and the use of "safety signals." Here
are some descriptions of these three general types of avoidance:

I. Subtle behavioral avoidance. Subtle behavioral avoidance

typically happens when a person enters a situation that he or
she associates with intense emotions, and escape from the
situation is not an option. As a result, the person may engage
in a variety of subtle behaviors of which he or she may not even
be fully aware. Some of these subtle behaviors might be used to
prevent physiological arousal associated with strong emotions.
For example, someone who has frequent panic attacks might
avoid drinking caffeinated beverages so as not to experience a
racing heart or trembling and shaking. Similarly, someone who
is anxious in social situations may avoid eye contact when
attending social gatherings. Someone who feels anxious about
being late may set their alarm dock extra early. Or, someone
who feels down or depressed might mal<:e an excuse in order to
leave a positive event like a birthday party early.

2. Cognitive avoidance strategies. Cognitive avoidance strategies

are often difficult to identify, and you may not even be
aware that you are using these strategies. The word "cognitive"
here refers to anything you might do to avoid having to
think about, remember, or pay attention to something that

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 folly engaging in the
experience of being in the situation). Distraction might seem I

usefo.l 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 fearfol 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 mal(e them feel more comfortable or help
calm them in times of extreme distress, despite the fact that
these items usually lack any real usefo.lness 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.

)emonstrntion of !Emotion Avoidance Strategies

Let's try an exercise to help you understand the concept of emotion

avoidance, and to see how emotion avoidance strategies work (and
don't work).

For about one minute, try and think about a white bear.

How successful were you in thinking about this animal?

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?

This experiment is based on research conducted by psychologists

Dr. Daniel Wegner of Harvard University and Dr. David Schneider
of Rice University. Their research focuses on what happens when

139
 Ke-e.p h;indi; in m~ poc,/c_e,fc; in pvblie- le.II m~<;e./f thcit I'm e-/e.;:in C..;ivv~ h;md c;;:initiu:.v ;md
p/;ic.-e.i; b;ib~ wi pe.c,
C;ive.fvll~ ve.p/;:i~ c;c,e.11;ivio<; to
C-ove.v m~ movth ;ind no<;e. with m~
c,/e-e.v'e. g-11e.v;:ifo e.vide.nc,e. th;:it I'm
Don't e.<it pve.p;:we.d food.; v11/e.c,i; I not e-onfamin;:ite.d
e-;in <;u. it be.1~ m;ide. Aff-e.v g-tl-i~ home., I v·e.mivtd m~<;e./f
V.;e. p/;i.;tie- vfon.;i /.; ;if ve..;favv;inti; of how offon I w;i<;he.d m~ h;i11dc;
Avoid be.i~ ne.;iv pe.opb who <ippe.;:iv
1
'div~ ' ov CJic;he.ve.le.cl
1

Ope.11 doov<; with fa.;ve.

lvrn off b;:ithvoom fcivc,e.fc; with
pcipe.v towe.I
V.;e. e.xm ddug-nt whe.11 w;ic;hi~
e-/othe.c;

figure 9.1
List of Emotion Avoidance Strategies

people use mental control strategies, such as thought suppression.

The purpose of this experiment was to show that attempts to
suppress certain thoughts paradoxically produces an increase in the
frequency of those thoughts. Essentially, their work showed that
when people are asked to not think about something, they actually
become overly focused on it and cannot help but think about it.
This experiment illustrates the idea that attempts to suppress nega-
tive thoughts and emotions are generally unsuccessful. In fact, they
are likely to increase the frequency and intensity of the very thoughts
and emotions the individual is trying to suppress. And, just in
case you were wondering, the idea for this experiment originated
from a quote in Fyodor Dostoevsky's Winter Notes on Summer
Impressions: "Try to pose for yourself this task: not to think of a polar
bear, and you will see that the cursed thing will come to mind every
minute." 1

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) W'inter 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? \"Vrite
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 VvTote 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 ofit 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.

When you're done, just tal{e a moment to notice what happened

during the exercise. Did you try to avoid? What emotions did you
experience? How difficult was it for you to go through the experience
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.

Again, take a moment to notice your experience. How successful were

you in not thinking about the memory or situation? How well were
you able to keep thoughts and feelings associated with the memory
away? What strategies did you use to suppress the emotional :response,
and how well did they work for the duration of the exercise?

You may notice that you were able to avoid thinking about the
memory or the details of the situation for at least a short period of
time. However, to be sure you were not thinking of the memory,
which was the purpose of the task, you probably needed to occasion-
ally "check" to make sure thoughts about the memory or situation
were not in your mind. This very process then involved thinking
about the memory or situation.

'141
SllHmmary

In this chapter, we examined the role of emotion avoidance in per-

petuating emotional distress. Emotion avoidance refers to any strate-
gies we might use to avoid feeling strong emotions, or to prevent our
emotions from becoming more intense. Avoidance strategies tend
to be helpfol for alleviating distress in the short term, but tend to
make things worse in the long term. Three general types of emotion
avoidance strategies include subtle behavioral avoidance (such as
avoiding eye contact in social situations, or avoiding touching door-
knobs for fear of contamination); cognitive avoidance (such as
distracting oneself with the TY, or trying to tell yourself the source
of distress is not that important to you), and using safety signals
(such as only going places with a certain person, or only going
out with a water bottle). Finally, we demonstrated how emotion
avoidance often backfires, such as when you try not to think about
something important or distressing to you.

In the next chapter, we will discuss another aspect of behavior that

contributes to emotional experiences-emotion-driven behaviors
or "EDBs"-and discuss strategies for countering avoidance and
maladaptive EDBs.

Homework

~ 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. This form contains three
columns that relate to the three types of strategies discussed in
this chapter (subtle behavioral avoidance, cognitive avoidance,
and safety signals).

~Continue monitoring your weekly experiences using the

OASIS and ODSIS.

~ Remember to use the Progress Record to record the total scores

from the OASIS and ODSIS week by week.

142
At1swer each of the following by circling true (T) or false (F). Answers
can be found in the appendix.

r. Emotion avoidance refers to any strategies we may use to

avoid feeling strong emotions, or prevent our emotions from
becoming more intense.

T F

2. J..jmonon
T:' •
avOi'dance is
• sornecmng
1 •
we snou
I la' pracnce
• regu larly
I

as a strategy for controlling our emotions.

T F

3. Subtle behavioral avoidance, cognitive avoidance, and safety

signals are all examples of emotion avoidance strategies.

T F

4. Safety signals can prevent us from learning that situations are

not dangerous and reinforces the idea that uncomfortable,
unexpected emotional experiences are unmanageable and
overwhelming.

T F

143
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
foel 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.

sul:ltle Beh<.1vio'ra1 Avoidance ·· · ·.· SafetySign~1~'··

144
 [Jnderstanding Behaviors 2: Emotion-Driven
Behaviors

I11111.'
JIi ' 11!I1i 1!I'11I I !'1 I'
I I
J)
! "
J ll I
1
1

!i I 1 1, l

!Goa is

~ To learn about emotion-driven behaviors (EDBs)

~I To learn how EDBs influence emotional experiences

f:\'B To learn to identify and counter EDBs

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?

l<ey Concepts

The key concept for this chapter is emotion-driven behaviors.

Emotion-driven behaviors (EDBs) are responses that relieve the inten-
sity of the feeling when we are experiencing strong emotions. In this
chapter you will be focusing on what you do in response to your

145
 emotional expenences. 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 ofi:en 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.

IEmotion-tr»riven Behaviors (IEDBs)

What are IEDBs?

One very important aspect of emotions is that they tell us to act in a

certain way or drive certain behaviors. For example, when we feel
afraid, our tendency is to try to run away and escape-it's a natural
response that protects us. As we discussed in Chapter 5, we refer to
these responses as emotion-driven behaviors or EDBs. For instance,
the act of running away when we become really scared is an EDB
meant to protect us from whatever is scaring us (flight, fight or freeze
response). It is a behavior di.riven by the emotion itself. Similarly,
if something makes us very angry, the tendency will be to lash out,
perhaps shout (or at the very least begin thinking about shouting) at
whoever or whatever caused the offense-or, at the extreme, even
possibly physically attack the person in self~defense.

Our ability to respond quickly to our emotions and to avoid threat-

ening situations is necessary and adaptive. Indeed, EDBs serve
an important function in our survival, and are helpfol when we
are threatened by something that is truly dangerous. But in other
situations, EDBs may be out of proportion to the actual situation
we are in, or may be less adaptive or even harmful to us in managing
a particular situation. For instance, if you have a job interview

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 dub 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.

Another important aspect of human emotions is that they are ofren-

times rooted in what has happened in the past, or what we think
might happen in the future. Because we have the ability to think
about the future or the past, our thoughts alone can ofren elicit
emotional experiences without actually being triggered by anything
happening in the present context of the situation. Therefore, if we
are responding to the emotions elicited by thoughts about a future
or past event, this too can be considered an EDB.

EDBs are different from emotion avoidance in that EDBs tend to

happen in response to an emotion that has been triggered, whereas
avoidance strategies tend to happen b~fore an emotion has even had
a chance to occur. However, like emotion avoidance, EDBs can also
become powerful habits in maintaining the cycle of emotions.

:xamples of EIJBs

Anxiety

m Someone becomes very emotional about the safety of his or her

family and frantically begins calling family members to see if
they are alright

0 Anxiety about safety of family members >> seeking

reassurance that they are safe.

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.

D Depression and feeling overwhelmingly negative and

hopeless >> increased isolation from others.

Fear

[lJ Someone excessively washes their hands in response to feeling

dirty or contaminated.

[J Fears of contamination >> washing behaviors.

Anger

~ Someone feels frustrated and angry over receiving a parking

ticket. In response, they tear up the ticket and yell at the
parking enforcement officer.

D Anger over receiving a parking ticket» tear up the ticket

and yell at the officer

As these examples illustrate, EDBs may be less adaptive in some

situations, and more adaptive in others. To understand the differ-
ence, let's look a little more closely at the example of EDBs in
response to fear of contamination. If we come into contact with
something that is undeniably contaminated and likely to make us
sick, like picking up the just-used handkerchief of a child with a bad
cold and runny nose, and we are afraid that we might catch the
child's cold, it makes sense that we would engage in the EDB of
washing our hands (which is also very much in line with what our
doctors tell us to do). But what if we feel anxiety even at the possibility
of coming into contact with something that is dirty and likely to
make us sick? What if every time we touch a doorknob, we then
proceed to wash our hands vigorously for several minutes under
hot water, to the point that our hands become dry and cracked and
possibly bleed? In this instance, the washing behavior is no longer
protective and, in fact, may actually reduce our ability to stay healthy~
The behavior that was adaptive in one situation is no longer adaptive
under other conditions.

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.

THER.APIST: So the coughing made you ap_vjous?

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.

THERAPIST: What type of disease do you think she might have?

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 Bu. 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?

BRIAN: Well, I immediately noticed this desire to get out of there.

At that moment, all I wanted to do was get away.

THERAPIST: I see. So your an,Yiety, or maybe even fear in that sin1ation, prompted
you to escape.

BRIAN: Definitely. We were going to the same Boor, 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.

THERAPIST: So in addition to covering your mouth, watching the elevator display,

and quickly escaping, you had the additional EDB of washing your
hands and around your mouth.

How IEDBs Maintain the !Emotional Response

Although EDBs are adaptive in certain situations, and inay reduce

distressing emotions in the short term, they don't always work in the
long term. For example, someone may begin writing a term paper
but repeatedly stop (escape-an EDB) because writing the paper
elicits strong depressive thoughts and emotions about potential
failure that drain energy and motivation. However, even though this
immediate termination of the work provides some relief in the short
term, the person will usually feel even worse later on because now
they still have the same concerns about the paper, but also have
additional pressure to write it in a short amount of time and may
feel bad about themselves for putting it off. On the other hand, if a
person experiences anxiety about work and automatically responds
by doing work "perfectly'' and as soon as possible, this may not actu-
ally be helpful in the long run. Trying to make something "perfect"
(which is one way of trying to establish control over a seemingly
uncontrollable threatening situation) usually leads to higher and
higher standards for work, and more anxiety about additional tasks.
In both cases, engaging in EDBs reinforces and strengthens the
connection between these situations and emotional experiences.

150
 It is important understand the function of our behaviors and to
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:-----------------------------------

Now take a dose look at the behaviors. What was the purpose or
function of the ED Bs? 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?

Of course, when considering your ED Bs you will want to pay

special attention to the relationship between your behaviors and the
emotions you experience. As you reflect upon your EDBs, you may
find that your behaviors are simply ways you have developed to
control your emotions. Unfortunately, you are likely to find that
these strategies have not been working, or that they only real1y helped
reduce your negative emotions in the short term. Bur what happens
long term? When we escape situations that frighten us, for instance,
we usually feel an instant, bur momentary, sense of relief. We might
wipe our brow and think to ourselves, "Whew, I got out of there
just in the nick of time." But what happens the next time we go
back into that situation? Will we be more or less afraid? You got

151
 it ... chances are we'll be as afraid, if not more afraid than we
were before.

This brings up an important point-that there is often a price to

pay for engaging in EDBs. That price can be the consequences of
engaging in non-adaptive and sometimes destructive behaviors, or
simply how you feel about yourself when you're not acting in a way
that is consistent with who you want to be (think of throwing the
tennis racquet or golf club). But why would we continue to engage
in EDBs that make us feel bad in the long term? The answer is
negative reinforcement. Negative reinforcement refers to the positive
feeling that sometimes comes from taking something negative away.
So, for example, every time you "take away" at least part of your
anxiety by engaging in EDBs like leaving a situation early, or
washing your hands, or eating snack foods instead of getting your
work done, you get rid of the uncomfortable feeling, even if just
temporarily. Because engaging in the EDB was rewarding in this
way, you are likely to repeat the same EDB again in the future.
Because of negative reinforcement, EDBs tend to lock in our
emotional responses in the future. To make matters worse, it can
even make the emotion more intense next time you're in a similar
situation. For example, if you "narrowly escape" a panic attack in a
crowd by leaving, you are left with the idea that being in crowds
means the potential of having a really bad panic attack. Chances are,
the next time you encounter a crowd your "narrow escape" of this
threatening situation will be at the forefront of your mind, amplify-
ing the idea that crowds are dangerous and increasing your anxiety
about being in a crowd. So it's as if the price keeps going up.
It doesn't seem very fair, does it? Luckily, you have some say in the
matter, because even if your emotions prompt you to engage in
certain behaviors, you can still make a decision to adopt new,
more adaptive behaviors and work hard to make changes in your
behavioral response.

Remember, as we discussed in Chapter 5, the goal of this treatment

is not to get rid of uncomfortable emotions like anxiety, and as
such you're not here to learn more efficient, craftier ways to control,
suppress, or avoid your emotions. Again, strategies to control or sup-
press emotions will most likely end up maintaining or intensifying
the very emotions you are trying to control. Instead, this treatment

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.

Cm.miering !Patterns of Avoidance and HJJ!Bs

Adopting Patterns of Approach as Opposed to AYoidance

One way to begin responding to emotional expenences more

adaptively is to adopt behaviors that promote a pattern of approach,
as opposed to avoidance. In other words, it is important to begin
engaging in activities and situations that are likely to bring up the
emotions you are currently avoiding, in order to gather more infor-
mation about your ability to cope in any given situation. Using the
previous example, if you always avoid crowds out of a fear you
will have a panic attack, you will only have enough information to
associate crowds with panic attacks. Your experience might be
summed up like this: Crowds = inevitable panic attack, inevitable
collapse, possibility of death. But if you were to allow yourself to
approach this situation instead of avoid it, gathering more and more
information about your ability to cope in this situation, your experi-
ence might eventually be summed up like this: Crowds= occasional
panicky sensations, rare full-blown panic attack, zero collapses, no
death. You'll learn more about this in chapter 12, but for now, what
are some situations that you are currently avoiding, that you want to
work on approaching? Write them in the space provided.

The Power of Alternative Action

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

153
 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).

One point that is important to bring up here is that engaging in

alternative behaviors (e.g., whistling a happy tune) is quite different
from engaging in alternative thoughts. Trying to convince yourself
you love peanut butter when you really hate peanut butter just
doesn't work, just like telling yourself you are happy when you are
down does not work. Trying to talk yourself into a feeling you don't
have is an example of a cognitive avoidance strategy (see Chapter 9)
and, as we discussed in Chapter 8, the goal when it comes to thoughts
is not to convince yourself you are thinking something other than
what you are thinking, but rather to allow yourself to be more flex-
ible in your thinking, identifying maladaptive automatic appraisals
and gathering objective evidence that supports or disconfirms these
appraisals. What we are discussing here is engaging in alternative
motor behaviors to those initially driven by the emotion (EDBs)-
not telling yourself you aren't afraid, but simply "whistling" instead
of cowering in fear or trying to escape. Changing behaviors in this
way has been shown to be an effective way to alter emotional experi-
ences, which in turn may also affect thoughts.

It may be helpful at this point to identify some of your typical EDBs

and work on developing alternative behaviors. It's okay if you have
trouble identifying all of them at this point. You'll get a chance to work
on identifying EDBs for homework. But, for right now, just note some

154
 Table 10.1
EOBs Alternative Action

of the EDBs you would like to change as part of your treatment and
then develop some dear alternative actions that you believe will be a
more adaptive way of responding to your emotions long term.

Summary

In this chapter, we have discussed another aspect of behaviors that play

an important role in emotional experiences-emotion-driven behaviors
(EDBs). EDBs are strategies we might use to make ourselves feel less
uncomfortable when we are feeling strong emotions. We discussed how
EDBs, which can be a natural, adaptive part of emotional experiences,
can become maladaptive, such as when they are excessive to the demands
of the situation (e.g., over-preparing for a meeting). We explored some
examples of maladaptive EDBs in a range of emotions, and discussed
how these EDBs serve to maintain distress. Finally, we discussed the
powerful impact that countering maladaptive EDBs through alterna-
tive actions can have on your emotional experiences.

In the next chapter, we will explore the last remaining component in

the three components of emotional experiences-physical sensations.

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 helpfol 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.

~ Continue monitoring your weekly experiences using the

OASIS and ODSIS.

~ Remember use the Progress Record to record the total scores

to

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.

I. Emotion-driven behaviors (EDBs) are almost never helpful or

adaptive, even in the short term.

T F

2. ED Bs tend to happen in response to an emotion that has been

triggered, whereas avoidance strategies usually happen before
an emotion has even had a chance to occur.

T F

3. Adopting behaviors that promote a pattern of approach, as

opposed to avoidance, is one strategy for changing current
emotional responses.

T F

4. While identifying EDBs is very important, changing how we

behave rarely helps change the way we feel.

T F

156

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158
 Understanding and Conftonting
Physical Sensations

~oals

~~J To identify internal physical sensations associated with your

emotions

SJ To understand the role that internal physical sensations play in

determining your emotional responses

ill To confront uncomfortable internal physical sensations

through exposure exercises

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.

Understanding Physical Sensations

In previous chapters, treatment has focused on two parts of emotional

experience--thoughts and behaviors-and on exploring how they
influence our emotions. There is one more part of the emotional

160
 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?

In order to understand how physical sensations are contributing

to uncomfortable emotional experiences, it is crucial to first be able
to understand what a physical sensation feels like, apart from any
interpretations of what it might mean. Only then can you begin to

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.

In order to conduct these exercises, you will need a stopwatch or

timer (so you will know how long to conduct each exercise for) as
well as a thin straw (a coffee stirrer will work).

Here is a list of exercises.

I. Hyperventilation

For approximately 60 seconds, take rapid, deep breaths

through your mouth, using a lot of force, as if you were
blowing up a balloon. This exercise is likely to produce
lightheadedness, dizziness, and feelings of unreality.

2. Breathe through a thin straw

For approximately 120 seconds, breathe through a thin straw

while blocking air from your nose. This exercise will elicit
sensations consistent with difficulty breathing and restricted
air Bow. It may induce anxiety early on, so it is important to
continue the exercise for at least 1-2 minutes, in order to
allow enough time for the anxiety to slowly subside.

163
 3. Spin in circles

For approximately 60 seconds, stand up and turn around

quickly (approximately one full rotation every three seconds)
with your eyes closed. Alternatively, you can spin in a chair that
swivels. If you conduct this exercise standing, make sure you
are near a soft chair or couch in case you lose your balance, and
where you can sit down afterwards and experience the sensa-
tions that are produced. This exercise is designed to produce
dizziness, lightheadedness, and disorientation.

4- Run in place

For approximately one minute, run in place while lifting your

knees as high as you can. This exercise will likely elicit rapid
heart rate, shortness of breath, flushed cheeks, and increased
body heat.

After each exercise, use the Symptom Induction 1est Form provided,
to take note of the following:

r. Any physical sensations you experienced

2. The intensity of these physical sensations on a 0-8 scale (where

O=not at all intense, 4=moderate intensity, and 8=extreme
intensity)

3. The level of distress you experienced during the exercise on a

0-8 scale (O=no distress, 4=moderate distress, 8=extreme
distress)

4. The similarity to symptoms you experience during strong

emotions on a 0-8 scale (O=not at all similar, 4=moderately
similar, 8=extremely similar).

In general, just take a moment to connect with your experience,

noticing any emotions, thoughts, or behaviors (particularly avoid-
ance behaviors) triggered by the experience.

164
 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. Afrer the exercise, please note:

r. the physical symptoms you experienced

2. the mi:ensity of the symptoms (0-8 scale; 0 = no intensity, 8 =

extreme intensity)

3. the level of disi:ress 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.

PROCEDURE Symptoms Experienced Intensity Distress Similarity

Hyperventilation (60 seconds)

Breathe through thin straw (2 minutes)

Spinning while standing (60 seconds)

Running in place (60 seconds)

Other: ( _ seconds)

Other: seconds)

Other: (_seconds)

Other: (_seconds)

Other: (_seconds)

Other: (__seconds)

Other: (__seconds)

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 helpfol,
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 wealmess, 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!

166
 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.

Third, you may not experience distress when completing these

exercises in a safe environment, such as at your home, or when
accompanied by a person who conveys a sense of safety, such as a
dose friend or spouse. In this case, you should consider taking the
exercises out of the "safe" environment, or try doing them alone.

Finally, you might not be afraid of the sensations because you

know they were produced by the exercises, rather than occurring
in response to a distressing situation or accompanied by strong
emotion. For some people, it's also more distressing to have these
sensations occur out of the blue, or in situations they didn't expect
them to occur. Of course, you will not be able to recreate this situa-
tion, but you may still benefit from working with these exercises to
help you become more comfortable with the sensations whenever
they may occur.

~epeatedly Confrornting Physical Sensations

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 halfhearteclly 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 ~ything 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

In this chapter~
the role of physical sensations in emotional experi-
ences was explored. Just as emotions can influence physical sensa-
tions, physical sensations can influence emotions. We discussed
the importance of experiencing physical sensations just as sensations,
rather than as something threatening in and of themselves. It is often
the interpretation or appraisal of what these sensations might mean
that make them more aversive. For example, some of the physical
sensations that accompany distress and anxiety are identical to phys-
ical sensations experienced by children playing in a playground, but
whereas in the first scenario these sensations are viewed as distress-
ing, in the second they are viewed as thrilling,

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
lifo experiences.

168
Homework

~ Continue engaging in symptom induction exercises on a daily

basis and recording your progress on the Symptom Induction
Practice Form at the end of this chapter.

~ Continue monitoring your weekly experiences using the

OASIS and ODSIS.

~ Remember to use the Progress Record to record the total scores

from the OASIS and ODSIS week by week.

Answer each of the following by circling true (T) or false (F). Answers
can be found in the appendix.

r. Internal physical sensations can become "signs" that our

emotions are more intense than they really are, and can influ-
ence the intensity of our emotional response and what we do in
response to our emotions

T F
2. 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.

T F
3. When experiencing strong physical sensations during an
emotional experience, it is very important to focus on them
and to try to reduce their intensity so that you can get your
emotions under control.

T F
4. Confronting physical sensations repeatedly can help you learn
that they are not dangerous, and that the intensity of the
sensations will return back to normal on their own after a short
period of time.

T F

169
.....
Cl I Symptom Induction Practice form
DAY1: DAY2: DAY3:

Trial Intensity Distress Similarity Trial Intensity Distress Similarity Trial Intensity Distress Similarity

1. 1. 1.

2. 2. 2.

3. -----------··· ~----------------
3. 3.
4. 4. 4.
5. --------·· ------······---- ------------ 5. 5.

DAY 4: DAY5: DAY 6:

Trial Intensity Distress Similarity Trial Intensity Distress Similarity Trial Intensity Distress Similarity

1. 1. 1.

2. 2. 2.

3. ________ 3. 3.

4. 4. 4.
c; c:;
-'• ----- -'· 5.
 I,·;
!I 1
I
r 'I'I
i
l Il
I Ii
JI

I I!
I': 1
1 Putting It into Practice: Facing Your Emotions
111
t I' I
I' I I
I in the Situations in which They Occur
IIli
I.
I ii I I!
I ! I I' I I 11
I!: I! I Iii j 11
i ! " i ii
i

1f11!1:
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1111Ir.i11
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Goals

1!:'1! To understand the ouroose of emotion exoosures

L L L

liliJ To learn how to design effective emotion exposure exercises

~~] To develop a fear and avoidance hierarchy

[}il To repeatedly practice confronting strong emotions through

emotion exposure exercises

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?

In the last chapter, we introduced exercises developed to purposely

bring about physical sensations similar to those you may experience
during times of distress or emotional discomfort. Did you practice
these exercises repeatedly? If you did not try these exercises, we urge
you to spend the next few days trying them. It is important to do
these exercises repeatedly, so that you can begin to recognize physical
sensations as sirnply sensations, and begin to notice what thoughts
or behaviors might be associated with physical sensations.

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 Coirncepts

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.

lntrnducUon to !Emotion Exposures

This next phase of treatment represents the most important step in

truly acquiring, understanding, and knowing all of the important
skills we have presented so far. When we learn something new, in
order to make it truly ours-automatic and "second nature"-we
need to learn by doing. Have you ever tried to teach someone how
to ride a bike just by describing it to them? Although they may "get"
the concept rationally; and be able to visualize how it is done, unless
they put it all together while actually on the bike, practicing the
concepts over and over, they will never truly learn how to ride a bike
as a skill, and will continue to fall off. The same concept holds true
here: you have been introduced to all of the skills and concepts you
need in order to successfully confront, accept, and manage uncom-
fortable emotional experiences, but unless you put these skills into
practice in the real world, they will never become automatic and
second nature, and you will not have truly learned.

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 'vVill gradually confront situations that produce
strong emotions and modify your responses to those emotions. All
of the skills you've learned so far (presem-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.

The exercises used to evoke uncomfortable emotions (emotion

exposures) will vary from person to person, but might include having
a conversation with a stranger, watching a distressing movie, or
imagining and then processing a particularly difficult event you
experienced in the past. Following are types of emotion exposure

173
 exercises you can use to bring on strong, uncomfortable emotions
and practice the skills you have learned so far.

Situationally Based !Emotion !Exposures

For situationally based emotion exposures, you will confront situations
that are likely to bring on intense emotional reactions. You may
currently avoid many of these situations. Depending on your
symptoms, these situations might include putting yourself in an
enclosed place for a period of time, having a conversation with a
stranger, or even starting conversations with a group of people.
When you conduct situational exposures, see if you can apply the
skills you have learned so far. Can you use your breath to anchor
yourselfin the present, interrupting catastrophic thoughts about the
future or ruminations about what happened in the past in a similar
situation? Can you do a quick "three-point check" of your thoughts,
feelings and behaviors? Can you identify maladaptive automatic
appraisals and thinking traps? Can you find new, more adaptive
reappraisals of the situation? Are you noticing any maladaptive EDBs
or avoidance strategies you are using? Can you replace rnaladaptive
EDBs with alternative actions, and prevent yourself from using
avoidance strategies? Are you reacting to physical sensations in a way
that makes the situation feel even worse? It is also important to
monitor your anticipatory thoughts, feelings, and behaviors prior to
doing situational exposures, and compare these with your thoughts,
feelings, and behaviors just after completing the exposure. Were
your anticipatory fears and/or appraisals cqnfirmed? Were your
physical sensations as intense or intolerable as you had anticipated?
Were you able to counter avoidance strategies and maladaptive
EDBs?

When you allow yourself to fully engage in situational exposures,

without engaging in safety behaviors or other avoidance strategies,
several important things can occur:

I. Interpretations and automatic appraisals about the dangerousness

of the situation will begin to change, sometimes automatically.

2. Newer, more adaptive interpretations and appraisals begin

to emerge.

174
 3. Avoidance, and subsequent impairment, begins to be reversed.

4. EDBs are recognized and modified.

maginal 1Emotio11 IExposurns

You can also conduct emotion exposures through a provocative

exploration of an emotionally arousing experience. These explora-
tions should be conducted in a quiet setting, with your eyes closed.
Imagine, in great detail, the events leading up to a difficult experi-
ence, including details about images, thoughts, and feelings as you
think about the progression of events. During these exposures, you
should try to fully experience the emotions associated with the
experience, whether it be panic, intense sadness or loneliness, fear
and anxiety, or intense anger. Using the skills you have acquired, see
if you can view this experience objectively. What maladaptive
appraisals do you notice? Are there other ways you can interpret
the experience? What physical sensations come up when you think
about the experience? Can you tolerate these sensations as just
that-sensations? How have your appraisals about the experience,
your emotional response to the experience, and/ or your physical
response to the experience, influenced your ongoing behaviors?
For example, when you think about the experience, do you tend to
isolate yourself from others, or turn to alcohol or substances to
"numb out" the feelings associated with the experience? Are there
new, more adaptive behaviors you can engage in, in response, such
as spending time with a good friend or going for a walk?

»t1ysical Sensation !Emotion Exposures

You may also choose to continue to conduct the physical sensation
exposures you completed in Chapter 11, continuing to process the
emotions brought up by inducing p4ysical sensations.

>racticing Emotion Exposures

A crucial factor in the success of treatment lies in your continued

practice of emotion exposures.

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 helpfol. 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 successfolly.
This allows an opportunity for you to experience mastery over an
aversive experience early on, while simultaneously challenging
yourself

Emotion exposures can be designed around any situation that evokes

uncomfortable emotions for you, allowing you to practice emotion
regulation skills you have learned (nonjudgmental, present-focused
awareness, identifying and challenging automatic appraisals, coun-
tering emotion avoidance and EDBs, and tolerating physical sensa-
tions). For example, if you are struggling with symptoms of panic
when using public transportation, you may want to take a crowded
subway to work. If you are struggling with fear in social situations,
you may purposely engage in a conversation with an unfamiliar
coworker. Or, if you are experiencing intrusive and distressing
thoughts, you may want to write down your most feared thoughts
and read them aloud daily. Here's an example of the Emotion and
Situational Avoidance Hierarchy that Kevin created to challenge his
fears about having a panic attack (Figure 12.1). Notice how he
focused on including a range of situations. See what situations you
can come up with to start facing uncomfortable emotions. (For
examples of Emotion and Situational Avoidance Hierarchy forms
for other disorders, please visit the Treatments That Work™ Web site
at www.oup.com/us/ttw.

176
 Do Not
Avoid

No
Distress

':'·. ,· Description Avoid I tiisttes~

.. · '· .. .·· ·..·•··· .·.·. -·

1 Driving-on the- hlf11wa~ B B

WORST

2 f1~1ng- B B

3 Taking- a bvc; 7 1

4 e:.le-vatorc; 0 1

5 6-atlng- at a re-c;fawant 0 0

6 Shopping- at the- mall 5 0

7 Gnolng-f¥"ou-ir~ <;hopping- 4 5

8 Gnolng- to a movie- 4 4

9 Gnolng- for a walk ) 4

10 Po~ <;ome-thlng-ph~c;lc.-all~ c;we-nvovc; ) )

figure 12.1
Kevin's Emotional and Situational Avoidance Hierarchy

177
!Emotional arnd Sihnatiornal Avoidarnce 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.

Work toward making your exposures optimally effective by continu-

ally reducing avoidance and increasing their difficulty. This is the
most essential part of treatment-the time where real learning of
skills takes place. It can also be helpful to review your Record of
Emotion Exposure Practice form after each exposure. Examining
avoidance behaviors can help you plan for other exposures. In the
example that follows, Sarah has picked "Going to a party" from her
Emotional and Situational Avoidance Hierarchy as an exposure exer-
cise, and has recorded this experience on her Record of Emotion
Practice form. Notice how the therapist helps Sarah design another
exposure based on her experiences with this exposure.

THERAPIST: How did you do with challenging yourself to go the party?

SARAH: Ir 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.

THERAPIST: How did you feel when you got there?

SARAH: I noticed a lot of physical sensations and just wanted to get out of
there. Bur as I stayed longer it wasn't so bad. I got more comfortable

179
 EJ(posure Task: Pr-ivi~ on the. e.xpr-o;<;wa~ for- at kast 15" minvto;

Prior to the task:

Anticipatory Distress (0 - 8): !!_
Thoughts, Feelings, and Behaviors you noticed before the task:
Thoughts: I'll h;ive. ;i panic- arnc,f:. that will c,;iv<;e. me. to lo<;e. c-onfr-ol of the. c-ar-. I'll
c,;iv<;e. an ac,c,ide.nt and po<;c;ibl~ die..
Feelings: /te-avt y-;ic,i~ te.nc;ion in ne.4

Behaviors: None.

Reevaluate your automatic appraisals about the.task:

I've. had panic- af!a4s be.for-e- whik dr-ivi~ a~d no.le.r- lo<;t c-o~fr-ol of the. c,;;ir-. Pvr-i.1'1§-
atfac,f:.c; I some.time-<; e-e-1 ovt o c-onfr-ol lii/t Ive. alwa <; be-e-n 1n c-onfr-ol o m be-hav1ovt;
while. dr-ivin I did t involve.d in an ac,c,ide-nt onc-e. bvt no one. wa<; hvr-t. e-n i I did
iffet into an ac,c,ide.nt, wovld pr-obabl~ <;vwive-.
After completing the task:
Thoughts, Feelings, and Behaviors you noticed during the task:
Thoughts: I'm t¥i~ to have. a panic- amc..k. If I fu.1 panic.i?J. I mvst be- ovt of c-onfr-ol.
I'm t¥i~ to lo<;e- c-onrrol of the. c-dl'".
Feelings: /te.avt was y-;ic-i~ <;we.ati~ diz.z.=i at timo;

Behaviors: 0rr-i e.d the. wh=I ti ti mainfaine.d a r-i 'd odvr-e. a11d ke. c-hu.-1::.in the.
mir-r-or- to make. <;vr-e. no one. c-ovld r-e.ve.nt me- r-om v/lin the- c,;;iy- oV&I'" to the. side- o the:.
y·oad. I had 1-r-ovbk mai11fainil'li} a c-onc;fant <:pe-e.d.
Number of minutes you did the task: 2-D min.
Maximum distress during the task (O -· 8): I
Distress at the end of the task (O - 8): 2:
Any attempts to avoid your emotions (distraction, safety signals, etc.)?
Af one. point, whe-n I ~<; fu.li~ pa11ivP). I tvr-n;0 the. v•dio on and tvme.d vp ;tie. volvme..
I ako fovnd m~<;e.lf Mi~ to n:.§'l;ifo m~ br-e.ath1~ to pr-e.ve.nf m1c;e-lf fr-om hav11'1i} an
arnc..k. I did naf· t¥ info the. pa"i~ lane..
What did you take away from this exposure taslc? Did your feared outcomes occur?
If so, how were you able to cope with them?

Ne..xf time., I'll make. the. e.xpo<;vr-e. moY-e- difFc..vlt b1 dr-ivi~ in the. passi~ lane.. Also, I
think. the. e.x o<;vr-e. ne.e.ds to be. a litHe- Ion · I'" to allow ffie. anxie- to l'"e.•11 c-ome. down
b r-e. I t o the. e.x r-e-<;swa . The.r-e. ;we. a nvmbe.r- o W5s will n=d to addr-e-.;<; a<;
we.II, <;v a<; <;fa~il'li} at a c-on<;+.int spe.e.d and not looki~ in the. miwor- <;o mvc-h bvt I
dcf nifol~ made. some. pr-o,¥o;c;.

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.

THERAPIST: So your anxiety lessened as you stayed?

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?

SARAH: Yeah, I think going to another party and purposefully introducing

myself to a group of people. Perhaps something like the first group I see,
so I don't avoid by sizing up groups or looking for more :friendly ones.

In the preceding example, Sarah works with the therapist to make

the exposures progressively more difficult by addressing her avoid-
ance and bringing up the emotions that make her uncomfortable.

:ey Things to Remember abcmt Exposure IPrnctice

How do you get to Symphony Hall? Practice, practice, practice.

Whenever possible, you should try to set up several exposures in a
week, at the very least. But the more you can do, the better. Of
course, other opportunities for reducing emotion avoidance and
changing EDBs will likely occur on a daily basis. But you should
work toward designing exposures specifically to address current pat-
terns of emotion avoidance, and conduct them on a regular basis.
Actually scheduling exposures and putting them in your planner is a
good way to assist you in completing these exercises. Also, it's impor-
tant to consider the logistics around conducting the exposures.
Clearly, less planning would be needed for a trip to a crowded mall
than for a plane flight to a nearby city. Since exposures can some-
times be difficult to arrange, and if properly designed should evoke
intense emotions, it's very common for people to put them off or
avoid. If you find yourself "too busy" to conduct the exposures, take

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. ff 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.

When conducting emotion exposures, it's important to try to engage

in them without any avoidance, and to use each exposure as an oppor-
tunity to change your EDBs. Often, it's better to conduct an exposure
that is lower on the hierarchy, but with no avoidance, than to attempt
a more distressing exposure with lots of avoidance behaviors on board.
The key to conducting emotion exposures is to elicit the emotions
that you have been trying to avoid. In order for you to fully connect
with the emotions, you will need to reduce patterns of avoidance
that have been corning between you and the emotions themselves.
There's no need to do anything to protect yourself from the emo-
tional experience during the exposures, because the emotions are not
dangerous; what you thought was going to happen is not likely,
and even if it did, you would find a way to manage it. During the
emotion exposures, it's generally best to connect with the emotion
and to "avoid avoiding." Even how you approach the task itself can

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 totake 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 tru(y 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

~ Complete your Emotional and Situational Avoidance Hierarchy.

Generate a list of 10 emotional situations that you currently
avoid, including some situations you rarely avoid, as well as
several situations that you always or almost always avoid. Focus
on the types of concerns that your treatment has focused on up
to this point. Also, choose situations that will help you achieve
your treatment goals, and will be most meaningful to achieving
improvement in various areas of your life.

~ Continue to engage in emotion exposures and record your

practice on the Record of Emotion Exposure Practice form.
Emotion exposures can be exposures to emotions triggered by
external events or situations, as well as internal triggers like
physical sensations (for example, exposures designed to bring
about a rapid heartbeat).

183
 ~ Repeatedly engage in physical sensation exposures following
the instructions in Chapter 11.

~ Continue monitoring your weekly experiences using the

OASIS and ODSIS.

~ Remember to use ~he Progress Record to record 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.

I. Emotion exposures are exercises that are specifically designed to

provoke strong emotional responses.

T F

2. It is unlikely that automatic appraisals are modified as a result

of emotion exposures.

T F

3. During an emotion exposure, it is important to identify pat-

terns of avoidance and ED Bs so that these behaviors can be
modified.

T F

4. Maintaining control over emotions during exposures is a good

strategy for gradually and systematically easing into emotion-
ally provoking situations.

T F

184
 Record of Emotion Exposure Practice

Prior to the task:

Anticipatory Distress (0-8): _ __
fhoughts, 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?

185
 lVIedications for Anxiety, Depression, and
Related Emotional Disorders
·Il:I !j'!.': I11111'1 Ii·
1 .I
:!
, /: i
1
I! Ii; I/I
11"
'Ii
i

ii' I ' I ) I!! I' I I! I I

Goals

lffi To learn about medications for anxiety, panic, and depression

£iJj To learn ways in which medications can be used in

combination with the methods outlined in this program

Reasons for Taking Drngs for !Emotional Disorders

Many people with emotional disorders are prescribed IT).edications

to help alleviate their symptoms. If this is true for you, you may tal<:e
this medication regularly or perhaps only when you feel you need it.
Many people go through this program without ever starting medica-
tion; others would just as soon not take the medication, but are
doing so on the advice of their physicians. However, there are a
number of people who want medication for their anxiety and/or
depression. For some, the anxiety and depression are so severe that
they feel they cannot handle even one more day and need relief as
soon as possible. Even the medication that takes the longest to act
would begin to take effect in three weeks. Some of the shorter-acting
medications can work within a day or two. Others may not feel that
they have the time to devote to mastering the information in this
workbook right now. Still others may believe strongly that medica-
tion is the best treatment for their anxiety.

In any case, almost 60% of the people who come to our clinic for
psychological treatment are talcing some kind of medication for their
anxiety and mood symptoms. Some have been riling 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
I
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.

Different Types of Medications

Antidepressant Drngs
There are several classes of antidepressants that are used to help
manage anxiety, panic attacks, and depression. Antidepressants
called serotonin specific reuptake inhibitors (SSRis) indude medica-
tions such as fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine
(Luvox), and paroxetine (Paxil). Related antidepressants called sero-
tonin-norepinepherine reuptake inhibitors (SNRis) include venla-
faxine (Effexor) and serzone (Nefazodone). These two classes of
medications have become first line drug treatments for a number of
emotional disorders. In general, they are less toxic and cause fewer
side effects than older medications such as tricyclic antidepressants and
monamine oxidase inhibitors (described next). Nevertheless, some
people still experience stomach upset and other gastrointestinal

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 Zolofr.

Tricyclic antidepressants (TCAs) include imipramine (Tofranil),

clomipramine (Anafranil), desipramine (Norpramin), nortriptyline
(Pamelor), and amitriptyline (Elavil). Tofranil used to be the most
commonly used antidepressant for anxiety and panic, but has been
largely replaced by the newer SSRis, as noted above. These medica-
tions are generally helpful for emotional disorders when adminis-
tered in the range of 150-300mg (with the exception of Pamelor
75-150mg and Anafranil 25-250mg). There may be some worsen-
ing of anxiety or mood initially. However, the initial worsening is
only minor when beginning with small doses (such as l Omg of
Tofranil). These doses are gradually increased to effective levels. Also,
the initial worsening goes away after the first week or so of treat-
ment. Other side effects include dry mouth, constipation, blurred
vision, weight gain and lightheadedness. However, these side effects
are generally harmless and go away after a few weeks. It usually takes
several weeks before the medications take full effect. So, getting
through the first few weeks is critical. It is difficult because the first
few weeks are when the side effects are the strongest but the medica-
tion is not yet having a positive effect. However, shortly after that,
the side effects decrease and so will emotion disorder symptoms.

Another type of antidepressant medication is the monoamine-oxidase

inhibitors (MAO inhibitors). The best-known medication in this
category for emotional disorders is phenelzine (Nardil). Others
include tranylcypromine (Pamate) and isocarboxazid (Marplan).
MAO inhibitors can cause side effects such as lightheadedness, weight
gain, muscle twitching, sexual dysfunction, and sleep disturbance.
As with other medications, treatment usually begins with low doses,
such as 15-.30 mg per day of Nardil, and is gradually increased
to effective levels, such as 60-90 mg per day of Nardil. The MAO
inhibitors are seldom used for emotional disorders these days,
because there are severe dietary restrictions when on this medication.

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.

The antidepressant medications seem to be about equally effective

for the emotional disorders. One thorny problem with antidepres-
sant medications is the side effects during the first few weeks.
In addition, the side effects are sometimes similar to symptoms of
panic and anxiety. For that reason, many people do not want to
continue taking the antidepressant, or at least do not want to increase
the dosage to levels that are needed to reduce panic and anxiety (this
is called the therapeutic dosage). And yet, research has shown that
it is important to take enough of this medication to get the full
benefits. Therefore, it is best to stick it out through the first few
weeks until reaching that therapeutic dosage. To help you stick it
out, remember

r. Side effects are not an indication of something wrong or harmful

happening to your body; That is, the side effects do not indicate I.

that physical damage is occurring to your body. Nor do they

indicate a physical disease. In fact, side effects indicate that
medications are having their intended chemical effects.

2. Side effects are not an indication that your anxiety is increasing.

Instead, side effects indicate that your body is going through a
period of adjustment to the medication, and sometimes the side
effects of this adjustment are symptoms that are similar to panic
and anxiety; however, they are not actual panic and anxiety.

3. Side effects usually go away after a few weeks.

4. Strategies described in this treatment will help you to be less

afraid of the side effects and achieve therapeutic dosages of
medication.

It is much easier to stop taking antidepressants than benzodiazepines

(described below). In other words, there are usually fewer with-
drawal symptoms when antidepressants are ended than when
benzodiazepines are ended. Therefore, the rates at which symptoms
return when treatment is discontinued (also called the relapse rates)
are much lower for antidepressants (around 40%-50%) than for
benzodiazepines.

190
Berm:idiazepilfles

Lower potency benzodiazepines, called minor tranquilizers, used to

be commonly prescribed medications for anxiety and panic, although
they are prescribed much less frequently now. Two of the most
common minor tranquilizers are diazepam (Valium) and chlordiaz-
epoxide (Librium). These medications were typically prescribed for
short-term relief of anxiety. They are generally believed to be unhelp-
ful for some anxiety, like panic attacks, unless they are prescribed
in very high dosages. For example, you might need 30 mg or more
of Valium a day to make a dent in your panic attacks. At this dosage,
chances are you would feel very sedated (that is, sleepy). Also, over
time, you may need increasingly larger dosage of the medication to
obtain the same effects. This is called tolerance. Unless you work
carefully with your physician, there is a danger that you may become
psychologically and physically dependent on the medication (i.e.,
addiction), which is intended only for short-term treatment of
anxiety. For these reasons, minor tranquilizers are not typically pre-
scribed by psychiatrists and physicians knowledgeable in the medi-
cation treatment of emotional disorders.

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 oflower 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 donazepam (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 ofXanax 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.

Side effects of these medications include sleepiness, poor coordina-

tion, and memory problems. However, starting with low doses and
gradually increasing over time can reduce these side effects. The initial
feeling of sleepiness usually subsides as one adapts to the medication.
 It is important to realize that the side effects decrease over time and
are not dangerous.

The various benzodiazepines differ in how long they remain active in

your body. This is referred to as half~life (or, the amount of time it
takes for half a dose of medication to be eliminated from the body).
With longer half-life, medication is taken less frequently. Klonopin
has a longer half-lifo (15-50 hours) than Xanax (12-15 hours).
Therefore, Klonopin is taken less frequently thanXanax. With shorter
half-lifo, people often feel the effects of the medication wearing off
and notice increased anxiety when the levels of medication in the
body are low, such as when waking up in the morning.

Benzodiazepines are believed to work by increasing the effect of a

chemical in the brain called GABA (gamma amino butryic acid).
GABA is distributed throughout the brain. It functions to inhibit or
"put the brakes on" the firing of nerve cells. Benzodiazepines help
GABA to put the brakes on those areas of the brain that cause anxiety.
As you can probably imagine, stopping benzodiazepines will "let up
on the brakes" and is usually associated with an increase in anxiety.
This is one reason why many if not most people relapse when they
stop benzodiazepines.

Withdrawal symptoms are also felt when benzodiazepines are stopped.

These include anxiety, jitteriness, difficulties concentrating, irritabil-
ity, sensitivity to light or sound, muscle tension or aching, headaches,
sleep disturbance, and stomach upset. Sometimes these withdrawal
symptoms lead people to become very concerned and anxious, espe-
cially because the withdrawal symptoms are similar to symptoms of
anxiety. People are sometimes so upset by the withdrawal symptoms
that they begin the medication again in order to get rid of the with-
drawal symptoms. Alternatively, they may relapse (i.e., recurrence
of anxiety). Relapse is especially likely if the withdrawal symptoms
are mistakenly viewed as being harmful. Actually, most withdrawal
symptoms are not harmful. Instead, withdrawal symptoms reflect
the body's adjustments to the chemical changes. Also, withdrawal
symptoms go away with time. With this type of information and
some other behavioral strategies, the withdrawal process is generally
much easier. Thus, slow tapering off of benzod.iazepines, combined

192
 with the types of strategies described below, dramatically reduce with-
drawal and relapse when benzodiazepines are discontinued.

Stopping Your Medication

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.

I. Withdraw from your medication relatively slowly. Don't try to

do it all at once. Once again, your physician will be able to give
you the best advice on how fast is best for you.

2. Set a target date for stopping your medication. Once again,

this will have to be planned with your physician so make it a
reasonable date in view of your own tapering schedule. On the
other hand, the date should not be too far away. Generally, the
quicker the better as long as it is within a schedule that is safe
for you as determined by your physician.

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

If prescribed at the right dosage and taken as directed, medications

can be effective for some people in the short-term relief of anxiety or
depression. However, the majority of medications are not effective
in the long term unless you continue to take them, and even then
they can lose some of their effectiveness over time. This program is
designed to help you learn some new, more helpful methods of
coping with your emotions. It is common for people to be interested
in discontinuing their medication treatment after completing this
program. If you are taking medications and are interested in discon-
tinuing them, it is important that you do so only under the direct
supervision of your prescribing physician. For some people, discon-
tinuing medications can bring an increase in physical symptoms and
a temporary increase in anxious or depressed mood. This is a normal
experience and represents a period of adjustment for your body.
The skills you have learned in this program can help you through

194
 this process. The Stopping Anxiety lvfedication Workbook, 2e might
also be useful in helping you to manage this change.

Homework

~ If you are currently taking medication and wish tostop taking

it, then your assignment for this week is to speak with your
doctor or prescribing physician about the best way to do it.

~ 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.

~ Draw up a specific, step-by-step plan for yourself.

Self-Assessment Quiz

I. It is essential that withdrawal from medication is conducted

gradually, under the supervision of your prescribing physician

T F

2. You are unlikely to feel any different when you withdraw from
your medication.

T F

3. Experiencing physical symptoms or anxiety/panic when

withdrawing from medication is a sign of loss of all your
treatment gams.

T F

4- Experiencing physic:U symptoms or anxiety/panic when

withdrawing from medication is a sign that you will not be able
to get off the medication

T F

5. The great majority of patients who have completed this program

are able to get off their medications

T F

195
 iI
_i !

i:

Moving On From Here~Recognizing Your

Accomplishments and Looking to Your Future

Goals

£~ To review skills for coping with emotions

~ To evaluate your progress

tili To develop a plan for practicing what you have learned in

treatment

f~ To set new goals for the future

~~ To learn strategies for maintaining the progress you have made

Key Concepts

The purpose of this chapter is to review key treatment concepts and to

help you to continue to strengthen the skills that you have learned in
this book. This chapter will also help you navigate the inevitable ups
and downs of everyday life, and help you to recognize and ultimately
prevent patterns that can lead to a worsening or recurrence of your
symptoms, which we call "relapse." Ultimately, this chapter will help
you to maintain all of the gains you have made so far in treatment.

Review Skills for Coping with Emotions

The following steps can be helpful in reminding you how to respond

adaptively to uncomfortable emotions, so that emotions do not
become unmanageable and out of control.

L 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? Wbat am I feeling, emotionally and physically?
Try and objectively observe your experience, without trying to
judge, "manage" or "control" it.

2. Consider any automatic appraisals or interpretations you are

currently experiencing within the context of your emotions and
the situation at hand-am I falling into any thinking traps
here? Are there other ways to interpret this situation?

3. Modify any maladaptive behaviors you might be engaging in

response to the situation and emotions triggered by engaging in
actions that are the direct opposite of your EDBs (i.e., instead
of escaping, remain in the situation; instead of checking, leave
the house and don't look back). Remember, modifying EDBs
involves provoking emotions and doing something different
from what you "feel like" doing (e.g., approaching something
that provokes fear instead of escaping, and maybe trying to
smile when you do it; or, getting out and doing things even
though you're depressed and don't feel like it). In addition, see
if you can identify any emotion avoidance strategies you may
be using, and take steps to prevent them (e.g., instead of
distracting yourself with the TY, turn the TV off; instead of
carrying your medication bottle when you go out, leave it
behind at home; instead of averting your gaze, make direct eye
contact when speaking with someone). This is an essential
aspect of confronting your emotions.

4. Pay attention to your physical sensations. Are you tired,

hungry, or rundown? Are your physical sensations contributing
to your emotions, or vice versa? Are your appraisals of your
physical sensations matching the current, present-moment
context? See if you can tolerate your physical sensations with-
out trying to manage them o~ control them, allowing them to
naturally run their course.

Evaluate Your Progress

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.

Second, take a moment to evaluate how your level of emotion aware-

ness has changed during treatment. Look back at your completed
Anchoring in the Present forms. Do you notice any improvement
in your ability to anchor yourself in the present moment as a result
of treatment? Also, how effective have you become in not judging
your emotional experiences? Are you more willing to experience
negative emotions? If there has been significant improvement in
your ability to nonjudgmentally observe both your emotions and
your reaction to your emotions, circle YES on the Progress Evaluation
Form. If not, circle NO.

Third, look at your thoughts. Have you made significant changes in

the ways you think about things that used to elicit strong emotions?
Do you think about your emotions, and the physical sensations
that contribute to emotions, in the same ways that you used to?
Are you less likely to jump to conclusions and to blow things out of
proportion? Circle the appropriate answer (yes or no) on the Progress
Evaluation Form.

Fourth, consider changes in your ability to handle physical symptoms.

Take a look at your initial fear ratings for the physical symptoms on
the Physical Symptom Induction Test Form. Now, rate your current
level of fear of the same symptoms and activities. Are you better
able to handle the physical symptoms produced by hyperventilation,
spinning, exercising, drinking coffee, etc.? If there has been a signifi-
cant reduction in your distress caused by experiencing physical sensa-
tions, circle YES next to the item labeled Symptom and Activity
Exercises on the Progress Evaluation Form. If not, circle NO.

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

Evaluate your own progress since you began this program

Anxiety and Depression

Significant reduction in severity of anxiety, fear, and feelings of depression. Yes No

Present-focused Emotion Awareness

Significant improvement in ability to nonjudgmemally observe both emotions Yes No

and reactions to our emotions

Negative Thoughts

Significant reduction in jumping to conclusions and blowing things out of proportion Yes No
Symptom and Activity Exercises

Significant reduction in distress caused by experiencing physical sensations. Yes No

Avoidance

Significant reduction in emotion avoidance. Yes No

Emotion Driven Behaviors

Significant reduction of non-adaptive EDBs. Yes No

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. Ifnot, 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.

Developing a Practice Plan

At this point, it might be useful to return to the list of treatment

goals you identified early in this treatment program. How are you
doing with meeting your goals? How might you revise them? You
may still have a number of activities or situations to practice, or you
might want to continue to work on developing certain skills that

200
 Practice Plan
Things to Practice Specific Plans

Present-focused emotion awareness

Increasing cognitive flexibility

Reducing avoidance and changing EDBs

Emotion exposures

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.

!Being Ymu Own Therapist

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 tal<:e 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.

I. Maintain awareness of your emotions. Remember the ARC,

and try to practice nonjudgmental, present-focused awareness
of your emotional experiences.

2. Continue to practice cognitive reappraisal and increase flexibility

in your thinking.

3. Avoid avoidance. Remember, any time you engage in emotion

avoidance, you reward your negative emotions and make them
worse.

4. Continue practicing emotion exposures and modifying EDBs

to prevent maladaptive cycles of emotions from returning, or
new ones from developing.

5. Remember, practice makes perfect.

Anticipating Difficulties and Managing Setbacks

Regardless of the gains you have made in treatment, it is likely that

you will experience intense or uncomfortable emotions at some time
in the future. This can often occur in response to life stressors.
Everyone experiences fluctuations in their emotional life-the ups
and downs of everyday life. And, sometimes, strong emotions can
occur that may not appear to directly relate to with any obvious
stressors. While this can be quite distressing, fluctuation in your
symptoms is natural and normal and does not necessarily mean you
have relapsed. Throughout the course of treatment, you have been
developing a more detached, less judgmental stance toward your
emotional experiences. As treatment ends and you turn your focus
toward practicing your newly established skills on a daily basis, it is
essential that you bring this same nonjudgmental stance to bear on
the inevitable ups and downs you are likely to experience over time.
You now have the knowledge, skills, and strategies to effectively
cope with the recurrence of symptoms in the future. For instance,

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 lifo.

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.

It may have already been a difficult journey; but additional chal-

lenges lie ahead. However, with what you have learned through this
treatment, you now have the valuable skills necessary to meet these
challenges. For many, the end of treatment is just the beginning of
making more substantial changes in their lives. Hopefully this treat-
ment has been helpful in providing you with important skills for
responding more adaptively to your emotions. With these skills in
hand, you can move forward with addressing your symptoms and
achieving your goals. To quote Michelangelo, "Every block of stone
has a statue inside it and it is the task of the sculptor to discover it."
You are the sculptor, and now you have the tools ... all that's left is to
carve the stone.

Self~Assessment Quiz

Answer each of the following by circling true (T) or false (F). Answers
can be found in the appendix.

I. Fluctuations in your symptoms are natural and normal and

do not necessarily mean you have relapsed

T F

2. Setting aside time weekly to review progress in continued use

of treatment strategies can be a good strategy for making
further gains and preventing relapse.

T F

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

205
 ii I! Ii\ II11
1
11 / 111 j i 1 Ii ii
11 !1111 / I1111 l I 11 I I i II
Seif-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 iO

1. F 2. T
3. T 4. F

Chapter ii

1. T 2. T
3. F 4. T

Chapter i2

1. T 2. F
3. T 4. F

Chapter 13

1. T 2. F 3. F
4. F 5. T

Chapter i4

1. T 2. T 3. F

208
 Tabla perl6dica de los eierr'.er;tos
Grupos ;:>nn.~.ipales Gr•.'j'')S princ:ipales
r--
. JA"
---.
SA
l

rn
10
rie-·1
l 1 2A 3A 4A SA 6A 7A
2 l3 14 15 16 17 4.002602
3 4 5 6 7 8 9 IO
2 Li Be B c N 0 F Ne
6.941 9.012182 Metales de tra1i~1ci6n 10.811 12.0107 14.0067 15.9994 18.998403 20.1797
ll 12 II 1 13 J4 15 16 17 18 I
3 Na Mg 3B 4B SB 6B 7B r-8B--, IB 2B Al Si I p s CI Ar
22.989770 24.3050 3 4 5 6 7 8 9 iO ll 12 . 26.981538 28.0855 30.97376 l 32.065 35 .45 3 39.948
19 20 21 22 23 24 25 26 27 28 29 30 31 32 34 35 36
4 K Ca Sc Ti v Cr Mn Fe Co Ni Cu Zn Ga Ge 33
As I Se Br Kr
I 39.0983 I 40.078 144.9559 l 0 47.867 50.9415 5!.9961 54.938049 55.845 58.933200 53.6934 63.546 65.39 69.723 72.64 74.92160 78.96 79.904 83.80
37 I 38 39 40 41 42 43 44 45 46 47 48 49 50 51 _,_
<:")
53 54
5 I Rb I Sr Y Zr Nb Mo Tc Ru j Rh Pd Ag Cd In Sn Sb Te I Xe
85.4678 ~ 87.62 88.90585 91.224 9::.906381 95.94 [981 I 0 l.07 J02.90550 106.42 107.8682 112.411 114.818 118.710 121.760 127.60 126.90447 131.293
~ 56 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86
6 Cs Ba Lu Hf Ta w Re Os Ir Pt Au Hg Tl Pb Bi Po At Rn

~'"°''"
87 'm"
88 '"""
103
178.49
104
I 80.9479
105
183.84

106 I
l 86.207

107
190.23
108
192.217
109
195.078
110
196.96655
111
200.59
112
204.3833
113 I
207.2

114
20S.98038
1J5
[208.98]

116 I
[209.99] [222.02]
I 18
7 Fr
l [223 02J
Ra
(226.03 j
Lr
[262.11 l
Rf
[261.ll]
Db
(262.11]
Sg
(266.12]
Bh
J [264.12]
Hs
(269.131
Mt
(268.14]
Ds
(2:3 l. I 5]
Rg
(272.15] [277] [284] I (289] (288] (2921 J [2941

-- ss I 69
~'Scne de los lanlamciGs l
1 57 59 60 61 62 63 64 65 66 67 68 70
*La Ce Pr Nd Pm Sm Eu Gd Tb Dy Ho Er Tm Yb
I 138.9055 140.116 140.90765 144.24 (145] 150.36 151.964 157.25 158.92534 162.50 164.93032 167.259 I168.93421 173.04
I 89 90 YI 92 93 94 95 96 97 98 99 100 IOI 102
[ tSene dclc' 1ctf111dos i t Ac Th Pa U Np Pu Am Cm Bk Cf Es Fm Md No
_\ [227.03] 232.0381 231.035881238.02891 [237.05] [244.06] (243.06] [247.07] (247.07] f'.'.51.0S] [252.08] [257.10] [258.10] [259.10)

0 Los r6tulos gue se encuentrnn en la parte superior de cada grupo ( lA, 2A, etc.) se utilizan de forma comun en Estados Unidos. Los r6tulos gue aparecen
debajo de estos (1, 2, etc.) son los rccomendaclos por la Union Internacional de Qufmica Pura y Aplicacla (JUPAC).
Los nombres y ,;fmbolos gue corresponden a los elementos i L2 y posteriores aun nose han decidido.
Los pesos at6micos entre corchetes correspondcn a los is6topos m{1s ant1guos o mas importantes de los elernentos ra<liactivos.
Puede obtener mas informaci6n en http://www.webelcments.com.
 Lista de elementos con sus sfmbolos y pesos at6micos
~~~o~.,~~~~~~~~~~~~~~~~~~~

Ntimero Peso Ntimcro Peso Numero Peso

Elcmento Sim bolo at6mico at6mico Elemento Sim bolo at6mico atOmico Eie1nentu Sfmboio atOmico at(nnico

Actinio Ac 89 227.03'1 F6sforo p 15 30.973761 Plutonio Pu 9,1 244.06"

Alurninio ,\I 13 26.981538 Francia Fr 87 223.02° Polonia Po 84 208.98<1
Americio Am 95 243.0Ga Gadolinio Gd 64 157.25 Potasio K 19 39.0983
Antimonio Sb i;··
~1 121.760 Galio Ga 31 69.723 Praseodimio Pr 59 140.90765
Argon Ar 18 39.948 Germania Ge 32 72.64 Prometio Pm 61 145"
Arsenico As '.l3 74.92160 Hafnio Hf 72 178.49 Protactinio Pa l)J 231.03588
Asta to At 85 209.99" Hasio Hs 108 269.13" Radio R~ 88 226.03"
Azufre s 16 32.065 Helio I-le 2 4.002602" Radon Rn 86 222.02"
Bario Ba 56 137.327 Hidrogeno H 1 1.00794 Renio Rt: 75 186./.07"
Berilio Be 4 9.012182 Hierro Fe 26 55.845 Rodia Rh 45 102.90550
Bcrkelio Bk 97 247.07" Holmio Ho 67 164.93032 Roentgenio Rg 111 272.15"
Bismuto Bi 83 208.98038 lndio In 49 114.818 Rubidio Rb 37 85.4678
Bohrio Bh 107 264.12" Iridio Ir 77 192.217 Rutenio Ru 44 101.07
Bora B 5 10.811 1terbio Yb 70 173.04 Rutherfordio Rf 104 261.11"
Bromo Br 35 79.904 I trio y 39 88.90585 Samaria Sm 62 150.36
Cadm10 Cd 48 112.411 Lantana La 57 138.9055 Seaborgio Sg 106 266"
Calc10 , Ca 20 40.078 Laurencio Lr 103 262.11" Selenio Se 34 78.96
Califomio Cf 98 251.08• Litio Li 3 6.941 smcio Si 14 28.0855
Carbono c 6 12.0107 Lutecio Lu 71 174.967 Sodio Na 11 22.989770
Cerio Ce 58 140.116 Magnesia Mo- 12 24.3050 Talia Tl 81 204.3833
Ces10 Manganeso Mn "' 25 54.938049 73
Cs 55 132.90545 Tantalio Ta 180.9479
Circonio Zr 40 91.224 Meitnerio Mt 109 268.14" Tecnecio Tc 43 98°
Cloro Cl 17 35.453 Mendelevio Md 101 258.10" Telurio Te 52 127.60
Cobnlto Co 27 58.933200 Mercurio I-lg 80 200.59 Terb10 Tb 65 158.92534
Cob re Cu. 29 63.546 Molibdeno Mo 42 95.94 Titania Ti '.22 47.867
Cnpton Kr 36 83.80 Neodirnio Nd 60 144.24 Torio Th 90 232.0381
Cromo Cr 24 51.9961 Neon Ne 10 20.1797 Tulio Tm 69 168.93421
Curio Cm 96 247.07" Neptunio Np 93 237.05" Tungsteno w 74 183.84
Darmstatio Ds 110 281.15" Niobio Nb 41 92.90638 Urania u 92 238.02891
Disprosio Dy 66 162.50 Nfquel Ni 28 58.6934 Vanadio v ..,~

..,;..__"") 50.9415
Dubnio Db 105 262.11• Nitr6geno N 7 14.0067 Xenon Xt: 54 131.293
Einstcnio Es 99 252.03• Nobelio No 102 259.10" Yoda 53 126.90447
Erbio Er 68 167.259 Oro Au 79 196.96655 Zinc Zn 30 65.39
Escandio Osmio Os 76 190.23 .b
Sc 21 44.955910 112 277°
Estai'io Sn 50 118.710 Oxfgeno 0 8 15.9994 .b 113 284-"
Paladio Pd 46 106.42 ,b
Estroncio Sr 38 87.62 114 289n
Europio Eu 63 151.964 Plata Ag 47 107.8682 *b 115 23s•
Fenrno Platino Pt 78 195.078 ,b
Fm 100 257.10" 116 292"
Fluor F 9 18.9984032 Plorno Pb 82 207.2 .b 118 294"

ilMasa def .JScilopo n1<is antiguo o 1n8s i1nportante.

bLos nombres cic los clementos 11.2 y posteriores aun nose han decidido.
 \. ,,

.. •,,